Prevalence of colorectal cancer testing and screening in a multiethnic primary care population

Characterization of the Hispanic or latino population in health research: a systematic review

The size and diversity of the Hispanic population in the United States has dramatically increased, with vast implications for health research. We conducted a systematic review of the characterization of the Hispanic population in health research and described its implications. Relevant studies were identified by searches of PubMed, Embase Scopus, and Science/Social Sciences Citation Index from 2000 to 2011. 131 articles met criteria. 56% of the articles reported only "Hispanic" or "Latino" as the characteristic of the Hispanic research population while no other characteristics were reported. 29% of the articles reported language, 27% detailed country of origin and 2% provided the breakdown of race. There is great inconsistency in reported characteristics of Hispanics in health research. The lack of detailed characterization of this population ultimately creates roadblocks in translating evidence into practice when providing care to the large and increasingly diverse Hispanic population in the US.

Colonoscopist and primary care physician supply and disparities in colorectal cancer screening

OBJECTIVE. : To determine whether racial/ethnic disparities in colonoscopy use vary by physician availability. DATA SOURCE. : We used 100 percent Texas Medicare claims data for 2003-2007. STUDY DESIGN. : We identified beneficiaries aged 66-79 in 2007, examined racial/ethnic differences in colonoscopy use from 2003 to 2007, and estimated the percentage of white, black, and Hispanic beneficiaries who underwent colonoscopy by level of physician availability and area income. PRINCIPAL FINDINGS. : For the 974,879 beneficiaries, colonoscopy use was higher in whites (40.7 percent) compared to blacks (35.0 percent) and Hispanics (28.7 percent, p< .001). For whites, increasing availability of colonoscopists and primary care physicians (PCPs) was associated with higher colonoscopy use. For blacks and Hispanics, colonoscopy use was unchanged or decreased with increases in colonoscopist and PCP availability. In multilevel models, the odds of colonoscopy were 20 percent lower for blacks (OR 0.80, 95 percent CI 0.79-0.82) and 32 percent lower for Hispanics (OR 0.68, 95 percent CI 0.66-0.69) compared to whites; adjusting for availability of colonoscopists or PCPs did not attenuate racial/ethnic disparities. We found greater racial/ethnic disparities in areas with greater colonoscopist and PCP availability. CONCLUSIONS. : Greater area availability of colonoscopists and PCPs is associated with increased use of colonoscopy in whites but decreased use in minorities, resulting in larger racial/ethnic disparities.

Colonoscopist and primary care physician supply and disparities in colorectal cancer screening

OBJECTIVE. : To determine whether racial/ethnic disparities in colonoscopy use vary by physician availability. DATA SOURCE. : We used 100 percent Texas Medicare claims data for 2003-2007. STUDY DESIGN. : We identified beneficiaries aged 66-79 in 2007, examined racial/ethnic differences in colonoscopy use from 2003 to 2007, and estimated the percentage of white, black, and Hispanic beneficiaries who underwent colonoscopy by level of physician availability and area income. PRINCIPAL FINDINGS. : For the 974,879 beneficiaries, colonoscopy use was higher in whites (40.7 percent) compared to blacks (35.0 percent) and Hispanics (28.7 percent, p< .001). For whites, increasing availability of colonoscopists and primary care physicians (PCPs) was associated with higher colonoscopy use. For blacks and Hispanics, colonoscopy use was unchanged or decreased with increases in colonoscopist and PCP availability. In multilevel models, the odds of colonoscopy were 20 percent lower for blacks (OR 0.80, 95 percent CI 0.79-0.82) and 32 percent lower for Hispanics (OR 0.68, 95 percent CI 0.66-0.69) compared to whites; adjusting for availability of colonoscopists or PCPs did not attenuate racial/ethnic disparities. We found greater racial/ethnic disparities in areas with greater colonoscopist and PCP availability. CONCLUSIONS. : Greater area availability of colonoscopists and PCPs is associated with increased use of colonoscopy in whites but decreased use in minorities, resulting in larger racial/ethnic disparities.

Cancer Screening Behaviors of African American Women Enrolled in a Community-Based Cancer Prevention Trial

Background: African American women have increased mortality rates for cervical, breast, and colorectal cancers, yet not all receive the recommended screening tests for these cancers. We characterized the cancer screening behaviors of African American women enrolled in a community-based cancer prevention trial. Methods: We examined cross-sectional data from 1123 African American customers aged ≥18 years from 37 beauty salons in North Carolina who completed the North Carolina BEAUTY and Health Project baseline survey. Mixed logistic regression models were used to identify correlates of receiving cervical, breast, and colorectal cancer screening tests within recommended screening guidelines. Results: Overall, 94% (1026 of 1089) of women aged ≥18 years reported receiving a Pap smear test within the last 3 years, 70% (298 of 425) of women aged ≥40 years reported receiving a mammography within the last year, and 64% (116 of 180) of women aged ≥50 years were considered to be within recommended screening guidelines for colorectal cancer. Age was correlated with recent Pap smear testing and mammography. Women who reported receiving a recent Pap smear test were more likely to report a mammogram in the last year, and women with a recent mammogram were more likely to be within recommended screening guidelines for colorectal cancer. Many women reported multiple barriers to getting recommended cancer screening tests. Conclusions: Almost all women reported receiving a Pap smear test within the last 3 years. Future interventions should focus on increasing breast and colorectal cancer screening among African American women.

A review of the evidence for disparities in child vs adult health care: a disparity in disparities

Racial and ethnic health disparities in primary care have been well documented in the US healthcare system. However, very little attention has been directed toward inequities in child health. The aim of this review is to provide context for the scope of the challenges associated with addressing pediatric health disparities in primary care by comparing the weight of evidence regarding racial/ethnic health disparities for children vs adults. A multisystem health disparities conceptual model will frame the search strategy and analysis of the review. This paper will: (1) identify knowledge deficits in the understanding of existing disparities in pediatric primary care relative to adult primary care; (2) assess root causes of disparities for children vs adults; and (3) propose recommendations for a research agenda and policy implementation to eliminate disparities in pediatric primary care.

Association of local capacity for endoscopy with individual use of colorectal cancer screening and stage at diagnosis

BACKGROUND

Limited capacity for endoscopy in areas in which African Americans and Hispanics live may be a reason for persistent disparities in colorectal cancer (CRC) screening and stage at diagnosis.

METHODS

The authors linked data from the National Health Interview Survey on the use of CRC screening and data from Surveillance, Epidemiology, and End Results-Medicare on CRC stage with measures of county capacity for colonoscopy and sigmoidoscopy (endoscopy) derived from Medicare claims.

RESULTS

Hispanics lived in counties with less capacity for endoscopy than African Americans or whites (for National Health Interview Survey, an average of 1224, 1569, and 1628 procedures per 100,000 individuals aged > or = 50 years, respectively). Individual use of CRC screening increased modestly as county capacity increased. For example, as the number of endoscopies per 100,000 residents increased by 750, the odds of being screened increased by 4%. Disparities in screening were mitigated or diminished by adjustment for area endoscopy capacity, racial/ethnic composition, and socioeconomic status. Similarly, among individuals with CRC, those who lived in counties with less endoscopy capacity were marginally less likely to be diagnosed at an early stage. Adjustment for area characteristics diminished disparities in stage for Hispanics compared with whites but not African Americans.

CONCLUSIONS

Increasing the use of CRC screening may require interventions to improve capacity for endoscopy in some areas. The characteristics of the area where an individual resides may in part mediate disparities in CRC screening use for both African Americans and Hispanics, and disparities in cancer stage for Hispanics.

Healthy colon, healthy life (colon sano, vida sana): colorectal cancer screening among Latinos in Santa Clara, California

Colorectal cancer (CRC) screening rates are low among Latinos. To identify factors associated with CRC screening, we conducted a telephone survey of Latino primary care patients aged 50-79 years. Among 1,013 participants, 38% were up-to-date (UTD) with fecal occult blood test (FOBT); 66% were UTD with any CRC screening (FOBT, sigmoidoscopy, or colonoscopy). Individuals less than 65, females, those less acculturated, and patients of female physicians were more likely to be UTD with FOBT. CRC screening among Latinos is low. Younger patients, women, and patients of female physicians receive more screening.

Informed decision making changes test preferences for colorectal cancer screening in a diverse population

PURPOSE

We wanted to better understand patient preferences and decision making about options for colorectal cancer screening. Consistency in patient preferences could improve patient-clinician communication about tests by simplifying and focusing discussions.

METHODS

In a cross-sectional sample of primary care patients, cognitive ranking tasks were used to estimate patient preferences for fecal occult blood testing, flexible sigmoidoscopy, colonoscopy, and double-contrast barium enema before and after consideration of 13 test attributes, such as accuracy and scientific evidence. Patients also ranked the 13 test attributes and attribute descriptions in terms of importance. Friedman's nonparametric test was used to measure overall discrimination among items, and the average Pearson correlation coefficient (r) among participants was used to measure the degree of consistency in choices.

RESULTS

Participants (n = 168) averaged 62.1 years of age, and 64.3% were of minority racial ethnicity. For test-specific attributes, preferences were for high test accuracy (r = 0.63, P < .001), amount of colon examined (r = 0.64, P < .001), strong scientific evidence for efficacy (r = 0.59, P < .001), minimum discomfort (r = 0.50, P < .001), and low risk of complications (r = 0.38, P < .001). When all 13 attributes were considered together, agreement dropped (r = 0.13, P < .001), but attributes considered most important for decision making were test accuracy, scientific evidence for efficacy, amount of colon examined, and need for sedation. Test preferences showed moderate agreement (r = 0.20, P < .001), and choices were fairly consistent before and after exposure to test-specific attributes (kappa = 0.17, P = .007). Initially the modal choice was fecal occult blood testing (59%); however, after exposure to test specific attributes, the modal choice was colonoscopy (54%).

CONCLUSION

Participants were clear about the attributes that they prefer, but no single test has those attributes. Preferences were varied across participants and were not predictable; clinicians should discuss the full range of recommended tests for colorectal cancer with all patients.

Gastrointestinal malignancies: when does race matter?

BACKGROUND

African Americans have a poorer survival from gastrointestinal cancers. We hypothesized that socioeconomic status may explain much of this disparity.

STUDY DESIGN

Four years of population-based Medicare and Medicaid administrative claims files were merged with the Michigan Tumor Registry. Data were identified for 18,260 patients with colorectal (n = 13,001), pancreatic (n = 2,427), gastric (n = 1,739), and esophageal (n = 1,093) cancer. Three outcomes were studied: the likelihood of late stage diagnosis, the likelihood of surgery after diagnosis, and survival. Bivariate analysis was used to compare stage and operation between African-American and Caucasian patients. Cox proportional hazard models were used to evaluate differences in survival. Statistical significance was defined as p < 0.05.

RESULTS

In unadjusted analyses, relative to Caucasian patients, African-American patients with colorectal and esophageal cancer were more likely to present with metastatic disease, were less likely to have surgery, and were less likely to survive during the study period (p < 0.05). In a multivariate analysis, African-American patients had a higher likelihood of death from colorectal cancer than Caucasian patients. This difference, however, did not persist when late stage and surgery were taken into account (hazard ratio = 1.15, 95% CI = 1.06 to 1.24). No racial differences in survival were observed among patients with esophagus, gastric, or pancreatic cancer.

CONCLUSIONS

These data suggest that improvements in screening and rates of operation may reduce differences in colorectal cancer outcomes between African-American and Caucasian patients. But race has little influence on survival of patients with pancreatic, esophageal, or gastric cancer.

Biological, psychological and behavioral, and social variables influencing colorectal cancer screening in African Americans

BACKGROUND

Provider recommendation of colorectal cancer (CRC) screening is an important predictor of screening in African Americans. Little is known about influences of screening in African Americans without provider recommendations.

OBJECTIVES

The objectives of this study were to test, using the biopsychosocial (BPS) model, the relative predictive strength for screening of variables grouped into biological, psychological and behavioral, and social system factors and to compare CRC screening predictors in African Americans with and without provider recommendations.

METHODS

Secondary analysis of the 2002 Maryland Cancer Survey data was done using (a) hierarchical logistic regression to examine the relative influence of factors on screening and (b) simultaneous logistic regression to examine predictors of screening in individuals with and without provider recommendations to screen. Factors included biological (age and gender), psychological and behavioral (mammogram, prostate specific antigen, body mass index, activity level, fruit and vegetable consumption, alcohol, smoking, and cancer perceptions), and social system (education, employment, insurance, and healthcare provider access).

RESULTS

The social system factor influenced CRC screening in the overall sample (n = 492). In African Americans with provider recommendations (n = 337), the very active were 2.43 (95% confidence interval [CI] = 1.11-5.28) times more likely to screen than were less active. Insured were 3.25 (95% CI = 1.14-9.31) times more likely to screen than were uninsured. In African Americans without provider recommendations (n = 155), 65- to 69-year-olds were 9.99 (95% CI = 2.31-43.32) times more likely to screen than were those 50- to 54-year-olds without screening.

DISCUSSION

The BPS model confirms social system factor strength in influencing CRC screening in African Americans. Identifying other social system variables that enhance healthcare provider access is critical to increase provider visits, which will generate recommendations and subsequent CRC screening.

Disparities in colorectal cancer in African-Americans vs Whites: Before and after diagnosis

There are differences between African-American and white patients with colorectal cancer, concerning their characteristics before and after diagnosis. Whites are more likely to adhere to screening guidelines. This is also the case among people with positive family history. Colorectal cancer is more frequent in Blacks. Studies have shown that that since 1985, colon cancer rates have dipped 20% to 25% for Whites, while rates have gone up for African-American men and stayed the same for African-American women. Overall, African-Americans are 38% to 43% more likely to die from colon cancer than are Whites. Furthermore, it seems that there is an African-American predominance in right-sited tumors. African Americans tend to be diagnosed at a later stage, to suffer from better differentiated tumors, and to have worse prognosis when compared with Whites. Moreover, less black patients receive adjuvant chemotherapy for resectable colorectal cancer or radiation therapy for rectal cancer. Caucasians seem to respond better to standard chemotherapy regimens than African-Americans. Concerning toxicity, it appears that patients of African-American descent are more likely to develop 5-FU toxicity than Whites, possibly because of their different dihydropyridine dehydrogenase status. Last but not least, screening surveillance seems to be higher among white than among black long-term colorectal cancer survivors. Socioeconomic and educational status account for most of these differences whereas little evidence exists for a genetic contribution in racial disparity. Understanding the nature of racial differences in colorectal cancer allows tailoring of screening and treatment interventions.

Colorectal cancer screening among underserved minority population: discrepancy between physicians' recommended, scheduled, and completed tests

OBJECTIVE

This study examines the correlates of: (1) health care provider recommendation of CRC testing; (2) provider scheduling for recommended CRC testing using sigmoidoscopy, colonoscopy, or double-contrast barium enema; and (3) adherence to CRC scheduling among underserved minority populations.

METHODS

Medical record and schedule logbook reviews and interviewer-administered surveys.

SETTING

Large urban safety-net, outpatient primary care setting in Los Angeles County.

PARTICIPANTS

306 African-American and Latino patients aged 50 years and older.

RESULTS

A vast majority of minority patients do not receive standard CRC testing in urban safety-net primary care settings. Of those patients who were actually scheduled for sigmoidoscopy or colonoscopy, almost half completed the procedure. Completing CRC testing was associated with marital status, co-morbid chronic physical conditions, number of risk factors for colorectal cancer, and lower perceived barriers to CRC testing.

CONCLUSION

Effective interventions to reduce CRC mortality among underserved minority populations require an integrated approach that engages patients, providers, and health care systems.

PRACTICE IMPLICATIONS

Designing interventions that (1) increase physician-patient communications for removing patients' perceived barriers for CRC testing and (2) promote a non-physician-based navigator system that reinforces physicians' recommendation are strongly recommended.

Colorectal cancer screening: prevalence among low-income groups with health insurance

We examined the prevalence of colorectal cancer (CRC) screening in a low-income, racial/ethnic minority sample, among whom 97 percent had health insurance that covered CRC screening. This is a model for examining the impact of health insurance on racial/ethnic disparities in screening. Screening rates (67 percent self-reported; 52 percent adjusted based on a validation substudy) were higher than among similar population-based samples who have lower levels of insurance coverage. There were no differences by race/ethnicity. This study suggests that insurance coverage for CRC screening should be considered as part of a comprehensive approach to address CRC disparities.

Influence of family history and preventive health behaviors on colorectal cancer screening in African Americans

BACKGROUND

African Americans (AAs) have low rates of colorectal cancer (CRC) screening. To the authors' knowledge, factors that influence their participation, especially individuals with a family history of CRC ("family history"), are not well understood.

METHODS

A secondary analysis of the 2002 Maryland Cancer Survey data examined predictors of risk-appropriate, timely CRC screening ("screening") in AAs with a family history and in individuals without a family history. Predictors that were evaluated included age, sex, family history, mammogram or prostate-specific antigen (PSA) screening, body mass index, activity, fruit/vegetable consumption, alcohol, smoking, perceived risk of cancer, education, employment, insurance, access to a healthcare provider, and healthcare provider recommendation of fecal occult blood test (FOBT) and/or sigmoidoscopy/colonoscopy.

RESULTS

In individuals without a family history of CRC (N = 492), recommendation for FOBT (odds ratio [OR] of 11.90; 95% confidence interval [95% CI], 6.84-20.71) and sigmoidoscopy/colonscopy (OR of 7.06; 95% CI, 4.11-12.14), moderate/vigorous activity (OR of 1.74; 95% CI, 1.06-2.28), and PSA screening history (OR of 2.68; 95% CI, 1.01-7.81) were found to be predictive of screening. In individuals with a family history (N = 88), recommendation for sigmoidoscopy/colonscopy (OR of 24.3; 95%, CI 5.30-111.34) and vigorous activity (OR of 5.21; 95% CI, 1.09-24.88) were found to be predictive of screening. However, family history did not predict screening when the analysis was controlled for age, education, and insurance. AAs who had a family history were less likely to screen compared with their white counterparts (N = 293) and compared with AAs who were at average risk for CRC (P < .05).

CONCLUSIONS

Regardless of family history, healthcare provider recommendation and activity level were important predictors of screening. Lower screening rates were observed in AAs who had a family history compared with individuals who did not. The authors believe that, for AAs who have a family history, further examination of barriers and facilitators to CRC screening within the cultural context is warranted.