Trends in colorectal cancer screening with home-based fecal occult blood tests in adults ages 50 to 64 years, 2000-2008

Cancer Screening in the United States During the Second Year of the COVID-19 Pandemic

PURPOSE

To examine whether cancer screening prevalence in the United States during 2021 has returned to prepandemic levels using nationally representative data.

METHODS

Information on receipt of age-eligible screening for breast (women age 50-74 years), cervical (women without a hysterectomy age 21-65 years), prostate (men age 55-69 years), and colorectal cancer (men and women age 50-75 years) according to the US Preventive Services Task Force recommendations was obtained from the 2019 and 2021 National Health Interview Survey. Past-year screening prevalence in 2019 and 2021 and adjusted prevalence ratios (aPRs), 2021 versus 2019, with their 95% CIs were calculated using complex survey logistic regression models.

RESULTS

Between 2019 and 2021, past-year screening in the United States decreased from 59.9% to 57.1% (aPR, 0.94; 95% CI, 0.91 to 0.97) for breast cancer, from 45.3% to 39.0% (aPR, 0.85; 95% CI, 0.82 to 0.89) for cervical cancer, and from 39.5% to 36.3% (aPR, 0.9; 95% CI, 0.84 to 0.97) for prostate cancer. Declines were most notable for non-Hispanic Asian persons. Colorectal cancer screening prevalence remained unchanged because an increase in past-year stool testing (from 7.0% to 10.3%; aPR, 1.44; 95% CI, 1.31 to 1.58) offset a decline in colonoscopy (from 15.5% to 13.8%; aPR, 0.88; 95% CI, 0.83 to 0.95). The increase in stool testing was most pronounced in non-Hispanic Black and Hispanic populations and in persons with low socioeconomic status.

CONCLUSION

Past-year screening prevalence for breast, cervical, and prostate cancer among age-eligible adults in the United States continued to be lower than prepandemic levels in the second year of the COVID-19 pandemic, reinforcing the importance of return to screening health system outreach and media campaigns. The large increase in stool testing emphasizes the role of home-based screening during health care system disruptions.

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Evaluation of Colonoscopy and Sigmoidoscopy Utilization for Colorectal Cancer Screening in Georgia, USA

Colorectal cancer (CRC) is the third most prevalent cancer, and the second most common cancer-related cause of death in the United States (USA). Timely screening reduces both CRC incidence and mortality. Understanding population behaviors and factors that influence CRC screening is important for directing interventions targeted at reducing CRC rates. The 1997-2018 Behavioral Risk Factor Surveillance System (BRFSS) data were analyzed for trends in colonoscopy and sigmoidoscopy utilization for CRC screening among adults in Georgia, USA. Overall, in Georgia, there has been an increase in the prevalence of colonoscopy and sigmoidoscopy utilization from 48.1% in 1997 to 71.2% in 2018 (AAPC = 2.30, p < 0.001). Compared nationally, this increase was less pronounced (from 41.0% in 1997 to 73.7% in 2018 (AAPC = 2.90, p < 0.001) overall for USA). Logistic regression analysis of the 2018 BRFSS data, adjusting for sociodemographic factors, shows that sex (female vs. male [aOR = 1.20, C.I. = 1.05, 1.38]); marital status (couple vs. single [aOR = 1.20, C.I. = 1.04, 1.39]); healthcare coverage (yes vs. no [aOR = 3.86, C.I. = 3.05, 4.88]); age (60-69 years [aOR = 2.38, C.I. = 2.02, 2.80], 70-79 [aOR = 2.88, C.I. = 2.38, 3.48] vs. 50-59 years); education (high school [aOR = 1.32, C.I. = 1.05, 1.65], some post high school [aOR= 1.63, C.I. = 1.29, 2.06], college graduate [aOR = 2.08, C.I. = 1.64, 2.63] vs. less than high school); and income ($25,000-$49,999 [aOR = 1.24, C.I. = 1.01, 1.51], $50,000+ [aOR = 1.56, C.I. = 1.27, 1.91] vs. <$25,000) were all significantly associated with colonoscopy and sigmoidoscopy utilization. In Georgia, a significant increase over time in colonoscopy and sigmoidoscopy utilization for CRC screening was observed pertaining to the associated sociodemographic factors. The findings from this study may help guide tailored programs for promoting screening among underserved populations.

Evaluation of Blood Stool Test Utilization for Colorectal Cancer Screening in Georgia, USA

Colorectal cancer (CRC) is the third most prevalent cancer and the second most common cause of cancer-related deaths in the United States (USA). Early screening has been demonstrated to improve clinical outcomes for CRC. Assessing patterns in CRC screening utilization is important for guiding policy and implementing programs for CRC prevention and control. This study examines the trends and sociodemographic factors associated with blood stool test utilization (BSTU) for CRC screening in Georgia, USA. The Behavioral Risk Factor Surveillance System (BRFSS) data were analyzed for Average Annual Percent Change (AAPC) in BSTU between 1997 and 2014 among adults aged 50+ who have had a blood stool test within the past two years, and logistic regression analysis of the 2016 data was performed to identify the associated sociodemographic factors. In Georgia, an overall decrease was observed in BSTU, from 27.8% in 1997 to 16.1% in 2014 (AAPC = -2.6, p = 0.023). The decrease in BSTU was less pronounced in Georgia than nationally (from 26.1% in 1997 to 12.8% in 2014 (AAPC = -4.5, p < 0.001)). BSTU was significantly associated with black race/ethnicity (Black vs. White (aOR = 1.43, p = 0.015)), older age (≥70 vs. 50-59 (aOR = 1.62, p = 0.006)), having insurance coverage (no vs. yes (aOR = 0.37 p = 0.005)), and lower income (≥USD 50,000 vs. Collapse

Key Words

• FOBT
• Georgia
• USA
• blood stool test
• colorectal cancer
• screening

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MESH Headings Collapse

Grants Collapse

Affiliation(s)

Benjamin E. Ansa Institute of Public and Preventive Health, Augusta University, Augusta, GA 30912, USA; (B.D.); (J.A.J.)
Nicollette Lewis Medical College of Georgia, Augusta University, Augusta, GA 30912, USA;
Zachary Hoffman Department of Psychology, Augusta University, Augusta, GA 30912, USA; Transitions of Augusta, Augusta, GA 30912, USA
Biplab Datta Institute of Public and Preventive Health, Augusta University, Augusta, GA 30912, USA; (B.D.); (J.A.J.)
J. Aaron Johnson Institute of Public and Preventive Health, Augusta University, Augusta, GA 30912, USA; (B.D.); (J.A.J.)

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Predictors of Colorectal Cancer Screening Modality Among Newly Age-Eligible Medicaid Enrollees

INTRODUCTION

This study examines individual- and practice-level predictors of screening modality among 1,484 Medicaid enrollees who initiated colorectal cancer screening (fecal immunochemical test/fecal occult blood tests or colonoscopy) within a year of turning age 50 years. Understanding screening modality patterns for patients and health systems can help optimize colorectal cancer screening initiatives that will lead to high screening completion rates.

METHODS

Multivariable logistic regression was conducted in 2019 to analyze Medicaid claims data (January 2013-June 2015) to explore predictors of colonoscopy screening (versus fecal testing).

RESULTS

Overall, 64% of enrollees received a colonoscopy and 36% received a fecal immunochemical test/fecal occult blood test. Male (OR=1.21, 95% CI=1.08, 1.37) compared with female enrollees and those with 4-6 (OR=1.57, 95% CI=1.15, 2.15), 7-10 (OR=2.23, 95% CI=1.64, 3.03), and ≥11 (OR=1.79, 95% CI=1.22, 2.65) primary care visits compared with 0-3 visits had higher odds of colonoscopy screening. Non-White, non-Hispanic enrollees (OR=0.71, 95% CI=0.58, 0.87) compared with White, non-Hispanics Whites had lower odds of colonoscopy screening. Practices with an endoscopy facility within their ZIP code (OR=1.50, 95% CI=1.08, 2.08) compared with practices without a nearby endoscopy facility had higher odds of colonoscopy screening.

CONCLUSIONS

Among newly age-eligible Medicaid enrollees who received colorectal cancer screening, non-White, non-Hispanic individuals were less likely and male enrollees and those with ≥4 primary care visits were more likely to undergo colonoscopy versus fecal immunochemical test/fecal occult blood test. Colonoscopy also was the more common modality among adults whose primary care clinic had an endoscopy facility in the same ZIP code. Future research is needed to fully understand patient, provider, and practice preferences regarding screening modality.

Cancer fatalism and adherence to national cancer screening guidelines: Results from the Hispanic Community Health Study/Study of Latinos (HCHS/SOL)

BACKGROUND

Sociocultural factors, such as health insurance status, income, education, and acculturation, predict cancer screening among U.S. Hispanics/Latinos. However, these factors can be difficult to modify. More research is needed to identify individual-level modifiable factors that may improve screening and subsequent cancer outcomes in this population. The aim of this study was to examine cancer fatalism (i.e., the belief that there is little or nothing one can do to lower his/her risk of developing cancer) as a determinant of adherence to national screening guidelines for colorectal, breast, prostate, and cervical cancer among Hispanics/Latinos.

METHODS

Participants were from the multi-site Hispanic Community Health Study/Study of Latinos (HCHS/SOL) Sociocultural Ancillary Study (N = 5313). The National Cancer Institute (NCI) Health Interview National Trends Survey was used to assess cancer fatalism and receipt of cancer screening. Adherence was defined as following screening guidelines from United States Preventive Services Task Force and the American Cancer Society during the study period.

RESULTS

Adjusting for well-established determinants of cancer screening and covariates (health insurance status, income, education, acculturation, age, Hispanic/Latino background), lower cancer fatalism was marginally associated with greater adherence to screening for colorectal (OR 1.13, 95% CI [.99-1.30], p = .07), breast (OR 1.16, 95% CI [.99-1.36], p = .08) and prostate cancer (OR 1.18, 95% CI [.97-1.43], p = .10), but not cervical cancer.

CONCLUSIONS

The associations of cancer fatalism were small and marginal, underlining that sociocultural factors are more robust determinants of cancer screening adherence among Hispanics/Latinos.

Intention to undergo faecal occult blood testing in an ethnic minority

AIM

To explore factors associated with the intention of an ethnic minority of Israeli Arabs to undergo faecal occult blood testing using the Health Belief Model.

METHODS

This was a quantitative correlational study that utilized a questionnaire constructed based on the Health Belief Model. The questionnaire was administered to a convenience sample of 200 Israeli Arabs aged 50 and over. Data were collected during January to March 2018.

FINDINGS

The research findings show that respondents had a high intention to undergo faecal occult blood testing in the future, although only 66.5% of the respondents had ever undergone it in the past. Physicians and nurses were the most significant sources of information regarding the faecal occult blood testing. The Health Belief Model explained 46% of variance in the intention to undergo the faecal occult blood testing among Israeli Arabs, with perceived benefits of testing being the most significant predictor of this intention.

CONCLUSION

The Health Belief Model can serve as a basis for planning intervention programmes to be implemented by health care professionals to raise the intention of ethnic minorities to undergo faecal occult blood testing.

Association Between Neighborhood Cohesion and Cancer Screening Utilization in Chinese American Older Adults

This study aims to examine the association between neighborhood cohesion and cancer screening utilization in a community-dwelling Chinese American older population. Data were drawn from the Population Study of Chinese Elderly including 3159 Chinese American older adults aged 60 and above in the greater Chicago area. Cancer screening utilization was assessed by asking whether participants had undergone colon, breast, cervical, or prostate cancer screening. Neighborhood cohesion was measured through six questions. Logistic regression analysis showed that greater neighborhood cohesion was associated with higher likelihood of utilizing a mammogram (OR 1.32, 95% CI 1.14-1.52), a Pap test (OR 1.22, 95% CI 1.06-1.41), but not of a blood stool test (OR 1.10, 95% CI 0.98-1.23), a colonoscopy (OR 1.05, 95% CI 0.94-1.17), and a PSA test (OR 1.13, 95% CI 0.95-1.34). This study suggests positive associations between neighborhood cohesion and breast and cervical cancer screening utilization among a Chinese American older population.

Multilevel predictors of colorectal cancer testing modality among publicly and privately insured people turning 50

Understanding multilevel predictors of colorectal cancer (CRC) screening test modality can help inform screening program design and implementation. We used North Carolina Medicare, Medicaid, and private, commercially available, health plan insurance claims data from 2003 to 2008 to ascertain CRC test modality among people who received CRC screening around their 50th birthday, when guidelines recommend that screening should commence for normal risk individuals. We ascertained receipt of colonoscopy, fecal occult blood test (FOBT) and fecal immunochemical test (FIT) from billing codes. Person-level and county-level contextual variables were included in multilevel random intercepts models to understand predictors of CRC test modality, stratified by insurance type. Of 12,570 publicly-insured persons turning 50 during the study period who received CRC testing, 57% received colonoscopy, whereas 43% received FOBT/FIT, with significant regional variation. In multivariable models, females with public insurance had lower odds of colonoscopy than males (odds ratio [OR] = 0.68; p < 0.05). Of 56,151 privately-insured persons turning 50 years old who received CRC testing, 42% received colonoscopy, whereas 58% received FOBT/FIT, with significant regional variation. In multivariable models, females with private insurance had lower odds of colonoscopy than males (OR = 0.43; p < 0.05). People living 10-15 miles away from endoscopy facilities also had lower odds of colonoscopy than those living within 5 miles (OR = 0.91; p < 0.05). Both colonoscopy and FOBT/FIT are widely used in North Carolina among insured persons newly age-eligible for screening. The high level of FOBT/FIT use among privately insured persons and women suggests that renewed emphasis on FOBT/FIT as a viable screening alternative to colonoscopy may be important.

Predictors of colorectal cancer screening awareness among people working in a hospital environment

Background

Compliance rates for colorectal cancer (CRC) screening are much lower than those desired. Appropriate information on CRC risks and screening methods is supposed to stimulate motivation for screening. We aimed to identify parameters associated with the decision for CRC screening and colonoscopy in a population expected to have high awareness of disease prevention.

Methods

In a single-center, cross-sectional study, we used an anonymous questionnaire (AQ) to record the demographics, habits and screening behavior for cancers and other common diseases of all employees older than 50 years in our hospital.

Results

Among 287 active employees, 83% (n=237) answered the AQ (age 55±4 years). Thirty percent (n=70) underwent colonoscopy while 17% (n=40) underwent CRC screening (39/40) colonoscopy). Comparatively, among women 97% had a Pap-smear, 92% a mammography, while among men 83% had been tested for serum prostate-specific antigen. Age, male sex, alcohol consumption and university education correlated positively with CRC screening (P<0.05 for all). After multivariate analysis, university education remained an independent determinant of CRC screening (OR 2.488, 95%CI 1.096-5.648; P=0.029). Among subjects who had not undergone colonoscopy in the past, ignorance of the need for CRC screening (OR 0.360, 95%CI 0.150-0.867; P=0.023) and indifference to undergo such a procedure (OR 0.188, 95%CI 0.066-0.537; P=0.002) were independent determinants for not planning a future screening colonoscopy.

Conclusions

Education was the most important factor in the decision to undergo CRC screening. Colonoscopy was the preferred screening method. Ignorance of and indifference to CRC risks were the major obstacles for a future screening colonoscopy.

Decreasing Black-White Disparities in Colorectal Cancer Incidence and Stage at Presentation in the United States

Background: There are long-standing black-white disparities in colorectal cancer incidence and outcomes in the United States. Incidence and stage at diagnosis reflect the impact of national efforts directed at colorectal cancer prevention and control. We aimed to evaluate trends in black-white disparities in both indicators over four decades to inform the future direction of prevention and control efforts.Methods: We used Surveillance, Epidemiology, & End Results (SEER) data to identify whites and blacks with histologically confirmed colorectal cancer from January 1, 1975 through December 31, 2012. We calculated the age-adjusted incidence and the proportion of cases presenting in late stage by race and year. We then calculated the annual percentage change (APC) and average APC for each indicator by race, examined changes in indicators over time, and calculated the incidence disparity for each year.Results: There were 440,144 colorectal cancer cases from 1975 to 2012. The overall incidence decreased by 1.35% and 0.46% per year for whites and blacks, respectively. Although the disparity in incidence declined from 2004 to 2012 (APC = -3.88%; P = 0.01), incidence remained higher in blacks in 2012. Late-stage disease declined by 0.27% and 0.45% per year in whites and blacks, respectively. The proportion of late-stage cases became statistically similar in whites and blacks in 2010 (56.60% vs. 56.96%; P = 0.17).Conclusions: Black-white disparities in colorectal cancer incidence and stage at presentation have decreased over time.Impact: Our findings reflect the positive impact of efforts to improve colorectal cancer disparities and emphasize the need for interventions to further reduce the incidence gap. Cancer Epidemiol Biomarkers Prev; 26(5); 762-8. ©2016 AACR.

A Randomized Trial to Compare Alternative Educational Interventions to Increase Colorectal Cancer Screening in a Hard-to-Reach Urban Minority Population with Health Insurance

This randomized controlled trial assessed different educational approaches for increasing colorectal cancer screening uptake in a sample of primarily non-US born urban minority individuals, over aged 50, with health insurance, and out of compliance with screening guidelines. In one group, participants were mailed printed educational material (n = 180); in a second, participants' primary care physicians received academic detailing to improve screening referral and follow-up practices (n = 185); in a third, physicians received academic detailing and participants received tailored telephone education (n = 199). Overall, 21.5% of participants (n = 121) received appropriate screening within one year of randomization. There were no statistically significant pairwise differences between groups in screening rate. Among those 60 years of age or older, however, the detailing plus telephone education group had a higher screening rate than the print group (27.3 vs. 7.7%, p = .02). Different kinds of interventions will be required to increase colorectal cancer screening among the increasingly small population segment that remains unscreened. ClinicalTrials.gov Identifier: NCT02392143.

Temporal Trends in Colorectal Cancer Screening among Asian Americans

Asian Americans (AA) are less likely to be screened for colorectal cancer compared with non-Hispanic Whites (NHW), with a widening disparity for some AA subgroups in the early 2000s. Whether these patterns have continued in more recent years is unknown. We examined temporal trends in colorectal cancer screening among AA overall compared with NHWs and by AA subgroup (Chinese, Japanese, Korean, Filipino, South Asian, Vietnamese) using data from the 2003, 2005, 2007, and 2009 California Health Interview Surveys. Unadjusted (PR) and adjusted (aPR) prevalence ratios for colorectal cancer screening, accounting for sociodemographic, health care, and acculturation factors, were calculated for respondents ages 50 to 75 years (NHW n = 60,125; AA n = 6,630). Between 2003 and 2009, colorectal cancer screening prevalence increased from 43.3% to 64.6% in AA (P ≤ 0.001) and from 58.1% to 71.4% in NHW (P ≤ 0.001). Unadjusted colorectal cancer screening was significantly lower among AA compared with NHW in 2003 [PR = 0.74; 95% confidence interval (CI), 0.68-0.82], 2005 (PR = 0.78; 95% CI, 0.72-0.84), 2007 (PR = 0.91; 95% CI, 0.85-0.96), and 2009 (PR = 0.90; 95% CI, 0.84-0.97), though disparities narrowed over time. After adjustment, there were no significant differences in colorectal cancer screening between the two groups, except in 2003. In subgroup analyses, between 2003 and 2009, colorectal cancer screening significantly increased by 22% in Japanese, 56% in Chinese, 47% in Filipino, and 94% in Koreans. In our study of California residents, colorectal cancer screening disparities between AA and NHW narrowed, but were not eliminated and screening prevalence among AA remains below nationwide goals, including the Healthy People 2020 goal of increasing colorectal cancer screening prevalence to 70.5%. Cancer Epidemiol Biomarkers Prev; 25(6); 995-1000. ©2016 AACR.

Cancer statistics for Hispanics/Latinos, 2015

Cancer is the leading cause of death among Hispanics/Latinos, who represent the largest racial/ethnic minority group in the United States, accounting for 17.4% (55.4 million/318 million) of the total US population in 2014. Every 3 years, the American Cancer Society reports on cancer statistics for Hispanics based on incidence data from the National Cancer Institute, the Centers for Disease Control and Prevention, and the North American Association of Central Cancer Registries and mortality data from the National Center for Health Statistics. Among Hispanics in 2015, there will be an estimated 125,900 new cancer cases diagnosed and 37,800 cancer deaths. For all cancers combined, Hispanics have 20% lower incidence rates and 30% lower death rates compared with non-Hispanic whites (NHWs); however, death rates are slightly higher among Hispanics during adolescence (aged 15-19 years). Hispanic cancer rates vary by country of origin and are generally lowest in Mexicans, with the exception of infection-associated cancers. Liver cancer incidence rates in Hispanic men, which are twice those in NHW men, doubled from 1992 to 2012; however, rates in men aged younger than 50 years declined by 43% since 2003, perhaps a bellwether of future trends for this highly fatal cancer. Variations in cancer risk between Hispanics and NHWs, as well as between subpopulations, are driven by differences in exposure to cancer-causing infectious agents, rates of screening, and lifestyle patterns. Strategies for reducing cancer risk in Hispanic populations include increasing the uptake of preventive services (e.g., screening and vaccination) and targeted interventions to reduce obesity, tobacco use, and alcohol consumption.

Genetic architecture of colorectal cancer

Colorectal cancer (CRC) is a complex disease that develops as a consequence of both genetic and environmental risk factors. A small proportion (3-5%) of cases arise from hereditary syndromes predisposing to early onset CRC as a result of mutations in over a dozen well defined genes. In contrast, CRC is predominantly a late onset 'sporadic' disease, developing in individuals with no obvious hereditary syndrome. In recent years, genome wide association studies have discovered that over 40 genetic regions are associated with weak effects on sporadic CRC, and it has been estimated that increasingly large genome wide scans will identify many additional novel genetic regions. Subsequent experimental validations have identified the causally related variant(s) in a limited number of these genetic regions. Further biological insight could be obtained through ethnically diverse study populations, larger genetic sequencing studies and development of higher throughput functional experiments. Along with inherited variation, integration of the tumour genome may shed light on the carcinogenic processes in CRC. In addition to summarising the genetic architecture of CRC, this review discusses genetic factors that modify environmental predictors of CRC, as well as examples of how genetic insight has improved clinical surveillance, prevention and treatment strategies. In summary, substantial progress has been made in uncovering the genetic architecture of CRC, and continued research efforts are expected to identify additional genetic risk factors that further our biological understanding of this disease. Subsequently these new insights will lead to improved treatment and prevention of colorectal cancer.

Has the National Cancer Screening Program reduced income inequalities in screening attendance in South Korea?

PURPOSE

In 1999, the Korean government introduced the National Cancer Screening Program (NCSP) to increase the cancer-screening rate, particularly among the low-income population. This study investigates how the NCSP has decreased both relative and absolute income inequalities in the uptake of cancer screening in South Korea.

METHODS

A nationally representative cross-sectional repeated data from the Korea National Health and Nutrition Examination Survey 1998-2012, managed by the Ministry of Health and Welfare, was used to assess changes over time and the extent of discontinuity at the NCSP-recommended initiation age in the uptake of screening for breast, colorectal, and gastric cancers across income quartiles.

RESULTS

Relative inequalities in the uptake of screening for all cancers decreased significantly over the policy period. Absolute inequalities did not change for most cancers, but marginally increased from 9 to 14% points in the uptake of screening for colorectal cancer among men. At the recommended initiation age, absolute inequalities did not change for breast and colorectal cancers but increased from 5 to 16% points for gastric cancer, for which relative inequality significantly decreased.

CONCLUSIONS

The NCSP, which reduced out-of-pocket payment, may not decrease absolute gap although it leads to overall increases in the uptake of cancer screening and decreases in relative inequalities. Further investigations are needed to understand barriers that prevent the low-income population from attending cancer screening.

Elimination of cost-sharing and receipt of screening for colorectal and breast cancer

BACKGROUND

The aim of the cost-sharing provision of the Patient Protection and Affordable Care Act (ACA) was to reduce financial barriers for preventive services, including screening for colorectal cancer (CRC) and breast cancer (BC) among privately and Medicare-insured individuals. Whether the provision has affected CRC and BC screening prevalence is unknown. The current study investigated whether CRC and BC screening prevalence among privately and Medicare-insured adults by socioeconomic status (SES) changed before and after the ACA.

METHODS

Data obtained from the National Health Interview Survey pertaining to privately and Medicare-insured adults from 2008 (before the ACA) and 2013 (after the ACA) were used. There were 15,786 adults aged 50 to 75 years in the CRC screening analysis and 14,530 women aged ≥40 years in the BC screening analysis. Changes in guideline-recommended screening between 2008 and 2013 by SES were expressed as the prevalence difference (PD) and 95% confidence interval (95% CI) adjusted for demographics, insurance, income, education, body mass index, and having a usual provider.

RESULTS

Overall, CRC screening prevalence increased from 57.3% to 61.2% between 2008 and 2013 (P<.001). Adjusted CRC screening prevalence during the corresponding period increased in low-income (PD, 5.9; 95% CI, 1.8 to 10.2), least-educated (PD, 7.2; 95% CI, 0.9 to 13.5), and Medicare-insured (PD, 6.2; 95% CI, 1.7 to 10.7) individuals, but not in high-income, most-educated, and privately insured respondents. BC screening remained unchanged overall (70.5% in 2008 vs 70.2% in 2013) and in the low SES groups.

CONCLUSIONS

Increases in CRC screening prevalence between 2008 and 2013 were confined to respondents with low SES. These findings may in part reflect the ACA's removal of financial barriers.

Opportunities and challenges for the use of large-scale surveys in public health research: a comparison of the assessment of cancer screening behaviors

Large-scale surveys that assess cancer prevention and control behaviors are a readily available, rich resource for public health researchers. Although these data are used by a subset of researchers who are familiar with them, their potential is not fully realized by the research community for reasons including lack of awareness of the data and limited understanding of their content, methodology, and utility. Until now, no comprehensive resource existed to describe and facilitate use of these data. To address this gap and maximize use of these data, we catalogued the characteristics and content of four surveys that assessed cancer screening behaviors in 2005, the most recent year with concurrent periods of data collection: the National Health Interview Survey, Health Information National Trends Survey, Behavioral Risk Factor Surveillance System, and California Health Interview Survey. We documented each survey's characteristics, measures of cancer screening, and relevant correlates; examined how published studies (n = 78) have used the surveys' cancer screening data; and reviewed new cancer screening constructs measured in recent years. This information can guide researchers in deciding how to capitalize on the opportunities presented by these data resources.

Assessing the effectiveness of a cancer screening test in the presence of another screening modality

OBJECTIVES

Analysis of cancer screening effectiveness is challenging in part because of competing tests, which are additional screening tests that identify the condition of interest. For example, studies investigating screening with faecal occult blood tests to prevent colorectal cancer mortality need to consider the occurrence of screening colonoscopy. This paper compares analytic approaches to accounting for competing tests in analyses of cancer screening data.

METHODS

We used simulations to compare bias and efficiency across approaches in different scenarios, quantify bias, and make recommendations for analyzing the effectiveness of a screening test in the presence of competing tests.

RESULTS

Under all scenarios, the best performing approach for accommodating competing screening tests was censoring at the time of the competing screening test (range in bias across scenarios: -7.6% to 1.6%). Bias from other approaches ranged from 23.9% to 652.1%.

CONCLUSIONS

Censoring at the competing screening exam is the recommended approach for studying cancer screening effectiveness in the presence of competing tests. Censoring avoids confounding by prior competing test results and selection bias resulting from analyzing data on participants after they received a competing screening exam. Results from this study are broadly applicable to screening studies for other conditions, including other types of cancer.

Strategies to improve repeat fecal occult blood testing cancer screening

BACKGROUND

A comparative effectiveness intervention by this team improved initial fecal occult blood testing (FOBT) rates from 3% to 53% among community clinic patients. The purpose of this study was to evaluate the effectiveness and costs associated with a literacy-informed intervention on repeat FOBT testing.

METHODS

Between 2008 and 2011, a three-arm quasi-experiential comparative effectiveness evaluation was conducted in eight community clinics in Louisiana. Clinics were randomly assigned to receive: enhanced care, a screening recommendation, and FOBT kit annually; a brief educational intervention where patients additionally received a literacy appropriate pamphlet and simplified FOBT instructions; or nurse support where a nurse manager provided the education and followed up with phone support. In year 2, all materials were mailed. The study consisted of 461 patients, ages 50 to 85 years, with a negative initial FOBT.

RESULTS

Repeat FOBT rates were 38% enhanced care, 33% education, and 59% with nurse support (P = 0.017). After adjusting for age, race, gender, and literacy, patients receiving nurse support were 1.46 times more likely to complete repeat FOBT screening than those receiving education [95% confidence interval (CI), 1.14-1.06; P = 0.002] and 1.45 times more likely than those in enhanced care but this was not significant (95% CI, 0.93-2.26; P = 0.10). The incremental cost per additional person screened was $2,450 for nurse over enhanced care.

CONCLUSION

A mailed pamphlet and FOBT with simplified instructions did not improve annual screening.

IMPACT

Telephone outreach by a nurse manager was effective in improving rates of repeat FOBT, yet this may be too costly for community clinics.

How microRNAs influence both hereditary and inflammatory-mediated colon cancers

MicroRNAs have emerged as important post-translational regulators of gene expression and are involved in several physiological and pathological states including the pathogenesis of human colon cancers. In regards to tumor development, microRNAs can act as oncogenes or tumor suppressors. Two hereditary predispositions (i.e., Lynch syndrome and familial adenomatous polyposis) contribute to the development of colon cancer. In addition, individuals who suffer from inflammatory bowel diseases such as Crohn's disease or ulcerative colitis have a higher risk of developing colon cancer. Here, we discuss the occurrence of the deregulated expression of microRNAs in colon cancer that arise as a result of hereditary predisposition and inflammatory bowel disease.

Cancer screening in the United States, 2013: a review of current American Cancer Society guidelines, current issues in cancer screening, and new guidance on cervical cancer screening and lung cancer screening

Each year the American Cancer Society (ACS) publishes a summary of its recommendations for early cancer detection, a report on data and trends in cancer screening rates, and select issues related to cancer screening. In this issue of the journal, current ACS cancer screening guidelines are summarized, as are updated guidelines on cervical cancer screening and lung cancer screening with low-dose helical computed tomography. The latest data on the use of cancer screening from the National Health Interview Survey also are described, as are several issues related to screening coverage under the Patient Protection and Affordable Care Act of 2010.

Colorectal Cancer Screening Disparities for Rural Minorities in the United States

Background: Despite the existence of effective screening, colorectal cancer remains the second leading cause of cancer death in the United States. Adults living in rural areas and members of minority populations both experience disparities in colorectal cancer screening. Methods: Cross-sectional prevalence study of Behavioral Risk Factor Surveillance System from the Centers for Disease Control from 1998 to 2005. Primary outcome: Predicted probability of reporting timely colorectal cancer screening. Independent variables: rural residence, race/ethnicity. We adjusted for demographic and socioeconomic characteristics of respondents. Results: After adjustment rural non-Hispanic whites (44.3%), rural African American/blacks (44.8%), urban and rural Hispanic/Latinos (43.7% and 40.8%, respectively), urban and rural American Indian/Alaska Natives (45.8% and 46.8%), and urban and rural Asians (35.4% and 39.6%) had lower compared with urban non-Hispanic whites (49.5%; P < .05% for all comparisons). Urban Asians were least likely to report use of fecal occult blood testing (8.6%, 95% confidence interval = 6.3% to 10.9%) and rural Asians were least likely to report use of endoscopy screening (21.2%, 95% confidence interval = 16.2% to 26.2%). Discussion: Rural minorities may face different barriers to colorectal cancer screening than urban minorities or rural non-Hispanic whites. Further research to develop interventions to improve screening in these populations is warranted.

Effect of flexible sigmoidoscopy-based screening on incidence and mortality of colorectal cancer: a systematic review and meta-analysis of randomized controlled trials

BACKGROUND

Randomized controlled trials (RCTs) have yielded varying estimates of the benefit of flexible sigmoidoscopy (FS) screening for colorectal cancer (CRC). Our objective was to more precisely estimate the effect of FS-based screening on the incidence and mortality of CRC by performing a meta-analysis of published RCTs.

METHODS AND FINDINGS

Medline and Embase databases were searched for eligible articles published between 1966 and 28 May 2012. After screening 3,319 citations and 29 potentially relevant articles, two reviewers identified five RCTs evaluating the effect of FS screening on the incidence and mortality of CRC. The reviewers independently extracted relevant data; discrepancies were resolved by consensus. The quality of included studies was assessed using criteria set out by the Evidence-Based Gastroenterology Steering Group. Random effects meta-analysis was performed. The five RCTs meeting eligibility criteria were determined to be of high methodologic quality and enrolled 416,159 total subjects. Four European studies compared FS to no screening and one study from the United States compared FS to usual care. By intention to treat analysis, FS-based screening was associated with an 18% relative risk reduction in the incidence of CRC (0.82, 95% CI 0.73-0.91, p<0.001, number needed to screen [NNS] to prevent one case of CRC = 361), a 33% reduction in the incidence of left-sided CRC (RR 0.67, 95% CI 0.59-0.76, p<0.001, NNS = 332), and a 28% reduction in the mortality of CRC (relative risk [RR] 0.72, 95% CI 0.65-0.80, p<0.001, NNS = 850). The efficacy estimate, the amount of benefit for those who actually adhered to the recommended treatment, suggested that FS screening reduced CRC incidence by 32% (p<0.001), and CRC-related mortality by 50% (p<0.001). Limitations of this meta-analysis include heterogeneity in the design of the included trials, absence of studies from Africa, Asia, or South America, and lack of studies comparing FS with colonoscopy or stool-based testing.

CONCLUSIONS

This meta-analysis of randomized controlled trials demonstrates that FS-based screening significantly reduces the incidence and mortality of colorectal cancer in average-risk patients.