Age-related vulnerabilities of older adults with colon adenomas: evidence from Project Prevent

Lifetime prevalence and correlates of colorectal cancer screening among low-income U.S. Veterans

PURPOSE

The Veterans Health Administration (VHA) is the largest integrated healthcare system in the U.S. While preventive healthcare services are high priority in the VHA, low-income U.S. Veterans experience adverse life circumstances that may negatively impact their access to these services. This study examined lifetime prevalence as well as demographic, socioeconomic, military-specific, and clinical correlates of colorectal cancer (CRC) screening among low-income U.S. Veterans ≥ 50 years of age.

METHODS

Cross-sectional data on 862 participants were analyzed from the 2021-2022 National Veteran Homeless and Other Poverty Experiences study.

RESULTS

Overall, 55.3% (95% confidence interval [CI] 51.3-59.3%) reported ever-receiving CRC-screening services. In a multivariable logistic regression model, never-receivers of CRC screening were twice as likely to reside outside of the Northeast, and more likely to be married (odds ratio [OR] = 1.86, 95% CI 1.02, 3.37), have BMI < 25 kg/m2 [vs. 25- < 30 kg/m2] (OR = 1.75, 95% CI 1.19, 2.58), or ≥ 1 chronic condition (OR = 1.46, 95% CI 1.06, 2.02). Never-receivers of CRC screening were less likely to be female (OR = 0.53, 95% CI 0.29, 0.96), aged 65-79y [vs. ≥ 80y] (OR = 0.61, 95% CI 0.40, 0.92), live in 5 + member households (OR = 0.33, 95% CI 0.13, 0.86), disabled (OR = 0.45, 0.22, 0.92), with purchased health insurance (OR = 0.56, 95% CI 0.33, 0.98), or report alcohol-use disorder (OR = 0.10, 95% CI 0.02, 0.49) and/or HIV/AIDS (OR = 0.28, 95% CI 0.12, 0.68).

CONCLUSION

Nearly 55% of low-income U.S. Veterans reported ever screening for CRC. Variations in CRC-screening behaviors according to veteran characteristics highlight potential disparities as well as opportunities for targeted behavioral interventions.

Knowledge, Attitudes, and Beliefs About Colorectal Cancer Screening in Puerto Rico

The purpose of this study was to describe the psychosocial factors influencing participation in colorectal cancer screening (CRCS) among Puerto Rican men and women. We conducted seven focus groups in metropolitan and rural areas of Puerto Rico (PR) with men and women (using gender specific groups) aged 50 to 80 years (n = 51) who were non-adherent to CRC guidelines. The focus group guide included questions related to colorectal cancer (CRC) and CRC screening knowledge, attitudes, and beliefs. We analyzed data using a modified grounded theory approach to identify emergent themes. Focus groups revealed seven major themes that represented barriers to CRCS: (1) lack of CRC knowledge, (2) lack of knowledge about colorectal cancer screening tests as well as the required preparation, (3) embarrassment, (4) low perceived benefit of CRCS and sense of fatalism, (5) transportation (mostly among participants in rural areas), (6) lack of time, and (7) financial burden. All participants understood the benefits of CRCS once the procedure was explained. Additionally, participants reported a lack of provider recommendation for CRCS. In this group of Puerto Rican participants who were non-adherent to CRCS, there were misconceptions about CRC, screening tests available, and preparation and testing procedures. Participants' low levels of knowledge and negative attitudes concerning CRCS and low reported provider recommendation were important deterrents to screening. These findings suggest the need for educational efforts to increase knowledge and attitudes about CRCS and improved patient-provider communication to reduce missed opportunities to recommend.

Economic Perspective of Cancer Care and Its Consequences for Vulnerable Groups

Simple Summary

For cancer patients, many different reasons can cause financial burdens and economic threads. Sociodemographic factors, rural/remote location and income are known determinants for these vulnerable groups. This economic vulnerability is related to the reduced utilization of cancer care and the impact on outcome. Financial burden has been reported in many countries throughout the world and needs to be addressed as part of the sufficient quality of cancer care.

Abstract

Within healthcare systems in all countries, vulnerable groups of patients can be identified and are characterized by the reduced utilization of available healthcare. Many different reasons can be attributed to this observation, summarized as implementation barriers involving acceptance, accessibility, affordability, acceptability and quality of care. For many patients, cancer care is specifically associated with the occurrence of vulnerability due to the complex disease, very different target groups and delivery situations (from prevention to palliative care) as well as cost-intensive care. Sociodemographic factors, such as educational level, rural/remote location and income, are known determinants for these vulnerable groups. However, different forms of financial burdens likely influence this vulnerability in cancer care delivery in a distinct manner. In a narrative review, these socioeconomic challenges are summarized regarding their occurrence and consequences to current cancer care. Overall, besides direct costs such as for treatment, many facets of indirect costs including survivorship costs for the cancer patients and their social environment need to be considered regarding the impact on vulnerability, treatment compliance and abundance. In addition, individual cancer-related financial burden might also affect the society due to the loss of productivity and workforce availability. Healthcare providers are requested to address this vulnerability during the treatment of cancer patients.

Colorectal cancer lifetime risk accuracy and behavior change intentions before and after risk assessment

PURPOSE

This study examined accuracy of perceived lifetime risk of colorectal cancer prior to and following receipt of cancer risk assessment (CRA) feedback among average risk adults. The specific aims were to identify predictors of improved risk perceptions and assess whether improvement in perceived lifetime risk accuracy was associated with changes in behavioral intentions for physical activity, diet, and colorectal cancer screening.

METHODS

Adults with no known history of colorectal cancer (n = 419) were enrolled in a study examining the impact of colorectal cancer risk assessment feedback. Risk perceptions and behavioral intentions were ascertained before and after risk assessment administration.

RESULTS

Accuracy of perceived lifetime risk significantly improved after CRA feedback, often as a result of lowered perceived risk. Those who were White, married, attended some college, and had higher numeracy were more likely to report accurate lifetime risk post-CRA. No differences in behavioral intentions were reported between those with and without improved accuracy.

CONCLUSION

Minorities and those with low numeracy were less likely to report accurate perceptions post-CRA. Although improved accuracy was not associated with increased behavioral intentions as expected, it is reassuring that intentions for health behaviors were not inhibited as perceived risk decreased.

Cancer Screening in the Elderly: A Review of Breast, Colorectal, Lung, and Prostate Cancer Screening

There are relatively limited data on outcomes of screening older adults for cancer; therefore, the decision to screen older adults requires balancing the potential harms of screening and follow-up diagnostic tests with the possibility of benefit. Harms of screening can be amplified in older and frail adults and include discomfort from undergoing the test itself, anxiety, potential complications from diagnostic procedures resulting from a false-positive test, false reassurance from a false-negative test, and overdiagnosis of tumors that are of no threat and may result in overtreatment. In this paper, we review the evidence and guidelines on breast, colorectal, lung and prostate cancer as applied to older adults. We also provide a general framework for approaching cancer screening in older adults by incorporating evidence-based guidelines, patient preferences, and patient life expectancy estimates into shared screening decisions.

Does colorectal cancer risk perception predict screening behavior? A systematic review and meta-analysis

Although health behavior theories postulate that risk perception should motivate colorectal cancer (CRC) screening, this relationship is unclear. This meta-analysis aims to examine the relationship between CRC risk perception and screening behavior, while considering potential moderators and study quality. A search of six databases yielded 58 studies (63 effect sizes) that quantitatively assessed the relationship between CRC risk perception and screening behavior. Most included effect sizes (75 %) reported a positive association between CRC risk perception and screening behavior. A random effects meta-analysis yielded an overall effect size of z = 0.13 (95 % CI 0.10-0.16), which was heterogeneous (I (2) = 99 %, τ(2) = 0.01). Effect sizes from high-quality studies were significantly lower than those from lower quality studies (z = 0.02 vs. 0.16). We found a small, positive relationship between CRC risk perception and reported screening behavior, with important identified heterogeneity across moderators. Future studies should focus on high quality study design.

Higher serum uric acid levels and advanced age are associated with an increased prevalence of colorectal polyps

The present study retrospectively analyzed the laboratory data of patients who had undergone a colonoscopy between April 2011 and March 2014, with the aim of assessing whether these variables could be used to predict the presence of colorectal polyps (CP). A total of 1,471 patients were enrolled (731 men, 68.5±10.8 years; 740 women, 66.7±10.8 years). One-way analysis of variance was performed to analyze the association between the presence of CP and a range of laboratory variables. Logistic regression analysis was performed to establish a regression equation to predict the presence of CP. Receiver-operator characteristics analysis was applied to investigate the performance of the regression equation. Patients with CP were older than those without CP (P<0.0001). Serum uric acid (UA) levels were higher in patients with CP, compared to those without CP (P=0.0007). To investigate the possibility that older age and higher UA levels could predict the presence of CP, logistic regression analysis was performed (P=0.0008). The regression equation was as follows: ln(p/1 - p) = 2.79015 - 0.01836 × age - 0.28542 × UA (mg/dl), where p indicates the presence of CP. Receiver-operator characteristic analysis showed the area under the curve to be 0.62092 and the threshold value of P was 0.4370. Sensitivity and specificity of the threshold value were 77.6 and 44.2%, respectively. Advanced age and higher serum UA levels were associated with the presence of CP. In conclusion, logistic regression analysis obtained a regression equation that predicted the presence of CP with a higher sensitivity, but poorer specificity, compared to fecal occult blood testing.

Factors influencing colorectal cancer screening in low-income African Americans in Tennessee

This study examined demographic and lifestyle factors that influenced decisions and obstacles to being screened for colorectal cancer in low-income African Americans in three urban Tennessee cities. As part of the Meharry Community Networks Program (CNP) needs assessment, a 123-item community survey was administered to assess demographic characteristics, health care access and utilization, and screening practices for various cancers in low-income African Americans. For this study, only African Americans 50 years and older (n=460) were selected from the Meharry CNP community survey database. There were several predictors of colorectal cancer screening such as being married and having health insurance (P< .05). Additionally, there were associations between obstacles to screening and geographic region such as transportation and health insurance (P< .05). Educational interventions aimed at improving colorectal cancer knowledge and screening rates should incorporate information about obstacles and predictors to screening.

Unwillingness to participate in colorectal cancer screening: examining fears, attitudes, and medical mistrust in an ethnically diverse sample of adults 50 years and older

PURPOSE

Identify the influence of medical mistrust, fears, attitudes, and sociodemographic characteristics on unwillingness to participate in colorectal cancer (CRC) screening.

DESIGN

Cross-sectional, disproportionally allocated, stratified, random-digit-dial telephone questionnaire of noninstitutionalized households.

SETTING

New York City, New York; Baltimore, Maryland; San Juan, Puerto Rico.

SUBJECTS

Ethnically diverse sample of 454 adults ≥50 years of age.

MEASURES

Health status, cancer screening effectiveness, psychosocial factors (e.g., perceptions of pain, fear, trust), and CRC screening intentions using the Cancer Screening Questionnaire, which addresses a range of issues related to willingness of minorities to participate in cancer screening.

ANALYSIS

Multivariate logistic regression was used to model the probability of reporting unwillingness to participate in CRC screening.

RESULTS

Fear of embarrassment during screening (odds ratio [OR] = 10.72; 95% confidence interval [CI], 2.15-53.39), fear of getting AIDS (OR = 8.75; 95% CI, 2.48-30.86), fear that exam might be painful (OR = 3.43; 95% CI, 1.03-11.35), and older age (OR = 1.10; 95% CI, 1.04-1.17) were positively associated with unwillingness to participate in CRC screening. Fear of developing cancer (OR = .12; 95% CI, .03-.57) and medical mistrust (OR = .19; 95% CI, .06-.60) were negatively associated with unwillingness to screen.

CONCLUSIONS

Findings suggest that CRC health initiatives should focus on increasing knowledge, addressing fears and mistrust, and normalizing CRC screening as a beneficial preventive practice, and should increase focus on older adults.

Adaptation process and psychosocial resources of Chinese colorectal cancer patients undergoing adjuvant treatment: a qualitative analysis

OBJECTIVES

To examine how Chinese patients with colorectal cancer (CRC) dynamically adapt to diagnosis and treatment and explore how patients evolve and deploy different resources throughout the illness trajectory.

METHODS

Semi-structured interviews were conducted on a purposive sample of 16 histologically diagnosed Chinese CRC patients about to complete or who had very recently completed all treatment without recurrence. Recorded interviews were transcribed verbatim and analyzed by using grounded theory techniques.

RESULTS

Three major adaptation-related themes were identified: (1) utilization of medical resources, (2) transition of resource utilization, and (3) continuous resistance to demands. Initial prevailing fatalistic views of diagnosis associated predominantly with frequent medical surveillance and with respondents' weighting of treatment and expertise of medical professionals. As treatment progressed, there was a shift toward reliance on personal and social resources to field cancer-related demands concurrent with a gradual distancing from medical care. Upon treatment completion, fatalism re-emerged regarding disease recurrence, which, like diagnosis, was seen as not amenable to individual control, even with close adherence to medical follow-ups and dietary adjustment. Maintaining positive states of mind and good relationships with family and friends were cores strategies respondents adopted to preserve psychological well-being.

CONCLUSIONS

Maintenance and enhancement of personal and social resources throughout the CRC trajectory may have considerably more utility than traditional descriptive studies hitherto suggested. Considering personal and social resources within dynamic rather than static models could avoid the pitfall of attributing maladaptive responses to initial dispositions and socioeconomic conditions that are seemingly unalterable and enduring over time.

Understanding the role of cancer worry in creating a "teachable moment" for multiple risk factor reduction

The manuscript examines the influence of contextual factors on whether and for whom a colon polyp diagnosis might be a teachable moment, as indicated by engagement with a proactively delivered intervention. Baseline and 8-month follow-up data were analyzed from a two-site behavioral intervention trial with patients in Massachusetts and North Carolina, USA who had recently undergone polypectomy for pre-cancerous colon polyps and were randomized to a behavior change intervention condition (N=591). Intervention "buy-in" was used as an indicator of response consistent with the polyp identification serving as a teachable moment. Cancer worry, personal risk, health-related self-identity and other sociodemographic factors were tested to predict intervention buy-in. As predicted, those who were most worried about colon cancer were most likely to engage in the intervention. One indicator of personal risk, number of risk behaviors, was significantly and negatively associated with buy-in. Predictors of intervention buy-in and cancer worry were not consistent. We recommend that expanded measures of affect and health-related self-identity should be considered in future research to understand the motivational potential of health events for increasing engagement in effective behavior change interventions.

Predictors of colorectal cancer screening behaviors among average-risk older adults in the United States

OBJECTIVE

To critically evaluate recent studies that examined determinants of CRC screening behaviors among average-risk older adults (>or=50 years) in the United States.

METHODS

A PUBMED (1996-2006) search was conducted to identify recent articles that focused on predictors of CRC initiation and adherence to screening guidelines among average-risk older adults in the United States.

RESULTS

Frequently reported predictors of CRC screening behaviors include older age, male gender, marriage, higher education, higher income, White race, non-Hispanic ethnicity, smoking history, presence of chronic diseases, family history of CRC, usual source of care, physician recommendation, utilization of other preventive health services, and health insurance coverage. Psychosocial predictors of CRC screening adherence are mostly constructs from the Health Belief Model, the most prominent of which are perceived barriers to CRC screening.

CONCLUSIONS

Evidence suggests that CRC screening is a complex behavior with multiple influences including personal characteristics, health insurance coverage, and physician-patient communication. Health promotion activities should target both patients and physicians, while focusing on increasing awareness of and accessibility to CRC screening tests among average-risk older adults in the United States.

Cognitive Mediators Linking Social Support Networks to Colorectal Cancer Screening Adherence

This paper argues that normative considerations are more important than attitudinal factors in engaging colorectal cancer screening, and tests a model explaining how unique cultural expressions of social networks influence screening adherence. Structural equation modeling was used to understand colorectal cancer screening in a population-based sample of 341 Japanese Americans aged 50 and over. The model accounted for 25% of the variance in screening adherence. Adherence was most strongly associated with family/friend subjective norms about colorectal cancer screening use. Emotional family support, but not the size of the networks, was indirectly related to adherence via increased family/friend subjective norms, while emotional friend support was directly related to adherence. While usual source of care was directly associated with adherence, better provider-patient communication was directly and indirectly associated with adherence via increased perceived benefits. The findings of this study support strengthening informal support networks to enhance adherence among Japanese Americans at risk.

Predictors of perceived risk for colon cancer in a national probability sample in the United States

This study examines potential predictors of perceived risk for colon cancer in a U.S. sample of 2,949 individuals aged 45 and older with no colon cancer history. We examined perceived comparative risk for colon cancer as the outcome in ordinal regression analyses, and perceived absolute risk for colon cancer in linear regression analyses. Potential predictors included demographics, current risk behaviors, self-reported health, family and personal cancer history, emotion variables (colon cancer worry, general anxiety, and fear of positive screening findings), general cancer beliefs (causes, lack of preventability, information overload), and cancer information seeking. Those who had poorer self-reported health, a family cancer history, and increased colon cancer worry had higher perceived comparative and absolute colon cancer risk (all ps < .05). Those who were younger, interviewed in Spanish, had increased anxiety, and information overload had higher comparative risk; those with a personal history of cancer and fear that colon cancer screening would result in positive findings had higher absolute risk (all ps < .05). We determined that older individuals, those with risk factors, and those with good subjective health may not realize their colon cancer risk. Those distressed about colon cancer and who report cancer prevention information overload may require different messages.

Colorectal cancer screening: physician recommendation is influential advice to Marylanders

BACKGROUND

In comparison to the United States, Maryland is facing a significantly higher burden of colorectal cancer incidence and mortality. The primary objective of this study was to determine the predictors of colorectal cancer screening use in Maryland.

METHODS

We performed secondary analyses on Maryland Cancer Survey 2002 data from 2994 respondents to investigate important predictors for individual colorectal cancer screening tests. CRC screening outcomes were defined as (1) FOBT within the past year, (2) sigmoidoscopy within the past 5 years, or (3) colonoscopy within the past 10 years.

RESULTS

We found that clinician recommendation for a screening test is the best predictor in both age categories (50-64 years and 65+ years); it is a very strong indicator and consistently improves the odds of use by a factor of at least 8 for any screening test.

CONCLUSIONS

There remains a great need for improved colorectal cancer screening in Maryland. According to our results, it is clear that the most influential way to improve overall colorectal cancer screening for each test and both age groups is to increase clinician recommendation for these tests.