Participation of high-risk subjects in colon cancer screening

No association between colorectal cancer worry and screening uptake in Appalachian Ohio

BACKGROUND

Limited data are available on the association between colorectal cancer (CRC) worry and CRC screening uptake, particularly in rural and underserved populations where there is an excess burden of CRC.

METHODS

Between September 2009 and March 2010, we conducted a cross-sectional study among a randomly selected sample of Appalachian Ohio residents aged 51-75 years (n= 1084). We also reviewed their medical records. Multivariable-adjusted models examined the association between CRC worry and screening by medical record review, assessed effect modification by CRC worry and determined the correlates of higher CRC worry.

RESULTS

Approximately 50% of participants were adherent to CRC screening guidelines. There was no significant association between higher CRC worry and screening adherence [odds ratio (OR) = 1.32, 95% confidence interval (CI): 0.86-2.02]. CRC worry did not modify the association between any covariate and screening adherence. Participants who were unemployed/disabled (OR = 2.15, 95% CI: 1.34-3.45) and had higher CRC risk perception (OR = 3.49, 95% CI: 2.19-5.56) had higher odds of moderate-to-extreme worry.

CONCLUSIONS

These findings highlight the need for meaningful exploration of why higher CRC worry is not associated with adherence to CRC screening, particularly in rural, medically underserved populations. Development and implementation of interventions to increase CRC screening in such areas is a significant public health priority.

Colorectal cancer screening disparities in Asian Americans and Pacific Islanders: which groups are most vulnerable?

BACKGROUND

Colorectal cancer (CRC) is a significant cause of mortality among Asian Americans and Pacific Islanders (AAPIs), yet studies have consistently reported lower CRC screening rates among AAPIs than among non-Latino Whites and African Americans. Moreover, existing research tends to aggregate AAPIs as one group when reporting CRC screening, masking the disproportionate burden in cancer screening that exists across AAPI groups.

METHODS

This study examines differences in CRC screening rates in both aggregated and disaggregated AAPI groups as compared with non-Latino Whites in order to identify the most vulnerable AAPI subgroups in terms of obtaining CRC screening. This study utilizes merged data from the 2001, 2003, and 2005 California Health Interview Survey (CHIS), specifically the data pertaining to adults aged 50 and older (n = 52,491) from seven AAPI groups (Chinese, Japanese, Korean, Filipino, South Asian, Vietnamese, and Pacific Islander) and non-Latino Whites. Andersen's Behavioral Model of Health Services Use was utilized to select potential confounders to racial/ethnic differences in CRC screening.

RESULTS

When AAPI groups were considered as an aggregate, their CRC screening rate (46.8%) was lower than that of non-Latino Whites (57.7%). When AAPI groups were disaggregated, further disparity was noted: Koreans (32.7%) showed the lowest CRC screening rate, whereas Japanese (59.8%) had the highest. When the influence of potential predisposing, enabling, and need confounders was adjusted, Koreans, Filipinos, and South Asians were found to have a lower likelihood than non-Latino Whites to undergo CRC screening. Comparisons among AAPI subgroups further revealed that Filipinos, Koreans, Pacific Islanders, and South Asians were less likely than Chinese, Japanese, and Vietnamese to receive CRC screening.

CONCLUSION

These results highlight the importance of identifying differences in CRC screening behavior among disaggregated AAPI subgroups in order to help health professionals and policy-makers prioritize which AAPI subgroups need the most urgent interventions in terms of CRC screening promotion.

Individual-level factors in colorectal cancer screening: a review of the literature on the relation of individual-level health behavior constructs and screening behavior

OBJECTIVE

Compliance with colorectal cancer screening recommendations requires considerable conscious effort on the part of the individual patient, making an individual's decisions about engagement in screening an important contributor to compliance or noncompliance. The objective of this paper was to examine the effectiveness of individual-level behavior theories and their associated constructs in accounting for engagement in colorectal cancer screening behavior.

METHODS

We reviewed the literature examining constructs from formal models of individual-level health behavior as factors associated with compliance with screening for colorectal cancer. All published studies examining one or more constructs from the health belief model, theory of planned behavior, transtheoretical model, or social cognitive theory and their relation to screening behavior or behavioral intentions were included in the analysis.

RESULTS

By and large, results of studies supported the theory-based predictions for the influence of constructs on cancer screening behavior. However, the evidence base for many of these relations, especially for models other than the health belief model, is quite limited.

CONCLUSIONS

Suggestions are made for future research on individual-level determinants of colorectal cancer screening.

A randomized trial of two print interventions to increase colon cancer screening among first-degree relatives

OBJECTIVE

First-degree relatives (FDRs) of people diagnosed with colorectal cancer (CRC) have a two- to threefold increased risk of developing the same disease. Tailored print interventions based on behavior change theories have demonstrated considerable promise in facilitating health-promoting behaviors. This study compared the impact of two mailed print interventions on CRC screening outcomes among FDRs.

METHODS

This randomized trial compared effects of two mailed print interventions--one tailored and one nontailored--on participation in CRC screening among FDRs of CRC survivors. Data collected via phone interviews from 140 FDRs at baseline, 1 week post-intervention, and 3 months post-intervention.

RESULTS

At 3 months, both the tailored and nontailored interventions yielded modest but statistically insignificant increases in adherence to any CRC screening test (14% vs. 21%, respectively; p=0.30). While there were no main effects for tailored versus nontailored interventions, there were significant interactions that showed that the tailored print intervention had significantly greater effects on forward stage movement for CRC screening depending on stage of adoption at baseline, race, and objective CRC risk. Receipt of the tailored intervention was 2.5 times more likely to move baseline precontemplators and contemplators forward in stage of adoption for colonoscopy (95% CI: 1.10-5.68) and was three times more likely to move Caucasians forward in stage of adoption for FOBT (95% CI: 1.00-9.07). In addition, the tailored intervention was 7.7 times more likely to move people at average risk forward in stage of adoption for colonoscopy (95% CI: 1.25-47.75).

CONCLUSION

The tailored print intervention was more effective at moving Caucasians, those in precontemplation and contemplation at baseline, and those at average risk forward in their stage of adoption for CRC screening.

PRACTICE IMPLICATIONS

Both tailored and nontailored print interventions showed moderate effects for increasing CRC screening participation. Tailored print interventions may be more effective for certain subgroups.

Correlates and predictors of colorectal cancer screening among male automotive workers

BACKGROUND

Most studies examining factors associated with colorectal cancer (CRC) screening (CRCS) are cross-sectional and thus temporal relationships cannot be determined. Furthermore, less attention has been paid to psychosocial predictors of CRCS. We examined both cross-sectional correlates of prior CRCS and predictors of prospective CRCS initiation and maintenance during The Next Step Trial, a 2-year worksite behavioral intervention to promote regular CRCS and dietary change.

METHOD

The sample included 2,693 White male automotive workers at increased occupational risk for, but no history of, CRC who completed a baseline survey. Stratified analyses were conducted for three dependent variables (prior CRCS, CRCS initiation, and CRCS maintenance). We also assessed prior CRCS as a moderator in prospective analyses. Multivariable logistic regression analyses with generalized linear mixed models were used to adjust for cluster sampling.

RESULTS

Except for education, cross-sectional correlates of prior CRCS including older age, family history of CRC or polyps, personal history of polyps, self-efficacy, family support, and intention were also significant prospective predictors of increased CRCS during the trial. Despite differences in the patterns of association for CRCS initiation and maintenance in stratified analyses, the only associations with prospective CRCS that were significantly moderated by prior CRCS were family history and CRCS availability.

CONCLUSIONS

Correlates of prior CRCS that also were prospective predictors of CRCS may be suitable targets for intervention. Additionally, intervention messages addressing psychosocial constructs may be relevant for both CRCS initiation and maintenance. However, studies with more diverse samples are needed to replicate the results reported here.

Screening colonoscopy use among individuals at higher colorectal cancer risk

GOALS

To describe screening colonoscopy use in those with a family history of colorectal cancer (CRC).

BACKGROUND

Colonoscopy is an effective means of screening for CRC and is preferred for individuals at higher risk. We therefore derived population-based estimates of colonoscopy use and analyzed how individual characteristics and family history correlate with colonoscopy.

STUDY

Individuals between the ages of 41 and 75 years who responded to the Cancer Control Module of the 2000 National Health Interview Study were analyzed. Screening colonoscopy was defined as having a colonoscopy for screening purposes within the last 10 years. Screening colonoscopy was the dependent variable and family history was the independent variable in a logistic regression model that included self-described sociodemographic characteristics.

RESULTS

Of the 13,160 individuals in the analysis, 6.8% had a family history of CRC, corresponding to approximately 5.5 million individuals in the United States. Those with a family history were significantly more likely to report screening colonoscopy (27.8%) than those without a family history (7.7%; P<0.001). In those with a family history, screening colonoscopy significantly correlated with tobacco use, education, and age. There was no trend for increased screening colonoscopy with having multiple family members or a young family member with CRC.

CONCLUSIONS

Over 5.5 million people in the US have a family history of CRC, and only 1 in 4 report having had a screening colonoscopy by the year 2000. Improving knowledge about CRC and addressing other barriers to screening in this group will be important components of improving screening colonoscopy utilization.

Factorial validity and invariance of a survey measuring psychosocial correlates of colorectal cancer screening among African Americans and Caucasians

BACKGROUND

Psychosocial constructs are widely used to predict colorectal cancer screening and are targeted as intermediate outcomes in behavioral intervention studies. Reliable and valid instruments for measuring general colorectal cancer screening psychosocial constructs are needed; yet, few studies have conducted psychometric analyses. This study replicated a five-factor structure for 16 theory-based, general colorectal cancer screening items measuring salience and coherence, cancer worries, perceived susceptibility, response efficacy, and social influence. In addition, we examined factorial invariance across race and sex.

METHODS

African American and Caucasian patients (n = 1,413) attending an urban, primary care clinic were included in this study. These individuals completed a baseline survey as part of a colorectal cancer screening intervention trial. Single and multigroup confirmatory factor analyses using maximum-likelihood estimation were done.

RESULTS

The five-factor general colorectal cancer screening model provided excellent fit and was invariant across race-sex subgroups.

CONCLUSIONS

The findings of invariance across sex and race subgroups support the use of these scales to measure group differences.

Screening behavior of individuals at high risk for colorectal cancer

BACKGROUND AND AIMS

Periodic colonoscopy is an effective means of reducing the incidence and mortality of colorectal cancer in individuals with a family history of the disease. The aims of this study were to determine the degree of compliance and to identify the factors related significantly to noncompliance with periodic screening in this high-risk population.

METHODS

A total of 178 individuals who had undergone genetic counseling for colorectal cancer between 1986 and 1998 and who had been advised to undergo periodic screening because of familial colorectal cancer (FCRC) or hereditary nonpolyposis colorectal cancer (HNPCC) were invited to complete a self-report questionnaire on psychosocial issues and screening experiences. Compliance data were derived from medical records and via self-report.

RESULTS

A total of 149 individuals (84%) participated in the study. Noncompliance with screening advice was rare (in 3% of cases), but significant delays (more than 1 year) in undergoing screening were observed in approximately 25% of the cases. The number of perceived barriers to screening (eg, discomfort, embarrassment) was the only variable related significantly to noncompliance/screening delay (odds ratio, 1.2; 95% confidence interval, 1.1-1.3). Use of sedatives during the procedure and receipt of a reminder letter seemed to facilitate better compliance.

CONCLUSIONS

Although few high-risk individuals abstain from screening entirely, approximately one in 4 deviates significantly from the recommended frequency of screening. Increased compliance may be achieved by reducing the discomfort and embarrassment associated with the procedure and by the use of reminder letters.

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.

Predictors of colorectal cancer screening participation in the United States

OBJECTIVE

Our aim was to identify predictors of colorectal cancer screening in the United States and subgroups with particularly low rates of screening.

METHODS

The responses to a telephone-administered questionnaire of a nationally representative sample of 61,068 persons aged >/=50 yr were analyzed. Current screening was defined as either sigmoidoscopy/colonoscopy in the preceding 5 years or fecal occult blood testing (FOBT) in the preceding year, or both.

RESULTS

Overall, current colorectal cancer screening was reported by 43.4% (sigmoidoscopy/colonoscopy by 22.8%, FOBT by 9.9%, and both by 10.7%). The lowest rates of screening were reported by the following subgroups: those aged 50-54 yr (31.2%), Hispanics (31.2%), Asian/Pacific Islanders (34.8%), those with education less than the ninth grade (34.4%), no health care coverage (20.4%), or coverage by Medicaid (29.2%), those who had no routine doctor's visit in the last year (20.3%), and every-day smokers (32.1%). The most important modifiable predictors of current colorectal cancer screening were health care coverage (OR = 1.7, 95% CI = 1.5-1.9) and a routine doctor's visit in the last year (OR = 3.5, 95% CI = 3.2-3.8). FOBT was more common in women than in men (OR = 1.8, 95% CI = 1.6-2.0); sigmoidoscopy/colonoscopy was more common in Hispanics (OR = 1.4, 95% CI = 1.1-1.7) and Asian/Pacific Islanders (OR = 2.4, 95% = CI 1.5-3.9) relative to whites, in persons without routine doctor's visits in the preceding year (OR = 3.3, 95% CI = 2.8-4), and in persons with poor self-reported health (OR = 1.3, 95% CI = 1.2-1.5).

CONCLUSIONS

Interventions should be developed to improve screening for the subgroups who reported the lowest screening rates. Such interventions may incorporate individual screening strategy preferences.

Colorectal cancer screening: an overview of current trends

Colorectal cancer can be cured and, in some cases, even prevented if detected early through screening. Studies have demonstrated that regular screening for colorectal cancer with fecal occult blood testing, sigmoidoscopy, or colonoscopy can reduce mortality from this disease. Unfortunately, rates of participation in these screening tests are unacceptably low among the U.S. population. Nurses have a significant role to play in assisting individuals to incorporate regular colorectal cancer screening into their health maintenance routines.

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.

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.

Colorectal cancer screening beliefs. Focus groups with first-degree relatives

OBJECTIVES

The purpose of this paper is to describe the perceived benefits and barriers to colorectal cancer screening reported by first-degree relatives of colorectal cancer patients.

MATERIALS AND METHODS

In this study, the authors used focus groups to identify perceived benefits and barriers to colorectal cancer screening among parents and children of colorectal cancer patients. Four focus groups were conducted with relatives of colorectal cancer patients seen at two university medical centers in the Midwest. The groups ranged in size from five to eight members each and were stratified by gender.

RESULTS

Four benefits of colorectal cancer screening were identified by participants: finding colorectal cancer early, decreasing the chances of dying from colorectal cancer, freedom from worry about colorectal cancer, and reassurance that one was cancer-free. Four main barriers were identified that applied to all four types of colorectal cancer screening or to colorectal cancer screening in general. These included inadequate public awareness of colorectal cancer, inconsistent recommendations from healthcare providers, concerns about the efficacy of screening tests, and embarrassment. Barriers unique to each screening test also were identified.

CONCLUSIONS

Understanding individual beliefs about the benefits and barriers to colorectal cancer screening will allow clinicians and researchers to develop effective interventions to increase screening. Results from the focus groups have been used to develop an instrument to measure benefits and barriers to colorectal cancer screening, which now needs to be tested with more culturally and socioeconomically diverse groups.

Chemopreventive effect of N-(2-cyclohexyloxy-4-nitrophenyl)methane sulfonamide (NS-398), a selective cyclooxygenase-2 inhibitor, in rat colon carcinogenesis induced by azoxymethane

Non-steroidal anti-inflammatory drugs (NSAIDs) such as sulindac and indomethacin inhibit colon carcinogenesis, and selective cyclooxygenase (COX)-2 inhibitors are considered to be potential chemopreventive agents without the side effects of usual NSAIDs. We reported that NS-398, N-(2-cyclohexyloxy-4-nitrophenyl)methane sulfonamide, suppressed the formation of preneoplastic lesions, aberrant crypt foci (ACF), induced by azoxymethane (AOM) in a short-term assay of rat colon carcinogenesis. In this study, we examined the effects of long-term NS-398 administration on rat colon carcinogenesis. After three AOM treatments at weekly intervals, a dose of 10 mg/kg of NS-398 in 5% Arabic gum solution was administered by gavage three times per week in group 2 until the termination of the experiment. Rats in group 1 were fed in a basal diet and given 5% Arabic gum solution alone after AOM treatment. At 40 weeks after the first AOM treatment, all rats were killed and the whole intestines including colon were examined. While the incidences of whole intestinal and colon neoplasms in group 1 were 84.6% and 80.8%, respectively, those in group 2 (given NS-398) were 51.9% and 44.4% respectively (P=0.0177 and P=0.0103 by Fisher's exact test, respectively). The multiplicities in group 2 (0.67+/-0.78 and 0.48+/-0.58) were also decreased significantly compared with those (1.39+/-1.10 and 1.08+/-0.74) in group 1 (P<0.01 by Welch's method and P<0.002 by Student's t test, respectively). In immunohistochemistry for proliferative cell nuclear antigen (PCNA), the PCNA-stained cell index (7.40+/-0.5) in group 2 was significantly decreased from that in group 1 (14.03+/-0.82) (P<0.001 by Welch's method). The results suggest that NS-398, a selective COX inhibitor, has a chemopreventive activity against colon carcinogenesis without side-effects such as gastric ulceration.

Promoting cancer screening among the first-degree relatives of breast and colorectal cancer patients: the design of two randomized trials

BACKGROUND

In this paper two large nationwide trials are described, both of which will test a comparable telephone-based counseling intervention to promote cancer screening among the first-degree relatives (FDRs) of breast and colorectal cancer patients. The unit of randomization will be the family unit of eligible FDRs. Access to FDRs will be obtained from their relatives with cancer. Selected intervention and design issues are reviewed, including how both projects will respond to FDRs who exhibit significant levels of cancer-specific anxiety or distress and how potential high-risk cancer families will be accommodated.

METHODS

Pursuant to the development of both studies, two feasibility surveys were conducted to determine whether patients would grant access to their FDRs and whether the FDRS identified by these patients would be receptive to the telephone intervention.

RESULTS

Approximately 80% (106 of 132) of breast cancer patients agreed to provide access to their eligible FDRs when contacted on-site at participating hospitals and clinics. Of those subsequently selected for telephone follow-up (n = 95 or 90%), 80% (n = 76) were successfully contacted by telephone, and of these 97% (n = 74) provided the names and telephone numbers of their FDRs. Among colorectal cancer patients contacted on-site (n = 46), 96% (n = 44) agreed to provide access to their FDRs, and of those contacted by telephone (n = 33 or 75%), 91% (n = 30) provided the requested information about their FDRs. Once contacted, 95% of breast cancer FDRs (55 of 58) and 91% of colorectal cancer patients (51 of 56) endorsed the intervention strategy.

CONCLUSIONS

It is argued that this intervention, if proven effective, could provide an exportable strategy for reaching large numbers of high-risk individuals to promote cancer screening.

Surveillance behavior of women with a reported family history of colorectal cancer

STUDY OBJECTIVE

The present study tested whether the surveillance behavior of women with a family history of colorectal cancer (CRC) differed from that of women without such a history.

DESIGN

The study included 72,710 subjects from the population of E3N, a cohort study, part of the European Prospective Investigation on Cancer, investigating risk factors for cancer among women.

RESULTS

Fecal occult-blood testing (FOBT) was reported by 19.4% of the women with no CRC in their family and by 21.8% of those with one or more CRC (frequency odds ratio (FOR) = 1.01; ns). The degree of kinship did not influence FOBT. Colonoscopy was reported by 10.9% of women with no CRC in their family; its frequency increased with increasing number of subjects affected by CRC in the family, in particular when it concerned first-degree relatives. Colonoscopy was reported almost four times more frequently by subjects having two or more first-degree relatives with CRC (FOR = 3.55; 95% CI 2.47-5.10) than by those without any affected member; the frequency of colonoscopy increased, though less sharply, among women with second-degree affected relatives, compared with those without any affected relative in their family.

CONCLUSION

In conclusion, whereas FOBT was unaffected by family history of CRC, screening colonoscopy was more frequent among women with a reported family history and differed with the degree of kinship of the affected relatives. The high rate of colonoscopy observed among subjects with first- and second-degree relatives is likely due to physician participation in screening decisions.

Participation in colorectal cancer screening: a review

The purpose of this review is to evaluate the published literature on adherence to colorectal cancer (CRC) screening with fecal occult blood testing (FOBT) and sigmoidoscopy. Specifically, the review addresses the following: 1) prevalence of FOBT and sigmoidoscopy; 2) interventions to increase adherence to FOBT and sigmoidoscopy; 3) correlates or predictors of adherence to FOBT and sigmoidoscopy; and 4) reasons for nonadherence. Other objectives are to put the literature on CRC screening adherence in the context of recently reported findings from experimental interventions to change prevention and early detection behaviors and to suggest directions for future research on CRC screening adherence. CRC screening offers the potential both for primary and for secondary prevention. Data from the 1992 National Health Interview Survey show that 26% of the population more than 49 years of age report FOBT within the past 3 years and 33% report ever having had sigmoidoscopy. The Year 2000 goals set forth in Healthy People 2000 are for 50% of the population more than 49 years of age to report FOBT within the past 2 years and for 40% to report that they ever had sigmoidoscopy. Thus, systematic efforts to increase CRC screening are warranted. To date, attempts to promote CRC screening have used both a public health model that targets entire communities, e.g., mass media campaigns, and a medical model that targets individuals, e.g., general practice patients. Most of these efforts, however, did not include systematic evaluation of strategies to increase adherence. The data on FOBT show that the median adherence rate to programmatic offers of FOBT is between 40% and 50%, depending on the type of population offered the test, e.g., patients or employees. Approximately, 50% of those initially offered testing in unselected populations will respond to minimal prompts or interventions. A salient issue for FOBT, however, is whether or not the behavior can be sustained over time. Fewer studies examined adherence to sigmoidoscopy. Adherence was highest in relatives of CRC cases and in employer-sponsored programs offered to workers at increased risk of CRC. At present, we know very little about the determinants of CRC screening behaviors, particularly as they relate to rescreening.

Results of a pilot study of endoscopic screening of first degree relatives of colorectal cancer patients in Italy

STUDY OBJECTIVE

Screening recommendations for colorectal cancer include sigmoidoscopy in asymptomatic, average risk persons aged 50 and over and colonoscopy every three to five years in high risk groups. Little is known about the eligible population's compliance with endoscopic screening. This is the first Italian report of an endoscopic screening programme for colorectal cancer patients' relatives.

DESIGN

In 1986, a pilot project for colorectal cancer screening by endoscopy in high risk subjects was started in the Desio (Milan, Italy) public health service region. The results obtained after seven years are described.

SETTING

The names of 536 inhabitants with colorectal cancer diagnosed between January 1975 and December 1984 and their relatives' addresses were obtained from the Regione Lombardia Health System records and from the municipal registry offices respectively.

PARTICIPANTS

From October 1986 to October 1993, 778 first degree relatives aged 20-75 were offered colonoscopy.

MAIN RESULTS

After seven years, 233 (29.9%) had undergone endoscopic examination, mostly up to the splenic flexure. Being > 60 in age at the start of the programme negatively affected the participation (p < 0.05). Two cancers were detected and adenomatous polyps were found in another 24 of those screened (frequencies 0.9% and 10.3% respectively). Male gender (p < 0.05), increasing age in males (p < 0.01), and two or more affected relatives in females (p < 0.01) positively affected the frequency of polyps detection.

CONCLUSION

These results suggest that about 30% of the eligible population would comply at least with sigmoidoscopic screening. The collaboration of family doctors and more widespread public information about the ability to cure colorectal cancer are necessary for better compliance.

A survey of screening compliance among first degree relatives of people with colon cancer in New South Wales

OBJECTIVE

To survey screening practices, knowledge, and attitudes towards screening among first degree relatives of people with colon cancer.

SETTING

A random sample of people with colon cancer listed on the New South Wales (NSW) Cancer Registry were mailed a questionnaire to be passed on to an appropriate first degree relative.

METHODS

Two hundred and twenty five first degree relatives completed a self administered questionnaire.

RESULTS

Although there were high levels of awareness about colorectal cancer, and attitudes towards colorectal cancer were generally positive, screening rates were low, and only three relatives had been screened in accordance with current Australian recommendations. Factors associated with previous participation in any type of screening test (usually once) included receiving a medical recommendation to screen, having more than one relative with colorectal cancer, being a sibling of the relative with colon cancer, the relative with cancer being female, and perceiving screening as messy, but not painful.

CONCLUSIONS

Strategies to enhance screening awareness and participation among relatives need to be considered. This study provides some insight into factors to be considered in developing awareness programmes. Further research is required to explore these factors, and to identify ways to overcome barriers.

Colorectal screening patterns and perceptions of risk among African-American users of a community health center

This study investigated risk perceptions and screening patterns for colorectal cancer among predominately low-income African-Americans age 50 and older who used a community health center. The majority of respondents either rated their risk as below average (36%) or did not know their risk (37%) for colorectal cancer. Individuals who provided a risk estimate versus those who did not know their risk were younger and held more accurate beliefs about colorectal cancer. Attributions of perceived risk best distinguished respondents who evaluated their risk to be below average versus average and above average. Compared to respondents who could not explain their risk, those who provided psychological, personal action, and heredity causes were more likely to view their risk as below average than average or above average. In comparison to national norms, these subjects reported higher frequencies of ever having had a digital rectal exam (DRE, 90%), fecal occult blood test (FOBT, 75%) and sigmoidoscopy (SIG, 33%). Moreover, 63%, 53%, and 81% reported their most recent screening for DRE, FOBT, and SIG, respectively, in accordance with ACS and NCI recommended guidelines. However, a subsequent medical audit failed to confirm these self-reports. These results suggest that: 1) educational efforts are needed to enhance knowledge and accuracy of risk perceptions for colorectal cancer; 2) further studies on attributions of risk are needed that may prove useful for developing intervention programs, and 3) studies need to interpret self-report data for colorectal cancer with caution.

Participation in a women's breast cancer risk counseling trial. Who participates? Who declines? High Risk Breast Cancer Consortium

BACKGROUND

Little is known about what factors influence women to participate its trials designed for women at high risk for breast cancer. Yet the recruitment phase is of utmost importance in determining whether the trial can achieve its goals. The purpose of this study was to examine predictors of participation in a risk counseling trial for first-degree relatives of breast cancer patients.

METHODS

Subjects were identified by their relatives who had received a diagnosis of breast cancer at one of six institutions. Letters of introduction were sent to potentially eligible, unaffected relatives. They were informed about the risk counseling study and given the opportunity to decline. Letters were sent to 1392 first-degree relatives; of these, 1149 women were contacted for an interview and 14% refused. Of the 987 respondents, 47% accepted and 53% declined to participate. Bivariate and multivariate statistics were used to examine predictors of participation.

RESULTS

In the total sample, there were five significant multivariable predictors of participation: level of education, recent clinical breast examination (CBE), objective and perceived breast cancer risk, and any current use of alcohol. Participation was moderated by time since the relative's diagnosis. There was a statistically significant relationship to education such that women with a higher level of education were significantly more likely to participate if they were approached within 2 months of their relative's diagnosis of breast cancer.

CONCLUSIONS

Like many other kinds of trials, participants in this risk counseling trial were significantly more likely to have more than a high school education and more likely to be nonsmokers than the nonparticipants. They also were significantly more likely to drink alcohol (dichotomous measure), have had a recent CBE, and have higher subjective and objective breast cancer risks. Different types of recruitment strategies may be needed depending on the characteristics of the people being recruited and the timing of the invitation.

Gail model breast cancer risk components are poor predictors of risk perception and screening behavior

The Gail model is being used increasingly to determine individual breast cancer risk and to tailor preventive health recommendations accordingly. Although widely known to the medical and biostatistical communities, the risk factors included in the model may not be salient to the women to whom the model is being applied. This study explored the relationship of the individual Gail model risk factors to perceived risk of breast cancer and prior breast cancer screening among women with a family history of breast cancer. Data from baseline interviews with 969 women found a striking disparity between the objective risk factors included in the model and the accuracy of perceived risk and screening behaviors of this population, particularly among women over the age of 50 years. Risk perception accuracy was unrelated to all of the Gail model risk factors for all age groups. Reported mammography adherence was only associated with having had a breast biopsy in both age groups. Breast self examination (BSE) practice was independent of all measured factors for both age groups. These findings support the need for further research to identify additional determinants of risk perception and motivators of screening behavior.

Screening flexible sigmoidoscopy: patient attitudes and compliance

OBJECTIVE

To measure patients' expectations and attitudes about screening flexible sigmoidoscopy and their discomfort during the procedure, and to identify factors affecting compliance among patients scheduled for sigmoidoscopy.

DESIGN

Patient survey at the time sigmoidoscopy was ordered and again one week after the procedure was performed.

SETTING

An academic general internal medicine practice.

PATIENTS

105 consecutive patients scheduled for screening flexible sigmoidoscopy.

MAIN RESULTS

Seventy-five percent of patients (79/105) scheduled for sigmoidoscopy complied with the procedure. Compliance was higher among men and among patients who had family histories of colon cancer. Although many patients experienced moderate to extreme embarrassment (27%), discomfort (42%), and pain (31%), patients experienced less embarrassment (p = 0.03) and pain (p = 0.02) than they had expected. Patients aged 65 years and older were twice as likely as younger ones (52% versus 25%) to experience moderate to extreme pain (p = 0.04). Only 1.4% of patients reported that they would probably not have the test again.

CONCLUSION

Although flexible sigmoidoscopy is an uncomfortable procedure for some patients, especially those aged 65 and older, in general it is not as bad as patients expect and most would have the test again. Therefore, rather than assuming sigmoidoscopy is too uncomfortable for all patients to tolerate as a screening test, clinicians should inform their patients about the potential benefits and risks of sigmoidoscopy and about what the patient can expect during the procedure, thus enabling the patient to make an informed decision about whether to undergo screening sigmoidoscopy.

Feasibility of family based screening for colorectal neoplasia: experience in one general surgical practice

Relatives of patients with colorectal cancer have on average a two to threefold increased risk for developing bowel neoplasia although in some families the risk is much higher. This study examined the compliance for endoscopic screening and faecal occult blood testing among first degree relatives of patients with colorectal cancer to determine the feasibility of offering a screening service in a surgical practice. The endoscopic method (flexible sigmoidoscopy or colonoscopy) offered depended upon the extent of family history. Spouses of patients were offered flexible sigmoidoscopy as a group for comparison. Compliance in first degree relatives was significantly higher than in spouses (69% v 47%, p < 0.01) and among those relatives of patients who had died recently from colorectal cancer but time since diagnosis in the index case had no effect. Adenomas were found in 14 of 92 (15%) relatives and three of 30 (10%) spouses. It is estimated that, under our screening guidelines, every 100 patients with colorectal cancer would generate a list of 35-40 relatives who would be screened once by flexible sigmoidoscopy and perhaps 75, who because of their young age, might be screened twice in their lifetime. Also, from this same 100 patients, about 12-15 relatives would merit entry in a colonoscopic screening programme because of their more extensive family history. These results indicate that endoscopic screening of relatives of patients with colorectal cancer is feasible within a practice.