Correlation of 18-F-fluorodeoxyglucose (FDG) accumulation with glucose transporter (Glut-1) expression in esophageal squamous cell carcinoma

Financial Interventions to Improve Screening in Primary Care: A Systematic Review

INTRODUCTION

Although health screenings offer timely detection of health conditions and enable early intervention, adoption is often poor. How might financial interventions create the necessary incentives and resources to improve screening in primary care settings? This systematic review aimed to answer this question.

METHODS

Peer-reviewed studies published between 2000 and 2023 were identified and categorized by the level of intervention (practice or individual) and type of intervention, specifically alternative payment models (APMs), fee-for-service (FFS), capitation, and capital investments. Outcomes included frequency of screening, performance/quality of care (e.g., patient satisfaction, health outcomes), and workflow changes (e.g., visit length, staffing).

RESULTS

Of 51 included studies, a majority focused on practice-level interventions (n=32), used APMs (n=41) that involved payments for achieving key performance indicators (KPIs; n=31) and were of low or very low strength of evidence based on GRADE criteria (n=42). Studies often included screenings for cancer (n=32), diabetes care (n=18), and behavioral health (n=15). KPI payments to both practices and individual providers corresponded with increased screening rates, whereas capitation and provider-level FFS models yielded mixed results. A large majority of studies assessed changes in screening rates (n=48) with less focus on quality of care (n=11) or workflow changes (n=4).

DISCUSSION

Financial mechanisms can enhance screening rates with evidence strongest for KPI payments to both practices and individual providers. Future research should explore the relationship between financial interventions and quality of care, in terms of both clinical processes and patient outcomes, as well as the role of these interventions in shaping care delivery.

Effect of a Patient Decision Aid on Preferences for Colorectal Cancer Screening Among Older Adults: A Secondary Analysis of a Randomized Clinical Trial

IMPORTANCE

Guidelines recommend individualized decision-making for colorectal cancer (CRC) screening among adults aged 76 to 84 years, a process that includes a consideration of health state and patient preference.

OBJECTIVE

To determine whether a targeted patient decision aid would align older adults' screening preference with their potential to benefit from CRC screening.

DESIGN, SETTING, AND PARTICIPANTS

This is a prespecified secondary analysis from a randomized clinical trial. Participants aged 70 to 84 years who were not up to date with screening and had an appointment within 6 weeks were purposively sampled by health state (poor, intermediate, or good) at 14 community-based primary care practices and block randomized to receive the intervention or control. Patients were recruited from March 1, 2012, to February 28, 2015, and these secondary analyses were performed from January 15 to March 1, 2022.

INTERVENTIONS

Patient decision aid targeted to age and sex.

MAIN OUTCOMES AND MEASURES

The primary outcome of this analysis was patient preference for CRC screening. The a priori hypothesis was that the decision aid (intervention) group would reduce the proportion preferring screening among those in poor and intermediate health compared with the control group.

RESULTS

Among the 424 participants, the mean (SD) age was 76.8 (4.2) years; 248 (58.5%) of participants were women; and 333 (78.5%) were White. The proportion preferring screening in the intervention group was less than in the control group for those in the intermediate health state (34 of 76 [44.7%] vs 40 of 73 [54.8%]; absolute difference, -10.1% [95% CI, -26.0% to 5.9%]) and in the poor health state (24 of 62 [38.7%] vs 33 of 61 [54.1%]; absolute difference, -15.4% [95% CI, -32.8% to 2.0%]). These differences were not statistically significant. The proportion of those in good health who preferred screening was similar between the intervention and control groups (44 of 74 [59.5%] for intervention vs 46 of 75 [61.3%] for control; absolute difference, -1.9% [95% CI, -17.6% to 13.8%]).

CONCLUSIONS AND RELEVANCE

The findings of this secondary analysis of a clinical trial did not demonstrate statistically significant differences in patient preferences between the health groups. Additional studies that are appropriately powered are needed to determine the effect of the decision aid on the preferences of older patients for CRC screening by health state.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT01575990.

Imaging biomarkers for the treatment of esophageal cancer

Esophageal cancer is known as one of the malignant cancers with poor prognosis. To improve the outcome, combined multimodality treatment is attempted. On the other hand, advances in genomics and other “omic” technologies are paving way to the patient-oriented treatment called “personalized” or “precision” medicine. Recent advancements of imaging techniques such as functional imaging make it possible to use imaging features as biomarker for diagnosis, treatment response, and prognosis in cancer treatment. In this review, we will discuss how we can use imaging derived tumor features as biomarker for the treatment of esophageal cancer.

A Decision Aid to Promote Appropriate Colorectal Cancer Screening among Older Adults: A Randomized Controlled Trial

Background. Concerns have been raised about both over- and underutilization of colorectal cancer (CRC) screening in older patients and the need to align screening behavior with likelihood of net benefit. Objective. The purpose of this study was to test a novel use of a patient decision aid (PtDA) to promote appropriate CRC screening in older adults. Methods. A total of 424 patients ages 70 to 84 y who were not up to date with CRC screening participated in a double-blinded randomized controlled trial of a PtDA targeted to older adults making decisions about whether to undergo CRC screening from March 2012 to February 2015. Intervention. Patients were randomized to a targeted PtDA or an attention control. The PtDA was designed to facilitate individualized decision making—helping patients understand the potential risks, benefits, and uncertainties of CRC screening given advanced age, health state, preferences, and values. Outcomes. Two composite outcomes, appropriate CRC screening behavior 6 mo after the index visit and appropriate screening intent immediately after the visit, were defined as completed screening or intent for patients in good health, discussion about screening with their provider for patients in intermediate health, and no screening or intent for patients in poor health. Health state was determined by age and Charlson Comorbidity Index. Results. Four hundred twelve (97%) and 421 (99%) patients were analyzed for the primary and secondary outcomes, respectively. Appropriate screening behavior at 6 mo was higher in the intervention group (55% v. 45%, P = 0.023) as was appropriate screening intent following the provider visit (61% v. 47%, P = 0.003). Limitations. The study took place in a single geographic region. The appropriate CRC screening classification system used in this study has not been formally validated. Conclusions. A PtDA for older adults promoted appropriate CRC screening behavior and intent.

Trial Registration: Clinicaltrials.gov, registration number NCT01575990. https://clinicaltrials.gov/ct2/show/NCT01575990?term=epic-d&rank=1

Design of a randomized clinical trial of a colorectal cancer screening decision aid to promote appropriate screening in community-dwelling older adults

BACKGROUND

Appropriate colorectal cancer screening in older adults should be aligned with the likelihood of net benefit. In general, patient decision aids improve knowledge and values clarity, but in older adults, they may also help patients identify their individual likelihood of benefit and foster individualized decision-making. We report on the design of a randomized clinical trial to understand the effects of a patient decision aid on appropriate colorectal cancer screening. This report includes a description of the baseline characteristics of participants.

METHODS

English-speaking primary care patients aged 70-84 years who were not currently up to date with screening were recruited into a randomized clinical trial comparing a tailored colorectal cancer screening decision aid with an attention control. The intervention group received a decision aid that included a values clarification exercise and individualized decision-making worksheet, while the control group received an educational pamphlet on safe driving behaviors. The primary outcome was appropriate screening at 6 months based on chart review. We used a composite measure to define appropriate screening as screening for participants in good health, a discussion about screening for patients in intermediate health, and no screening for patients in poor health. Health state was objectively determined using patients' Charlson Comorbidity Index score and age.

RESULTS

A total of 14 practices in central North Carolina participated as part of a practice-based research network. In total, 424 patients were recruited to participate and completed a baseline visit. Overall, 79% of participants were White and 58% female, with a mean age of 76.8 years. Patient characteristics between groups were similar by age, gender, race, education, insurance coverage, or work status. Overall, 70% had some college education or more, 57% were married, and virtually all had Medicare insurance (90%). The three primary medical conditions among the cohort were a history of diabetes, pneumonia, and cancer (28%, 26%, and 21%, respectively).

CONCLUSION

We designed a randomized clinical trial to test a novel use of a patient decision aid to promote appropriate colorectal cancer screening and have recruited a diverse study population that seems similar between the intervention and control groups. The study should be able to determine the ability of a patient decision aid to increase individualized and appropriate colorectal cancer screening.

Colorectal Cancer Incidence Patterns in the United States, 1974-2013

Background

Colorectal cancer (CRC) incidence in the United States is declining rapidly overall but, curiously, is increasing among young adults. Age-specific and birth cohort patterns can provide etiologic clues, but have not been recently examined.

Methods

CRC incidence trends in Surveillance, Epidemiology, and End Results areas from 1974 to 2013 (n = 490 305) were analyzed by five-year age group and birth cohort using incidence rate ratios (IRRs) and age-period-cohort modeling.

Results

After decreasing in the previous decade, colon cancer incidence rates increased by 1.0% to 2.4% annually since the mid-1980s in adults age 20 to 39 years and by 0.5% to 1.3% since the mid-1990s in adults age 40 to 54 years; rectal cancer incidence rates have been increasing longer and faster (eg, 3.2% annually from 1974-2013 in adults age 20-29 years). In adults age 55 years and older, incidence rates generally declined since the mid-1980s for colon cancer and since 1974 for rectal cancer. From 1989-1990 to 2012-2013, rectal cancer incidence rates in adults age 50 to 54 years went from half those in adults age 55 to 59 to equivalent (24.7 vs 24.5 per 100 000 persons: IRR = 1.01, 95% confidence interval [CI] = 0.92 to 1.10), and the proportion of rectal cancer diagnosed in adults younger than age 55 years doubled from 14.6% (95% CI = 14.0% to 15.2%) to 29.2% (95% CI = 28.5% to 29.9%). Age-specific relative risk by birth cohort declined from circa 1890 until 1950, but continuously increased through 1990. Consequently, compared with adults born circa 1950, those born circa 1990 have double the risk of colon cancer (IRR = 2.40, 95% CI = 1.11 to 5.19) and quadruple the risk of rectal cancer (IRR = 4.32, 95% CI = 2.19 to 8.51).

Conclusions

Age-specific CRC risk has escalated back to the level of those born circa 1890 for contemporary birth cohorts, underscoring the need for increased awareness among clinicians and the general public, as well as etiologic research to elucidate causes for the trend. Further, as nearly one-third of rectal cancer patients are younger than age 55 years, screening initiation before age 50 years should be considered.

The American Cancer Society challenge goal to reduce US cancer mortality by 50% between 1990 and 2015: Results and reflections

In 1996, the Board of Directors of the American Cancer Society (ACS) challenged the United States to reduce what looked to be possible peak cancer mortality in 1990 by 50% by the year 2015. This analysis examines the trends in cancer mortality across this 25-year challenge period from 1990 to 2015. In 2015, cancer death rates were 26% lower than in 1990 (32% lower among men and 22% lower among women). The 50% reduction goal was more fully met for the cancer sites for which there was enactment of effective approaches for prevention, early detection, and/or treatment. Among men, mortality rates dropped for lung cancer by 45%, for colorectal cancer by 47%, and for prostate cancer by 53%. Among women, mortality rates dropped for lung cancer by 8%, for colorectal cancer by 44%, and for breast cancer by 39%. Declines in the death rates of all other cancer sites were substantially smaller (13% among men and 17% among women). The major factors that accounted for these favorable trends were progress in tobacco control and improvements in early detection and treatment. As we embark on new national cancer goals, this recent past experience should teach us that curing the cancer problem will require 2 sets of actions: making new discoveries in cancer therapeutics and more completely applying those discoveries in cancer prevention we have already made. CA Cancer J Clin 2016;66:359-369. © 2016 American Cancer Society.

Colorectal Cancer Screening in US Seniors Ages 76-84 Years

The US Preventive Services Task Force recommends patient-physician discussions about the appropriateness of colorectal cancer (CRC) screening among adults ages 76-84 years who have never been screened. In this study, we used data from the 2010 National Health Interview Survey to examine patterns of CRC screening and provider recommendation among seniors ages 76-84 years, and made some comparisons to younger adults. Nationally-representative samples of 1379 adults ages 76-84 years and 8797 adults ages 50-75 years responded to questions about CRC screening status, receipt of provider recommendation, and discussion of test options; 22.7% (95% CI 20.1-25.3) of seniors ages 76-84 had never been tested for CRC and therefore were not up-to-date with guidelines; 3.9% (95% CI 2.0-7.6) of these individuals reported a recent provider recommendation for screening. In multivariate analyses, the likelihood of never having been tested was significantly greater for seniors of other/multiple race or Hispanic ethnicity; with high school or less education; without private health insurance coverage; who had ≤ 1 doctor visit in the past year; without recent screening for breast, cervical, or prostate cancer; with no or unknown CRC family history; or with ≤ 1 chronic disease. Among the minority of respondents ages 50-75 and 76-84 reporting a provider recommendation, 73.2% indicated that the provider recommended particular tests, which was overwhelmingly colonoscopy (≥ 89 %). Nearly one-quarter of adults 76-84 have never been screened for CRC, and rates of provider recommendation in this group are very low. Greater attention to informed CRC screening discussions with screening-eligible seniors is needed.

Colon cancer screening in U.S. adults aged 65 and older according to life expectancy and age

OBJECTIVES

To examine receipt of colorectal cancer (CRC) screening according to age and life expectancy (LE) in adults aged 65 and older.

DESIGN

Population-based survey.

SETTING

United States.

PARTICIPANTS

Community dwelling adults aged 65 and older who participated in the 2008 or 2010 National Health Interview Survey (N = 7,747).

MEASUREMENTS

Receipt of CRC screening (e.g., colonoscopy within 10 years) was examined according to age and LE (≥10 and <10 years), adjusting for sociodemographic characteristics and survey year. Frequency of CRC screening was also examined according to age and LE at time of screening (e.g., age at colonoscopy rather than at interview). Participants screened when they were aged 75 and older or had less than a 10-year LE were considered to have received screening inconsistent with guidelines.

RESULTS

Overall, 38.5% of participants had less than a 10-year LE; 40.2% were aged 75 and older, and 56.3% had received recent CRC screening (90.1% by colonoscopy). CRC screening was higher in 2010 (58.9%) than 2008 (53.7%, P <.001) and was associated with longer LE and younger age, although 51.1% of adults aged 75 and older reported receiving CRC screening, as did 50.9% of adults with less than a 10-year LE. Based on age and LE at time of screening (rather than at interview), 28.4% of CRC screening of adults aged 65 and older was targeted to those aged 75 and older and those with less than a 10-year LE. Of adults aged 65 to 75 with a 10-year LE or more (adults recommended for screening by guidelines), 39.2% had not recently been screened.

CONCLUSION

Older adults with little chance of benefit because of limited LE commonly undergo CRC screening, whereas many adults aged 65 to 75 with a 10-year LE or greater are not screened.

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

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

Older adults' preferences for colorectal cancer-screening test attributes and test choice

BACKGROUND

Understanding which attributes of colorectal cancer (CRC) screening tests drive older adults' test preferences and choices may help improve decision making surrounding CRC screening in older adults.

MATERIALS AND METHODS

To explore older adults' preferences for CRC-screening test attributes and screening tests, we conducted a survey with a discrete choice experiment (DCE), a directly selected preferred attribute question, and an unlabeled screening test-choice question in 116 cognitively intact adults aged 70-90 years, without a history of CRC or inflammatory bowel disease. Each participant answered ten discrete choice questions presenting two hypothetical tests comprised of four attributes: testing procedure, mortality reduction, test frequency, and complications. DCE responses were used to estimate each participant's most important attribute and to simulate their preferred test among three existing CRC-screening tests. For each individual, we compared the DCE-derived attributes to directly selected attributes, and the DCE-derived preferred test to a directly selected unlabeled test.

RESULTS

Older adults do not overwhelmingly value any one CRC-screening test attribute or prefer one type of CRC-screening test over other tests. However, small absolute DCE-derived preferences for the testing procedure attribute and for sigmoidoscopy-equivalent screening tests were revealed. Neither general health, functional, nor cognitive health status were associated with either an individual's most important attribute or most preferred test choice. The DCE-derived most important attribute was associated with each participant's directly selected unlabeled test choice.

CONCLUSION

Older adults' preferences for CRC-screening tests are not easily predicted. Medical providers should actively explore older adults' preferences for CRC screening, so that they can order a screening test that is concordant with their patients' values. Effective interventions are needed to support complex decision making surrounding CRC screening in older adults.

Colorectal testing utilization and payments in a large cohort of commercially insured US adults

OBJECTIVES

Screening decreases colorectal cancer (CRC) mortality. The national press has scrutinized colonoscopy charges. Little systematic evidence exists on colorectal testing and payments among commercially insured persons. Our aim was to characterize outpatient colorectal testing utilization and payments among commercially insured US adults.

METHODS

We conducted an observational cohort study of outpatient colorectal test utilization rates, indications, and payments among 21 million 18-64-year-old employees and dependants with noncapitated group health insurance provided by 160 self-insured employers in the 2009 Truven MarketScan Databases.

RESULTS

Colonoscopy was the predominant colorectal test. Among 50-64-year olds, 12% underwent colonoscopy in 1 year. Most fecal tests and colonoscopies were associated with screening/surveillance indications. Testing rates were higher in women, and increased with age. Mean payments for fecal occult blood and immunochemical tests were $5 and $21, respectively. Colonoscopy payments varied between and within sites of service. Mean payments for diagnostic colonoscopy in an office, outpatient hospital facility, and ambulatory surgical center were $586 (s.d. $259), $1,400 (s.d. $681), and $1,074 (s.d. $549), respectively. Anesthesia and pathology services accompanied 35 and 52% of colonoscopies, with mean payments of $494 (s.d. $354) and $272 (s.d. $284), respectively. Mean payments for the most prevalent colonoscopy codes were 1.4- to 1.9-fold the average Medicare payments.

CONCLUSIONS

Most outpatient colorectal testing among commercially insured adults was associated with screening or surveillance. Payments varied widely across sites of service, and payments for anesthesia and pathology services contributed substantially to total payments. Cost-effectiveness analyses of CRC screening have relied on Medicare payments as proxies for costs, but cost-effectiveness may differ when analyzed from the perspectives of Medicare or commercial insurers.

Implementing the CDC's Colorectal Cancer Screening Demonstration Program: wisdom from the field

BACKGROUND

Colorectal cancer, as the second leading cause of cancer-related deaths among men and women in the United States, represents an important area for public health intervention. Although colorectal cancer screening can prevent cancer and detect disease early when treatment is most effective, few organized public health screening programs have been implemented and evaluated. From 2005 to 2009, the Centers for Disease Control and Prevention funded 5 sites to participate in the Colorectal Cancer Screening Demonstration Program (CRCSDP), which was designed to reach medically underserved populations.

METHODS

The authors conducted a longitudinal, multiple case study to analyze program implementation processes. Qualitative methods included interviews with 100 stakeholders, 125 observations, and review of 19 documents. Data were analyzed within and across cases.

RESULTS

Several themes related to CRCSDP implementation emerged from the cross-case analysis: the complexity of colorectal cancer screening, the need for teamwork and collaboration, integration of the program into existing systems, the ability of programs to use wisdom at the local level, and the influence of social norms. Although these themes were explored independently from 1 another, interaction across themes was evident.

CONCLUSIONS

Colorectal cancer screening is clinically complex, and its screening methods are not well accepted by the general public; both of these circumstances have implications for program implementation. Using patient navigation, engaging in transdisciplinary teamwork, assimilating new programs into existing clinical settings, and deferring to local-level wisdom together helped to address complexity and enhance program implementation. In addition, public health efforts must confront negative social norms around colorectal cancer screening.

Age-based and sex-based disparities in screening colonoscopy use among medicare beneficiaries

BACKGROUND

The use of screening colonoscopy among older persons is controversial due to variability in life expectancy and sex-based differences in colorectal cancer incidence. We assessed the relation between sex, age, and receipt of screening colonoscopy overall and within strata of life expectancy.

METHODS

We used Medicare data to identify beneficiaries during the years 2001 to 2005 who had not undergone a colonoscopy in the prior 3 years. Medicare claims were used to identify screening colonoscopy use; life expectancy was estimated using a life table approach. We used Poisson regression to examine sex and age differences in screening colonoscopy, adjusted for patient demographic characteristics.

RESULTS

Our sample consisted of 161,229 patients (61.9% female; mean age 76.9 y). The screening colonoscopy rates for females and males were 16.9 and 24.4 screening colonoscopies per 1000 person-years, respectively (P<0.001). The screening colonoscopy rate was highest for patients with the longest life expectancy (10 to 15 y: 27.2 screening colonoscopies per 1000 person-years) compared with 3.4 per 1000 person-years in the life expectancy <5-year group. Within specific life expectancy categories, older patients had significantly lower screening rates; in the 10- to 15-year life expectancy category, patients 75 to 79 years old had a lower rate (21.9 screening colonoscopies per 1000 person-years) than patients 68 to 69 years old (34.1 screening colonoscopies per 1000 person-years; P<0.001).

CONCLUSIONS

In a large cohort of Medicare beneficiaries, there was evidence of screening colonoscopy use even among patients with a short life expectancy. After accounting for life expectancy, females and older persons were less likely to undergo screening colonoscopy.

Tailoring colorectal cancer screening by considering risk of advanced proximal neoplasia

BACKGROUND

Quantifying the risk of advanced proximal colorectal neoplasia might allow tailoring of colorectal cancer screening, with colonoscopy for those at high risk and less invasive screening for very low-risk persons.

METHODS

We analyzed findings from 10,124 consecutive adults aged≥50 years who underwent screening colonoscopy to the cecum. We quantified the risk of advanced neoplasia (tubular adenoma≥1 cm, a polyp with villous histology or high-grade dysplasia, or adenocarcinoma) both proximally (cecum to splenic flexure) and distally (descending colon to anus). The prevalence of advanced proximal neoplasia was quantified by age, gender, and distal findings.

RESULTS

The mean (standard deviation) age was 57.5 (6.0) years; 44% were women; 7835 (77%) had no neoplasia, and 1856 (18%) had 1 or more nonadvanced adenomas. Overall, 433 subjects (4.3%) had advanced neoplasia (267 distally, 196 proximally, 30 both), 33 (0.33%) of which were adenocarcinoma (18 distal, 15 proximal). The risk of advanced proximal neoplasia increased with age decade (1.13%, 2.00%, and 5.26%, respectively; P=.001) and was higher in men (relative risk [RR], 1.91; confidence interval [CI], 1.32-2.77). In women aged less than 70 years, the risk was 1.1% overall (vs 2.2% in men; RR, 1.98; CI, 1.42-2.76) and 0.86% in those with no distal neoplasia (vs 1.54% in men; RR, 1.81; CI, 1.20-2.74).

CONCLUSIONS

Risk of advanced proximal neoplasia is a function of age and gender. Women aged less than 60 to 70 years have a very low risk, particularly those with no distal adenoma. Sigmoidoscopy with or without occult blood testing may be sufficient and even preferable for screening these subgroups.

Proximal and distal colorectal cancer resection rates in the United States since widespread screening by colonoscopy

BACKGROUND & AIMS

Screening decreases colorectal cancer (CRC) incidence and mortality. Colonoscopy has become the most common CRC screening test in the United States, but the degree to which it protects against CRC of the proximal colon is unclear. We examined US trends in rates of resection for proximal vs distal CRC, which reflect CRC incidence, in the context of national CRC screening data, before and since Medicare's 2001 decision to pay for screening colonoscopy.

METHODS

We used the Nationwide Inpatient Sample, the largest US all-payer inpatient database, to estimate age-adjusted rates of resection for distal and proximal CRC, from 1993 to 2009, in adults. Temporal trends were analyzed using Joinpoint regression analysis.

RESULTS

The rate of resection for distal CRC decreased from 38.7 per 100,000 persons (95% confidence interval [CI], 35.4-42.0) to 23.2 per 100,000 persons (95% CI, 20.9-25.5) from 1993 to 2009, with annual decreases of 1.2% (95% CI, 0.1%-2.3%) from 1993 to 1999, followed by larger annual decreases of 3.8% (95% CI, 3.3%-4.3%) from 1999 to 2009 (P < .001). In contrast, the rate of resection for proximal CRC decreased from 30.0 per 100,000 persons (95% CI, 27.4-32.5) to 22.7 per 100,000 persons (95% CI, 20.6-24.7) from 1993 to 2009, but significant annual decreases of 3.1% (95% CI, 2.3%-4.0%) occurred only after 2002 (P < .001). Rates of resection for CRC decreased for adults ages 50 years and older, but increased for younger adults.

CONCLUSIONS

These findings support the hypothesis that population-level decreases in rates of resection for distal CRC are associated with screening, in general, and that implementation of screening colonoscopy, specifically, might be an important factor that contributes to population-level decreases in rates of resection for proximal CRC.

Screening colonoscopy in the US: attitudes and practices of primary care physicians

BACKGROUND

Rising colorectal cancer (CRC) screening rates in the last decade are attributable almost entirely to increased colonoscopy use. Little is known about factors driving the increase, but primary care physicians (PCPs) play a central role in CRC screening delivery.

OBJECTIVE

Explore PCP attitudes toward screening colonoscopy and their associations with CRC screening practice patterns.

DESIGN

Cross-sectional analysis of data from a nationally representative survey conducted in 2006-2007.

PARTICIPANTS

1,266 family physicians, general practitioners, general internists, and obstetrician-gynecologists.

MAIN MEASURES

Physician-reported changes in the volume of screening tests ordered, performed or supervised in the past 3 years, attitudes toward colonoscopy, the influence of evidence and perceived norms on their recommendations, challenges to screening, and practice characteristics.

RESULTS

The cooperation rate (excludes physicians without valid contact information) was 75%; 28% reported their volume of FOBT ordering had increased substantially or somewhat, and the majority (53%) reported their sigmoidoscopy volume decreased either substantially or somewhat. A majority (73%) reported that colonoscopy volume increased somewhat or substantially. The majority (86%) strongly agreed that colonoscopy was the best of the available CRC screening tests; 69% thought it was readily available for their patients; 59% strongly or somewhat agreed that they might be sued if they did not offer colonoscopy to their patients. All three attitudes were significantly related to substantial increases in colonoscopy ordering.

CONCLUSIONS

PCPs report greatly increased colonoscopy recommendation relative to other screening tests, and highly favorable attitudes about colonoscopy. Greater emphasis is needed on informed decision-making with patients about preferences for test options.

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

BACKGROUND

National surveys have reported declines in rates of home-based fecal occult blood test (FOBT) screening for colorectal cancer (CRC) in the last decade. However, socioeconomic status (SES) and racial/ethnic differences in FOBT trends and their changes relative to endoscopic CRC screening have not been evaluated.

METHODS

Data on adults ages 50 to 64 years from the 2000, 2005, and 2008 National Health Interview Surveys were used. Weighted analyses and multivariate logistic regression were used to study trends in the use of FOBT and endoscopic CRC screening during this period.

RESULTS

Between 2000 and 2008, significant declines in FOBT prevalence occurred in higher SES groups, but not in lower SES groups (uninsured and publicly insured, those without a usual source of care, lower educated, lower income, and immigrants to the United States) or Hispanics. Endoscopic CRC screening during the period studied consistently increased in all higher SES subgroups. In contrast, few lower SES subgroups (publicly insured, lower educated, near poor individuals, long-term immigrants) and Hispanics experienced increases in CRC endoscopic screening, and these increases were smaller than those observed in higher SES subgroups.

CONCLUSIONS

Socially and economically disadvantaged groups experienced little or no change in FOBT prevalence, and few of these groups experienced contemporaneous increases in CRC endoscopic screening. These trends suggest the continued availability and acceptance of FOBT in these groups. If national CRC screening goals are to be achieved in populations with lower access to colonoscopy, then annual high-sensitivity FOBT should be promoted as an immediately accessible and viable alternative.

Colorectal, prostate, and skin cancer screening among Hispanic and White non-Hispanic men, 2000-2005

BACKGROUND

Hispanic men have lower colorectal, prostate, and skin cancer screening rates than white non-Hispanic men. Programs designed to increase screening rates, including the national Screen for Life campaign specifically for promoting colorectal cancer (CRC) screening, regional educational/research programs, and state cancer control programs, have been launched. Screen for Life and some intervention programs included educational materials in Spanish as well as English.

OBJECTIVE

To assess whether CRC as well as prostate and skin cancer screening rates among Hispanic and white non-Hispanic men changed between 2000 and 2005.

METHODS

Cancer screening rates were compared between 2000 and 2005 using the National Health Interview Survey data. The age ranges of the study subjects and definitions of cancer screening were site specific and based on the American Cancer Society recommendations.

RESULTS

Hispanic men were less likely to comply with cancer screening guidelines than white non-Hispanic men. However, significant increases in CRC endoscopic screening were observed in both ethnic groups. It increased 2.1-fold and 2.4-fold for Hispanics and white non-Hispanics, respectively (P < .05). In contrast, the use of home fecal occult blood tests decreased among white non-Hispanics but remained similar among Hispanics. Prostate-specific antigen screening remained stable, while the use of skin cancer screening tended to increase among both groups.

CONCLUSION

Although cancer screening rates may be affected by multiple factors, our study suggested the intervention programs such as the Centers for Disease Control and Prevention's national Screen for Life campaign may have raised CRC screening awareness and may contributed to the increase in endoscopic screening rates among both ethnic groups.

Matching colonoscopy and pathology data in population-based registries: development of a novel algorithm and the initial experience of the New Hampshire Colonoscopy Registry

BACKGROUND

The quality of polyp-level data in a population-based registry depends on the ability to match each polypectomy recorded by the endoscopist to a specific diagnosis on the pathology report.

OBJECTIVE

To review impediments encountered in matching colonoscopy and pathology data in a population-based registry.

DESIGN

New Hampshire Colonoscopy Registry data from August 2006 to November 2008 were analyzed for prevalence of missing reports, discrepancies between colonoscopy and pathology reports, and the proportion of polyps that could not be matched because of multiple polyps submitted in the same container.

SETTING

New Hampshire Colonoscopy Registry.

PATIENTS

This study involved all consenting patients during the study period.

INTERVENTION

Develop an algorithm for capturing number, size, location, and histology of polyps and for defining and flagging discrepancies to ensure data quality.

MAIN OUTCOME MEASUREMENTS

The proportion of polyps with no assumption or discrepancy, the proportion of patient records eligible for determining the adenoma detection rate (ADR), and the number of patients with ≥3 adenomas.

RESULTS

Only 50% of polyps removed during this period were perfectly matched, with no assumption or discrepancy. Records from only 69.9% and 29.7% of eligible patients could be used to determine the ADR and the number of patients with ≥3 adenomas, respectively.

LIMITATIONS

Rates of missing reports may have been higher in the early phase of establishment of the registry.

CONCLUSION

This study highlights the impediments in collecting polyp-level data in a population-based registry and provides useful parameters for evaluating the quality and accuracy of data obtained from such registries.

Trends in colorectal cancer test use among vulnerable populations in the United States

BACKGROUND

Evaluating trends in colorectal cancer (CRC) screening use is critical for understanding screening implementation, and whether population groups targeted for screening are receiving it, consistent with guidelines. This study examines recent national trends in CRC test use, including among vulnerable populations.

METHODS

We used the 2000, 2003, 2005, and 2008 National Health Interview Survey to examine national trends in CRC screening use overall and for fecal occult blood test (FOBT), sigmoidoscopy, and colonoscopy. We also assessed trends by race/ethnicity, educational attainment, income, time in the United States, and access to health care.

RESULTS

During 2000 to 2008, significant declines in FOBT and sigmoidoscopy use and significant increases in colonoscopy use and in the percentages of adults up-to-date with CRC screening occurred overall and for most population subgroups. Subgroups with consistently lower rates of colonoscopy use and being up-to-date included Hispanics; people with minimal education, low income, or no health insurance; recent immigrants; and those with no usual source of care or physician visits in the past year. Among up-to-date adults, there were few subgroup differences in the type of test by which they were up-to-date (i.e., FOBT, sigmoidoscopy, or colonoscopy).

CONCLUSIONS

Although use of CRC screening and colonoscopy increased among U.S. adults, including those from vulnerable populations, 45% of adults aged 50 to 75-or nearly 35 million people-were not up-to-date with screening in 2008.

IMPACT

Continued monitoring of CRC screening rates among population subgroups with consistently low utilization is imperative. Improvement in CRC screening rates among all population groups in the United States is still needed.

Survey respondents planning to have screening colonoscopy report unique barriers

Tailoring colorectal cancer screening interventions to address the needs of individuals for whom screening is recommended requires accurate identification of the barriers experienced by each targeted group. The primary purpose of this survey study was to test differences in the barriers to undergoing screening colonoscopy reported by men and women. In addition, we were interested in differences in barriers reported by 1) 50-year-olds versus those age 51 to 80 years, 2) persons reporting readiness for colonoscopy versus those not reporting readiness, and 3) persons who had had a primary care encounter in the preceding 12 months versus those who had not. Four thousand members of a health maintenance organization (Scott & White Health Plan) were surveyed. Response rate overall was 30.85%. No differences in barriers to screening colonoscopy were identified for men versus women. We did identify differences in barriers reported by persons reporting readiness versus those not reporting readiness. Findings suggest that interventions to increase rates of screening colonoscopy require addressing different sets of barriers depending on whether persons report readiness to have a colonoscopy within 6 months.

Trends in cancer screening among Hispanic and white non-Hispanic women, 2000-2005

BACKGROUND

Hispanics are the largest and fastest growing ethnic group in the United States. Compared with white non-Hispanic women, however, Hispanic women have significantly lower cancer screening rates. Programs designed to increase cancer screening rates, including the national Screen for Life campaign, which specifically promoted colorectal cancer (CRC) screening, regional educational/research programs, and state cancer control programs, have been launched. Screen for Life and some of these other intervention programs have targeted Hispanic populations by providing educational materials in Spanish in addition to English.

METHODS

The objective of this study was to compare changes in colorectal, breast, and cervical cancer screening rates from 2000 to 2005 among Hispanic and white non-Hispanic women, using data from the National Health Interview Survey (NHIS). The age ranges of study subjects and the definitions of cancer screening were site specific and based on the American Cancer Society (ACS) screening recommendations.

RESULTS

Although overall screening rates were found to be lower among Hispanic women, CRC screening increased about 1.5-fold among both Hispanic and white non-Hispanic women, mainly driven by endoscopic screening, which increased 2.1-fold and 2.9-fold, respectively, from 2000 to 2005 (p < 0.01). Fecal occult blood testing (FOBT) for CRC declined among white non-Hispanic women and remained stable among Hispanic women during the same period. Mammogram and Pap smear screening tended to decline during the study period for both ethnic groups, especially white non-Hispanic women.

CONCLUSION

Although cancer screening rates may be affected by multiple factors, culturally sensitive and linguistically appropriate national educational programs may have contributed to the increase in endoscopic CRC screening compliance.

Exploring disparities and variability in perceptions and self-reported colorectal cancer screening among three ethnic subgroups of U. S. Blacks

PURPOSE/OBJECTIVES

To explore perceptions of colorectal cancer (CRC) and self-reported CRC screening behaviors among ethnic subgroups of U. S. blacks.

DESIGN

Descriptive, cross-sectional, exploratory, developmental pilot.

SETTING

Medically underserved areas in Hillsborough County, FL.

SAMPLE

62 men and women aged 50 years or older. Ethnic subgroup distribution included 22 African American, 20 English-speaking Caribbean-born, and 20 Haitian-born respondents.

METHODS

Community-based participatory research methods were used to conduct face-to-face individual interviews in the community.

MAIN RESEARCH VARIABLES

Ethnic subgroup, health access, perceptions of CRC (e.g., awareness of screening tests, perceived risk, perceived barriers to screening), healthcare provider recommendation, and self-reported CRC screening.

FINDINGS

Awareness of CRC screening tests, risk perception, healthcare provider recommendation, and self-reported use of screening were low across all subgroups. However, only 55% of Haitian-born participants had heard about the fecal occult blood test compared to 84% for English-speaking Caribbean-born participants and 91% for African Americans. Similarly, only 15% of Haitian-born respondents had had a colonoscopy compared to 50% for the English-speaking Caribbean and African American subgroups.

CONCLUSIONS

This exploratory, developmental pilot study identified lack of awareness, low risk perception, and distinct barriers to screening. The findings support the need for a larger community-based study to elucidate and address disparities among subgroups.

IMPLICATIONS FOR NURSING

Nurses play a major role in reducing cancer health disparities through research, education, and quality care. Recognition of the cultural diversity of the U. S. black population can help nurses address health disparities and contribute to the health of the community.

Fecal occult blood testing beliefs and practices of U.S. primary care physicians: serious deviations from evidence-based recommendations

BACKGROUND

Fecal occult blood testing (FOBT) is an important option for colorectal cancer screening that should be available in order to achieve high population screening coverage. However, results from a national survey of clinical practice in 1999-2000 indicated that many primary care physicians used inadequate methods to implement FOBT screening and follow-up.

OBJECTIVE

To determine whether methods to screen for fecal occult blood have improved, including the use of newer more sensitive stool tests.

DESIGN

Cross-sectional national survey of primary care physicians.

PARTICIPANTS

Participants consisted of 1,134 primary care physicians who reported ordering or performing FOBT in the 2006-2007 National Survey of Primary Care Physicians' Recommendations and Practices for Cancer Screening.

MAIN MEASURES

Self-reported data on details of FOBT implementation and follow-up of positive results.

RESULTS

Most physicians report using standard guaiac tests; higher sensitivity guaiac tests and immunochemical tests were reported by only 22.0% and 8.9%, respectively. In-office testing, that is, testing of a single specimen collected during a digital rectal examination in the office, is still widely used although inappropriate for screening: 24.9% of physicians report using only in-office tests and another 52.9% report using both in-office and home tests. Recommendations improved for follow-up after a positive test: fewer physicians recommend repeating the FOBT (17.8%) or using tests other than colonoscopy for the diagnostic work-up (6.6%). Only 44.3% of physicians who use home tests have reminder systems to ensure test completion and return.

CONCLUSIONS

Many physicians continue to use inappropriate methods to screen for fecal occult blood. Intensified efforts to inform physicians of recommended technique and promote the use of tracking systems are needed.

When budgets are tight, there are better options than colonoscopies for colorectal cancer screening

A critical challenge facing cancer screening programs, particularly those aimed at uninsured people with low incomes, is choosing the screening test that makes the most efficient use of limited budgets. For colorectal cancer screening, there is growing momentum to use colonoscopy, which is an expensive test. In this study, we modeled scenarios to assess whether the use of fecal occult blood tests or colonoscopy provides the most benefit under conditions of budget constraints. We found that although colonoscopy is more accurate, under most scenarios, fecal occult blood tests would result in more individuals' getting screened, with more life-years gained.

Primary care, economic barriers to health care, and use of colorectal cancer screening tests among Medicare enrollees over time

PURPOSE

Colorectal cancer (CRC) screening remains underutilized. The objective of this study was to examine the impact of primary care and economic barriers to health care on CRC testing relative to the 2001 Medicare expansion of screening coverage.

METHODS

Medicare Current Beneficiary Survey data were use to study community-dwelling enrollees aged 65 to 80 years, free of renal disease and CRC, and who participated in the survey in 2000 (n = 8,330), 2003 (n = 7,889), or 2005 (n = 7,614). Three outcomes were examined: colonoscopy/sigmoidoscopy within 5 years (recent endoscopy), endoscopy more than 5 years previously, and fecal occult blood test (FOBT) within 2 years.

RESULTS

Endoscopy use increased and FOBT use decreased during the 6-year period, with no significant independent differences between those receiving care from primary care physicians and those receiving care from other physicians. Beneficiaries without a usual place of health care were the least likely to undergo CRC testing, and that gap widened with time: adjusted odds ratio (AOR) = 0.27 (95% confidence interval [CI], 0.19-0.39) for FOBT, and AOR = 0.35 (95% CI, 0.27-0.46) for endoscopy in 2000 compared with AOR = 0.18 (95% CI, 0.11-0.30) for FOBT and AOR = 0.22 (95% CI, 0.17-0.30) for endoscopy in 2005. Disparities in use of recent endoscopy by type of health insurance coverage in both 2000 and 2005 were greater for enrollees with a high school education or higher than they were for less-educated enrollees. There were no statistically significant differences by delayed care due to cost after adjustment for health insurance.

CONCLUSION

Despite expanding coverage for screening, complex CRC screening disparities persisted based on differences in the usual place and cost of health care, type of health insurance coverage, and level of education.

Racial and ethnic trends of colorectal cancer screening among Medicare enrollees

BACKGROUND

Colorectal cancer (CRC) screening rates have remained lower than the Healthy People 2010 goal, particularly among minority populations.

PURPOSE

This study aimed to examine the racial-ethnic trends in CRC screening and the continued impact of healthcare access indicators on screening differences after Medicare expanded coverage.

METHODS

The study used data from the Medicare Current Beneficiary Survey for 2000, 2003, and 2005. The sample was restricted to non-Hispanic whites, non-Hispanic blacks, and Hispanics. The primary outcome was the proportion of enrollees who underwent lower-gastrointestinal endoscopy within 5 years and/or home fecal occult blood test within 1 year.

RESULTS

Over the 6-year period under study, the proportion screened increased among each of the three racial-ethnic groups, but lower proportions of blacks and Hispanics underwent screening compared with whites at each time point. Hispanic-white differences persisted but black-white differences narrowed in 2003 and widened in 2005. In each survey year, racial differences attenuated after adjustment for type of supplemental health insurance and disappeared after further adjustment for educational and income levels.

CONCLUSIONS

Despite expanding benefits for CRC screening, which would be expected to disproportionally benefit racial and ethnic minorities, racial disparities in use of screening persist in part because of differences in the types of health insurance coverage, education, and income. There was a slight reversal of the initial attenuation of the black-white difference after the Medicare policy change. Efforts are needed to increase the reach of CRC screening to minority populations, particularly those lacking adequate health insurance coverage or with less education or income.

Colorectal cancer screening barriers and facilitators in older persons

BACKGROUND

This systematic review identifies factors that are most consistently mentioned as either barriers to or facilitators of colorectal cancer (CRC) screening in older persons.

METHODS

A systematic literature search (1995-2008) was conducted to identify studies that reported barriers to or facilitators of CRC screening uptake, compliance or adherence specifically for older persons (> or = 65 years). Information on study characteristics and barriers and facilitators related to subjects; healthcare providers; policies; and screening tests were then abstracted and analyzed.

RESULTS

Eighty-three studies met the eligibility criteria. Low level of education, African American race, Hispanic ethnicity, and female gender were the most frequently reported barriers, whereas being married or living with a partner was the most frequently reported facilitator. The most cited barrier related to healthcare providers was lack of screening recommendation by a physician; having a usual source of care was a commonly reported facilitator. Lack of health insurance, and dual coverage with Medicare and Medicaid were the most frequently reported barriers, whereas Medicare's coverage of screening colonoscopy was consistently reported as a facilitator.

CONCLUSIONS

Barriers to, and facilitators of, CRC screening among older persons are reported. Particular attention should be paid to modifiable factors that could become the focus of interventions aimed at increasing CRC screening participation in older persons.

Socioeconomic and racial patterns of colorectal cancer screening among Medicare enrollees in 2000 to 2005

BACKGROUND

Lower rates of screening among minorities and low-income populations contribute to colorectal cancer health disparities. Therefore, we examined patterns of colorectal cancer screening and associations with race-ethnicity, education, and income over time.

METHODS

Repeated cross-sectional data from the Medicare Current Beneficiary Survey of noninstitutionalized colorectal cancer-free Medicare enrollees ages 65 to 80 years interviewed in 2000 (n = 8,355), 2003 (n = 7,922), and 2005 (n = 7,646). We examined rates of colonoscopy/sigmoidoscopy use within 5 years (recent endoscopy), colonoscopy/sigmoidoscopy use >5 years previously, or fecal occult blood test (FOBT) within 2 years.

RESULTS

Among those included in the analyses, there was a steady increase in recent endoscopy rates and decrease in FOBT use over the 6-year period among all racial, educational, and income groups. During each of the survey years, those less educated or in lower-income groups were less likely to undergo colorectal cancer screening in a dose-response fashion. In multinomial regression analyses that adjusted for factors including health insurance, there were no significant differences in recent endoscopy or FOBT rates between Blacks or Hispanics and Whites, but differences by education and income remained. Compared with those in higher-income group, lower-income enrollees had lower rates of screening, and differences by income were larger for enrollees residing in metropolitan areas.

CONCLUSION

Among Medicare beneficiaries, there are persistent colorectal cancer screening disparities due to a complex combination of socioeconomic disadvantages from lower education and income, place of residence, and inadequate insurance. However, insurance alone does not eliminate socioeconomic differences in colorectal cancer screening.

Colorectal cancer screening by primary care physicians: recommendations and practices, 2006-2007

BACKGROUND

Primary care physicians (hereafter, physicians) play a critical role in the delivery of colorectal cancer (CRC) screening in the U.S. This study describes the CRC screening recommendations and practices of U.S. physicians and compares them to findings from a 1999-2000 national provider survey.

METHODS

Data from 1266 physicians responding to the 2006-2007 National Survey of Primary Care Physicians' Recommendations and Practices for Breast, Cervical, Colorectal, and Lung Cancer Screening (cooperation rate=75%) were analyzed in 2008. Descriptive statistics were used to examine physicians' CRC screening recommendations and practices as well as the office systems used to support screening activities. Sample weights were applied in the analyses to obtain national estimates.

RESULTS

Ninety-five percent of physicians routinely recommend screening colonoscopy to asymptomatic, average-risk patients; 80% recommend fecal occult blood testing (FOBT). Only a minority recommend sigmoidoscopy, double-contrast barium enema, computed tomographic colonography, or fecal DNA testing. Fifty-six percent recommend two screening modalities; 17% recommend one. Nearly all physicians who recommend endoscopy refer their patients for the procedure. Four percent perform sigmoidoscopy, a 25-percentage-point decline from 1999-2000. Although 61% of physicians reported that their practice had guidelines for CRC screening, only 30% use provider reminders; 15% use patient reminders.

CONCLUSIONS

Physicians' CRC screening recommendations and practices have changed substantially since 1999-2000. Colonoscopy is now the most frequently recommended test. Most physicians do not recommend the full menu of test options prescribed in national guidelines. Few perform sigmoidoscopy. Office systems to support CRC screening are lacking in many physicians' practices. Given ongoing changes in CRC screening technologies and guidelines, the continued monitoring of physicians' CRC screening recommendations and practices is imperative.

Impact of age and comorbidity on colorectal cancer screening among older veterans

BACKGROUND

The Veterans Health Administration, the American Cancer Society, and the American Geriatrics Society recommend colorectal cancer screening for older adults unless they are unlikely to live 5 years or have significant comorbidity that would preclude treatment.

OBJECTIVE

To determine whether colorectal cancer screening is targeted to healthy older patients and is avoided in older patients with severe comorbidity who have life expectancies of 5 years or less.

DESIGN

Cohort study.

SETTING

Veterans Affairs (VA) medical centers in Minneapolis, Minnesota; Durham, North Carolina; Portland, Oregon; and West Los Angeles, California, with linked national VA and Medicare administrative claims.

PATIENTS

27 068 patients 70 years or older who had an outpatient visit at 1 of 4 VA medical centers in 2001 or 2002 and were due for screening.

MEASUREMENTS

The main outcome was receipt of fecal occult blood testing (FOBT), colonoscopy, sigmoidoscopy, or barium enema in 2001 or 2002, on the basis of national VA and Medicare claims. Charlson-Deyo comorbidity scores at the start of 2001 were used to stratify patients into 3 groups ranging from no comorbidity (score of 0) to severe comorbidity (score > or =4), and 5-year mortality was determined for each group.

RESULTS

46% of patients were screened from 2001 through 2002. Only 47% of patients with no comorbidity were screened despite having life expectancies greater than 5 years (5-year mortality, 19%). Although the incidence of screening decreased with age and worsening comorbidity, it was still 41% for patients with severe comorbidity who had life expectancies less than 5 years (5-year mortality, 55%). The number of VA outpatient visits predicted screening independent of comorbidity, such that patients with severe comorbidity and 4 or more visits had screening rates similar to or higher than those of healthier patients with fewer visits.

LIMITATIONS

Some tests may have been performed for nonscreening reasons. The generalizability of findings to persons who do not use the VA system is uncertain.

CONCLUSION

Advancing age was inversely associated with colorectal cancer screening, whereas comorbidity was a weaker predictor. More attention to comorbidity is needed to better target screening to older patients with substantial life expectancies and avoid screening older patients with limited life expectancies. primary funding source: VA Health Services Research and Development.