Participation in colorectal cancer screening: a review

Screening and preventable illness

If an agent does not discount the future at a constant rate, as in some forms of myopia, her optimal strategy is unattainable without some commitment device. We apply this familiar idea to a model of screening and disease prevention, and explore how financial incentives can correct suboptimal health choices. In general, myopia need not imply under-screening. While the optimal intervention for prevention effort is a state-invariant subsidy, the optimal intervention for screening may involve a tax or a subsidy. When screening and prevention are coincident, a simple and practical subsidy equal to one minus the discount factor to both screening and intervention is indicated.

Magnetic resonance colonography for colorectal cancer screening

Colorectal cancer screening has vast potential. Beyond considerations of cost and diagnostic accuracy, the effectiveness of any colorectal screening strategy will be dependent on the degree of patient acceptance. Magnetic resonance (MR) colonography has been shown to be accurate regarding the detection of clinically relevant colonic polyps exceeding 10 mm in size, with reported sensitivity and specificity values exceeding 95%. To further enhance patient acceptance, strategies for fecal tagging have recently been developed. By modulating the signal of fecal material to be identical to the signal characteristics of the enema applied to distend the colon, fecal tagging in conjunction with MR colonography obviates the need for bowel cleansing. This article will describe the techniques underlying MR colonography and early clinical experience with fecal tagging techniques.

Colorectal cancer screening compliance by medicine residents: perceived and actual

OBJECTIVE

Implementation of colorectal cancer (CRC) screening with widely available techniques can result in a significant reduction in CRC-related mortality. Clinical practice paradigms are often ingrained in physicians during residency. We, therefore, investigated both compliance and perceived obstacles to CRC screening in the practices of physicians-in-training.

METHODS

We conducted a retrospective analysis of medical records of patients who were receiving their primary care in the internal medicine resident clinics at the University of Nebraska Medical Center and were at average risk for CRC. In addition to demographics, data on the use of screening mammography, Pap smear, cholesterol, fecal occult blood testing (FOBT), and flexible sigmoidoscopy (FS) were collected. A questionnaire was also distributed to all internal medicine residents to assess their CRC screening knowledge and perceived screening compliance.

RESULTS

One hundred eight patient charts were reviewed. The percentage of patients appropriately screened for each test was as follows: mammography 66%, Pap smear 65%, cholesterol 53%, FOBT 13%, and FS 16%. Residents dramatically overestimated their perceived FS and FOBT screening rates, 78% and 88%, respectively. Most residents identified barriers to FS screening. Although rudimentary CRC screening knowledge appeared adequate, a number of knowledge-based deficiencies were identified.

CONCLUSIONS

Internal medicine residents at our institution demonstrate poor CRC screening compliance especially when compared with other health care maintenance interventions. This cannot be entirely accounted for by inadequate knowledge; discrepancy between the perceived and actual implementation of CRC screening may be important. Efforts to improve screening compliance should include a focus on physicians-in-training.

Knowledge, beliefs, and barriers relevant to colorectal cancer screening in an urban population: a pilot study

A sample of 115 urban, working-class, predominantly minority men and women was interviewed by telephone to assess knowledge, beliefs, and barriers relevant to colorectal cancer (CRC) and CRC screening. More than half (53.9%) were unable to name a CRC screening test. Misconceptions were common. Dispelling inaccurate beliefs, establishing an individual's preference for fecal occult blood tests or flexible sigmoidoscopy, and helping individuals take a proactive role in the receipt of CRC screening are important goals for health education efforts aimed at increasing rates of CRC screening. Participants' willingness to engage in detailed telephone conversations about CRC and CRC screening was encouraging.

Patient experience and preferences toward colon cancer screening: a comparison of virtual colonoscopy and conventional colonoscopy

BACKGROUND

Virtual colonoscopy has excellent sensitivity for the detection of cancer and polyps greater than 1 cm in diameter. For virtual colonoscopy to succeed as a screening test for colorectal neoplasia, it must be well tolerated and accepted by patients. Patients' experiences with virtual colonoscopy and conventional colonoscopy were assessed and compared.

METHODS

Patients referred to the GI clinic for colonoscopy for any indication were recruited to undergo virtual colonoscopy before conventional colonoscopy. Patients were asked to complete a questionnaire twice: after virtual colonoscopy and after completing both tests. Three variables, overall pain, discomfort, and lack of respect, were assessed by using a 7-point Liken scale with higher scores denoting a worse experience. Patients' preferences for virtual colonoscopy versus conventional colonoscopy were determined with a time tradeoff technique. To verify response stability, patients were asked to return an additional questionnaire by mail at 24 hours.

RESULTS

Two hundred ninety-five patients completed the questionnaire immediately after the procedures, and 83 patients completed the questionnaire at 24 hours. At both 0 and 24 hours, patients reported more pain, discomfort, and less respect after virtual colonoscopy than conventional colonoscopy (p < 0.01). The overall agreement (Kappa statistic) between times 0 and 24 hours was fair. Patients reported that they preferred conventional colonoscopy and would wait longer for conventional colonoscopy (mean = 4.9 weeks) than undergo a virtual colonoscopy (p < 0.01).

CONCLUSIONS

Patients tolerate both virtual colonoscopy and conventional colonoscopy, although they report more pain, discomfort, and less respect undergoing virtual colonoscopy. Efforts to improve patient experience during virtual colonoscopy need to be investigated.

Willingness-to-pay for colorectal cancer screening

Willingness-to-pay (WTP) techniques are increasingly being used in economic evaluation, as a means of assessing the value of new health care technologies. This paper presents the results of a WTP investigation of two types of screening for colorectal cancer. A questionnaire was issued to a general population via general practitioners (GPs), yielding a sample of approximately 2000 cases for analysis. Regression models demonstrated that WTP was significantly influenced by factors such as gender, income, age, risk perceptions, illness experiences and health beliefs. The median WTP for screening emerged as being pound30 or pound50, depending on the method used to elicit WTP, but independent of the screening protocol. Combining the results with those from related research, it emerged, first, that WTP subjects offered higher values for flexible sigmoidoscopy screening than the costs actually incurred by revealed preference studies and, second, they offered WTP values similar to the likely resource costs of the screening procedures.

Declining the offer of flexible sigmoidoscopy screening for bowel cancer: a qualitative investigation of the decision-making process

Qualitative methods were used to investigate decision-making among a group of older adults who declined the offer of flexible sigmoidoscopy screening for bowel cancer. Interviews were conducted with 60 people (30 men and 30 women) who either had not responded to the screening letter or who responded saying that they were not interested in participating. The findings suggest that low perceived susceptibility to bowel cancer, in terms of current health status, family history or absence of bowel symptoms. was an important factor in the decision to decline screening. Procedural barriers such as embarrassment, pain/discomfort and perceived unpleasantness of the test were reported as relatively minor, although the test was considered more physically intrusive than other screening tests. Avoidant attitudes emerged as an important theme and were reported by a third of respondents. Distinct patterns of decision-making were also observed and three groups emerged from accounts: (i) forgetting or avoiding making a decision about the test (ii) a confident rejection of the test based on a few salient factors, and (iii) a more careful consideration of the test focusing on issues of susceptibility. The findings are discussed in the context of models of health behaviour and bowel cancer screening participation research.

One-time screening for colorectal cancer with combined fecal occult-blood testing and examination of the distal colon

BACKGROUND

Fecal occult-blood testing and sigmoidoscopy have been recommended for screening for colorectal cancer, but the sensitivity of such combined testing for detecting neoplasia is uncertain. At 13 Veterans Affairs medical centers, we performed colonoscopy to determine the prevalence of neoplasia and the sensitivity of one-time screening with a fecal occult-blood test plus sigmoidoscopy.

METHODS

Asymptomatic subjects (age range, 50 to 75 years) provided stool specimens on cards from three consecutive days for fecal occult-blood testing, which were rehydrated for interpretation. They then underwent colonoscopy. Sigmoidoscopy was defined in this study as examination of the rectum and sigmoid colon during colonoscopy, and sensitivity was estimated by determining how many patients with advanced neoplasia had an adenoma in the rectum or sigmoid colon. Advanced colonic neoplasia was defined as an adenoma 10 mm or more in diameter, a villous adenoma, an adenoma with high-grade dysplasia, or invasive cancer. Classification of subjects according to the findings was based on the most advanced lesion.

RESULTS

A total of 2885 subjects returned the three specimen cards for fecal occult-blood testing and underwent a complete colonoscopic examination. A total of 23.9 percent of subjects with advanced neoplasia had a positive test for fecal occult blood. As compared with subjects who had a negative test for fecal occult blood, the relative risk of advanced neoplasia in subjects who had a positive test was 3.47 (95 percent confidence interval, 2.76 to 4.35). Sigmoidoscopy identified 70.3 percent of all subjects with advanced neoplasia. Combined one-time screening with a fecal occult-blood test and sigmoidoscopy identified 75.8 percent of subjects with advanced neoplasia.

CONCLUSIONS

One-time screening with both a fecal occult-blood test with rehydration and sigmoidoscopy fails to detect advanced colonic neoplasia in 24 percent of subjects with the condition.

Effect of dietary restriction on participation in faecal occult blood test screening for colorectal cancer

OBJECTIVES

To determine if participation in colorectal cancer screening using faecal occult blood testing (FOBT) is affected by a restrictive diet and if it is associated with certain demographic variables.

PARTICIPANTS AND SETTING

1,203 residents of South Australia aged 50-69 years, with no "currently active bowel disease", randomly selected from a database of people willing to be contacted about unspecified health issues.

DESIGN

Randomised controlled trial: participants were offered screening by immunochemical FOBT by mail in 1998. Half were randomly allocated to a group instructed to follow a low-peroxidase diet, as required for guaiac FOBT, while the other group was not so restricted.

MAIN OUTCOME MEASURES

Effect of diet restriction on participation (return of correctly completed FOBT sample cards within 15 weeks); time taken to return cards; relationships between participation and demographic variables.

RESULTS

Participation rates were 65.9% (no-diet group) and 53.3% (diet group) (difference, 12.6%; 95% CI, 7.1%-18.1%). In the first week, rates of return as a proportion of all tests returned were 13.1% (no-diet) and 1.6% (diet) (difference, 11.5%; 95% CI, 8.6%-14.4%), increasing to 54.3% and 44.5%, respectively, after five weeks (difference, 9.8%; 95% CI, 4.2%-15.4%). Participation was significantly associated with older age (odds ratio, 1.40; 95% CI, 1.10-1.78), but not sex, Index of Social Disadvantage or rural versus urban address.

CONCLUSIONS

Dietary restrictions create a barrier to FOBT-based screening for colorectal cancer. The use of immunochemical rather than guaiac FOBT removes this barrier.

Predictors of inadequate bowel preparation for colonoscopy

OBJECTIVE

Inadequate preparation of the bowel for colonoscopy can result in both missed pathological lesions and cancelled procedures. We looked prospectively at the quality of colonic preparation and evaluated potential associations between specific patient characteristics and inadequate colonic preparation.

METHODS

Data were gathered on consecutive patients presenting for colonoscopy who received either a polyethylene glycol lavage or oral sodium phosphate bowel preparation. Patient demographic and medical history information was gathered before scheduled colonoscopy. The endoscopist evaluated the preparation quality during the procedure. Complete data were gathered on 649 of 714 eligible patients (90.8%). Possible predictors of inadequate colonic preparation were analyzed using univariate statistics and multivariate logistic regression models.

RESULTS

An inadequate colonic preparation was reported in 21.7% of observed colonoscopies. Only 18% of patients with an inadequate colonic preparation reported a failure to adequately follow preparation instructions. A later colonoscopy starting time, a reported failure to follow preparation instructions, inpatient status, a procedural indication of constipation, taking tricyclic antidepressants, male gender, and a history of cirrhosis, stroke or dementia were all independent predictors of an inadequate colon preparation (all p < 0.05). A procedural indication of previous polypectomy was a negative predictor of inadequate colonic preparation (p < 0.05).

CONCLUSION

Several patient characteristics were significantly associated with colonic preparation quality independent of preparation type, compliance with preparation instructions, and procedure starting time. This information may help to identify patients at an increased risk for inadequate colonic preparation for whom alternative preparation protocols would be appropriate.

The role of inadequate health literacy skills in colorectal cancer screening

Colorectal cancer is ideally suited for early detection strategies that are likely to improve survival rates. Screening with either a fecal occult blood test (FOBT) or flexible sigmoidoscopy has been shown to identify precancerous polyps or cancers in early stages. However, persons with limited education and of lower socioeconomic status infrequently participate in screening programs in general and have very low rates of colorectal screening. Low literacy, which is common among persons with limited education and low income, may be an overlooked factor in understanding patients' decision making about colorectal cancer screening. This article provides information from focus groups about colorectal cancer screening, which we examine in the context of relevant literature on cancer screening and literacy. Using the health belief model, we examine the association between inadequate health literacy skills and low rates of colorectal cancer screening. The theoretical model also provides insights into strategies for improving knowledge, attitudes, and beliefs and screening rates for this challenging patient population.

Virtual colonoscopy: a novel imaging modality for colorectal cancer

Advances in computed tomography (CT) technology and computer capabilities have contributed to the development of a new imaging modality for colorectal lesions called CT colonography or virtual colonoscopy. Virtual colonoscopy is a rapid, minimally invasive scan of the cleansed and distended colon. Early work has demonstrated that this test is safe and well tolerated, and that it may be sensitive and specific enough to identify most significant precancerous or cancerous lesions. A number of technical and practical problems remain before virtual colonoscopy can be applied at a population level.

Differing attitudes toward virtual and conventional colonoscopy for colorectal cancer screening: surveys among primary care physicians and potential patients

OBJECTIVES

To investigate attitudes among primary care physicians and potential patients concerning "virtual" and conventional colonoscopy for colorectal cancer screening.

METHODS

We sent 1000 questionnaires to primary care physicians by electronic or postal mail and administered 400 to potential patients. Questionnaires contained progressively detailed information about the tests and asked for choices based on information presented.

RESULTS

One hundred eight-eight primary care physicians and 323 potential patients were included. Results indicated the following: 76.6% of potential patients and 47.3% of physicians initially preferred virtual colonoscopy because of its noninvasive nature; 23.6% of potential patients and 52.9% of physicians valued the ability of conventional colonoscopy to visualize the mucosa directly; and 67.4% of potential patients and 51.6% of physicians preferred virtual colonoscopy because it does not require sedation. Considering all information, most potential patients preferred virtual to conventional colonoscopy (60.2% vs 25.7%), whereas more physicians preferred conventional to virtual colonoscopy (44.9% vs 30.3%). Additionally, 82.3% of potential patients would comply more with recommendations for colorectal cancer screening, and 61.7% of physicians would refer more patients for screening, if virtual colonoscopy was available.

CONCLUSIONS

Potential patients preferred virtual to conventional colonoscopy, whereas physicians favored conventional colonoscopy. Physicians placed more importance on the ability of conventional colonoscopy to visualize the mucosa directly, the opportunity for therapy, and cost. Potential patients were more encouraged than physicians by the availability of virtual colonoscopy for improving participation in colorectal cancer screening.

Virtual colonoscopy: a new approach for colorectal cancer screening

Virtual endoscopy is the processing of computerized tomography image data to create a virtual environment of the human body to allow diagnosis of disease processes. This new technique allows the observer the opportunity to interact with an image that is artificially generated by the computer. Virtual colonoscopy provides a method for processing data that can display computer images of the colon in a more anatomic life-like format to facilitate image interpretation and improve diagnostic accuracy. The clinical application of virtual endoscopic techniques is also being used with other procedures such as bronchoscopy, gastroscopy, cystoscopy, sinus imaging, virtual angioscopy, and cerebral ventriculography. Current screening recommendations for colorectal cancer are discussed in this article along with methods, advantages, challenges, and future opportunities for virtual colonoscopy.

Cancer worries, risk perceptions and associations with interest in DNA testing and clinic satisfaction in a familial colorectal cancer clinic

Multi-disciplinary familial cancer clinics are becoming an integral part of cancer services. It is, therefore, important to assess how attendance at these clinics impacts on cancer-related concerns, risk perceptions and behavioural intentions, and how the clinic services are being received by those using them. This study has assessed a familial colorectal cancer clinic with respect to cancer-related worries and risk perceptions and their impact on interest in DNA testing and overall satisfaction with the clinic. Pre- and post-clinic questionnaires were completed by 127 patients and relatives attending the clinic. After attending the clinic, the proportion of people 'very' or 'extremely' worried about developing bowel cancer reduced from 49 (pre-clinic) to 34% (p = 0.002). Worry about bowel cancer was positively associated with younger age, higher education level and higher perceived risk of developing cancer. A reduction in level of risk perception correlated with a lower likelihood of feeling 'very worried' about developing bowel cancer. Of those intending to go ahead with DNA testing, 58% were 'very worried' about bowel cancer compared with 15% of those not intending to proceed with testing, suggesting that worry was a motivation for interest in DNA testing. One-third of participants indicated another session of genetic counselling would be helpful. Within this group, a higher proportion was very worried about bowel cancer (43%) than for those who did not want another session (17%). Attendance at this familial colorectal cancer clinic alleviated worry for many individuals, partly due to improved information about risk of colorectal cancer.

Socio-demographic correlates of screening intention for colorectal cancer

OBJECTIVE

To assess the relationship between socio-demographic factors and screening intention for colorectal cancer (CRC).

METHODS

A cross-sectional survey of a random sample of 884 Queenslanders aged 40-80 years was conducted using a computer-assisted telephone interviewing system. The factors measured included socio-demographic characteristics, personal history of CRC, knowledge of others with CRC and perceived symptom status. Chi-squared and Monte Carlo estimates of Fisher Exact Tests were performed to determine the associations between socio-demographic factors and screening intention. In multivariate analyses, multinomial logistic regression (MNLR) was utilised to examine potential determinants of screening intention.

RESULTS

77.5% (95% CI 74.0%-80.7%) of the respondents indicated their intention to participate in CRC screening if it were recommended by their doctor or health authorities. The likelihood ratio chi-squared tests in the MNLR analyses show that age (chi(df = 6)2 = 15.0; p = 0.02), education (chi(df = 8)2 = 19.4; p = 0.01), perceived symptom status (chi(df = 4)2 = 22.9; p = 0.00), sex (chi(df = 2)2 = 4.5; p = 0.11), income (chi(df = 14)2 = 19.6; p = 0.14) and personal history of CRC (chi(df = 2)2 = 4.3; p = 0.12) were potential determinants of screening intention. Other socio-demographic factors, including country of birth, private health insurance status, Socio-economic Index for Areas, and Rural and Remote Areas Classification codes, were not associated with screening intention.

CONCLUSIONS AND IMPLICATIONS

The results indicate that a variety of socio-demographic factors are associated with screening intention and need to be considered in the future development of a population-based screening program for CRC.

Effectiveness and economic impact of screening for colorectal cancer by mass fecal occult blood testing

OBJECTIVES

Fecal occult blood testing has been shown to reduce mortality from colorectal cancer in large randomized, controlled trials conducted in the United States, Denmark, and the United Kingdom, and mathematical simulation modeling found it to be cost-effective relative to other health care services. Before making a concerted effort to implement mass fecal occult blood testing based on this evidence alone, however, we considered it prudent to critically re-evaluate the effectiveness and economic impact of screening in the US population as a whole.

METHODS

To assess the effectiveness of screening, we projected published outcomes from each of the three large randomized controlled trials of fecal occult blood testing to the US population, as if each clinical trial had been done in the population as a whole. We then determined the resource costs of detection and treatment that would be associated with the outcomes predicted from each trial.

RESULTS

More than 1 million colorectal cancers could be expected to arise over 10 yr in the cohort of US residents eligible to enter a screening program in 1997, and trial outcomes indicate that > or = 60% of these cancers would be fatal. If the 60-67% compliance rate of the population-based randomized controlled trials were achieved, a fecal occult blood testing program would detect 30% of known colorectal cancers and save 100,000 lives over 10 yr. Screening would incur total costs of $3-4 billion over 10 yr, or $2,500 per life-year saved.

CONCLUSIONS

Mass fecal occult blood testing is cost-effective, and, although not inexpensive, many would consider the total cost acceptable. Even with a concerted effort to achieve compliance, however, the effectiveness of fecal occult blood testing would be limited to saving the lives of < or = 15% of those who otherwise would die from their cancer in the first 10 yr after beginning mass screening. The limitations of fecal occult blood testing suggest the need to further evaluate the role of endoscopy in screening, and to develop more effective, noninvasive screening tools.

Early detection for colorectal cancer: new aspects in fecal occult blood screening

The authors report on promising diagnostic methods of occult intestinal bleeding and discusses the potential new strategy of early detection of colorectal carcinomas in respect to old and new diagnostic measures available. Because of the limited sensitivity and specificity of classical methods used for the demonstration of occult fecal blood, the authors recommend the introduction of new techniques and markers in screening practice. It is presumed that new discoveries in molecular biology will improve the accuracy of early colorectal cancer prevention. Their implementation into routine screening, however, will not take place in the near future. Until their realization, improved screening efficacy is expected from the use of more specific and sensitive blood tests.

Preventable cancers: the role of obstetrician gynecologists in colorectal cancer screening

Colorectal cancer is second only to lung cancer as a cause of cancer deaths in the United States, and is the third most common cause of cancer deaths in U.S. women. Effective screening and intervention programs exist and, if followed, could halve the number of annual deaths from this disease. Detection of early-stage disease and, more important, premalignant polyps, is possible by following the recommendations of several national societies, including the American College of Obstetricians and Gynecologists. Recommended screening consists of identification of special risk factors, annual fecal occult blood testing, and flexible sigmoidoscopy every 5 years. Alternatively, a dual-contrast barium enema every 5 to 10 years or colonoscopy every 10 years are options. This article reviews the evidence underlying current screening guidelines, highlights emerging trends in screening, and analyzes the growing need for women's health care providers to understand and promote colorectal cancer screening as part of an optimal health maintenance program.

Colorectal cancer screening participation by older women

OBJECTIVE

Although recent screening guidelines recommend annual fecal occult blood testing (FOBT) for adults aged > or = 50, a number of studies report that these tests are underused. Systematic efforts to increase awareness of colorectal cancer (CRC) and to promote screening participation are needed to meet national objectives for CRC control.

METHODS

This study examined CRC-screening practices and evaluated factors related to recent participation in screening by FOBT in a sample of women aged 50 to 80 who were surveyed about their use of clinical preventive services at Group Health Cooperative, a managed care organization in western Washington State.

RESULTS

Of the 931 women eligible for analysis, 75% reported ever having been screened by FOBT and 48% reported having been screened within 2 years before the survey. Participation in screening did not vary by demographic characteristics or by perceived or actual risk of CRC. Women with a positive attitudes toward CRC screening had sevenfold greater odds of recent screening by FOBT (odds ratio=7.1; 95% confidence interval, 4.4 to 11.6). Only 58% of study women reported that their physicians encouraged CRC screening, but this factor was strongly related to participation (odds ratio=12.7; 95% confidence interval, 6.6 to 24.4).

CONCLUSIONS

We identified several areas in which understanding of CRC risk may be low. As a whole, these findings suggest that effective strategies to control CRC may include efforts to improve knowledge of risk and prevention, but must also appeal directly to primary care physicians to identify and address their barriers to screening recommendations.

Predictors of stage of adoption for colorectal cancer screening

BACKGROUND

Although colorectal cancer is the third most common cancer in women, little is known about predictors of adherence to screening.

METHODS

A randomly selected sample of 202 predominantly low-income and African-American women were interviewed. Knowledge of, attitudes and beliefs about, and practices related to flexible sigmoidoscopy (FS) screening were assessed.

RESULTS

The majority of participants were in the precontemplation stage of adoption (56%). There were significant differences by stage of adoption for FS beliefs, FS barriers, risk of developing colorectal cancer, worry about getting colorectal cancer, and physician recommendation to get a FS. Predictors of adherence to FS guidelines were perceiving fewer barriers to getting a FS and having a physician recommend a FS.

CONCLUSION

Seventy-two percent of the women in this study were nonadherent to FS screening guidelines. Psychosocial factors play an important role in screening for colorectal cancer. Ways of reducing barriers and increasing physician recommendations should be explored.

Cancer screening decisions

This review focuses on why people decide to obtain or to avoid screening for cancer. We discuss three topics: (a) physician prompts that may elicit compliant screening behavior, (b) the independent and joint effects of risk perceptions and worry, and (c) the costs and benefits of getting screened. Overall, the data suggest that each of these factors will influence screening. So, for example, people are more likely to seek screening if a physician recommends the behavior, if they feel personally vulnerable and worry a little about cancer, if insurance covers the screening, and if they believe that the test is an effective early detection procedure. Future research needs include studies comparing theories, longitudinal rather than cross-sectional studies, and true experiments. We also need to know more about why physicians are such powerful change agents and the trade-offs of increasing personal risk versus exacerbating worry. Practical recommendations for promoting cancer screening include encouraging physician interventions, explaining risk, and lowering the costs while emphasizing the benefits of screening.

Risk perception and risk communication for cancer screening behaviors: a review

This review summarizes and synthesizes research findings on risk perception and risk communication related to cancer screening behaviors. The focus is on cancers for which there is evidence that screening reduces mortality, i.e., cervical, breast, and colorectal cancers. The following questions are addressed: 1) Is perceived risk associated with relevant cancer screening behaviors? 2) What factors are associated with perceived risk? 3) Is the relationship between perceived risk and cancer screening behaviors modified by other factors? 4) Have interventions to change perceived risk been effective in modifying risk perceptions? 5) Are these changes related to subsequent cancer screening behaviors? Methodologic issues are discussed, and future research needs are identified. There was consistent evidence that perceived risk was associated with mammography screening, but there were insufficient data on these associations for cervical or colorectal cancer screening behaviors. There was some evidence that perceived risk mediated the association between other variables and screening behaviors; however, because of the small number of studies, the findings are best viewed as hypothesis generating. Studies of interventions to modify risk perceptions provided some support for the view that they are modifiable, but there was conflicting evidence that these changes were related to subsequent cancer screening. Methodologic studies of how best to measure perceived risk are needed. Because most data on the correlates of perceived risk were cross-sectional, it is difficult to determine whether perceived risk is a cause or an effect in relation to cancer screening. Longitudinal studies that measure perceived risk in defined populations with different cancer screening histories and that include follow-up for screening and repeated measurements of risk perception are needed to clarify this relationship.

Predictors of participation in primary care group-format back pain self-care interventions

OBJECTIVE

The goal of this study was to explain how primary care back pain patients who volunteer for a group-format self-care intervention differ from nonvolunteers. This is relevant to the generalizability of studies that rely on volunteers as well as the characteristics of patients who do not seek out self-care interventions.

SETTING

This study was conducted at a large health maintenance organization in western Washington state.

PATIENTS

"Volunteers" (n = 481) were primary care back pain patients participating in randomized trials of a self-management intervention who were recruited through passive nonintensive means (a mailed invitation). "Nonvolunteers" (n = 967) consisted of a representative sample of consecutive back pain patients. We compared the baseline characteristics of these two groups.

RESULTS

The relatively small percentage (8%) of primary care back pain patients who volunteered for, and ultimately participated in, group self-management classes tended to be white, older, better educated, and more likely to be retired than nonvolunteers. The two groups did not differ significantly on most clinical measures, including pain intensity and persistence. Patients experiencing the highest (and lowest) levels of pain-related activity interference were less likely to volunteer than those with moderate activity limitations, however.

CONCLUSIONS

Those individuals volunteering to participate in a group-format self-care intervention in a primary care setting differed from nonvolunteers primarily on demographic measures as opposed to clinical measures. Back pain patients experiencing the highest levels of activity limitations were somewhat less likely to participate than those with moderate activity limitations. Recruitment for effective self-care interventions is an important issue in determining their impact on a population basis.

Does provider prevention orientation influence female patients' preventive practices?

BACKGROUND

Health care provider encouragement for particular preventive behaviors is associated with patient adherence, but it is unclear whether a provider's overall prevention approach influences whether patients engage in recommended preventive measures. We examined whether older women who perceived that their health care provider encouraged a particular preventive behavior were more likely to follow that recommendation if they also perceived that the provider encouraged other preventive behaviors.

DATA AND METHODS

The sample included 1119 women aged 50 to 79 enrolled in a health maintenance organization. We examined associations of reported provider encouragement for post-menopausal hormone use, physical activity, fecal occult blood testing (FOBT), and flexible sigmoidoscopy with one another and with adherence to these measures according to recommended guidelines.

RESULTS

Among women reporting provider encouragement for physical activity, the likelihood of reporting regular physical activity was greater among women who reported encouragement for one other (odds ratio [OR]=1.99; confidence interval [CI]=1.35 to 2.95) and at least two other (OR=2. 38; 95% CI=1.62 to 3.48) preventive measures compared with women who reported no other encouragement. The likelihood of reporting adequate counseling for post-menopausal hormone use was greater among women reporting encouragement for at least two other preventive measures compared with those reporting no other encouragement. The likelihood of having had an FOBT or sigmoidoscopic examination was related to encouragement for those procedures, but not with greater encouragement for other preventive measures.

CONCLUSIONS

Patient perceptions of a provider's overall preventive practice approach may influence whether patients engage in recommended preventive practices, particularly for lifestyle factors.

The annual report to the nation on the status of cancer, 1973-1997, with a special section on colorectal cancer

BACKGROUND

This annual report to the nation addresses progress in cancer prevention and control in the U.S. with a special section on colorectal cancer. This report is the joint effort of the American Cancer Society, the National Cancer Institute (NCI), the North American Association of Central Cancer Registries (NAACCR), and the Centers for Disease Control and Prevention (CDC), including the National Center for Health Statistics (NCHS).

METHODS

Age-adjusted rates were based on cancer incidence data from the NCI and NAACCR and underlying cause of death as compiled by NCHS. Joinpoint analysis was based on NCI Surveillance, Epidemiology, and End Results (SEER) program incidence rates and NCHS death rates for 1973-1997. The prevalence of screening examinations for colorectal cancer was obtained from the CDC's Behavioral Risk Factor Surveillance System and the NCHS's National Health Interview Survey.

RESULTS

Between 1990-1997, overall cancer incidence and death rates declined. Joinpoint analyses of cancer incidence and death rates confirmed the declines described in earlier reports. The incidence trends for colorectal cancer have shown recent steep declines for whites in contrast to a leveling off of the rates for blacks. State-to-state variations occurred in colorectal cancer screening prevalence as well as incidence and death rates.

CONCLUSIONS

The continuing declines in overall cancer incidence and death rates are encouraging. However, a few of the top ten incidence or mortality cancer sites continued to increase or remained level. For many cancer sites, whites had lower incidence and mortality rates than blacks but higher rates than Hispanics, Asian and Pacific Islanders, and American Indians/Alaska Natives. The variations in colorectal cancer incidence and death rates by race/ethnicity, gender, age, and geographic area may be related to differences in risk factors, demographic characteristics, screening, and medical practice. New efforts currently are underway to increase awareness of screening benefits and treatment for colorectal cancer.

Colorectal cancer screening in older men and women: qualitative research findings and implications for intervention

As part of the formative research for developing interventions to increase colorectal cancer screening in men and women aged 50 and older, 14 focus groups were conducted to identify (1) knowledge, attitudes, and beliefs about colorectal cancer and colorectal cancer screening, (2) barriers to screening, and (3) strategies for motivating and supporting behavior change. Participants had either private insurance or Medicare and reported different levels of experience with colorectal cancer screening. Overall, they were poorly informed about colorectal cancer and the possible benefits of screening, reporting little or no information from physicians or mass media, negative attitudes toward screening procedures, and fear of cancer. Despite references to the subject matter as embarrassing or private, both men and women, African Americans and whites, appeared to talk candidly and comfortably in the permissive context of the focus group. This study's findings suggest that public education campaigns, decision aids, and targeted interventions are urgently needed to put colorectal cancer screening on the public's "radar screen," to increase awareness of the prevention and early detection benefits of screening, and to encourage people 50 and older-and the health care providers who serve them-to make screening a high priority.

The annual report to the nation on the status of cancer, 1973-1997, with a special section on colorectal cancer

BACKGROUND

This annual report to the nation addresses progress in cancer prevention and control in the U.S. with a special section on colorectal cancer. This report is the joint effort of the American Cancer Society, the National Cancer Institute (NCI), the North American Association of Central Cancer Registries (NAACCR), and the Centers for Disease Control and Prevention (CDC), including the National Center for Health Statistics (NCHS).

METHODS

Age-adjusted rates were based on cancer incidence data from the NCI and NAACCR and underlying cause of death as compiled by NCHS. Joinpoint analysis was based on NCI Surveillance, Epidemiology, and End Results (SEER) program incidence rates and NCHS death rates for 1973-1997. The prevalence of screening examinations for colorectal cancer was obtained from the CDC's Behavioral Risk Factor Surveillance System and the NCHS's National Health Interview Survey.

RESULTS

Between 1990-1997, overall cancer incidence and death rates declined. Joinpoint analyses of cancer incidence and death rates confirmed the declines described in earlier reports. The incidence trends for colorectal cancer have shown recent steep declines for whites in contrast to a leveling off of the rates for blacks. State-to-state variations occurred in colorectal cancer screening prevalence as well as incidence and death rates.

CONCLUSIONS

The continuing declines in overall cancer incidence and death rates are encouraging. However, a few of the top ten incidence or mortality cancer sites continued to increase or remained level. For many cancer sites, whites had lower incidence and mortality rates than blacks but higher rates than Hispanics, Asian and Pacific Islanders, and American Indians/Alaska Natives. The variations in colorectal cancer incidence and death rates by race/ethnicity, gender, age, and geographic area may be related to differences in risk factors, demographic characteristics, screening, and medical practice. New efforts currently are underway to increase awareness of screening benefits and treatment for colorectal cancer.

Engaging women's interest in colorectal cancer screening: a public health strategy

Screening rates for colorectal cancer are unacceptably low. New guidelines, public education campaigns, and expanded coverage of screening costs by healthcare insurance are expected to increase screening rates, but interventions targeting women may accelerate this change. Most American women already participate in regular cancer screening, in the form of Papanicolaou (Pap) tests and mammography, so they may be receptive to tailored messages about the need to add regular colorectal cancer screening to their preventive health regimen. In addition, their role in promoting the health of family members may position women to influence screening behavior in family and friends. Women may be particularly valuable change agents in populations where screening rates are traditionally low, such as medically underserved populations, the elderly or low socioeconomic status groups with competing health priorities, and populations with cultural values or practices inconsistent with the adoption of a new screening behavior. To serve as agents of change in their family and social networks, women must understand that colorectal cancer is not solely a man's disease and that the benefits of colorectal screening are similar to those of Pap testing and mammography. Colorectal cancer screening should also be promoted within a framework of a lifelong strategy for health maintenance for both men and women. The message to women should emphasize the value of colorectal cancer screening rather than the disagreement among experts over preferred screening strategies and should emphasize the value of shared decision making between the patient and her healthcare provider.

Interest in genetic testing among first-degree relatives of colorectal cancer patients

PURPOSE

The present study examined colorectal cancer screening behaviors, risk perceptions, and willingness to receive genetic testing to determine colorectal cancer susceptibility.

METHODS

We recruited 95 first-degree relatives of colorectal cancer patients, then conducted a brief telephone interview using a structured questionnaire that elicited information on sociodemographics, cancer screening behaviors, risk perceptions, and interest in genetic testing.

RESULTS

Among these high-risk individuals who were aged 40 years or older, only 31% reported fecal occult blood testing within the past year and 59% reported undergoing sigmoidoscopy or colonoscopy within the past 5 years. The majority of participants believed their relative risk of colorectal cancer was increased (68%). Eighty-four percent of the participants indicated that they would have a genetic test if one were available. Participants who believed that <50% of colorectal cancers were caused by heredity were more likely to be interested in genetic testing than were participants who believed that 50% or more of colorectal cancers were caused by heredity. Referral source, sociodemographic factors, clinical factors, and perceived personal risk were not significantly associated with interest in genetic testing.

CONCLUSION

Our results suggest that the demand for colorectal cancer susceptibility testing may be high among individuals with a family history of colorectal cancer. We also observed that a substantial number of first-degree relatives were not adhering to colorectal cancer screening guidelines. Accurate information on the genetic aspects of colorectal cancer and the benefits and limitations of genetic testing may help relatives of colorectal cancer patients make informed decisions about whether to undergo enhanced screening and genetic testing.

Socioeconomic factors and breast carcinoma in multicultural women

Breast carcinoma is the most common cancer in women in the U.S. and the second leading cause of cancer death in women. Furthermore, there are racial differences in breast carcinoma incidence, mortality, and survival rates. Social and economic factors within racial/ethnic groups are being examined as risk factors not only for breast carcinoma mortality and survival but also as determinants of the rate of incidence. Social and economic factors have been associated in the literature predominantly with cancer mortality and survival. When socioeconomic status (SES) is considered, certain studies suggest that racial disparities in breast carcinoma are smaller than when social and economic factors are examined alone, but these disparities still persist. Sources of data for this discussion include the National Cancer Institute (NCI) (the Surveillance, Epidemiology, and End Results [SEER] program, a group of population-based cancer registries that cover up to 14% of the U.S. population. SEER reports cancer incidence, mortality, and survival rates), the U.S. Bureau of the Census, the National Center for Health Statistics (NCHS), and numerous articles from the scientific literature. Socioeconomic factors or SES can be considered "cross-cutting risk factors" (i.e., they can be related to the risk of developing breast carcinoma [rate of incidence] as well as to the risk of dying [mortality] from this disease). They also are the risk factors that "cut across" racial and ethnic populations. Socioeconomic factors are related to breast carcinoma mortality and survival rates in multicultural women. Racial disparities in breast carcinoma mortality and survival rates can be explained partially by stage distribution at the time of diagnosis, which may be related to SES. For example, African-American women present with more advanced stage distributions for breast carcinoma than white women. Similarly, women of lower SES present with higher stage disease than women of upper SES who present with more localized breast carcinoma. The lack of data regarding the SES of cancer patients limits our understanding of the contributions of SES to cancer incidence and mortality rates. SES appears to be related to breast carcinoma incidence, mortality, and survival rates. Breast carcinoma mortality is higher in women of lower SES. Additional research on SES, race, culture, and the relation of these factors to cancer incidence rate is needed.

How should patients 80 years of age or older with colorectal carcinoma be treated? Long-term and short-term outcome and postoperative cytokine levels

PURPOSE

The aim of this study was to determine how extensive resection affects operative morbidity, mortality, and long-term survival in elderly patients with colorectal cancer.

METHODS

A total of 119 patients 80 years of age or older were given a diagnosis of colorectal carcinoma at our hospital between 1985 and 1997. Eleven patients who did not undergo surgery were excluded. The remaining 108 patients underwent laparotomy and were reviewed. Serum levels of interleukin-6 were measured perioperatively in 22 patients to assess the degree of operative stress.

RESULTS

Potentially curative resection was performed in 64 (88.9 percent) of the 72 patients in the active performance status group and 13 (36.1 percent) of the 36 patients in the sedentary performance status group (P < 0.001). The in-hospital mortality rate was 8.3 percent in group the active performance status group and 38 percent in the sedentary performance status group (P = 0.007). Patients in the sedentary performance status group and those who underwent emergency operations had higher levels of IL-6 than patients in the active performance status group or those who underwent elective operations.

CONCLUSIONS

Preoperative performance status, operative curability, and tumor stage have a significant impact on outcome in patients with colorectal cancer who are 80 years of age or older. Knowledge of early postoperative response of IL-6 is useful in predicting postoperative mortality and morbidity in this subgroup of patients.

Cancer screening in the elderly population

This article reviews the current state of knowledge regarding cancer screening in the geriatric population. Care of the elderly requires knowledge of underlying physiologic changes, comorbidities, quality-of-life factors, and life expectancies. There is always the danger that ageism may prevent elderly cancer patients from receiving the proper treatment. On the other hand, overzealous treatment can lead to adverse results if elderly patients are not properly targeted based on current evidence of the benefits and risks of specific screening practices.

Colorectal cancer screening

Colorectal cancer is an important problem in the United States, with over 130,000 new cases and 55,000 deaths each year. There is now strong evidence that screening for colorectal cancer with fecal occult blood testing can decrease mortality, and additional evidence that removing benign adenomas can decrease cancer incidence. Evidence-based screening guidelines depend on colorectal cancer risk. Individuals at higher risk because of a personal or family history deserve more intensive screening than asymptomatic individuals over age 50.