Colorectal cancer screening participation by older women

Current Quality of Videos on Colorectal Cancer Screening for General Public

BACKGROUND

One-third of American adults encompassed by current colorectal cancer screening guidelines fail to obtain recommended screening evaluations. Educational videos are a valuable medium through which to educate and encourage recommended health behaviors in patients.

METHODS

A cross-sectional study reviewing the quality of patient education videos addressing colorectal cancer screening. Video quality was assessed in 3 domains: accountability, content, and production.

RESULTS

Forty-four videos met inclusion criteria. Out of 33 possible points, videos scored a median of 15.0 (interquartile range 12.9-16.6). Videos scored 1.0 (interquartile range .8-1.0) out of 4.0 for accountability, 6.0 (interquartile range 4.4-8.0) out of 20 for content, and 8.0 (interquartile range 7.4-8.0) out of 9.0 for production. Colonoscopy was the most frequently discussed method of screening (38, 86%). While 13 (34%) videos discussed the risk of colorectal cancer in the general population and 15 (32%) discussed the risk in those with a family history, few videos addressed those with other risk factors. Most (31, 70%) videos discussed the medical consequences of not receiving screening, but only 1 (2%) video discussed the social consequences. Similarly, medical benefits were discussed in 34 (77%) videos while other benefits were not discussed by any video. Only one-fifth of the videos address three or more barriers to screening.

CONCLUSIONS

Videos on colorectal cancer screening have excellent production quality but need improvement in the domains of accountability and content. The videos included in this analysis did not adequately address the concerns of viewers nor the benefits of colorectal cancer screening.

Recognition and participation of colorectal cancer screening in Turkiye: A systematic review and meta-analysis study

Colorectal cancers (CRCs) have an important share in the prevalence and mortality among all cancers. It was aimed to make a systematic review and meta-analysis of researches about the prevalence of knowing fecal occult blood test (FOBT) and colonoscopy, which are among the CRC screening methods, and the prevalence of having these tests at any time in life. A literature search using five different databases were screened both in Turkish and English language and a total of 1176 studies were reached. Of these, 22 studies were selected to be included in this study. In the evaluation of the researches included in the study, the studies were read in a way to look for answers to PICOS questions. Open Meta-analyst demo program and random effects model was used. The prevalence rate and 95% confidence interval of knowing and having FOBT and colonoscopy were calculated. According to the meta-analysis results, the prevalence of knowing the FOBT among the CRC screening tests was 19.3%, the prevalence of having the FOBT was 13.2%, the prevalence of knowing colonoscopy was 31.7%, and the prevalence of having colonoscopy was 10.0%. As a conclusion prevalence of knowing and having FOBT and colonoscopy was low in risky individuals in Turkiye.

Implementing a multilevel intervention to accelerate colorectal cancer screening and follow-up in federally qualified health centers using a stepped wedge design: a study protocol

Background

Screening for colorectal cancer (CRC) not only detects disease early when treatment is more effective but also prevents cancer by finding and removing precancerous polyps. Because many of our nation’s most disadvantaged and vulnerable individuals obtain health care at federally qualified health centers, these centers play a significant role in increasing CRC screening among the most vulnerable populations. Furthermore, the full benefits of cancer screenings must include timely and appropriate follow-up of abnormal results. Thus, the purpose of this study is to implement a multilevel intervention to increase rates of CRC screening, follow-up, and referral-to-care in federally qualified health centers, as well as simultaneously to observe and to gather information on the implementation process to improve the adoption, implementation, and sustainment of the intervention. The multilevel intervention will target three different levels of influences: organization, provider, and individual. It will have multiple components, including provider and staff education, provider reminder, provider assessment and feedback, patient reminder, and patient navigation.

Methods

This study is a multilevel, three-phase, stepped wedge cluster randomized trial with four clusters of clinics from four different FQHC systems. In the first phase, there will be a 3-month waiting period during which no intervention components will be implemented. After the 3-month waiting period, we will randomize two clusters to cross from the control to the intervention and the remaining two clusters to follow 3 months later. All clusters will stay at the same phase for 9 months, followed by a 3-month transition period, and then cross over to the next phase.

Discussion

There is a pressing need to reduce disparities in CRC outcomes, especially among racial/ethnic minority populations and among populations who live in poverty. Single-level interventions are often insufficient to lead to sustainable changes. Multilevel interventions, which target two or more levels of changes, are needed to address multilevel contextual influences simultaneously. Multilevel interventions with multiple components will affect not only the desired outcomes but also each other. How to take advantage of multilevel interventions and how to implement such interventions and evaluate their effectiveness are the ultimate goals of this study.

Trial registration

This protocol is registered at clinicaltrials.gov (NCT04514341) on 14 August 2020.

Uptake of Colorectal Cancer Screening by Physicians Is Associated With Greater Uptake by Their Patients

BACKGROUND & AIMS

Physicians' own screening practices might affect screening in their patients. We conducted a population-based study to evaluate whether family physicians who underwent colorectal cancer testing were more likely to have patients who underwent colorectal cancer testing.

METHODS

We collected demographic and health care information on residents of Ontario, Canada from administrative databases; the sample was restricted to individuals at average risk of colorectal cancer who were 52-74 years old as of April 21, 2016. We obtained a list of all registered physicians in the province; physicians (n = 11,434) were matched with nonphysicians (n = 45,736) on age, sex, and residential location. Uptake of colorectal tests was defined by a record of a fecal occult blood test in the past 2 years, flexible sigmoidoscopy in the past 5 years, or colonoscopy in the past 10 years. Patients were assigned to family physicians based on billing claim frequency, and then the association between colorectal testing in family physicians and their patients was examined using a modified Poisson regression model.

RESULTS

Uptake of colorectal tests by physicians and nonphysicians (median age 60 years; 71% men) was 67.9% (95% confidence interval [CI], 67.0%-68.7%) and 66.6% (95% CI, 66.2%-67.1%), respectively. Physicians were less likely than nonphysicians to undergo fecal occult blood testing and were more likely to undergo colonoscopy; prevalence ratios were 0.44 (95% CI, 0.42-0.47) and 1.24 (95% CI, 1.22-1.26), respectively. Uptake of colorectal tests by family physicians was associated with greater uptake by their patients (adjusted prevalence ratio, 1.10; 95% CI, 1.08-1.12).

CONCLUSIONS

Approximately one-third of physicians and nonphysicians are overdue for colorectal cancer screening. Patients are more likely to be tested if their family physician has been tested. There is an opportunity for physicians to increase their participation in colorectal cancer screening, which could, in turn, motivate their patients to undergo screening.

Bowel cancer screening for women at midlife

In Australia one in 15 women will be diagnosed with colorectal cancer in their lifetime because of the high incidences of lifestyle risk factors. The risk could be reduced by taking aspirin. Evidence-based Clinical Practice Guidelines for the prevention, early detection and management of colorectal cancer produced by Cancer Council Australia and approved by the National Health and Medical Research Council recommended that 'population screening in Australia, directed at those at average risk of colorectal cancer and without relevant symptoms, is immunochemical fecal occult blood testing every 2 years, starting at age 50 years and continuing to age 74 years.' Women at high risk because of family history will need more intense screening. At the current 40% participation rate, it is estimated that biennial screening with fecal immunohistochemical tests (FIT) reduces colorectal cancer incidence by 23% and mortality by 36%. The major adverse effects of screening are the psychological impact of a positive FIT that does not prove to be cancer, or adenomas on colonoscopy (47.7%), and the rare side-effects of colonoscopy of hemorrhage, bleeding or even death. A range of factors that could increase a woman's participation rate includes advice to screen from her general practitioner and more information about the nature of the screening tests.

Assessment of recent HIV testing among older adults in the United States

Older adults are the fastest growing segment of people living with HIV, and unfortunately many are unaware of their HIV status. Many providers are reluctant to ask older adults about their sexual histories, evaluate their risk factors, and test for HIV, and older adults have low perception of HIV risk. Using data from the 2013 to 2014 National Health and Nutrition Examination Survey, this study assessed the prevalence of recent HIV testing among older adults in the United States (n = 1,056) and identified predictors and barriers to recent HIV testing. The prevalence of recent HIV testing was 28%. Recent HIV testing was associated positively with male gender, education level, having public insurance, having same sex sexual behavior, African, and Hispanic ethnicity, whereas age, income-to-poverty ratio, and Asian ethnicity were associated negatively with recent HIV testing. Public health social workers are advised that targeted HIV testing for Asian, economically disadvantaged, female older adults is needed to increase HIV awareness and detection and to decrease late diagnosis of HIV. Provided public insurance was identified as a predictor of recent HIV testing, facilitating economically disadvantaged older adults' eligibility for public insurance that will likely improve access to HIV testing services and increase HIV testing rates.

Physician Recommendation for Colorectal Cancer Screening by Race, Ethnicity, and Health Insurance Status Among Men and Women in the United States, 2000

In this study, the authors examined whether men and women in the United States had received a physician recommendation to get a colorectal cancer screening test, by race, ethnicity, and health insurance status using data from the 2000 National Health Interview Survey. Among men and women who had had a doctor visit in the past year but who had not had a recent fecal occult blood test, about 94.6% (95% CI 94.0-95.2) reported that their doctor had not recommended the test in the past year. African Americans, Hispanics, and American Indians/Alaska Natives were less likely to report receiving a recommendation for endoscopy compared to Whites.

A Randomised Trial of the Impact of New Faecal Haemoglobin Test Technologies on Population Participation in Screening for Colorectal Cancer

OBJECTIVES

To investigate the effect on participation in colorectal cancer screening of testing for blood products in faeces using technologies that remove dietary restrictions (i.e. immunochemical tests) and simplify faecal sampling (i.e. tests that use brush sampling).

METHODS

SETTING

Urban residents (n=1818) of Adelaide, Australia, aged between 50 and 69 years, randomly selected from the electoral roll.

DESIGN

Three randomised cohorts of 606 invitees were offered a screening test by mail in 2001. The Hemoccult SENSA and FlexSure OBT cohorts were instructed to sample three stools using a spatula while the InSureTM cohort sampled two stools using a brush. The Hemoccult SENSA cohort was asked to restrict certain (high-peroxidase) foods and drugs.

MAIN OUTCOME MEASURES

Participation (i.e. return of completed sample kits within 12 weeks) and generalised linear modelling (GLM) of relationships between participation, test technologies and demographic variables.

RESULTS

Participation was 23.4%, 30.5% and 39.6% for the Hemoccult, FlexSure and InSure cohorts, respectively (chi(2)=37.1, p<0.00001). GLM demonstrated that participation was increased by 28% by removal of restrictions (p=0.01) and by 30% by simplification of sampling (p=0.001); both together increased participation by 66% (p<0.001). The differences in participation between tests occurred in the first three weeks. Socio-economic status, gender or age did not significantly influence technology-based improvements in participation.

CONCLUSIONS

The brush-sampling faecal immunochemical test for haemoglobin (InSure) achieves the best participation rates by simplifying sampling and removing the need for restrictions of diet and drugs. Because participation in screening is vital to detection, this new technology should contribute to better detection of neoplasia at the population level.

Acceptability of Physician Directed Academic Detailing to Increase Colorectal Cancer Screening: an Application of the RESPECT Approach

BACKGROUND

In developing effective interventions to increase colorectal cancer (CRC) screening in at risk populations, a necessary first requirement is feasibility. This paper describes how the RESPECT approach to health education guided the conceptualization and implementation of physician-directed academic detailing (AD) to increase practice-wide CRC screening uptake.

METHODS

Physician-directed AD was one intervention component in a large educational randomized controlled trial to increase CRC screening uptake. Study participants, primarily urban minority, were aged 50 or older, insured for CRC screening with no out-of-pocket expense and out of compliance with current screening recommendations. The trial was conducted in the New York City metropolitan area. Participants identified their primary care physician; 564 individuals were recruited, representing 459 physician practices. Two-thirds of the physician practices were randomized to receive AD. The RESPECT approach, modified for AD, comprises: 1) Rapport, 2) Educate, but don't overwhelm, 3) Start with physicians where they are, 4) Philosophical orientation based on a humanistic approach to education, 5) Engagement of the physician and his/her office staff, 6) Care and show empathy, and 7) Trust. Feasibility was assessed as rate of AD delivery.

RESULTS

The AD was delivered to 283 (92.5%) of the 306 practices assigned to receive it; 222/283 (78.4%) delivered to the doctor.

CONCLUSION

The AD was feasible and acceptable to implement across a range of clinical settings. The RESPECT approach offers a framework for tailoring educational efforts, allowing flexibility, as opposed to strict adherence to a highly structured script or a universal approach.

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.

Colorectal cancer screening among Asian Americans

OBJECTIVES

Colorectal cancer (CRC) is the most commonly diagnosed cancer for all US populations including Asian Americans. CRC screening has considerable benefits to prevent CRC and reduce mortality. The purpose of this article was to review the published literature on rates of colorectal cancer screening and factors associated with colorectal cancer screening practice among Asian Americans.

METHODS

Through searching electronic reference databases from 2000 to 2013, 30 articles were found on Chinese, Filipino, Japanese, Korean, and Vietnamese Americans.

FINDINGS

Asian Americans had significantly low rates for CRC screening; Korean Americans reported the lowest rates, while higher screening rates were found among Japanese Americans. Older age, longer length of stay in the US, and having a physician's recommendation were the most common facilitators to receiving screening. The common inhibiting factors were financial issues, employment status, and worries/fears about the procedure.

CONCLUSIONS

Despite a number of Asian Americans being vulnerable to CRC, individual Asian subgroups were underserved with CRC screening and intervention. Further studies should focus on each individual Asian subgroup and culturally proficient CRC screening intervention programs should be developed for each.

Barriers to colorectal cancer screening in Palestine: a national study in a medically underserved population

BACKGROUND & AIMS

Cultural, religious, and financial barriers can hinder uptake of colorectal cancer (CRC) screening in Arab communities. We aim to understand attitudes and barriers that contribute to the low rate of CRC screening among Palestinians in the West Bank.

METHODS

We performed a national, cross-sectional study of Palestinian adults older than 50 years. A self-administered questionnaire was developed and validated. Data were randomly collected in all major districts of the West Bank. The primary outcome was the willingness to undergo CRC screening. Multivariable logistic regression models were used to assess the strength of association between the primary outcome and its predictors while controlling for possible confounders.

RESULTS

Of 1601 people approached for an interview, 1352 agreed to participate (response rate, 84%). Only 193 had undergone CRC screening (14%); 1069 (79%) agreed to take a fecal occult blood test, 906 (67%) agreed to a colonoscopy examination, and 1098 (81%) were willing to undergo CRC screening if recommended by a physician. Only 194 (14%) said they had been informed about CRC screening by a physician. Urban residents were more likely to be screened for CRC than nonurban residents (odds ratio, 0.73; 95% confidence interval, 0.56-0.93; P = .011). Multivariable analysis showed that lack of education beyond elementary school or familiarity with CRC screening, distrust of Western medicine, religious objection, and finding the test to be embarrassing were all associated with decreased odds of accepting CRC screening.

CONCLUSIONS

Based on a national, cross-sectional study of Palestinian adults, there are many cultural and religious barriers to CRC screening. Improving our understanding of these could increase screening among Arab populations in the Middle East and in Western countries.

Validation of self-reported colorectal cancer screening behaviors among Appalachian residents

OBJECTIVES

We determined the validity of self-reported colorectal cancer (CRC) screening data provided by Appalachian Ohio residents and identified correlates of providing accurate data.

DESIGN AND SAMPLE

We conducted cross-sectional telephone interviews between September 2009 and April 2010. Our study included Appalachian Ohio residents (n = 721) ages 51-75 years.

MEASURES

We compared self-reported CRC screening data to medical records to determine validity. Multivariable logistic regression was used to identify correlates of providing accurate self-reported screening data.

RESULTS

About 68% of participants self-reported having any CRC screening test within recommended guidelines, whereas medical records indicated that only 49% were within guidelines (concordance = 0.76). Concordance was higher for flexible sigmoidoscopy and fecal occult blood test compared with colonoscopy, although sensitivity and positive predictive value were much higher for colonoscopy. Participants overreported CRC screening behaviors for all tests. Participants who had a regular checkup in the last 2 years (OR = 2.78, 95% CI: 1.15-6.73), or who self-rated their health as good or better (OR = 1.88, 95% CI: 1.12-3.16) were more likely to provide accurate screening data.

CONCLUSIONS

Many participants failed to provide accurate CRC screening data, and validity varied greatly across individual CRC screening tests. Future CRC screening studies among Appalachian residents should use medical records, if possible, to determine screening histories.

The "Iowa get screened" colon cancer screening program

OBJECTIVE

To implement a colon cancer screening program for uninsured or underinsured Iowans.

METHODS

All 1995 uninsured patients or patients with Iowa Care insurance aged 50 to 64 years attending the University of Iowa Clinic or the Iowa City Free Medical Clinic were mailed information about the project. Recruitment also took place in person, by having the clinic receptionist hand subjects a research packet, and through community posters. Individuals with colonic symptoms or who were up to date with screening were ineligible. Eligible subjects received a free fecal immunochemical test (FIT), and those with positive FITs were provided with a colonoscopy at no cost to them.

RESULTS

Of 449 individuals who completed eligibility forms (23% of the study population), 297 (66%) were eligible and were provided with an FIT. Two-hundred thirty-five (79%) returned a stool sample, with 49 (21%) testing positive. Thirty of the 49 (61%) individuals had a colonoscopy, and 20 individuals had at least 1 polyp biopsied. Thirteen individuals had at least 1 tubular adenoma; 2 had adenomas more than 1 cm in diameter, with no colon cancers identified. Face-to-face recruitment had the highest rate of returned FITs (72%) compared with handing the subject a research packet (3%) or a mailing only (9%) (Chi-square, P < .001).

CONCLUSION

There was high interest in and compliance with colon cancer screening using a FIT among underinsured individuals. Although the FIT positivity rate was higher than expected, many individuals did not complete recommended follow-up colonoscopies. Population-based strategies for offering FIT could significantly increase colon cancer screening among disadvantaged individuals, but programs will have to develop sustainable mechanisms to include the necessary organization and address substantial costs of providing mass screening, as well as facilitating and providing colonoscopies for those who test positive.

Shared decision-making about colorectal cancer screening: a conceptual framework to guide research

OBJECTIVE

To develop a conceptual framework to guide research on shared decision-making about colorectal cancer (CRC) screening among persons at average risk and their providers.

METHODS

Based upon a comprehensive review of empirical literature and relevant theories, a conceptual framework was developed that incorporated patient characteristics, cultural beliefs, provider/health care system variables, health belief/knowledge/stage of adoption variables, and shared decision-making between patients and providers that may predict behavior. Relationships among concepts in the framework, shared decision-making process and outcomes, and CRC screening behavior were proposed. Directions for future research were presented.

RESULTS

Many of the concepts in the proposed framework have been examined in prior research. However, these elements have not been combined previously to explain shared decision-making about CRC screening.

CONCLUSION

Research is needed to test the proposed relationships and hypotheses and to refine the framework.

PRACTICE IMPLICATIONS

Findings from future research guided by the proposed framework may inform clinical practice to facilitate shared decision-making about CRC screening.

Contrasts in rural and urban barriers to colorectal cancer screening

OBJECTIVES

To contrast barriers to colon cancer (CRC) screening and Fecal Occult Blood Test (FOBT) completion between rural and urban safety-net patients.

METHODS

Interviews were administered to 972 patients who were not up-to-date with screening.

RESULTS

Rural patients were more likely to believe it was helpful to find CRC early (89.7% vs 66.1%, p < .0001), yet were less likely to have received a screening recommendation (36.4% vs. 45.8%, p = .03) or FOBT information (14.5% vs 32.3%, p < .0001) or to have completed an FOBT (22.0% vs 45.8%, p < .0001).

CONCLUSIONS

Interventions are needed to increase screening recommendation, education and completion, particularly in rural areas.

What influences the decision to participate in colorectal cancer screening with faecal occult blood testing and sigmoidoscopy?

INTRODUCTION

Uptake is an important determinant of the effectiveness of population-based screening. Uptake of colorectal cancer (CRC) screening generally remains sub-optimal.

AIM

To determine factors influencing the decision whether to participate or not among individuals invited for faecal occult blood test (FOBT) or flexible sigmoidoscopy (FS) screening.

METHODS

A questionnaire was sent to a stratified random sample of individuals aged 50-74, previously invited for a randomised CRC screening trial offering FOBT or FS, and a reference group from the same population not previously invited (screening naïve group). The questionnaire assessed reasons for (non)-participation, individuals' characteristics associated with participation, knowledge, attitudes and level of informed choice.

RESULTS

The response rate was 75% (n=341/452) for CRC screening participants, 21% (n=676/3212) for non-participants and 38% (n=192/500) for screening-naïve individuals. The main reasons for FOBT and FS participation were acquiring certainty about CRC presence and possible early CRC detection. Anticipated regret and positive attitudes towards CRC screening were strong predictors of actual participation and intention to participate in a next round. The main reason for non-participation in FOBT screening was lack of abdominal complaints. Non-participation in FS screening was additionally influenced by worries about burden. Eighty-one percent of participants and 12% of non-participants made an informed choice on participation.

CONCLUSION

Only 12% of non-participants made an informed choice not to participate. These results imply that governments and/or organizations offering screening should focus on adequately informing and educating target populations about the harms and benefits of CRC screening. This may impact uptake of CRC screening.

Effectively Communicating Colorectal Cancer Screening Information to Primary Care Providers: Application for State, Tribe or Territory Comprehensive Cancer Control Coalitions

BACKGROUND

Patients are more likely to be screened for colorectal cancer if it is recommended by a health care provider. Therefore, it is imperative that providers have access to the latest screening guidelines.

PURPOSE

This practice-based project sought to identify Kentucky primary care providers' preferred sources and methods of receiving colorectal cancer information to improve state comprehensive cancer control provider outreach initiatives.

METHODS

Four focus groups were conducted with primary care physicians, nurse practitioners, and physician assistants. Discussion included preferred sources and methods of receiving updated screening guidelines, legislation, and statewide public awareness campaign materials.

RESULTS

Providers (N = 17) identified their preferred methods for receiving colorectal cancer information as: routine emails from trusted sources (colleagues, professional societies and research, and advocacy agencies), scientific journals, existing conferences, and the media.

DISCUSSION

When delivering colorectal cancer information to primary care providers, multiple approaches are needed. An ideal partner for dissemination of information is state comprehensive cancer control coalitions, considering their prioritization of colorectal cancer screening and existing networks of partners who were identified as trusted sources.

TRANSLATION TO HEALTH EDUCATION PRACTICE

Assessment of primary care providers' preferred methods and sources of receiving colorectal cancer information informs strategies for practice among comprehensive cancer control coalitions.

The sociocultural health behavioral model and disparities in colorectal cancer screening among Chinese Americans

OBJECTIVE

The purpose of this study was to validate a Sociocultural Health Behavior Model using a structural equation analysis to determine the direction and magnitude of the interdependence of model components in relation to health behavior associated with colorectal cancer (CRC) screening among Chinese Americans.

METHODS

A cross-sectional design included a sample of 311 Chinese American men and women age 50 and older. The initial step involved use of confirmatory factor analysis which included the following variables: access/satisfaction with health care, enabling, predisposing, cultural, and health belief factors. Structural equation modeling analyses were conducted on factors for CRC screening.

RESULTS

Education and health insurance status were significantly related to CRC screening. Those with less than a high school education and without health insurance were more likely to be "never screened" for CRC than those having more education and health insurance. The path analysis findings also lend support for components of the Sociocultural Health Belief Model and indicated that there was a positive and significant relationship between CRC screening and the enabling factors, between cultural factors and predisposing, enabling, and access/satisfaction with health care factors and between enabling factors and access/satisfaction with health care.

CONCLUSIONS

The model highlights the significance that sociocultural factors play in relation to CRC screening and reinforced the need to assist Chinese with poor English proficiency in translation and awareness of the importance of CRC screening. The use of community organizations may play a role in assisting Chinese to enhance colorectal cancer screening rates.

Colon cancer screening in women

Colorectal cancer is the third leading cause of cancer-related deaths in women. Colorectal cancer is a preventable disease with accepted screening modalities that have been proven to save lives. As women are more likely than men to develop right-sided colon cancers, colonoscopy is the preferred screening test in women. Currently, women are less likely to undergo colorectal cancer screening than men. Frank discussions addressing the fear or embarrassment of endoscopic screening are important in helping women overcome these barriers. Enhanced education of both practitioners and patients targeted to improve colorectal cancer screening adherence will improve early diagnosis and patient survival.

Computer-delivered tailored intervention improves colon cancer screening knowledge and health beliefs of African-Americans

We conducted a randomized controlled trial among African-American patients attending a primary-care provider visit to compare efficacy of a computer-delivered tailored intervention to increase colorectal cancer (CRC) screening (n = 273) with non-tailored print material-an American Cancer Society brochure on CRC screening (n = 283). Health Belief Model constructs were used to develop tailored messages and examined as outcomes. Analysis of covariance models were used to compare changes between CRC knowledge and health belief scores at baseline and 1 week post-intervention. At 1 week, patients who received the computer-delivered tailored intervention had greater changes in CRC knowledge scores (P < 0.001), perceived CRC risk scores (P = 0.005), FOBT barriers scores (P = 0.034) and colonoscopy benefit scores (P < 0.001). Findings show that computer-delivered tailored interventions are an effective adjunct to the clinical encounter that can improve knowledge and health beliefs about CRC screening, necessary precursors to behavior change.

Colorectal cancer screening compliance and contemplation in gynecology patients

OBJECTIVE

Colorectal cancer screening (CRCS) should be a necessary part of gynecology (GYN) providers' preventive practices. The purpose of our study is to examine CRCS recommendations and adherence in this population.

METHODS

A questionnaire was administered to a prospective cohort of patients awaiting health maintenance exams at six academic and private gynecology offices. Patients reported demographics, CRC/breast/cervical screening adherence, CRCS recommendations, and future likelihood of CRCS.

RESULTS

A total of 461 women aged 51 years and older completed the questionnaire. Sixty-six percent of respondents were compliant with CRCS compared to 93% and 86% for breast and cervical cancer screening, respectively (p < 0.001). GYN providers recommended CRCS in 43% of patients. Sixty-three percent were planning to undergo future CRCS. On multivariable analysis, characteristics associated with CRCS adherence included (odds ratio, 95% confidence interval): older age (1.1 per year, 1.1-1.2), previous mammography (3.7, 1.4-9.7), family history (FH) of CRC/polyps (1.9, 1.0-3.4), friend with CRC (2.6, 1.5-4.7), and any doctor recommending CRCS (8.2, 4.6-14.7). CRCS rates were higher among patients who received a recommendation from a PCP (primary care provider) than from a GYN provider. Factors associated with intention to undergo CRCS include previous mammography (1.4, 4.2-12.0), any doctor recommendation (6.4, 3.7-11.0), and FH of CRC/polyps (3.5, 1.9-6.3). CRCS recommendations by both GYNs and PCPs had a greater impact on CRCS contemplation than those from a PCP or GYN alone.

CONCLUSION

In gynecology patients, having multiple providers recommend CRCS increases the likelihood of patients' intentions to undergo CRCS. However, CRCS compliance is primarily driven solely by PCP recommendations. Regardless, strategies must be in place to prompt gynecologists and nurse practitioners to discuss CRCS in eligible patients.

Factors Associated with Colorectal Cancer Screening Among Cambodians, Vietnamese, Koreans and Chinese Living in the United States

The purpose of this community-based participatory study was to identify factors associated with colorectal cancer (CRC) screening compliance and non-compliance among Cambodians, Vietnamese, Koreans and Chinese men and women 50 years and older living in the United States. A cross-sectional design was used in the study. The completed sample included 815 Asian Americans which included Cambodians (N=215), Vietnamese (N=195), Koreans (N=94) and Chinese (N=311). A 95-item questionnaire was developed and pilot tested for content validity and reliability. An in-person data collection approach was utilized and participants were given choice in responding in English or their native language. Of the 815 participants, 79.1% (N=645) reported never-screened, 7.9% (N=64), non-compliance, and 13.0% (N=106) compliance. Education was significantly associated with never-screened for CRC for Vietnamese and Chinese; employment status for Cambodians and Koreans; lack of health insurance for Cambodians, Korean and Chinese; English fluency and years lived in the U.S. for Vietnamese, Koreans, and Chinese. Less acculturated Asian Americans were more likely to be never screened, but differentially across ethnic subgroups. Barriers to screening included lack of knowledge, language, transportation, and time. Increased culturally-targeted public awareness and education programs are needed to improve CRC screening and compliance among high risk Asian American ethnic subgroups.

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.

Knowledge and attitudes regarding colorectal cancer screening among medical students: a tale of two schools

Colorectal cancer (CRC) screening has been shown to decrease the incidence of CRC cancers and decrease mortality. Studies show that the most important predictor of patient compliance with CRC screening is physician recommendation. We assessed the knowledge and attitudes of medical students regarding cancer screening. A study-specific questionnaire was distributed to medical students (MS) at two medical schools. There was a significant difference in the percentage of correctly answered questions regarding screening recommendations between first year MS and all other years for both schools. However, MS attitudes towards CRC screening were consistent between classes and schools. Although most MS had positive attitudes regarding cancer screening our survey identified several important deficits in knowledge.

Repeat participation in colorectal cancer screening utilizing fecal occult blood testing: a community-based project in a rural setting

BACKGROUND AND AIM

To investigate participation in a second round of colorectal cancer screening using a fecal occult blood test (FOBT) in an Australian rural community, and to assess the demographic characteristics and individual perspectives associated with repeat screening.

METHODS

Potential participants from round 1 (50-74 years of age) were sent an intervention package and asked to return a completed FOBT (n = 3406). Doctors of participants testing positive referred to colonoscopy as appropriate. Following screening, 119 participants completed qualitative telephone interviews. Multivariable logistic regression models evaluated the association between round-2 participation and other variables.

RESULTS

Round-2 participation was 34.7%; the strongest predictor was participation in round 1. Repeat participants were more likely to be female; inconsistent screeners were more likely to be younger (aged 50-59 years). The proportion of positive FOBT was 12.7%, that of colonoscopy compliance was 98.6%, and the positive predictive value for cancer or adenoma of advanced pathology was 23.9%. Reasons for participation included testing as a precautionary measure or having family history/friends with colorectal cancer; reasons for non-participation included apathy or doctors' advice against screening.

CONCLUSION

Participation was relatively low and consistent across rounds. Unless suitable strategies are identified to overcome behavioral trends and/or to screen out ineligible participants, little change in overall participation rates can be expected across rounds.

The relative importance of patient-reported barriers to colorectal cancer screening

BACKGROUND

Colorectal cancer (CRC) screening rates are suboptimal. The most important barriers identified by patients are poorly understood. A comprehensive assessment of barriers to all recommended modalities is needed.

METHODS

In 2007, a questionnaire was mailed to 6100 patients, aged 50-75 years, from 12 family medicine practices in the Virginia Ambulatory Care Outcomes Research Network. People aged 65-75 years and African Americans were oversampled. Patients were asked to rate 19-21 barriers to each of four recommended tests. In 2008, responses were coded on a 5-point scale; higher scores reflected stronger barrier endorsement.

RESULTS

The response rate was 55% (n=3357). Approximately 40% of respondents were aged >/=65 years, 30% were African-American, and 73% were adherent to screening. A clinician's failure to suggest screening and not knowing testing was necessary received the highest mean scores as barriers. Financial concerns and misconceptions were also cited. Barrier scores differed depending on whether respondents were never screened, overdue for screening, or adherent to guidelines. The top five barriers for each modality included test-specific barriers (e.g., handling stool, bowel preparation), which often outranked generic barriers to screening. Not knowing testing was necessary was a top barrier for all tests but colonoscopy.

CONCLUSIONS

Although physician advice and awareness of the need for screening are important, barriers to screening are not homogenous across tests, and test-specific barriers warrant consideration in designing strategies to improve screening rates. Barrier scores differ by screening status, highlighting the need to address prior screening experience. Evidence that patients are more familiar with colonoscopy than with other modalities suggests an opportunity to improve screening rates by educating patients about alternative tests.

The utility and predictive value of combinations of low penetrance genes for screening and risk prediction of colorectal cancer

Despite the fact that colorectal cancer (CRC) is a highly treatable form of cancer if detected early, a very low proportion of the eligible population undergoes screening for this form of cancer. Integrating a genomic screening profile as a component of existing screening programs for CRC could potentially improve the effectiveness of population screening by allowing the assignment of individuals to different types and intensities of screening and also by potentially increasing the uptake of existing screening programs. We evaluated the utility and predictive value of genomic profiling as applied to CRC, and as a potential component of a population-based cancer screening program. We generated simulated data representing a typical North American population including a variety of genetic profiles, with a range of relative risks and prevalences for individual risk genes. We then used these data to estimate parameters characterizing the predictive value of a logistic regression model built on genetic markers for CRC. Meta-analyses of genetic associations with CRC were used in building science to inform the simulation work, and to select genetic variants to include in logistic regression model-building using data from the ARCTIC study in Ontario, which included 1,200 CRC cases and a similar number of cancer-free population-based controls. Our simulations demonstrate that for reasonable assumptions involving modest relative risks for individual genetic variants, that substantial predictive power can be achieved when risk variants are common (e.g., prevalence > 20%) and data for enough risk variants are available (e.g., ~140–160). Pilot work in population data shows modest, but statistically significant predictive utility for a small collection of risk variants, smaller in effect than age and gender alone in predicting an individual’s CRC risk. Further genotyping and many more samples will be required, and indeed the discovery of many more risk loci associated with CRC before the question of the potential utility of germline genomic profiling can be definitively answered.

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 in Europe: differences in approach; similar barriers to overcome

Worldwide diagnoses of bowel cancer approximate an estimated one million new cases per year, comprising 9% of all cancer cases, and this has continued to increase over the last 25 years. With the association between cancer risk and increasing age, together with the suggestion that by 2015 there will be a 22% increase in the proportion of the population aged over 65 years and a 50% increase in the proportion of people aged over 80 years, there is likely to be a significant increase in the demand on cancer services throughout Europe and the rest of the world. This article discusses the current state of bowel cancer screening within Europe.

Having a personal health care provider and receipt of colorectal cancer testing

PURPOSE

We wanted to assess the relationship between having a personal health care provider and receiving colorectal cancer testing.

METHODS

Self-reported data were obtained from the United States 2004 Behavioral Risk Factor Surveillance System. Men and women aged 50 years and older were included, and associations of having a personal health care provider, age, sex, race/ethnicity, education, income, and health insurance status with colorectal cancer testing were examined. Multiple logistic regression was performed on a final sample of 120,221 individuals.

RESULTS

Having at least 1 personal health care provider significantly predicted up-to-date colorectal cancer testing in both the univariate (odds ratio [OR]=3.96; 95% confidence interval [CI] 3.56-4.41) and multiple regression models (OR = 2.91; 95% CI 2.58-3.28). Age, sex, race/ethnicity, education, income, and health insurance were also significantly associated with up-to-date colorectal cancer testing.

CONCLUSIONS

Having a personal health care provider was associated with up-to-date colorectal cancer testing. Efforts to increase and support the primary care workforce are needed to improve up-to-date colorectal cancer screening rates.

The impact of consumer-directed health plans and patient socioeconomic status on physician recommendations for colorectal cancer screening

BACKGROUND

Consumer-directed health plans are increasingly common, yet little is known about their impact on physician decision-making and preventive service use.

OBJECTIVE

To determine how patients' deductible levels and socioeconomic status may affect primary care physicians' recommendations for colorectal cancer screening.

DESIGN, SETTING, AND PARTICIPANTS

Screening recommendations were elicited using hypothetical vignettes from a national sample of 1,500 primary care physicians. Physicians were randomized to one of four vignettes describing a patient with either low or high socioeconomic status (SES) and either low- or high-deductible plan. Bivariate and multivariate analyses were used to examine how recommendations varied as a function of SES and deductible.

OUTCOME MEASURES

Rates of recommendation for home fecal occult blood testing, sigmoidoscopy, colonoscopy, and inappropriate screening, defined as no screening or office-based fecal occult blood testing.

RESULTS

A total of 528 (49%) eligible physicians responded. Overall, 7.2% of physicians recommended inappropriate screening; 3.2% of patients with high SES in low-deductible plans received inappropriate screening recommendations and 11.4% of patients with low SES in high-deductible plans for an adjusted odds ratio of 0.22 (0.05-0.89). The odds of a colonoscopy recommendation were over ten times higher (AOR 11.46, 5.26-24.94) for patients with high SES in low-deductible plans compared to patients with low SES in high-deductible plans. Funds in medical savings accounts eliminated differences in inappropriate screening recommendations.

CONCLUSIONS

Patient SES and deductible-level affect physician recommendations for preventive care. Coverage of preventive services and funds in medical savings accounts may help to mitigate the impact of high-deductibles and SES on inappropriate recommendations.

Perceptions of Iowa family physicians regarding colorectal cancer screening

BACKGROUND

Fewer than half of Americans have been screened for colorectal cancer (CRC), a largely preventable disease.

METHODS

All physician members (n = 1030) of the Iowa Academy of Family Physicians were mailed a 3-page investigator-developed survey about their attitudes, barriers, and practices regarding CRC screening.

RESULTS

The usable response rate was 29%. Forty-three percent practiced in rural settings. Ninety-five percent felt that they were well informed about American Cancer Society guidelines and 90% tried to follow the guidelines. Most doctors (88%) disagreed with the statement that there was "no time to adequately discuss screening," but they would like more time to discuss screening. Only 40% felt their medical records were organized to easily determine screening status, 40% encouraged office staff to participate in screening, and 16% had a written policy regarding CRC screening. Physicians estimated that they recommend screening to 78% of their patients and that 54% of their patients were actually up-to-date. Discussion of CRC screening was strongly dependent on visit type, with physicians estimating that CRC screening is discussed at 11% of acute visits, 42% of chronic visits, and 87% of health maintenance visits. Several office system factors were associated with a recommendation for screening in a multivariable linear regression model (R = 0.33).

CONCLUSIONS

Although nearly all physicians felt that they were well informed about American Cancer Society guidelines and tried to follow guidelines for CRC screening, few had office systems to facilitate screening. Physicians would like more time to discuss screening. Office systems likely have the most potential to improve CRC screening among patients attending primary care practices.

Acceptance of colonoscopy requires more than test tolerance

BACKGROUND

Colon cancer screening, including colonoscopy, lags behind other forms of cancer screening for participation rates. The intrinsic nature of the endoscopic procedure may be an important barrier that limits patients from finding this test acceptable and affects willingness to undergo screening. With colon cancer screening programs emerging in Canada, test characteristics and their impact on acceptance warrant consideration.

OBJECTIVES

To measure the acceptability of colonoscopy and define factors that contribute to procedural acceptability, in relation to another invasive gastrointestinal scope procedure, gastroscopy.

PATIENTS AND METHODS

Consecutive patients undergoing a colonoscopy (n=55) or a gastroscopy (n=33) were recruited. Their procedural experience was evaluated and compared pre-endoscopy, immediately before testing and postendoscopy. Questionnaires were used to capture multiple domains of the endoscopy experience and patient characteristics.

RESULTS

Patient scope groups did not differ preprocedurally for general or procedure-specific anxiety. However, the colonoscopy group did anticipate more pain. Those who had a gastroscopy demonstrated higher preprocedural acceptance than those who had a colonoscopy. The colonoscopy group had a significant decrease in scope concerns and anxiety postprocedurally. As well, they reported less pain than they anticipated. Regardless, postprocedurally, the colonoscopy group's acceptance did not increase significantly, whereas the gastroscopy group was almost unanimous in their test acceptance. The best predictor of pretest acceptability of colonoscopy was anticipated pain.

CONCLUSIONS

The findings indicate that concerns that relate specifically to colonoscopy, including anticipated pain, influence acceptability of the procedure. However, the experience of a colonoscopy does not lead to improved test acceptance, despite decreases in procedural anxiety and pain. Patients' preprocedural views of the test are most important and should be addressed directly to potentially improve participation in colonoscopy.

Validity of four self-reported colorectal cancer screening modalities in a general population: differences over time and by intervention assignment

Little is known about the validity of self-reported colorectal cancer screening. To date, few published studies have validated all four screening modalities per recommended guidelines or included a general population-based sample, and none has assessed validity over time and by intervention condition. To estimate the validity of self-reported screening, a random sample of 200 adults, ages > or =50 years, was selected from those completing annual surveys on screening behavior as part of an intervention study. Approximately 60% of the validation sample authorized medical record review. Sensitivity, specificity, and positive and negative predictive values were calculated for baseline and year 1 follow-up reports for each test and for overall screening adherence. Sensitivity at baseline ranged from 86.9% (flexible sigmoidoscopy) to 100% (colonoscopy). Sensitivity at follow-up was slightly lower. Adjusting for validity measures, the sample overreported screening prevalence at baseline for each of the four modalities. At follow-up, overreporting was greatest for fecal occult blood test (13.0%). Overreporting across intervention conditions was highest for fecal occult blood test (10.8% for control; 24.8% for the most intense intervention) and overall screening adherence (10.9% for control; 14.3% for the most intense intervention). Sensitivity and specificity of self-reported colorectal cancer screening compared with medical records were high; however, adjusting self-reported screening rates based on relative error rates reduced screening prevalence estimates. Those exposed to more intense interventions to modify screening behavior seemed more likely to overestimate their screening rates compared with those who were not exposed.

Barriers of and facilitators to physician recommendation of colorectal cancer screening

BACKGROUND

Colorectal cancer screening (CRCS) has been demonstrated to be effective and is consistently recommended by clinical practice guidelines. However, only slightly over half of all Americans have ever been screened. Patients cite physician recommendation as the most important motivator of screening. This study explored the barriers of and facilitators to physician recommendation of CRCS.

METHODS

A 3-component qualitative study to explore the barriers of and facilitators to physician recommendation of CRCS: in-depth, semistructured interviews with 29 purposively sampled, community- and academic-based primary care physicians; chart-stimulated recall, a technique that utilizes patient charts to probe physician recall and provide context about the barriers of and facilitators to physician recommendation of CRCS during actual clinic encounters; and focus groups with 18 academic primary care physicians. Grounded theory techniques of analysis were used.

RESULTS

All the participating physicians were aware of and recommended CRCS. The overwhelmingly preferred test was colonoscopy. Barriers of physician recommendation of CRCS included patient comorbidities, prior patient refusal of screening, physician forgetfulness, acute care visits, lack of time, and lack of reminder systems and test tracking systems. Facilitators to physician recommendation of CRCS included patient request, patient age 50-59, physician positive attitudes about CRCS, physician prioritization of screening, visits devoted to preventive health, reminders, and incentives.

CONCLUSION

There are multiple physician, patient, and system barriers to recommending CRCS. Thus, interventions may need to target barriers at multiple levels to successfully increase physician recommendation of CRCS.

Process evaluation in an intervention designed to improve rates of colorectal cancer screening in a VA medical center

Colorectal cancer (CRC) is the third most common cancer in the United States. Although CRC screening is recommended for individuals 50 years and older, screening completion rates are low. This can be attributed to provider and patient barriers. We developed an intervention to improve provider recommendation and patient screening among noncompliant male veterans in a 2-year randomized controlled trial and examined the relationship between participation and study outcomes among patients and providers. Overall, providers who attended intervention sessions recommended CRC screening during 64% of patient visits and providers who did not attend any intervention sessions recommended screening during 54% of visits (p < .01). Patients of providers who attended intervention sessions also were more likely to be screened (42% versus 29%, p < .05). The patient intervention did not have the desired impact. The subgroup of patients in the patient intervention was not more likely to complete CRC screening.

Influences on participation in a community-based colorectal neoplasia screening program by virtual colonoscopy in Australia

OBJECTIVE

To determine the effect of certain personal and health behaviour characteristics on participation in a community-based colorectal neoplasia (CRN) screening program using virtual colonoscopy.

METHODS

The study population comprised randomly selected subjects from the State electoral roll; screening by virtual colonoscopy was offered through letter of invitation. For non-responders, a further invitation was sent a month later. Non-response after a further month led to subjects being considered non-participants. Non-participants were contacted by letter to complete a structured questionnaire; participants completed a similar questionnaire immediately after their screening virtual colonoscopy.

RESULTS

Discussing the invitation to screening with someone else increased the likelihood of participation by 63% (prevalence ratio 1.63, 95% CI 1.38-1.93); knowing someone with cancer increased the likelihood of participation by 23% (PR 1.23, 95% CI 1.07-1.42). Among participants who discussed screening with another individual, the spouse was the most common (71%). Subjects who were single were less likely to participate (PR 0.79, 95% CI 0.67-0.94). The strongest reported influence for participation was information provided in the letter of invitation (29.8%). The most common reasons for non-participation were lack of time and perceived good health.

CONCLUSIONS AND IMPLICATIONS

This study suggests that a simple strategy to facilitate participation is to encourage subjects to discuss screening with others; further, to recognise that this may be most difficult for those who are single. Information provided to subjects prior to screening positively contributes to participation.

Low uptake of colorectal cancer screening 3 yr after release of national recommendations for screening

BACKGROUND

National guidelines recommending colorectal cancer (CRC) screening for average risk Canadians were released in 2001. The current study determined rates of CRC screening and predictors of screening 3 yr after the guidelines were released.

METHOD

A population-based random digit dial telephone survey of 1,808 Alberta men and women aged 50-74 yr assessed awareness about, and self-reported rates of, screening.

RESULTS

More average risk women than men reported a recent screening with a home fecal occult blood test (FOBT) (14.0%vs 9.8%, P= 0.013) but men had slightly higher rates of screening endoscopy in the past 5 yr (4.3%vs 1.6%, P= 0.003). Overall, only 14.3% of average risk adults (N = 1,476) were up-to-date on CRC screening. Multivariable predictors of being up-to-date on CRC screening differed for men and women although a doctor's recommendation for screening was a strong predictor for both genders (men OR 5.0, 2.9-8.3, women OR 3.8, 2.3-6.5). Screening for other cancers was also an important predictor in both men and women.

CONCLUSION

Three years after the release of national guidelines, rates of screening among average risk adults aged 50-74 yr were very low. Public education programs and primary care interventions to specifically invite average risk adults for screening may be required to increase CRC screening rates.

Colorectal cancer screening among men and women in the United States

BACKGROUND

A few previous studies have shown that men were more likely than women to be screened for colorectal cancer (CRC).

METHODS

The 2000 National Health Interview Survey (NHIS) was administered to 32,374 adults > or = 18 years of age. Participants were asked if they ever had a sigmoidoscopy or colonoscopy and if they ever had a home fecal occult blood test (FOBT). Men and women > or = 50 years were eligible for analysis. Participants were considered to be current in testing if they reported sigmoidoscopy in the last 5 years, colonoscopy in the last 10 years, or home FOBT in the last 1 year.

RESULTS

Overall, 62.9% of adults had ever had CRC testing, and 37.1% were current for testing. Compared to older men, a greater proportion of older women were not current for testing (62.6% for women vs. 56.7% for men > 75 years). In multivariate analysis, women were not less likely than men to be current in CRC testing (OR 0.98, 95% CI 0.88-1.08). When compared with white women, black women were less likely to be current for CRC screening (OR 0.79, 95% CI 0.65-0.95).

CONCLUSIONS

CRC screening is underused. Targeting interventions to improve CRC screening for all appropriate patients will be important.

Physician and staff perceptions of barriers to colorectal cancer screening in Appalachian Kentucky

BACKGROUND

Data indicate that in 1997 to 1999, only 44% of Appalachian Kentuckians underwent colorectal cancer screening consistent with guidelines. We investigated the reasons for, barriers to, and follow-up of colorectal cancer (CRC) screening recommendations in primary care practices seeing patients from Appalachian Kentucky.

METHODS

A mixed-methods [qualitative (focus group) and quantitative (survey)] approach was used to gather and analyze data in five primary care practices. A total of 34 participated in the focus groups.

RESULTS

In focus groups, physicians and office staff reported a number of indicators for CRC screening; physician, patient, and procedural barriers to CRC screening; and strategies to overcome these barriers to screening. Most physicians used personal experience to guide screening, but it was unclear what was meant by personal experience. Commonly cited patient barriers to screening were fear and embarrassment. Physicians reported several approaches to overcome these barriers, including establishing trust and educating patients. Survey data identified a number of resources to assist practices in promoting screening, most commonly, patient educational materials. Finally, fecal occult blood test was most commonly recommended because it is inexpensive and easy to administer.

CONCLUSIONS

Our mixed methods approach not only helped to understand the physicians' perceptions of the problems and barriers to CRC screening in Appalachian Kentucky, but also elucidated how practices endeavor to overcome these barriers and identified the additional resources practices would like in order to promote CRC screening.

Cancer of the colorectum in Maine, 1995-1998: determinants of stage at diagnosis in a rural state

CONTEXT

Despite screening for colorectal cancer, mortality in the United States remains substantial. In northern New England, little is known about predictors of stage at diagnosis, an important determinant of survival and mortality.

PURPOSE

The objective of this study was to identify predictors of late stage at diagnosis for colorectal cancer in a rural state with a predominantly white population and a large Franco-American minority.

METHODS

Incident cases from 1995-1998 were obtained from the Maine Cancer Registry. Individual-level variables (age, sex, race, French ethnicity by surname, and payer) and contextual/town-level variables (socioeconomic status, population density, Franco ancestry proportion, distance to health care, and weather) were modeled with multiple logistic regression for late stage.

FINDINGS

Increasing distance to primary care provider was associated with late stage for colorectal cancer. Compared to patients aged > or =85 years, those aged 65-84 years were less likely to be diagnosed late, while those aged 35-49 years were more likely--although not significantly--to have late stage at diagnosis. Associations were not found with socioeconomic variables.

CONCLUSIONS

The finding regarding distance to primary care may be consistent with studies showing that rurality and distance to care predict reduced utilization of health care services and worse health outcomes. The finding regarding age has implications for the education of younger high-risk patients and their physicians. The absence of positive findings with regard to socioeconomic variables may stem from the uniquely mixed sociodemographic profiles in rural and urban regions of Maine. Further research should refine these and other contextual measures to elucidate effects on rural health and should further evaluate the utility of assigning French ethnicity by surname in order to identify health disparities.

Non-compliance in surveillance for patients with previous resection of large (≥ 1 cm) colorectal adenomas

AIM: To assess the extent and reasons of non-compliance in surveillance for patients undergoing polypectomy of large (≥ 1 cm) colorectal adenomas.

METHODS: Between 1995 and 2002, colorectal adenomas ≥ 1 cm were diagnosed in 210 patients and subsequently documented at the Erlangen Registry of Colorectal Polyps. One hundred and fifty-eight patients (75.2%) could be contacted by telephone and agreed to be interviewed. Additionally, records were obtained from the treating physicians.

RESULTS: Fifty-four out of 158 patients (34.2%) neglected any surveillance. Reasons for non-compliance included lack of knowledge concerning surveillance intervals (45.8%), no symptoms (29.2%), fear of examination (18.8%) or old age/severe illness (6.3%). In a multivariate analysis, the factors including female gender (P = 0.036) and age > 62 years (P = 0.016) proved to be significantly associated with non-compliance in surveillance.

CONCLUSION: Efforts to increase compliance in surveillance are of utmost importance. This applies particularly to women’s compliance. Effective strategies for avoiding metachronous colorectal adenoma and cancer should focus on both the improvement in awareness and knowledge of patients and information about physicians for surveillance.

Barriers to colorectal cancer screening among Medicare consumers

BACKGROUND

Few studies have examined lack of physician recommendation and other reasons for under-utilization of colorectal cancer (CRC) screening in the Medicare population.

METHODS

Data from a telephone survey conducted in 2001 in a random sample of Medicare consumers residing in North and South Carolina were used to examine barriers to CRC screening, focusing on consumers' reports of receiving a physician's recommendation to obtain CRC screening and reasons for not being screened. Analyses were restricted to respondents with no history of CRC (n = 1901). Descriptive statistics were used to characterize respondents' CRC screening status, receipt of a physician's recommendation for screening, and reasons for not being screened. Logistic regression modeling was used to examine factors associated with receiving a physician recommendation for fecal occult blood test, sigmoidoscopy, colonoscopy, any endoscopy, and any CRC test.

RESULTS

Thirty-one percent of Medicare consumers had never been tested for CRC, and 18% had been tested but were not current with Medicare-covered intervals. Overall, 28% reported not receiving a physician recommendation for screening. Predictors of receiving a physician recommendation included sociodemographic (younger age, white race, more education), health status (increased CRC risk, comorbidity), and healthcare access (had a routine/preventive care visit in the past 12 months) factors. Lack of knowledge/awareness and the physician not ordering the test were commonly cited reasons for not having CRC tests.

CONCLUSIONS

Colorectal cancer screening was under-utilized by Medicare consumers in two states, and lack of physician recommendation was an important contributing factor. Providing a benefit under the Medicare program does not ensure its widespread use by consumers or their physicians.

Attitudes and knowledge of colorectal cancer and screening in Hong Kong: a population-based study

BACKGROUND

Colorectal cancer (CRC) ranks third of all cancer mortalities in Hong Kong. CRC screening can reduce mortality. However, participation in the CRC screening program depends on the knowledge and attitude of the population. The aim of this study is to investigate the knowledge and attitude towards CRC screening in the Hong Kong population.

METHODS

One thousand and thirty-three patients were interviewed by telephone survey. Knowledge and attitudes were assessed by using questionnaires.

RESULTS

Only 8.9% of the respondents were able to mention that CRC was the second commonest cancer cause of death; 4.5% believed they would have a higher chance of developing CRC as compared to other cancers, and 7.4% could mention one of the screening methods. Approximately half (50.3%) were unable to identify any available screening venue. Approximately one-third (29.5%) indicated that they would definitely join a free CRC screening program, but the percentage dropped to 7.9% when a paid screening program was offered. Some (30.4%) of the respondents had the wrong impression that they did not require CRC screening because they were asymptomatic. Multivariate analysis showed that the independent predictor for participating in free screening was the concern level of getting CRC, while that for a paid screening program was a positive family history of CRC and the concern level. The concern level was dependent on a positive family history and knowledge of CRC.

CONCLUSION

The general population in Hong Kong had deficient knowledge of CRC and screening. Education on the impact of CRC and beneficial effects of CRC screening should be offered before launching a CRC screening program.

Barriers to colorectal cancer screening: a comparison of reports from primary care physicians and average-risk adults

BACKGROUND

Barriers to colorectal cancer (CRC) screening are not well understood.

OBJECTIVES

We sought to compare barriers to CRC screening reported by primary care physicians (PCPs) and by average-risk adults, and to examine characteristics of average-risk adults who identified lack of provider recommendation as a major barrier to CRC screening.

RESEARCH DESIGN

This was a comparative study using data from the 1999-2000 Survey of Colorectal Cancer Screening Practices and the 2000 National Health Interview Survey (NHIS).

SUBJECTS

We recruited nationally representative samples of PCPs (n= 1235) from the SCCSP and average-risk adults (n = 6497) from the NHIS.

MEASURES

We measured barriers to CRC screening identified by PCPs and average-risk adults who were not current with screening.

RESULTS

Both PCPs and average-risk adults identified lack of patient awareness and physician recommendation as key barriers to obtaining CRC screening. PCPs also frequently cited patient embarrassment/anxiety about testing and test cost/lack of insurance coverage, but few adults identified these as major barriers. Of adults not current with testing, those who had visited a doctor in the past year or had health insurance were more likely to report lack of physician recommendation as the main reason they were not up-to-date compared with their counterparts with no doctor visit or health insurance. Only 10% of adults not current with testing and who had a doctor visit in the past year reported receiving a screening recommendation.

CONCLUSIONS

A need exists for continued efforts to educate the public about CRC and the important role of screening in preventing this disease. Practice-based strategies to systematically prompt health care providers to discuss CRC screening with eligible patients also are required.