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  • Review Article
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Black–White disparities across the colorectal cancer care continuum in the USA

Nature Reviews Gastroenterology & Hepatology volume 22, pages 603–618 (2025)Cite this article

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Abstract

Colorectal cancer (CRC) remains a substantial public health challenge globally and is the second leading cause of cancer-related death in the USA. Despite advances in screening and treatment, disparities in CRC outcomes persist, especially among Black individuals in the USA, who face higher CRC incidence and mortality and lower survival compared with White individuals. Inequities are largely attributed to social determinants of health (SDOH), such as access to health care, socioeconomic conditions and systemic inequities. In this Review, we examine Black–White disparities in CRC outcomes across the CRC care continuum in the USA, highlighting contributing modifiable (non-biological) and non-modifiable (biological) risk factors. We also discuss successful interventions that have reduced or eliminated disparities. Existing evidence suggests that Black–White differences in CRC screening participation, CRC incidence and CRC mortality can be resolved. Future efforts must emphasize improving access to screening and guideline-concordant treatment to achieve progress in the near term while addressing the underlying and historical SDOH that drive inequities to eliminate disparities in the long term. The Review underscores the need for sustained investment in addressing both immediate and systemic barriers to CRC screening and care in Black communities to eliminate disparities in CRC outcomes and improve the overall health of the nation.

Key points

  • Colorectal cancer (CRC) disproportionately affects Black individuals in the USA, who experience higher incidence and mortality, and lower survival rates than White individuals despite an overall decline in incidence.

  • Social determinants of health (SDOH) are structural, economic, social and environmental factors that drive disparities in CRC outcomes by affecting access to health care, participation in screening and receipt of timely, high-quality care.

  • Modifiable CRC risk factors that result from adverse SDOH and contribute to inequities include medical comorbidities more common in Black individuals, low participation in CRC screening and low receipt of guideline-concordant treatment.

  • There are limited data supporting biological factors as drivers of disparities, and observed Black–White biological differences in CRC outcomes are probably influenced by mechanisms through which social factors affect health.

  • Successful interventions that target SDOH and modifiable risk factors, such as screening participation, demonstrate that the reduction and elimination of Black–White disparities in CRC screening and CRC outcomes are achievable.

  • A dual approach focusing on near-term improvements in access to screening and care and long-term interventions addressing SDOH is essential to eliminate Black–White inequities in CRC outcomes and to reduce the overall effect of CRC.

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Fig. 1: Social determinants of health for CRC screening and outcomes.
Fig. 2: Trends in incidence rates for CRC, colon cancer and rectum cancer in Black and White individuals in the USA, 1975–2019, SEER 8 registries.
Fig. 3: Trends in CRC death rates for Black and White individuals in the USA, 1969–2022.
Fig. 4: Trends in 5-year overall survival rates for Black and White individuals in the USA by stage, 1975–1981, 1992–1998 and 2013–2019.
Fig. 5: State variation in CRC death rates by state and race in the USA, 2018–2022.
Fig. 6: Black-to-White CRC mortality rate ratio ranked by US state, 2018–2022.

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Data availability

Databases referred to in Fig. 2 can be accessed from the Surveillance, Epidemiology, and End Results (SEER) 8 registries program (https://seer.cancer.gov/data). Databases referred to in Figs. 3, 5 and 6 can be accessed from the National Cancer Institute mortality database (https://seer.cancer.gov/mortality). Databases referred to in Fig. 4 can be accessed from the SEER 8 areas for 1975–1981 and SEER 12 areas for 1992–1998 and 2013–2019 (https://seer.cancer.gov/data).

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Acknowledgements

The authors thank K. Heskett and J. J. Tuan for their assistance with the literature search for this article. The authors also thank E. Schafer for statistical support. This material is the result of work supported in part by resources from the Veterans Health Administration. The content is solely the responsibility of the authors and does not represent the views of the Department of Veterans Affairs or the US Government. F.P.M. is supported by National Cancer Institute grant R01CA271034 (to F.P.M.), Department of Veterans Affairs Health Services Research and Development grant 10I01HX003605 (to S.G. and F.P.M.), Stand up to Cancer, and the Eli and Edythe Broad Center of Regenerative Medicine and Stem Cell Research Ablon Scholars Program. W.T.M. is supported by National Institutes of Health grant KL2 TR001444 (to W.T.M.), Robert Wood Johnson Foundation Harold Amos Medical Faculty Development Program, and Bristol Myers Squibb Robert A. Winn Career Development Award. A.J. is supported by Intramural Research, American Cancer Society. S.G. is supported by National Cancer Institute grant R37 MERIT CA222866 (to S.G.) and Department of Veterans Affairs Health Services Research and Development grants 5I01HX001574 (to S.G.) and 1I01HX003605 (to F.P.M. and S.G.).

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Authors and Affiliations

  1. Vatche and Tamar Manoukian Division of Digestive Diseases, UCLA Kaiser Permanente Center for Health Equity and Jonsson Comprehensive Cancer Center, University of California Los Angeles, Los Angeles, CA, USA

    Folasade P. May

  2. Division of Surgical Oncology, Department of Surgery, University of California San Diego, La Jolla, CA, USA

    Winta T. Mehtsun

  3. Surveillance and Health Equity Science, American Cancer Society, Atlanta, GA, USA

    Ahmedin Jemal

  4. Department of Medicine, Division of Gastroenterology, University of California San Diego, San Diego, CA, USA

    Samir Gupta

  5. Moores Cancer Center, University of California San Diego, San Diego, CA, USA

    Samir Gupta

  6. GI Section, VA San Diego Healthcare System, San Diego, CA, USA

    Samir Gupta

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The authors contributed equally to all aspects of the article.

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Correspondence to Folasade P. May.

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Competing interests

F.P.M. is a medical adviser for Exact Sciences, Medtronic, Freenome, Geneoscopy, Guardant Health, InterVenn and Natura. S.G. is a medical adviser for Geneoscopy, Guardant Health, Universal Diagnostics, InterVenn and CellMax; and has received research support from Freenome and Exact Sciences. The other authors declare no competing interests.

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Related links

Delaware Cancer Control: https://dhss.delaware.gov/dph/dpc/cancer.html

Kaiser Permanente Northern California: https://about.kaiserpermanente.org

National Cancer Institute Cancer trends progress report: https://progressreport.cancer.gov

New York Citywide Colon Cancer Control Coalition: https://www.nyc.gov/site/doh/providers/resources/citywide-colon-cancer-control-coalition.page

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May, F.P., Mehtsun, W.T., Jemal, A. et al. Black–White disparities across the colorectal cancer care continuum in the USA. Nat Rev Gastroenterol Hepatol 22, 603–618 (2025). https://doi.org/10.1038/s41575-025-01087-3

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