Time to Remove ‘Race-Based’ GI Screening Recommendations

Gastroenterology guideline panels should avoid the use of race and ethnicity in their screening recommendations unless they are transparent about the proper context, two experts argued.

These panels should consider more specific variables to determine screening criteria, but also be transparent about the implications of either using race/ethnicity or removing it from a previous recommendation in the future, wrote Shazia M. Siddique, MD, MSHP, of the University of Pennsylvania in Philadelphia, and Folasade P. May, MD, PhD, of the University of California in Los Angeles in Gastroenterology.

“The use of race/ethnicity is pervasive in clinical practice,” they noted. “Adjustment for an individual’s race/ethnicity in diagnostic and predictive algorithms may lead to biases in individualized risk assessment and clinical decision-making, or create and perpetuate health inequities.”

They added that “inappropriate racial/ethnic-based recommendations could have the unintended consequence of increasing, rather than mitigating, health inequities.”

“Our goal was to shed light that healthcare providers sometimes make medical decisions based on a patient’s skin color, determine the clinical scenarios in which this may be happening, and question whether this is appropriate,” Siddique told MedPage Today. “We found inconsistencies in the way race is being reported and applied in guideline recommendations.”

“Recommendations based on race or ethnicity alone are likely to be too simplistic at best, and misguided at worst,” said David Greenwald, MD, of Mount Sinai Hospital in New York City, who was not involved in this study.

“They may not properly consider key factors of health inequities that could underly an epidemiologic observation,” said Greenwald, who is president of the American College of Gastroenterology (ACG).

He told MedPage Today that assessing whether the difference in outcomes attributed to race and ethnicity “is just a marker for different social risk factors and structural inequities in access to health care.”

“The true work is addressing those health inequities,” Greenwald said.

Siddique and May reviewed all U.S.-based gastroenterology clinical guidelines or guidance articles published from January 2010 to September 2021. They found seven guidelines with eight screening recommendations based on race or ethnicity from the American College of Gastroenterology (ACG), American Gastroenterological Association (AGA), American Society for Gastrointestinal Endoscopy (ASGE), and the American Association for the Study of Liver Diseases (AASLD).

Three guidelines (AGA 2011, ASGE 2015, and ACG 2016) incorporated race into Barrett’s esophagus recommendations. They describe being white as a “risk factor” to screen for Barrett’s esophagus using upper endoscopy, since whites showed higher esophageal adenocarcinoma prevalence rates than other racial and ethnic groups.

However, Siddique and May noted that identifying more specific risk factors, such as environmental and genetic mechanisms, is needed. A newer 2019 ASGE screening guideline for Barrett’s esophagus removed race as a risk factor, replacing it with age, obesity status, smoking history, and male sex.

AASLD guidance from 2018 recommended that Black and Asian individuals with chronic hepatitis B infection (HBV) screen earlier for hepatocellular carcinoma with ultrasound screening every 6 months: over age 40 for Black or Asian men and older than 50 for Asian women.

“Other factors such as chronicity of disease, source of transmission, recent immigration status, viremia, and prevalence of HBV in country of origin or acquisition were not incorporated into the recommendation,” Siddique and May wrote.

Race and/or ethnicity were also used for three current guidelines on gastric intestinal metaplasia (GIM) — two from ASGE (2015 and 2015) and one by the AGA in 2019. Both 2015 ASGE GIM recommendations endorsed surveillance for people “from racial/ethnic backgrounds” who have a greater risk of gastric cancer, lumping all “non-white” ethnic groups together, though their risks may be different.

The 2019 AGA guideline does better, noting that some individuals may be reasonable to screen based on “specific rationale,” including race/ethnicity.

“The authors included a careful and transparent explanation for this recommendation, based on a meta-analysis that acknowledges the differences amongst racial/ethnic groups were not statistically significant differences, but could not exclude the possibility of clinically meaningful differences,” Siddique and May wrote.

Interestingly, 2015 ASGE guidance recommended screening and treating all “non-white” races or ethnicities for H. pylori infections, explaining that socioeconomic factors alone may not explain the difference in prevalence between ethnic groups. Siddique and May noted that “this guideline cited purposefully the use of race/ethnicity as a means to help reduce inequities in access to care while acknowledging heterogeneities within racial/ethnic groups.”

“Future research should outline and postulate why differences in race/ethnicity exist, and aim to identify more specific variables to use instead of race/ethnicity, where applicable,” Siddique said. “It would also be wonderful if GI societies created task forces, as our sister specialty societies have, to delve deep into each of these clinical areas.”

Last Updated December 08, 2021