Has the use of cervical, breast, and colorectal cancer screening increased in the United States?

Clinical efficacy of human papillomavirus DNA detection in urine from patients with various cervical lesions

A considerable number of adult Korean women avoid a Pap smear due to fear and discomfort of the pelvic examination. A reliable but noninvasive and comfortable screening method would considerably increase the participation rate. To evaluate the clinical efficacy of urine-based human papillomavirus (HPV) detection by oligonucleotide microarray, the results of HPV test from matched cervical swab specimens were compared. HPV DNA was detected in 70 of 100 cervical samples. HPV 16 was the most prevalent type (38/70), followed by types 18, 58, 52, 33, 35, 31, and 51. HPV DNA was identified in 47 of 90 urine samples. HPV 16 was the most prevalent type (30/45), followed by types 18, 52, 35, 51, 58, 33, and 56. The HPV detection rates of the cervical swabs increased in accordance with the severity of the cytologic and histologic diagnosis. The type specific agreement of HPV DNA tests between cervical swabs and urine was good in HPV 16 (kappa index=0.64 [95% CI: 0.50-0.79]), 18, 52, and 58 and fair in HPV 33 and 35. We propose that a urine HPV test is a valuable adjunctive method for a conventional Pap smear and can be used in population screening for cervical cancer in countries where it is difficult to obtain colposcopic specimens for cultural or religious reasons.

Physician practice patterns and variation in the delivery of preventive services

BACKGROUND

Strategies to improve preventive services delivery (PSD) have yielded modest effects. A multidimensional approach that examines distinctive configurations of physician attributes, practice processes, and contextual factors may be informative in understanding delivery of this important form of care.

OBJECTIVE

We identified naturally occurring configurations of physician practice characteristics (PPCs) and assessed their association with PSD, including variation within configurations.

DESIGN

Cross-sectional study.

PARTICIPANTS

One hundred thirty-eight family physicians in 84 community practices and 4,046 outpatient visits.

MEASUREMENTS

Physician knowledge, attitudes, use of tools and staff, and practice patterns were assessed by ethnographic and survey methods. PSD was assessed using direct observation of the visit and medical record review. Cluster analysis identified unique configurations of PPCs. A priori hypotheses of the configurations likely to perform the best on PSD were tested using a multilevel random effects model.

RESULTS

Six distinct PPC configurations were identified. Although PSD significantly differed across configurations, mean differences between configurations with the lowest and highest PSD were small (i.e., 3.4, 7.7, and 10.8 points for health behavior counseling, screening, and immunizations, respectively, on a 100-point scale). Hypotheses were not confirmed. Considerable variation of PSD rates within configurations was observed.

CONCLUSIONS

Similar rates of PSD can be attained through diverse physician practice configurations. Significant within-configuration variation may reflect dynamic interactions between PPCs as well as between these characteristics and the contexts in which physicians function. Striving for a single ideal configuration may be less valuable for improving PSD than understanding and leveraging existing characteristics within primary care practices.

An update on imaging of colorectal cancer

Screening of asymptomatic average-risk patients for presence of colon cancer and early detection in precursor stages is of great interest to general population. Comprehensive evaluation of symptomatic or high-risk patients represents another important clinical focus. Available techniques for total colon imaging, rectal cancer staging and the role of positron emission tomography are discussed.

Effect of area poverty rate on cancer screening across US communities

STUDY OBJECTIVE

To analyse the contextual effect of area poverty rate on never having been screened for breast, cervical, and colorectal cancer by (1) describing the extent of the variation in screening behaviours among 98 US metropolitan areas; (2) determining if the variation in lack of screening can be explained by differences in the characteristics of the persons who resided in these areas; and (3) determining if living in a metropolitan area with a higher poverty rate increased the likelihood of never having been screened for cancer over and above individual characteristics.

DESIGN

Cross sectional survey using data from the 2002 Behavioral Risk Factor Surveillance System. Multilevel logistic regression included both individual level factors as well as area poverty rate.

SETTING

Ninety eight areas across the USA.

PARTICIPANTS

Over 118 000 persons residing in 98 areas; a sample aimed at estimating 48.3% of the US population age 18 or older.

MAIN RESULTS

After adjustment for individual level factors, increasing area level poverty rate (per 5%) remained associated with never having had a mammogram (odds ratio (OR) = 1.28, 95% confidence interval (CI): 1.03 to 1.37); clinical breast examination (OR = 1.28, 95% CI: 1.11 to 1.48), colonoscopy/sigmoidoscopy (OR = 1.10, 95% CI: 1.01 to 1.19), and a faecal occult blood test (OR = 1.19, 95% CI: 1.12 to 1.27). Poverty rate was not independently associated with never having had a Pap smear (OR = 1.12; 95% CI: 0.90 to 1.41). The size of the variance among metropolitan or micropolitan statistical areas (MMSAs) varied by type of screening test, with intraclass correlation coefficients ranging from 4.9% (never having had a Pap smear) to 1.2% (never having had a colonoscopy/sigmoidoscopy).

CONCLUSIONS

Area poverty rate was independently associated with never having been screened for breast and colorectal cancer, but not cervical cancer. The size of the variance among MMSAs was modest at best.

Hypnosis to manage anxiety and pain associated with colonoscopy for colorectal cancer screening: Case studies and possible benefits

This study explored using hypnosis for pain and anxiety management in 6 colonoscopy patients (5 men, 1 woman), who received a hypnotic induction and instruction in self-hypnosis on the day of their colonoscopy. Patients' levels of anxiety were obtained before and after the hypnotic induction using Visual Analogue Scales (VAS). Following colonoscopy, VASs were used to assess anxiety and pain during colonoscopy, perceived effectiveness of hypnosis, and patient satisfaction with medical care. Hypnotizability was assessed at a separate appointment. The authors also obtained data (time for procedure, number of vasovagal events, and recovery time) for 10 consecutive patients who received standard care. Results suggest that hypnosis appears to be a feasible method to manage anxiety and pain associated with colonoscopy, reduces the need for sedation, and may have other benefits such as reduced vasovagal events and recovery time.

Improving preventive service delivery at adult complete health check-ups: the Preventive health Evidence-based Recommendation Form (PERFORM) cluster randomized controlled trial

BACKGROUND

To determine the effectiveness of a single checklist reminder form to improve the delivery of preventive health services at adult health check-ups in a family practice setting.

METHODS

A prospective cluster randomized controlled trial was conducted at four urban family practice clinics among 38 primary care physicians affiliated with the University of Toronto. Preventive Care Checklist Forms were created to be used by family physicians at adult health check-ups over a five-month period. The sex-specific forms incorporate evidence-based recommendations on preventive health services and documentation space for routine procedures such as physical examination. The forms were used in two intervention clinics and two control clinics. Rates and relative risks (RR) of the performance of 13 preventive health maneuvers at baseline and post-intervention and the percentage of up-to-date preventive health services delivered per patient were compared between the two groups.

RESULTS

Randomly-selected charts were reviewed at baseline (n = 509) and post-intervention (n = 608). Baseline rates for provision of preventive health services ranged from 3% (fecal occult blood testing) to 93% (blood pressure measurement), similar to other settings. The percentage of up-to-date preventive health services delivered per patient at the end of the intervention was 48.9% in the control group and 71.7% in the intervention group. This is an overall 22.8% absolute increase (p = 0.0001), and 46.6% relative increase in the delivery of preventive health services per patient in the intervention group compared to controls. Eight of thirteen preventive health services showed a statistically significant change (p < 0.05) in favor of the intervention (adjusted RR (95% C.I.)): counseling on brushing/flossing teeth (9.2 (4.3-19.6)), folic acid counseling (7.5 (2.7-20.8)), fecal occult blood testing (6.7 (1.9-24.1)), smoking cessation counseling (3.9 (2.2-7.2)), tetanus immunization (3.0 (1.7-5.2)), history of alcohol intake (1.33 (1.2-1.5)), history of smoking habits (1.28 (1.2-1.4)) and blood pressure measurement (1.05 (1.00-1.10)).

CONCLUSION

This simple, low cost, clinically relevant intervention improves the delivery of preventive health services by prompting physicians of evidence-based recommendations in a checklist format that incorporates existing practice patterns. Periodic updates of the Preventive Care Checklist Forms will allow a feasible and easy-to-use tool for primary care physicians to provide evidence-based preventive health services to adults at routine health check-ups. The forms can also be incorporated into an electronic health record. The Preventive Care Checklist Forms are accessible in English and French at the College of Family Physicians of Canada web site.

Determinants of colorectal cancer screening behavior among Chinese Americans

Colorectal cancer (CRC) is the most commonly diagnosed cancer among Chinese Americans and is the third leading cause of cancer death in this population. The objectives of this study were to determine the rates of CRC screening (via fecal occult blood test (FOBT), flexible sigmoidoscopy (FSIG), and colonoscopy) among Chinese Americans and predictors of utilizing these screening procedures. Participants (N = 206) completed a self-administered questionnaire assessing cancer screening behaviors and beliefs about perceived risk of developing cancer and treatment efficacy. A series of logistic regressions indicated that physician recommendation to obtain CRC screening significantly predicted whether Chinese Americans undergo FOBT, FSIG, or colonoscopy screening (p < 0.001). Acculturation and perceived risk of developing CRC did not predict obtaining any of the screening procedures. FOBT was the most commonly reported screening method used by respondents (65%), followed by FSIG (54%) and colonoscopy (49%). These findings highlight the need to make physicians more aware of the impact their recommendations have in determining CRC screening behavior among Chinese Americans.

Accessibility of web sites containing colorectal cancer information to adults with limited literacy (United States)

OBJECTIVE

The Internet could be a key channel for disseminating information about colorectal cancer (CRC) screening. Little research, however, has systematically examined factors other than writing style related to the reading difficulty of cancer information on the Internet. In the present study we assessed the reading difficulty of 19 CRC Web sites.

METHODS

We assessed pages within selected sites containing information on CRC screening or prevention using the SMOG readability formula and Suitability Assessment of Materials instrument.

RESULTS

The average SMOG reading grade level was 12.8. The SAM results indicated common problems with the sites, including (1) lack of review of key ideas; (2) insufficient use of illustrations for key messages; (3) crowded layout and long line lengths; (4) small type size and lack of cues to highlight key content; and (5) lack of interactive features.

CONCLUSIONS

Many Web sites providing CRC information may be too difficult for the average American adult and much too difficult for adults with limited literacy. The unique features of the Internet that could support learning are not being utilized. The Internet could be a powerful tool for educating individuals about CRC, but the barrier of difficult content must be addressed along with access barriers.

Results of a randomized controlled trial to increase colorectal cancer screening in a managed care health plan

BACKGROUND

Colorectal cancer (CRC) is the third most common cause of cancer deaths; however, rates of regular screening for this cancer are low. A quality improvement (QI) program to increase CRC screening was developed for use in a managed care health plan.

METHODS

Thirty-six provider organizations (POs) contracting with the health plan were recruited for a randomized controlled effectiveness trial testing the QI program. The intervention was delivered over a 2-year period, and its effectiveness was assessed by chart review of a random sample of patients from each PO.

RESULTS

Thirty-two of the 36 POs were evaluable for outcome assessment. During the 2-year intervention period, only 26% of the eligible patients received any CRC screening test. Twenty-nine percent of patients had any CRC screening test within guidelines, with no differences between the intervention or control POs. Significant predictors of having received CRC screening within guidelines were older age (P = 0.0004), receiving care in an integrated medical group (P < 0.0001) and having had a physical examination within the past 2 years (P < 0.0001).

CONCLUSIONS

A facilitated QI intervention program for CRC screening that focused on the PO did not increase rates of CRC screening. Overall CRC screening rates are low and are in need of improvement.

Physician and patient influences on the rate of colorectal cancer screening in a primary care clinic

BACKGROUND

Colorectal cancer (CRC) screening rates remain low, despite widespread recommendations. The study purpose was to ascertain whether lack of CRC screening is attributable to physicians' failure to address CRC screening or to patients' failure to comply with physician recommendation. This relationship was also examined over time.

METHODS

Retrospective chart review of 400 preventive health visits.

RESULTS

Physicians appropriately addressed screening 16.5% of the time during 1998-1999 and 51% of the time during 2002-2003 (P <or= .001). The rate of test completion by patients was 53% in 1998-1999 and 31% in 2002-2003, resulting in completed CRC screening rates of 5% and 16.5%, respectively (P <or= .001).

CONCLUSIONS

Further education is needed, especially to target patient barriers to CRC screening test completion.

Latin American Cancer Research Coalition

The Latin American Cancer Research Coalition (LACRC) was funded by NCI as a Special Populations Network to 1) provide training to clinic staff in cancer control and foster development of Latino faculty training, 2) conduct a needs assessment with the community clinics, 3) enhance the ability of the clinics to promote healthy lifestyles, 4) collaborate on research projects to improve use of early detection, and 5) explore partnerships to increase access to culturally competent cancer care. The LACRC developed a model for cancer control focused on community-based clinics as the focal point for in-reach and community outreach targeted to Latinos to reduce cancer disparities. This framework was designed to link the community to local hospitals and academic centers, build capacity, and promote diffusion of innovations directly into delivery systems. Eight research projects submitted by junior investigator/clinic teams have been funded by NCI. These research projects range from recruiting for clinical trials to prevention to survivorship. The LACRC has trained 6 cancer control coordinators from partner sites and educated 59 undergraduate minority student interns in aspects of cancer control research. Central to LACRC's success to date has been the creation and maintenance of an infrastructure of trusting relationships, especially those developed between clinician/investigators and individuals within the greater Latino community. Community clinics can be effective agents for cancer control among Latinos. Latinos are likely to participate in research conducted by culturally representative teams of researchers using culturally appropriate recruiting strategies. Cancer 2006. (c) 2006 American Cancer Society.

Cancer Surveillance Research: a Vital Subdiscipline of Cancer Epidemiology

Public health surveillance systems relevant to cancer, centered around population-based cancer registration, have produced extensive, high-quality data for evaluating the cancer burden. However, these resources are underutilized by the epidemiology community due, we postulate, to under-appreciation of their scope and of the methods and software for using them. To remedy these misperceptions, this paper defines cancer surveillance research, reviews selected prior contributions, describes current resources, and presents challenges to and recommendations for advancing the field. Cancer surveillance research, in which systematically collected patient and population data are analyzed to examine and test hypotheses about cancer predictors, incidence, and outcomes in geographically defined populations over time, has produced not only cancer statistics and etiologic hypotheses but also information for public health education and for cancer prevention and control. Data on cancer patients are now available for all US states and, within SEER, since 1973, and have been enhanced by linkage to other population-based resources. Appropriate statistical methods and sophisticated interactive analytic software are readily available. Yet, publication of papers, funding opportunities, and professional training for cancer surveillance research remain inadequate. Improvement is necessary in these realms to permit cancer surveillance research to realize its potential in resolving the growing cancer burden.

Recruiting patients to medical research: double blind randomised trial of "opt-in" versus "opt-out" strategies

OBJECTIVE

To evaluate the effect of opt-in compared with opt-out recruitment strategies on response rate and selection bias.

DESIGN

Double blind randomised controlled trial.

SETTING

Two general practices in England.

PARTICIPANTS

510 patients with angina.

INTERVENTION

Patients were randomly allocated to an opt-in (asked to actively signal willingness to participate in research) or opt-out (contacted repeatedly unless they signalled unwillingness to participate) approach for recruitment to an observational prognostic study of patients with angina.

MAIN OUTCOME MEASURES

Recruitment rate and clinical characteristics of patients.

RESULTS

The recruitment rate, defined by clinic attendance, was 38% (96/252) in the opt-in arm and 50% (128/258) in the opt-out arm (P = 0.014). Once an appointment had been made, non-attendance at the clinic was similar (20% opt-in arm v 17% opt-out arm; P = 0.86). Patients in the opt-in arm had fewer risk factors (44% v 60%; P = 0.053), less treatment for angina (69% v 82%; P = 0.010), and less functional impairment (9% v 20%; P = 0.023) than patients in the opt-out arm.

CONCLUSIONS

The opt-in approach to participant recruitment, increasingly required by ethics committees, resulted in lower response rates and a biased sample. We propose that the opt-out approach should be the default recruitment strategy for studies with low risk to participants.

Correlates of colorectal cancer screening compliance among urban Hispanics

Colorectal cancer (CRC) is the second most common cancer among Latinos; screening can reduce mortality from CRC. The aims of this study are; to assess the current compliance with free colorectal cancer screening among Hispanic women who are participating in a national breast and cervical cancer screening program (NBCCEDP), and to examine the effects of a set of key constructs from the HBM and the TPB on compliance with the Fecal Occult Blood Test (FOBT). We consecutively recruited 950 women from among those attending an initial appointment at an NBCCEDP site in northern Manhattan, and administered a questionnaire. Patients were offered a free Hemoccult kit, alongside instructions and print materials. The rate of FOBT compliance (in kit return) was 77.3%. Fatalism remained a statistically significant influence on FOBT compliance in the multivariate models, and there was a trend for higher FOBT return among West Indies women (primarily from the Dominican Republic). The findings of this study demonstrate the feasibility and acceptability of distributing FOBT kits through an existing national program for cancer screening of women. The results justify replication in a more heterogeneous group of Hispanics, with longer-term followup.

Use of cervical cancer screening among insured women: the extent of missed opportunities

The objective of the study is to identify opportunities to improve cervical cancer screening among privately insured women. From MedStat's Marketscan database, we identified 735,181 women aged 21-64 years who remained in the same insurance plan during the entire period of 2000-2002. We obtained the percentages of women who had a Papanicolaou (Pap)-test reimbursement claim and any health-related claim during the 3-year period. For women without a Pap-test claim, we obtained information about the frequency of insurance claims, type of health-care provider, and type of insurance plan in which the women were enrolled. The multivariate logistic regression model was used to identify factors independently associated with not having a Pap test. Of the total sample, in the 3-year period, 96% had at least one health insurance reimbursement claim and 69% had at least one claim for a Pap test. Approximately, 87% of the women who had no Pap-test claim had a health claim; 44% of such claims were from primary care providers. In the multiple logistic regression model, factors that were independently associated with having no Pap test were old age, being dependents of employees, and enrollment in comprehensive insurance plans. Efforts to increase the use of cervical cancer screening service should consider additional risk factors besides lack of insurance coverage. Concerted efforts by insurance and health-care providers are needed to improve adherence to the recommended cervical cancer screening guidelines, both by consumers and service providers.

Predictors of fecal occult blood test (FOBT) completion among low-income adults

BACKGROUND

Fecal occult blood testing (FOBT) can reduce colorectal cancer (CRC) mortality. Unfortunately, CRC screening is underutilized. Sociocultural mediators of FOBT adherence have not been extensively studied in lower income, minority populations. This study prospectively studied FOBT return in a low-income, multiethnic population.

METHODS

Participants (N = 298), aged > or =40 years, were surveyed and given FOBT kits with instructions. Those not returning kits within 30 days received a reminder telephone call. Bivariate and multivariate analyses assessed predictors of FOBT card return at 90 days.

RESULTS

Participants (median age = 48) were predominately African American (69%), without private insurance (88%), and of low income. The largest group of participants preferred FOBT alone (46%), followed by whatever my doctor recommends (19%), endoscopy + annual FOBT (16%), endoscopy alone (14%), and no screening (5%). In multivariate analyses, FOBT return was predicted by age (OR = 1.05) and lack of reported FOBT barriers (OR = 3.81). Among those > or =50 and not up-to-date with screening, FOBT return was predicted by cancer fatalism (OR = 0.83). FOBT barriers were associated with age (OR = 0.96), less than high school education (OR = 2.05), and less physician trust (OR = 2.12). Endoscopy barriers were associated with age (OR = 0.93), less physician trust (OR = 1.95), and female gender (OR = 3.45).

CONCLUSIONS

Younger individuals and those with less education, less trust in health care providers, and more fatalistic beliefs are at risk for CRC screening non-adherence. Strategies addressing common misconceptions should improve CRC screening rates in low-income, multiethnic populations.

Does health insurance coverage of office visits influence colorectal cancer testing?

OBJECTIVE

To assess the effect of differing health insurance coverage of physician office visits on the use of colorectal cancer (CRC) tests among an employed and insured population.

METHOD

Cohort study of persons ages 50 to 64 years enrolled in fee-for-service (FFS) or preferred provider organization (PPO) health plans, where FFS plan enrollees bear disproportionate share of office visit coverage, for the period 1995 through 1999.

RESULTS

Compared with FFS plans, enrollees in PPO plans were significantly more likely to obtain CRC tests [adjusted relative risk (RR(a)), 1.27; 95% confidence intervals (CI), 1.21-1.24]. The association was more pronounced among hourly individuals (RR(a), 1.43; 95% CI, 1.41-1.45) than among salaried individuals (RR(a), 1.09; 95% CI, 1.05-1.10), consistent with a greater differential in office visit coverage among the hourly group.

CONCLUSIONS

Disproportionate cost-sharing seems to have a negative effect on the use of CRC tests most likely by discouraging nonacute care physician office visits.

A pilot study of participation in faecal occult blood testing and screening colonoscopy after health education in Hong Kong

Colorectal cancer is the second commonest cancer in Hong Kong. The screening behaviour of the Chinese population has not been assessed. The aim of this study is to report a pilot study of educating and subsequent evaluation of colorectal cancer screening behaviour in the Hong Kong Chinese population. Subjects were invited to attend a free health talk on colorectal cancer. Both self-paid faecal occult blood testing (FOBT) and free screening colonoscopy were offered after the education programme. Of the participants taking part in the education programme 113/119 (95%) completed the FOBT. Of the FOBT 8/113 (7%) showed positive result and three patients had neoplasia at colonoscopy. Twenty-five patients with negative FOBT also completed colonoscopy; two had adenomas. Screening colonoscopy after FOBT was accepted by 28% of subjects. Those younger than 65 years and those with a positive FOBT (7/8 versus 25/105 for those with negative FOBT, P=0.0003) were more likely to agree to screening colonoscopy. In conclusion, health education is important for ensuring high acceptance and implementation of colorectal cancer screening in Hong Kong Chinese. FOBT is an acceptable and feasible screening method in Hong Kong.

Health care provider-directed intervention to increase colorectal cancer screening among veterans: results of a randomized controlled trial

PURPOSE

Colorectal cancer screening is the most underused cancer screening tool in the United States. The purpose of this study was to test whether a health care provider-directed intervention increased colorectal cancer screening rates.

PATIENTS AND METHODS

The study was a randomized controlled trial conducted at two clinic firms at a Veterans Affairs Medical Center. The records of 5,711 patients were reviewed; 1,978 patients were eligible. Eligible patients were men aged 50 years and older who had no personal or family history of colorectal cancer or polyps, had not received colorectal cancer screening, and had at least one visit to the clinic during the study period. Health care providers in the intervention firm attended a workshop on colorectal cancer screening. Every 4 to 6 months, they attended quality improvement workshops where they received group screening rates, individualized confidential feedback, and training on improving communication with patients with limited literacy skills. Medical records were reviewed for colorectal cancer screening recommendations and completion. Literacy level was assessed in a subset of patients.

RESULTS

Colorectal cancer screening was recommended for 76.0% of patients in the intervention firm and for 69.4% of controls (P = .02). Screening tests were completed by 41.3% of patients in the intervention group versus 32.4% of controls (P = .003). Among patients with health literacy skills less than ninth grade, screening was completed by 55.7% of patients in the intervention group versus 30% of controls (P < .01).

CONCLUSION

A provider-directed intervention with feedback on individual and firm-specific screening rates significantly increased both recommendations and colorectal cancer screening completion rates among veterans.

Office systems and their influence on mammography use in rural and urban primary care

CONTEXT

Breast cancer screening rates are lower in rural communities. Although studies have addressed barriers to mammography for rural residents, physician practice barriers have received less attention.

PURPOSE

Controlled clinical trials have shown that the use of office reminder systems in primary care practices is related to increased clinical care rates. Therefore, we compared office systems use in primary care practices located in rural and urban communities and assessed the impact of these systems on rural-urban differences in mammography utilization.

METHODS

We identified female Kansas Medicare beneficiaries aged 65 to 79 from Medicare claims data (N = 24,030) and determined which beneficiaries received a mammogram between April 1, 1999, and March 31, 2001. We linked beneficiaries to their primary care providers and obtained surveys from 180 primary care practices on their use of office reminder systems.

FINDINGS

Mammography rates ranged from 20% to 92% (mean = 65%) among the 180 practices. Flowsheets with a mammography prompt were used by 33% of the practices, 38% utilized nonphysician staff to identify women due for mammograms, and 15% used computerized reminder systems. Urban practices used flowsheets more often than rural practices (44% versus 16%, P < 0.001). A multivariable regression model demonstrated higher mammography rates in urban practices, group practices, and practices using mammography flowsheets.

CONCLUSIONS

Despite success in randomized controlled trials, reminder systems are not used often by primary care providers and are used even less often in rural compared to urban practices. Consistent implementation may be a major barrier to the successful adaptation of flowsheets by primary care offices.

Long-term results from a randomized controlled trial to increase cancer screening among attendees of community health centers

PURPOSE

We assessed whether increased cancer screening rates that were observed with Cancer Screening Office Systems (Cancer SOS) could be maintained at 24 months' follow-up, a period in which clinics were expected to be largely self-sufficient in maintaining the intervention.

METHODS

Eight primary care clinics serving disadvantaged populations in Hills-borough County, Fla, agreed to take part in a cluster-randomized experimental trial. Charts of independent samples of established patients aged 50 to 75 years were abstracted, with data collected at baseline (n = 1,196) and at 24 months' follow-up (n = 1,296). Papanicolaou (Pap) smears, mammography, and fecal occult blood testing were assessed.

RESULTS

At 24 months of follow-up, intervention patients had received a greater number of cancer screening tests (mean 1.17 tests vs 0.94 tests, t test = 4.42, P <.0001). In multivariate analysis that controlled for baseline screening rates, secular trends, and other patient and clinic characteristics, the intervention increased the odds of mammograms slightly (odds ratio [OR]) = 1.26; 95% confidence interval [CI], 1.02-1.55; P = .03) but had no effect on fecal occult blood tests (OR = 1.17; 95% CI, 0.92-1.48; P =0.19) or Pap smears (OR = 0.88; 95% CI, 0.0.68-1.15; P = .34).

CONCLUSIONS

The Cancer SOS intervention had persistent, although modest, effects on screening at 24 months' follow-up, an effect that had clearly diminished from results reported at 12 months' follow-up. Further study is needed to develop successful intervention strategies that are either self-sustaining or that are able to produce long-term changes in screening behavior.

Social and cultural barriers to Papanicolaou test screening in an urban population

OBJECTIVE

To define screening behaviors, attitudes, and beliefs regarding cancer and its treatment among women with cervical cancer.

METHODS

Between August 2000 and July 2002, 148 consecutive women with invasive cervical cancer were queried about barriers to screening. Women presented to outpatient clinics, emergency departments, or inpatient units of 3 urban hospitals. Two groups of women were identified: those who denied having had a Papanicolaou (Pap) test and those who had recalled having Pap test in the past. Responses were compared using t tests, chi(2) tests, and binary logistic regression.

RESULTS

The 146 (99%) respondents were predominantly African Americans (50%) or Hispanic (27%). Thirty-six (25%) women reported no prior screening. Women never screened were significantly more likely to be Hispanic (odds ratio [OR] 3.0, 95% confidence interval [CI] 1.4-6.7), recent immigrants (OR 5.7, 95% CI 2.0-16), less educated (OR 3.6, 95% CI 1.6-8.0), and uninsured (OR 3.9, 95% CI 1.6-9.7). They were more likely to lack family support (adjusted OR 3.5, 95% CI 1.1-11) and lack knowledge about their risk for cervical cancer (adjusted OR 2.6, 95% CI 1.1-6.4). Unscreened women displayed fatalistic attitudes, believing cancer is bad luck (adjusted OR 2.6, 95% CI 1.0-6.9) and not wanting to know they had cancer (adjusted OR 3.0, 95% CI 1.0-9.4)..

CONCLUSION

We have identified factors and beliefs that are barriers to Pap test screening in urban cervical cancer patients. Further studies should evaluate effects of addressing cultural, cognitive, and financial barriers on Pap test compliance.

Automating the recognition and prioritization of needed preventive services: early results from the CHICA system

An ever-growing plethora of preventive services guidelines threatens to overwhelm primary care providers who are expected to recognize and prioritize these needed services for each patient. The Child Health Improvement through Computer Automation (CHICA) system was designed to facilitate this process through a workflow-sensitive interface that gathers and distills the most relevant patient data within pediatric settings. We evaluated family responses to 21 CHICA questions that assess risk factors and health behaviors over a three month period. 3005 patients provided 15,434 responses to these questions, and 1756 or 11.3% of these suggest risk factors which merit attention. This preliminary analysis suggests that, using CHICA, families identify significant risk factors that our clinicians acknowledge are often overlooked given the realities of practicing within this setting.

Racial differences in knowledge, attitudes, and cancer screening practices among a triracial rural population

BACKGROUND

Low-income, minority, and rural women face a greater burden with regard to cancer-related morbidity and mortality and are usually underrepresented in cancer control research. The Robeson County Outreach, Screening and Education Project sought to increase mammography use among low-income, minority, and rural women age > 40 years. The current article reports on racial disparities and barriers to screening, especially those related to knowledge, attitudes, and behaviors.

METHODS

A baseline survey was administered to 897 women age > 40 years who lived in rural Robeson County in North Carolina. The sample consisted of three principal racial groups: whites, African Americans, and Native Americans. Survey comparisons were made among racial groups with respect to knowledge, attitudes, and behaviors regarding breast and cervical carcinoma screening.

RESULTS

Overall, Native American and African-American women had lower levels of knowledge, more inaccurate beliefs, and more barriers to screening compared with white women. Among the notable findings were that 43% of the patient population did not mention mammograms and 53% did not mention Pap smears as breast and cervical carcinoma screening tests, respectively; furthermore, compared with white women, significantly fewer African-American and Native American women mentioned these tests (P < 0.001). Sixty-seven percent of all women reported that a physician had never encouraged them to receive a mammogram, although 75% reported having received a regular checkup in the preceding year.

CONCLUSIONS

Although all low-income rural women experienced significant barriers to receiving cancer screening tests, these barriers were more common for minority women compared with white women. More research is needed to identify ways to overcome such barriers, especially among Native American women. The results of the current study have important implications with respect to the designing of interventions aimed at improving cancer screening for all women.

Inconsistent self-reported mammography history: findings from the National Population Health Survey longitudinal cohort

Background

Self-reported information has commonly been used to monitor mammography utilization across populations and time periods. However, longitudinal investigations regarding the prevalence and determinants of inconsistent responses over time and the impact of such responses on population screening estimates are lacking.

Methods

Based on longitudinal panel data for a representative cohort of Canadian women aged 40+ years (n = 3,537) assessed in the 1994–95 (baseline) and 1996–97 (follow-up) National Population Health Survey (NPHS), we examined the prevalence of inconsistent self-reports of mammography utilization. Logistic regression models were used to estimate the associations between women's baseline sociodemographic and health characteristics and 2 types of inconsistent responses: (i) baseline reports of ever use which were subsequently contradicted by follow-up reports of never use; and (ii) baseline reports of never use which were contradicted by follow-up reports of use prior to 1994–95.

Results

Among women who reported having a mammogram at baseline, 5.9% (95% confidence interval (CI): 4.6–7.3%) reported at follow-up that they had never had one. Multivariate logistic regression analyses showed that women with such inconsistent responses were more often outside target age groups, from low income households and less likely to report hormone replacement therapy and Pap smear use. Among women reporting never use at baseline and ever use at follow-up, 17.4% (95%CI: 11.7–23.1%) reported their most recent mammogram as occurring prior to 1994–95 (baseline) and such responses were more common among women aged 70+ years and those in poorer health.

Conclusions

Women with inconsistent responses of type (i), i.e., ever users at baseline but never users at follow-up, appeared to exhibit characteristics typical of never users of mammography screening. Although limited by sample size, our preliminary analyses suggest that type (ii) responses are more likely to be the result of recall bias due to competing morbidity and age. Inconsistent responses, if removed from the analyses, may be a greater source of loss to follow-up than deaths/institutionalization or item non-response.

Perspectives on behavioral and social science research on cancer screening

The first section in the current article offered several themes that characterize behavioral and social science cancer screening research to date and are likely to be relevant for studying the adoption and utilization of future screening technologies. The themes discussed included the link between epidemiologic surveillance and the priorities of intervention, the "at-risk" perspective that often guides research on screening and initiatives to redress disparities, the need to monitor the diversification of personal screening histories, the range of intervention groups and study designs that can be tested, the importance of including key questions in population-level surveys and national health objectives, and the desirability of clarifying the characteristics of cancer screening that make it an attractive field of study in its own right. The second section commented on emerging areas in which more research will allow additional lessons to be learned. The other articles in the current supplement presented many more lessons in a variety of areas, and other authors are encouraged to write similar articles that help to identify general themes characterizing cancer screening research.

Projections of demand and capacity for colonoscopy related to increasing rates of colorectal cancer screening in the United States

BACKGROUND

There is debate about the optimal colorectal cancer screening test, partly because of concerns about colonoscopy demand.

AIM

To quantify the demand for colonoscopy with different screening tests, and to estimate the ability of the United States health care system to meet demand.

METHODS

We used a previously published Markov model and the United States census data to estimate colonoscopy demand. We then used an endoscopic database to compare current rates of screening-related colonoscopy with those projected by the model, and to estimate the number of endoscopists needed to meet colonoscopy demand.

RESULTS

Annual demand for colonoscopy ranges from 2.21 to 7.96 million. Based on current practice patterns, demand exceeds current supply regardless of screening strategy. We estimate that an increase of at least 1360 gastroenterologists would be necessary to meet demand for colonoscopic screening undergone once at age 65, while colonoscopy every 10 years could require 32 700 more gastroenterologists. A system using dedicated endoscopists could meet demand with fewer endoscopists.

CONCLUSIONS

Colorectal cancer screening leads to demand for colonoscopy that outstrips supply. Systems to train dedicated screening endoscopists may be necessary in order to provide population-wide screening. The costs and feasibility of establishing this infrastructure should be studied further.

Identifying opportunities for improved colorectal cancer screening in primary care

BACKGROUND

Although current recommendations advocate screening persons 50 years of age or older for colorectal cancer (CRC), actual screening practice is highly variable among primary care physicians (PCPs). Knowledge of the factors that influence whether or not screening is offered during a clinic visit is essential to develop effective screening strategies.

METHODS

A cross-sectional telephone survey of one in four randomly selected patients aged 50 years or older (n = 400) attending a primary care clinic within an integrated health care system in central Texas was conducted. A survey of all PCPs (n = 32) at the practice sites was also administered.

RESULTS

The visit type was an important determinant of whether CRC screening was discussed, with most discussion occurring during visits for physicals (P < 0.0001). This finding was corroborated by the physician survey. Patient age and education were also associated with a higher likelihood of having been offered CRC screening (P = 0.009 and 0.014, respectively). Patient race, gender, primary language, PCP, or clinics attended were not significantly associated with the discussion of CRC screening.

CONCLUSIONS

Discussions regarding CRC screening are most likely to occur during preventive care visits. Thus, facilitating preventive visits especially for the elderly represents an opportunity to improve CRC screening rates in primary care practice.

[Use of pap smear for cervical cancer screening and factors related with its use in Spain]

OBJECTIVE

To determine the percentage of women aged 40 to 70 years who had had at least one preventive Pap test (cytological examination) during the preceding 5 years, and the factors associated with use of the test.

DESIGN

Population survey.Setting. Home interviews during October 2000.

PARTICIPANTS

2409 women aged 40 to 70 years residing in Spain. The nonresponse rate was 20.3%.

MAIN MEASURES

The dependent variable was use of the Pap test, and independent factors examined were sociodemographic, social and health-related factors, information and attitude. Use of Pap tests was estimated with a 95% confidence interval (CI), and univariate and multivariate analysis were used to identify factors related with use of the test.

RESULTS

Almost half (49.6%; 95% CI, 47.6%-51.6%) of the women had had a Pap test. The factors associated most strongly with use of the test were intention to have the test done (odds ratio [OR], 4.76; 95% CI, 3.40-6.65), not having the test done because of fear of the diagnosis (OR, 3.22; 95% CI, 1.77-5.85), earlier testing (OR, 2.59; 95% CI, 2.06-3.27), and doctor's advice (OR, 2.44; 95% CI, 1.93-3.09). Other associated factors were considering the text necessary, upper or middle-upper socioeconomic status, access to private or combined private-public health care, age 40 to 50 years, and residing in a city with a population greater than 100000.

CONCLUSIONS

Half of all Spanish women aged 40 to 70 years had had a Pap test. Use of the test was related most clearly with the woman's attitude toward the test. Health care professionals should be aware of the importance of their role in encouraging Pap tests for screening.

Prevalence and correlates of repeat mammography among women aged 55-79 in the Year 2000 National Health Interview Survey

BACKGROUND

Utilization of mammography has increased steadily since the early 1990s. It is now important to expand the attention given to obtaining repeat examination. This study examines the prevalence and cross-sectional correlates of repeat mammography, among women aged 55-79, using a 12-month (N = 3,502) and a 24-month interval (N = 3,491).

METHODS

Data were from the Year 2000 Cancer Control Module of the National Health Interview Survey (NHIS-CCM). The NHIS-CCM asked about the most recent mammogram and the total number of mammograms over the prior 6 years. An algorithm estimated repeat mammography for the two intervals.

RESULTS

Prevalence estimates were 49% for the 12-month interval, and 64.1% for the 24-month interval. Correlates of lower likelihood of repeat mammography for both indicators were: no regular source of care, having public or no health insurance, less than a college education, household income less than $45K, not being married, current or never smoking, age 65-79, and lower absolute risk of breast cancer (Gail Model score).

CONCLUSIONS

A substantial percentage of women do not receive repeat mammography. The correlates of repeat mammography were similar to those often found for ever-had and recent mammography. There is probably some imprecision in the prevalence estimates due to the nature of NHIS-CCM questions. Issues pertinent to the definition of repeat examination are addressed.

A randomized controlled trial to increase cancer screening among attendees of community health centers

BACKGROUND

We assessed the efficacy of the Cancer Screening Office Systems (Cancer SOS), an intervention designed to increase cancer screening in primary care settings serving disadvantaged populations.

METHODS

Eight primary care clinics participating in a county-funded health insurance plan in Hillsborough County, Fla, agreed to take part in a cluster-randomized experimental trial. The Cancer SOS had 2 components: a cancer-screening checklist with chart stickers that indicated whether specific cancer-screening tests were due, ordered, or completed; and a division of office responsibilities to achieve high screening rates. Established patients were eligible if they were between the ages of 50 and 75 years and had no contraindication for screening. Data abstracted from charts of independent samples collected at baseline (n = 1,196) and at a 12-month follow-up (n = 1,237) was used to assess whether the patient was up-to-date on one or more of the following cancer-screening tests: mammogram, Papanicolaou (Pap) smear, or fecal occult blood testing (FOBT).

RESULTS

In multivariate analysis that controlled for baseline screening rates, secular trends, and other patient and clinic characteristics, the intervention increased the odds of mammograms (odds ratio [OR] = 1.62, 95% confidence interval [CI], 1.07-9.78, P = .023) and fecal occult blood tests (OR = 2.5, 95% CI, 1.65-4.0, P <.0001) with a trend toward greater use of Pap smears (OR = 1.57, 95% CI, 0.92-2.64, P = .096).

CONCLUSIONS

The Cancer SOS intervention significantly increased rates of cancer screening among primary care clinics serving disadvantaged populations. The Cancer SOS intervention is one option for providers or policy makers who wish to address cancer related health disparities.

[Usefulness of tomographic computer colonography for colorectal polyp detection]

BACKGROUND AND OBJECTIVE

Colonoscopy is the procedure of choice for the diagnosis of colorectal neoplasms. CT colonography (CTC), a recently developed minimal invasive radiological technique, permits the identification of colorectal tumors. The aim of the present study was to evaluate the efficacy of CTC in the detection of colorectal polyps, and to establish the factors determining a diagnostic accuracy.

PATIENTS AND METHOD

Patients with colorectal polyps admitted for endoscopic polypectomy were included. CTC was performed prior to colonoscopy in all patients. Demographic and clinical data were registered, as well as the polyp characteristics. Efficacy of CTC was analyzed with respect to each individual polyp and each patient.

RESULTS

Colonoscopy identified 87 colorectal polyps in 30 patients. CTC had a sensitivity of 70% for the detection of polyps of any size, being 92%, 73% and 55% for polyps > or = 10 mm, 5-9 mm and < or = 4 mm, respectively. On the other hand, the sensitivity of CTC for the detection of pedunculated, semipedunculated and sessile polyps was 85%, 92% and 56%, respectively. Accuracy of CTC was associated with polyp size (p = 0.007) and shape (p = 0.007). Sensitivity and specificity of CTC for the identification of patients with polyps > or = 10 mm were 88% and 100%, respectively.

CONCLUSIONS

CTC is a highly accurate technique for the identification of colorectal polyps. Its diagnostic accuracy depends on lesion's size and shape.

When there is too much to do: how practicing physicians prioritize among recommended interventions

BACKGROUND

Recent evidence suggests that patients are receiving only 50% of recommended processes of care. It is important to understand physician priorities among recommended interventions and how these priorities are influenced both intentionally as well as unintentionally.

METHODS

A survey was mailed to all primary care physicians (PCPs) from two VA hospital networks (N= 289), one of which had participated in a broad, evidence-based guideline development effort 8 to 12 months earlier, and all endocrinologists nationwide in the VA (N= 213); response rate, 63% (n= 315). Using the method of paired comparisons, we assessed physician priorities among 11 clinical triggers for interventions in the management of an uncomplicated patient with type 2 diabetes.

RESULTS

Both PCPs and specialists consistently identified several high-impact clinical triggers for treatment as the highest priority interventions (hemoglobin A1c = 9.5%, diastolic blood pressure [DBP]= 95 mm Hg, low-density lipoprotein = 145 mg/dl). Several low-impact interventions that are commonly used as performance measures also received relatively high ratings. Treatments that have recently been found to be highly beneficial were often rated as being of low importance (e.g., treating when DBP = 88 mm Hg). Almost 80% of PCPs rated tight glycemic control as more important than tight DBP control, in direct contrast to clinical trial evidence. Specialists' ratings followed the same general pattern, but were more consistent with the epidemiological evidence. The PCPs at the sites that participated in the guideline intervention rated blood pressure control significantly higher.

CONCLUSION

Although several high-priority aspects of diabetes care were clearly identified, there were also notable examples of ratings that were clearly inconsistent with the epidemiological literature. Recommendations based upon more recent evidence were substantially underrated and some guidelines used as performance measures were relatively overrated. These results support the arguments that a more proactive approach is needed to facilitate rapid dissemination of new high-priority findings, and that intervention priority, and not just ease of measurement, should be considered carefully when disseminating guidelines and when selecting performance measures.

Measuring quality in arthritis care: methods for developing the Arthritis Foundation's quality indicator set

OBJECTIVE

To develop a comprehensive set of explicit process measures to assess the quality of health care for osteoarthritis, rheumatoid arthritis, and analgesics use.

METHODS

Potential quality measures and a summary of existing data to support or refute the relationship between the processes of care proposed in the indicators and relevant clinical outcomes were developed through a comprehensive literature review. The proposed measures and literature summary were presented to a multidisciplinary panel of experts in arthritis and pain. Using a modification of the RAND/UCLA Appropriateness Method, the panel rated each proposed measure for its validity as a measure of health care quality.

RESULTS

Among 66 proposed indicators, the expert panel rated 51 as valid measures of health care including 14 for osteoarthritis, 27 for rheumatoid arthritis, and 10 for analgesics use.

CONCLUSIONS

Sufficient scientific evidence and expert consensus exist to support a comprehensive set of measures to assess the quality of heath care for osteoarthritis, rheumatoid arthritis, and analgesics use. These measures can be used to gain an understanding of the quality of care for patients with arthritis.

Safety of sodium phosphate tablets in patients receiving propofol-based sedation for colonoscopy

GOALS

To compare the incidence of peri-procedure adverse events in patients undergoing colon cleansing with sodium phosphate tablets or polyethylene glycol solution prior to colonoscopy with propofol-based sedation.

BACKGROUND

Propofol is a rapidly acting hypnotic sedative general anesthetic agent increasingly being used for colonoscopy. Although traditionally patients fast overnight prior to a general anesthetic, a new Food and Drug Administration-approved sodium phosphate tablet purgative requires ingestion of 20 tablets with 56 ounces of clear liquid 3 to 5 hours prior to colonoscopy.

STUDY

We retrospectively reviewed 97 outpatients who received propofol-based sedation for colonoscopy. This was a subset of a randomized, investigator-blinded, multicenter trial comparing sodium phosphate tablets with polyethylene glycol. Study data and anesthesia records were reviewed for peri-procedure hemodynamic, cardiac, and pulmonary adverse events as well as the need for hospital admission.

RESULTS

There were no statistically significant differences between the 2 groups when analyzed for the development of tachycardia, decrease in mean arterial pressure below 50 mmHg, or a reduction in the mean arterial pressure greater than 30% from the pre-procedure value. No patients in either group experienced hypoxia (oxygen saturation < 90%), excessive regurgitation, pneumonia, or hospital admission.

CONCLUSIONS

Peri-procedure adverse events occurred rarely and with no increased frequency in patients using the sodium phosphate tablet purgative and receiving propofol-based sedation. The sodium phosphate tablet purgative is safe for patients receiving propofol-based sedation for colonoscopy.

Adherence to colorectal cancer screening in mammography-adherent older women

Colorectal cancer (CRC) is the third leading cause of cancer mortality among women. Screening can prevent the development of CRC or diagnose early disease when it can effectively be cured, however existing screening methods are underutilized. In this study, we examined the utility of an updated Health Belief Model to explain CRC screening adherence. The present study included 280 older women seeking routine mammography at a large, urban breast diagnostic facility. Overall, 50% of women were adherent to CRC screening guidelines. Multiple regression indicated that self-efficacy, physician recommendation, perceived benefits of and perceived barriers to screening accounted for 40% of variance in CRC screening adherence. However, there was no evidence for two mediational models with perceived benefits and perceived barriers as the primary mechanisms driving adherence to CRC screening. These findings may inform both future theoretical investigations as well as clinical interventions designed to increase CRC screening behavior.

Cost-effectiveness of a tailored intervention to increase screening in HMO women overdue for Pap test and mammography services

BACKGROUND

Research has established the societal cost-effectiveness of providing breast and cervical cancer screening to women. Less is known about the cost of motivating women significantly overdue for services to receive screening.

METHODS

In this intent-to-treat study, a total of 254 women, aged 52-69, who were overdue for both Pap test and mammography, were randomized to two groups, a tailored, motivational outreach or usual care. For effectiveness, we calculated the percent of women who received both services within 14 months of randomization. We used a comprehensive cost model to estimate total cost, per-participant cost, and the incremental cost-effectiveness of delivering the outreach intervention from the health plan perspective. We also conducted sensitivity analyses around two key parameters, target population size and level of effectiveness.

RESULTS

Compared with usual care, outreach (P = 0.006) screened significantly more women. The intervention cost US dollars 167.62 (2000 U.S. dollars) for each woman randomized to outreach, and incremental cost-effectiveness of outreach over usual care was US dollars 818 per additional woman screened. Sensitivity analyses estimated incremental cost-effectiveness between Us dollars 19 and US dollars 90 per additional woman screened.

CONCLUSIONS

Larger health plans can likely increase Pap test and mammography services in this population for a relatively low cost using this outreach intervention.

Optimization of PCR based detection of human papillomavirus DNA from urine specimens

BACKGROUND

Human papillomavirus (HPV) causes cervical cancer. Current screening requires a yearly pelvic exam and Pap smear. However, these procedures are impractical for screening all women at risk for disease. Urine sampling has been successfully utilized to screen for Chlamydia trachomatis (CT) and Neisseria gonorrhoreae (NG) infections and has been considered for HPV DNA detection by several investigators. However, no study to date has been performed to specifically optimize HPV detection in urine.

OBJECTIVES

To compare handling and extraction techniques in order to optimize the HPV specific PCR system in urine specimens.

STUDY DESIGN

Examination of 10 characteristics that may contribute to PCR inhibition in urine was performed utilizing 10SG mulitstixs. Five different DNA extraction methods were compared in spiked specimens and in 10 clinical specimens. After the optimal extraction technique was identified, concentration of the sample with and without prior dilution was compared to the original protocol. Lastly, specimen handling was compared between immediate processing, refrigerating overnight, or freezing overnight.

RESULTS AND CONCLUSIONS

the presence of protein in urine enhanced amplification while nitrites decreased amplification. Of the extraction methods tested, the QIAamp DNA Mini Kit demonstrated the best amplification from urine samples spiked with HPV DNA and clinical specimens. The addition of a dilution step and a concentration step before applying the Qiagen protocol further increased amplification of beta-globin (from 50 to 63%) and the HPV L1 gene (from 13 to 33%). Lastly, refrigerating the specimens at 4 degrees C overnight appears to produce better amplification (62% beta-globin and 17% HPV positive) than either immediate processing (46% beta-globin and 13% HPV+) or freezing the specimen for 24h prior to processing (46% beta-globin and 10% HPV+). In these studies, amplification was low despite optimization. Additional improvements are required prior to clinical application of a urine-based HPV DNA detection system.

Barriers to colorectal cancer screening in rural primary care

BACKGROUND

Residents of rural communities may face unique barriers to obtaining colorectal cancer (CRC) screening, including reduced access to services. This study assessed the impact of patient, physician, and practice characteristics on rural primary care patient receipt of CRC screening.

METHODS

We surveyed patients (N = 801) over 50 years of age and primary care physicians (N = 36) in rural practices. Medical students administered surveys to assess patient demographics, self-reported CRC screening, practice features, local availability of endoscopy, and physician screening test preferences. We used multivariable logistic regression analyses to investigate associations between independent variables, and (1) patient CRC screening status and (2) adequacy of CRC discussions between physicians and patients.

RESULTS

Fifty-seven percent of patients reported being up-to-date with colorectal cancer screening and most in this group had received FOBT and endoscopy. A minority of patients (39%) reported adequate time to discuss CRC screening, and this was positively associated with being up-to-date with CRC screening in a multivariable analysis. Endoscopy was available in 58% of the practices and 44% of the practices had local gastroenterologists available on at least a monthly basis. The availability of endoscopic procedures and gastroenterological services were not associated with CRC screening or with use of endoscopy as a screening method.

CONCLUSIONS

CRC screening among rural primary care patients is related to adequacy of physician CRC screening discussions but not access to endoscopic procedures. Efforts to improve CRC screening should focus on improving physician-patient discussions of CRC.

Breast and Cervical Cancer Mortality in the Mississippi Delta, 1979–1998

BACKGROUND

Historically, the Mississippi Delta region has been medically underserved. This may lead to lower cancer prevention efforts and higher breast or cervical cancer mortality rates.

METHODS

Death rates for 1979 through 1998 were calculated for Mississippi Delta women and for women living elsewhere in the US.

RESULTS

Breast cancer mortality in the Delta was similar to that elsewhere in the US in recent years for both black and white women, but rates were lower in the Delta in the early years of the study period. Overall, cervical cancer mortality was similar in the two areas but rates declined more rapidly elsewhere in the US than in the Delta. Breast and cervical cancer mortality was higher among black women than among white women in both areas. Cervical cancer mortality was higher among white rural and black urban women in the Delta than their counterparts elsewhere.

CONCLUSION

These results can guide prevention activities for reducing mortality from these diseases.

Screening Preferences for Colorectal Cancer: A Patient Demographic Study

BACKGROUND

Colorectal cancer is a leading cause of cancer-related death. Screening for colorectal cancer is a rational and cost-effective strategy for reducing the incidence of colorectal cancer and related mortality. Despite endorsement by academic and health care organizations, patient awareness and compliance with screening is low, partly because of patient-related barriers to screening.

METHODS

A convenience sample of adults attending the internal medicine and family practice clinics of a community teaching hospital was studied. A description of fecal occult blood testing (FOBT), sigmoidoscopy, and colonoscopy procedures was given in a packet along with a questionnaire. The questionnaire focused on screening procedures followed in our hospital (i.e., yearly FOBT and sigmoidoscopy every 5 years or colonoscopy every 10 years for average-risk individuals).

RESULTS

Of the 193 patients who responded, 55% preferred sigmoidoscopy and FOBT, 29% chose colonoscopy, and 16% wanted no screening. Those with knowledge of someone with colon cancer or colon polyps reported a significantly higher preference for screening than those without such knowledge. Catholics were most likely to prefer no screening compared with non-Catholics. Ex-smokers (compared with all others) were more likely to want screening. Catholics were least likely to want colonoscopy. Patients with previous experience of colorectal screening preferred future screening. Those preferring no screening were significantly younger than those who expressed a preference for screening.

CONCLUSION

The results of this study demonstrate diversity in patient choices for colorectal cancer screening. A focus on people's preferences rather than on the test itself may help develop and target appropriate intervention for prevention of colorectal cancer.

Barriers to endoscopic colorectal cancer screening: are women different from men?

OBJECTIVES

The goals of this study were to compare women and men's understanding of screening flexible sigmoidoscopy (FS) and to identify predictors of endoscopic colorectal cancer (CRC) screening.

METHODS

We mailed a 36-item questionnaire to asymptomatic patients aged 50 years or older who were scheduled for routine health assessments at a large multispecialty health-care group. Data collection included demographics, health behaviors, psychosocial factors, and CRC screening compliance. We followed participants for 1 year and assessed completion of endoscopic CRC screening. Both cross-sectional results examining previous screening and prospective results examining screening 1 year later were evaluated.

RESULTS

554 (54%) of 998 patients responded to the survey. Responses of 13 patients were excluded in the analyses due to unverifiable screening outcome. The majority of the respondents were white, and their average age was 62 years. Women reported significantly more embarrassment and fear about having FS than men. Women were more willing to consider having a FS if a female endoscopist performed the procedure. Of the 334 participants who were eligible to have endoscopic CRC screening, 53 (16%) had the procedure within a year. The odds of having the endoscopic procedures increased with the length of time the patients were under the care of their primary care providers and how strongly patients believed that one should have an FS even without symptoms.

CONCLUSION

Our findings suggest some unique gender-specific attitudes and beliefs that act as potential barriers for CRC screening and further support the important role of primary care providers in facilitating timely completion of screening.

Diversity matters: Unique populations of women and breast cancer screening

BACKGROUND

Ethnic differences in breast cancer screening behaviors are well established. However, there is a lack of understanding regarding exactly what causes these differences and which characteristics in low-screening populations should be targeted in an effort to modify screening behavior.

METHODS

Stratified cluster sampling was used to recruit 1364 women (ages 50-70 years) from 6 ethnic groups: African-American women; U.S.-born white women; English-speaking Caribbean, Haitian, and Dominican women; and immigrant Eastern-European women. In interviews, respondents provided information concerning demographic and structural variables related to mammogram utilization (age, education, income, marital status, physician recommendation, access, and insurance) and a set of cognitive variables (fatalism, perception of personal risk, health beliefs concerning cancer) and socioemotional variables (stress, cancer worry, embarrassment, and pain).

RESULTS

For data analysis, the authors used a 2-step logistic regression with frequency of mammograms over a 10-year period (< or = 4 mammograms over 10 years or > or = 5 mammograms over 10 years) as a dependent variable. U.S.-born African-American women and Dominican women were screened as frequently as European-American women, but the remaining minority groups were screened with less frequency. With one exception, ethnicity ceased to predict screening frequency once cognitive and emotional variables were controlled.

CONCLUSIONS

Although women from clearly operationalized ethnic groups continue to screen at rates substantially below those of the majority groups, these differences appear to be explained substantially by differences in psychologic variables. This is encouraging because, rather than targeting culture for intervention, variables can be targeted that are amenable to change, such as emotions and beliefs.

Colorectal carcinoma mortality among Appalachian men and women, 1969-1999

BACKGROUND

Colorectal carcinoma screening can reduce mortality, but residents of poor or medically underserved areas may face barriers to screening. The current study assessed colorectal carcinoma mortality in Appalachia, a historically underserved area, from 1969 to 1999.

METHODS

All counties within the 13-state Appalachian region, which stretches from southern New York to northern Mississippi, were used to calculate annual death rates for the 31-year period. Joinpoint regression analysis was used to examine trends by age and race for the Appalachian region and the remainder of the United States. Five-year rates for 1995-1999 age-adjusted to the 2000 U.S. standard population were calculated by race and age group for the Appalachian region and elsewhere in the United States.

RESULTS

Trend analysis showed that colorectal carcinoma death rates among both racial and gender groups studied had declined in recent years. Despite this, the rates for white males and white females were still significantly higher in Appalachia than in the rest of the country at the end of the study period, 1999. Five-year colorectal carcinoma death rates among white males (ages < 50, 50-59, and 70-79 years) and white females (ages < 50, 50-59, 70-79, > or = 80 years) were significantly higher in Appalachia than elsewhere in the United States, whereas rates among black females 60-69 and 70-79 years old were significantly lower in Appalachia.

CONCLUSIONS

The Appalachian region may benefit from targeted prevention efforts to eliminate disparities in the colorectal carcinoma death rates among subgroups. Further studies are needed to determine whether the higher death rates in specific Appalachian subgroups are related to a higher incidence of the disease, the cancer being at a later stage at diagnosis, poorer treatment, or other factors.

Psychosocial and medical predictors of colorectal cancer screening among low-income medical outpatients

BACKGROUND

Identification of factors related to colorectal cancer screening (CRC) and intent to obtain fecal occult blood tests (FOBTs) among low-income persons are important because CRC incidence and mortality are higher among socioeconomically disadvantaged populations.

METHOD

Participants were 193 individuals 50 years of age and older. CRC screening and intent to obtain FOBTs were dependent measures. Demographic variables, objective risk factors, and health beliefs were independent measures.

RESULTS

Digital rectal examinations and FOBTs were obtained by 41% and 22%, respectively, during the previous year. Flexible sigmoidoscopies were obtained by only 19% of those 55 years of age and older during the previous five years. Multivariate analyses showed that family history of CRC, personal history of polyps, and physician recommendation were the strongest predictors of CRC screening. Family history of CRC and self-efficacy were related to intent to obtain FOBTs.

CONCLUSIONS

Results suggest the importance of physician assessment of personal and family CRC risk factors, as well as recommendation of CRC screening, to all patients as part of routine medical care.

Repeat mammography: Prevalence estimates and considerations for assessment

Despite recent controversies in mammography efficacy, encouraging women to obtain regular screenings is still an important public health priority. Published articles about repeat or regular screening were reviewed to determine trends in rates of mammography adherence. A search of MEDLINE and PsycINFO from January 1990 to December 2001 identified 45 empirical articles of U.S. samples that reported, or provided sufficient data to calculate, the percentage of women 50 years of age and older who obtained 2 or more consecutive, on-schedule mammograms. Keywords used in the searches included pairing mammography with regular, repeat, adherence, compliance, annual, rescreen, and maintenance. The weighted average repeat mammography percentage across all eventually included studies (N = 37) was 46.1% (confidence interval: 39.4%, 52.8%). There was no substantial difference in the average repeat screening percentages comparing studies that collected data from 1995 to 2001 versus 1991 to 1994. Within each of 3 time periods of data collection (pre-1991, 1991-1994, 1995-2001), there was substantial variation in repeat rates. This variation appears to be due to several characteristics of study design and sampling, including the definition/methods of collecting data about the adherence measure, prior mammography status, and use of an upper age limit at recruitment. Consensus is needed regarding the definition of repeat mammography. National surveys must include items to assess repeat mammography in order to have estimates that accurately represent population-level rates. Although this study involved mammography, similar challenges in assessing prevalence rates can occur with other screening behaviors.

Racial/ethnic differences in the self-reported use of screening mammography

The efficacy of mammography in reducing breast cancer mortality among women 50-69 years of age has been demonstrated in randomized controlled studies, but many women, especially ethnic minorities, have not been receiving regular mammographic screening. The current study investigated racial/ethnic differences in mammography use and their association with demographic characteristics and other factors. The study population consisted of 4,444 women aged 40 years and older who participated in the 1996 Medical Expenditure Panel Survey. Outcome measures studied included the self-reporting of mammography within the past two years and past year. Multivariate logistic regression modeling was used to examine the effect of race while controlling for other factors. In the univariate analysis, there was virtually no difference between white, black, and Hispanic women in mammography rates within either one or two years. However, multivariate logistic regression suggested that both blacks and Hispanics were more likely than whites to have received recent mammography, as black women were 31% and Hispanic women were 43% more likely than white women to have had a mammogram within the previous two years. Our results suggest that white women are no longer more likely to receive periodic screening mammography than black and Hispanic women, and in fact, might even be less likely to undergo the procedure. This reversal might indicate, at least in part, that programs and other activities to promote screening mammography among ethnic minority women have been successful and should now be expanded to include other women.