Determinants of colorectal cancer screening in women undergoing mammography

Barriers to Accessing Contraception and Cervical and Breast Cancer Screening During the COVID-19 Pandemic

Objective

This study sought to examine how access to contraception and cervical and breast cancer screening in British Columbia, Canada, has been affected by the COVID-19 pandemic.

Methods

From August 2020 to March 2021, 3691 female residents of British Columbia (age 25–69 y) participated in this study. We used generalized estimating equations to analyze the proportion of females accessing contraception and the proportion having difficulty accessing contraception across the different phases of pandemic control measures, and logistic regression to analyze attendance at cervical and breast cancer screening. We added sociodemographic and biological variables individually into the models. Self-reported barriers to accessing contraception and attending screening were summarized.

Results

During phases with the highest pandemic controls, self-reported access to contraception was lower (OR 0.94; 95% CI 0.90–0.98; P = 0.005) and difficulty with access was higher (OR 2.74; 95% CI 1.54–4.88; P = 0.001). A higher proportion of adults aged 25–34 years reported difficulty accessing contraception than those aged 35–39 years (P < 0.0001), and participants identifying as Indigenous had higher odds of access difficulties (OR 5.56; 95% CI 2.44–12.50; P < 0.001). Of those who required screening during the COVID-19 pandemic, 62% and 54.5% did not attend at least one of their cervical or breast screening appointments, respectively. Those with a history of breast cancer had significantly higher odds of self-reporting having attended their mammogram appointment compared with those without a history of breast cancer (OR 5.62; 95% CI 2.69–13.72; P < 0.001). The most common barriers to screening were difficulty getting an appointment and appointments being considered non-urgent.

Conclusions

The COVID-19 pandemic has uniquely affected access to contraception and cancer screening participation for various subgroups. Self-reported data present potential avenues for mitigating barriers.

Sociodemographic correlates of colorectal cancer screening completion among women adherent to mammography screening guidelines by place of birth

INTRODUCTION

Colorectal cancer screening rates in the U.S. still fall short of national goals, while screening rates for other cancer sites, such as breast, remain high. Understanding characteristics associated with colorectal cancer screening among different groups of women adherent to breast cancer screening guidelines can shed light on the facilitators of colorectal cancer screening among those already engaged in cancer prevention behaviors. The purpose of this study was to explore which demographic characteristics, healthcare access factors, and cancer-related beliefs were associated with colorectal cancer screening completion among U.S. and foreign-born women adherent to mammography screening recommendations.

METHODS

Analyses of the 2015 National Health Interview Survey were conducted in 2019. A sample of 1206 women aged 50-74 who had a mammogram in the past 2 years and were of average risk for colorectal cancer was examined. Logistic regression was used to determine demographic, health service, and health belief characteristics associated with colorectal cancer screening completion.

RESULTS

Fifty-five percent of the sample were adherent to colorectal cancer screening recommendations. Women over the age of 65 (AOR = 1.76, 95% CI 1.06-2.91), with any type of health insurance, and who were bilingual (AOR = 3.84, 95% CI 1.83-8.09) were more likely to complete screening, while foreign-born women (AOR = 0.53, 95% CI 0.34-0.83) were less likely. Cancer-related beliefs did not influence adherence. Stratified analyses by nativity revealed additional associations.

CONCLUSIONS

Demographic and health service factors interact to influence colorectal cancer screening among women completing breast cancer screening. Colorectal cancer screening interventions targeting specific underserved groups and financing reforms may enhance women's colorectal cancer screening rates.

Determinants Associated With Longitudinal Adherence to Annual Lung Cancer Screening: A Retrospective Analysis of Claims Data

OBJECTIVE

Lung cancer screening (LCS) efficacy is highly dependent on adherence to annual screening, but little is known about real-world adherence determinants. We used insurance claims data to examine associations between LCS annual adherence and demographic, comorbidity, health care usage, and geographic factors.

MATERIALS AND METHODS

Insurance claims data for all individuals with an LCS low-dose CT scan were obtained from the Colorado All Payer Claims Dataset. Adherence was defined as a second claim for a screening CT 10 to 18 months after the index claim. Cox proportional hazards regression was used to define the relationship between annual adherence and age, gender, insurance type, residence location, outpatient health care usage, and comorbidity burden.

RESULTS

After exclusions, the final data set consisted of 9,056 records with 3,072 adherent, 3,570 nonadherent, and 2,414 censored (unclassifiable) individuals. Less adherence was associated with ages 55 to 59 (hazard ratio [HR] = 0.80, 99% confidence interval [CI] = 0.67-0.94), 60 to 64 (HR = 0.83, 99% CI = 0.71-0.97), and 75 to 79 (HR = 0.79, 99% CI = 0.65-0.97); rural residence (HR = 0.56, 99% CI = 0.43-0.73); Medicare fee-for-service (HR = 0.45, 99% CI = 0.39-0.51), and Medicaid (HR = 0.50, 99% CI = 0.40-0.62). A significant interaction between outpatient health care usage and comorbidity was also observed. Increased outpatient usage was associated with increased adherence and was most pronounced for individuals without comorbidities.

CONCLUSIONS

This population-based description of LCS adherence determinants provides insight into populations that might benefit from specific interventions targeted toward improving adherence and maximizing LCS benefit. Quantifying population-based adherence rates and understanding factors associated with annual adherence are critical to improving screening adherence and reducing lung cancer death.

Insurance Stability and Cancer Screening Behaviors

Background: Disparities in rates of cancer screening are observed in underserved populations. Lack of stable health insurance may contribute to these disparities. The goal of this study was to examine the association between insurance stability and up-to-date cancer screening in underserved populations.

Methods and Findings: We enrolled 333 community participants aged 40–74 years across four different sites in three states: Chinese Americans in Boston, Massachusetts; Hispanics in Columbus, Ohio; Appalachian populations from Ohio's Appalachian counties; and Blacks and African Americans in Philadelphia, Pennsylvania. Self-reported screening rates were 77.9% for breast cancer, 71.1% for cervical cancer, and 67.7% for colorectal cancer (CRC). Screening rates fell short of Health People 2020 targets for breast, colorectal, and cervical cancer screenings. Being currently insured was associated with current CRC screenings (69.7% among insured vs. 30.7% among uninsured, p=0.0055), but not with breast or cervical cancer screenings. Stable 12-month insurance coverage was not statistically associated with up-to-date screenings.

Conclusion: Having current insurance was associated with CRC screening; stability of insurance was not associated with cancer screening. Insurance coverage alone is not the main driver of cancer 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.

Opportunities to Expand Colorectal Cancer Screening Participation

The Centers for Disease Control and Prevention's Screen for Life: National Colorectal Cancer Action Campaign has operated continuously since 1999 to promote colorectal cancer screening. The campaign's most recent formative research cycle was conducted in 2015 and included 16 focus groups in four United States cities with adults aged 50-75 years who had not received colorectal cancer screening as recommended. The most common reason for screening nonparticipation was aversion to some aspect of colonoscopy, such as preparation, the invasive nature of the test, or the possibility of complications. Other reasons for screening nonparticipation were absence of symptoms, lack of screening awareness/provider recommendation, and lack of family history. Screening promotion messages that resonated with participants included the following: multiple screening tests are available; colorectal cancer may not cause symptoms; screening should begin at age 50; and most cases of colorectal cancer occur in individuals with no family history of the disease. Efforts to increase colorectal cancer screening participation may be supported by disseminating messages that counter common concerns about screening. Raising awareness of the range of colorectal cancer screening options may be especially critical given that many unscreened individuals were unwilling to undergo a colonoscopy.

Assessing Colorectal Cancer Knowledge Among Puerto Rican Hispanics: Implications for Cancer Prevention and Control

In Puerto Rico, colorectal cancer (CRC) incidence and mortality rates are increasing. Moreover, adherence rates to CRC screening (52.2%) are still below the goals (70.5%) established by Healthy People 2020. Lack of knowledge is described as a significant barrier to adherence to CRC screening. The aim of this study was to assess CRC knowledge and screening rates among Puerto Rican Hispanics. Participants aged 40-85 years were recruited from the internal medicine outpatient clinics at the University of Puerto Rico. Demographic characteristics and knowledge about CRC, including risk factors and CRC screening tests, were obtained through face-to-face interviews. A mean CRC knowledge score was calculated based on correct responses to 13 validated questions. Mean knowledge scores were evaluated according to demographic characteristics using the Wilcoxon-Mann-Whitney test. A total of 101 participants were recruited with mean age of 63 (±10.6) years. Fifty-eight (58%) of participants were females, 59% reported ≥12 years of education, and 71% reported ever screening for CRC. The mean CRC knowledge score was significantly lower (p < 0.05) among participants with lower annual family income, those who had never received a recommendation for CRC screening by a healthcare provider, and those who had no history of CRC screening. Knowledge about CRC must be improved in Puerto Rico. Efforts must be made to promote and develop culturally appropriate CRC educational strategies. Future studies should focus on identifying other barriers and factors that may limit CRC screening in the Puerto Rican Hispanic population.

Gynecological Practice Represents the Ideal Setting for Early Opportunistic Cardiovascular Prevention: A Cross-Sectional Survey in an Urban Female Population

BACKGROUND

Cardiovascular diseases are the main cause of mortality for women worldwide, yet their impact is frequently underestimated. To raise awareness for preventative lifestyle measures other contacts with the healthcare system should be exploited. We analyzed access patterns to other healthcare specialists and population screening measures to identify options for opportunistic counseling on cardiovascular risk.

MATERIALS AND METHODS

We enrolled 1062 randomly selected German urban women aged 25-74 years in 2012-2013, divided into 5 age bands. Women were asked about sociodemographic characteristics, clinical and gynecological history, physician attendance patterns, screening behavior and primary sources of health and preventative information, and clinical examination attendance.

RESULTS

Obstetrician/gynecologists (OBGYN) were the most frequently consulted physicians within the last 12 months (75.3%), more than general practitioners (GP; 74%). Attendance rates to OBGYNs were not affected by education or income, solely a body mass index (BMI) >30 associated with significantly reduced rates of attendance (OR = 0.4, CI 95% = 0.17-0.78, p = 0.009). Women with low to medium Framingham risk scores were more likely to attend an OBGYN than a GP if they attended only one specialist. Attendance of population screening measures is limited (<60% for all offers) and hence unsuitable for systematic cardiovascular counseling.

CONCLUSION

OBGYN represent a very popular and equitable healthcare contact for women of all ages and this could be exploited for cardiovascular screening. Furthermore, the strikingly different sources of health information reported highlight a need for improved health communication and differentiation of messages.

Colorectal cancer screening and prevention in women

Colorectal cancer (CRC) is one of the leading cancers and cause of cancer deaths in American women and men. Females and males share a similar lifetime cumulative risk of CRC however, substantial differences in risk factors, tumor biology, and effectiveness of cancer prevention services have been observed between them. This review distills the evidence documenting the unique variation observed between the genders relating to CRC risk factors, screening and prevention. Consistent evidence throughout the world demonstrates that women reach equivalent levels of adenomas and CRC as men but it occurs nearly a decade later in life than in their male counterparts. Women have a higher proportion of tumors which are hypermethylated, have microsatellite instability and located in the proximal colon suggesting the serrated pathway may be of greater consequence in them than in men. Other CRC risk factors such as smoking, diet and obesity have been shown to have disparate effects on women which may related to interactions between estrogen exposure, body fat distribution, and the biologic underpinnings of their tumors. There is data showing the uptake, choice, and efficacy of different CRC screening methods in women is dissimilar to that in men. The mortality benefit from FOBT, sigmoidoscopy, and protection from interval CRC by colonoscopy appears to be lower in women than men. A greater understanding of these gender idiosyncrasies will facilitate an personalized approach to CRC prevention and should ultimately lead to a reduced burden of disease.

The effect of primary care physician counseling on participation rate and use of sedation in colonoscopy-based colorectal cancer screening program--a randomized controlled study

OBJECTIVES

Physician recommendation is a strong predictor of colorectal cancer (CRC) screening adherence, but there are no sufficient data specific to primary colonoscopy screening programs. The primary objective was to compare the effect of primary care physician's (PCP) counseling with information leaflet about CRC screening on participation rate in opportunistic primary colonoscopy screening program. Secondary objective was to determine the impact of this counseling on a decision to choose unsedated colonoscopy.

MATERIAL AND METHODS

Six hundred consecutive subjects 50-65 years of age visiting PCP group practice for routine medical consultation were randomly assigned in a 1:1 ratio either to discuss CRC screening with PCP or to receive an information leaflet on CRC screening only. The outcome measures were the participation rate and the proportion of unsedated colonoscopies assessed on subjects' self-reports collected six months after the intervention. Multivariate logistic regression model with backward selection was used to investigate the association between independent covariates and binary endpoints.

RESULTS

Participation rate was 47.0% (141 subjects) in the counseling group and 13.7% (41 patients) in the information leaflet group. The rates of unsedated colonoscopies were 77.0% and 39.0%, respectively. In a multivariate analyses, PCP's counseling was associated with higher participation in CRC screening (adjusted odds ratio [OR] 5.33, 95% confidence intervals [95% CI] 3.55-8.00) and higher rate of unsedated colonoscopies (OR 7.75, 95% CI 2.94-20.45).

CONCLUSION

In opportunistic primary colonoscopy screening, PCP's counseling significantly increases participation rate and decreases demand for sedation compared to recruitment with information materials only. NCT01688817.

Limited life expectancy among a subgroup of medicare beneficiaries receiving screening colonoscopies

BACKGROUND & AIMS

Life expectancy is an important consideration when assessing appropriateness of preventive programs for older individuals. Most studies on this subject have used age cutoffs as a proxy for life expectancy. We analyzed patterns of utilization of screening colonoscopy in Medicare enrollees by using estimated life expectancy.

METHODS

We used a 5% random national sample of Medicare claims data to identify average-risk patients who underwent screening colonoscopies from 2008 to 2010. Colonoscopies were considered to be screening colonoscopies in the absence of diagnoses for nonscreening indications, which were based on either colonoscopies or any claims in the preceding 3 months. We estimated life expectancies by using a model that combined age, sex, and comorbidity. Among patients who underwent screening colonoscopies, we calculated the percentage of those with life expectancies <10 years.

RESULTS

Among the 57,597 Medicare beneficiaries 66 years old or older who received at least 1 screening colonoscopy, 24.8% had an estimated life expectancy of <10 years. There was a significant positive association between total Medicare per capita costs in hospital referral regions and the proportion of patients with limited life expectancies (<10 years) at the time of screening colonoscopy (R = 0.25; P < .001, Pearson correlation test). In a multivariable analysis, men were substantially more likely than women to have limited life expectancy at the time of screening colonoscopy (odds ratio, 2.25; 95% confidence interval, 2.16-2.34).

CONCLUSIONS

Nearly 25% of Medicare beneficiaries, especially men, had life expectancies <10 years at the time of screening colonoscopies. Life expectancy should therefore be incorporated in decision-making for preventive services.

Gender differences in attitudes impeding colorectal cancer screening

Background

Colorectal cancer screening (CRCS) is the only type of cancer screening where both genders reduce risks by similar proportions with identical procedures. It is an important context for examining gender differences in disease-prevention, as CRCS significantly reduces mortality via early detection and prevention. In efforts to increase screening adherence, there is increasing acknowledgment that obstructive attitudes prevent CRCS uptake. Precise identification of the gender differences in obstructive attitudes is necessary to improve uptake promotion. This study randomly sampled unscreened, screening - eligible individuals in Ontario, employing semi-structured interviews to elicit key differences in attitudinal obstructions towards colorectal cancer screening with the aim of deriving informative differences useful in planning promotions of screening uptake.

Methods

N = 81 participants (49 females, 32 males), 50 years and above, with no prior CRCS, were contacted via random-digit telephone dialing, and consented via phone-mail contact. Altogether, N = 4,459 calls were made to yield N = 85 participants (1.9% response rate) of which N = 4 participants did not complete interviews. All subjects were eligible for free-of-charge CRCS in Ontario, and each was classified, via standard interview by CRCS screening decision-stage. Telephone-based, semi-structured interviews (SSIs) were employed to investigate gender differences in CRCS attitudes, using questions focused on 5 attitudinal domains: 1) Screening experience at the time of interview; 2) Barriers to adherence; 3) Predictors of Adherence; 4) Pain-anxiety experiences related to CRCS; 5) Gender-specific experiences re: CRCS, addressing all three modalities accessible through Ontario’s program: a) fecal occult blood testing; b) flexible sigmoidoscopy; c) colonoscopy.

Results

Interview transcript analyses indicated divergent themes related to CRCS for each gender: 1) bodily intrusion, 2) perforation anxiety, and 3) embarrassment for females and; 1) avoidant procrastination with underlying fatalism, 2) unnecessary health care and 3) uncomfortable vulnerability for males. Respondents adopted similar attitudes towards fecal occult blood testing, flexible sigmoidoscopy and colonoscopy, and were comparable in decision stage across tests. Gender differences were neither closely tied to screening stage nor modality. Women had more consistent physician relationships, were more screening-knowledgeable and better able to articulate views on screening. Men reported less consistent physician relationships, were less knowledgeable and kept decision-making processes vague and emotionally distanced (i.e. at ‘arm’s length’).

Conclusions

Marked differences were observed in obstructive CRCS attitudes per gender. Females articulated reservations about CRCS-associated distress and males suppressed negative views while ambiguously procrastinating about the task of completing screening. Future interventions could seek to reduce CRCS-related stress (females) and address the need to overcome procrastination (males).

Beliefs regarding mammography screening among women visiting the emergency department for nonurgent care

INTRODUCTION

One in 8 US women will develop invasive breast cancer in their lifetime. Despite evidence that mammography is an effective method of early detection, certain vulnerable groups, such as those using the emergency department as a medical home, do not adhere to mammography screening guidelines, and suffer disparate mortality from breast cancer. The purpose of this study was to investigate differences in beliefs regarding mammography screening among women attending the emergency department for nonurgent care and ultimately to develop interventions that promote mammography for this vulnerable population.

METHODS

We explored the relationship between stage of readiness to adopt mammography behavior and barriers, benefits, and perceived susceptibility by administering scales for risk, benefits, and barriers to a sample of 110 women who had presented to the emergency department of a public hospital for nonurgent complaints or were seated in the ED waiting room. We also collected sociodemographic information and stage of readiness.

RESULTS

Mammography adherence was about 60%. Most women who were not compliant with current guidelines were contemplators. Those who were not contemplating being screened were significantly less likely to perceive themselves to be at risk of getting breast cancer. Women who had more barriers to mammography perceived less benefit from having a mammogram. African American women perceived less benefit from having a mammogram.

DISCUSSION

Mammography promotion is appropriately placed in the ED waiting room given the suboptimal rate at which this population is being screened. Beliefs regarding mammography differ for women in various stages of mammography adoption and for minority women. Understanding these differences will allow intervention in this setting to be tailored to the population. ED nurses are an important and sometimes sole point of health care contact for patients who routinely visit the emergency department. As such, they have a valuable opportunity to provide cancer screening promotion messages. It is critical that nurses in this setting understand the complexities of delivering this information and the need to do so.

Influence of primary care on breast cancer outcomes among Medicare beneficiaries

PURPOSE

We used the Surveillance Epidemiology and End Results (SEER)-Medicare database to explore the association between primary care and breast cancer outcomes.

METHODS

Using a retrospective cohort study of 105,105 female Medicare beneficiaries with a diagnosis of breast cancer in SEER registries during the years 1994-2005, we examined the total number of office visits to primary care physicians and non-primary care physicians in a 24-month period before cancer diagnosis. For women with invasive cancers, we examined the odds of diagnosis of late-stage disease, according to the American Joint Commission on Cancer (AJCC) (stages III and IV vs stages I and II), and survival (breast cancer specific and all cause) using logistic regression and proportional hazards models, respectively. We also explored whether including noninvasive cancers, such as ductal carcinoma in situ (DCIS), would alter results and whether prior mammography was a potential mediator of associations.

RESULTS

Primary care physician visits were associated with improved breast cancer outcomes, including greater use of mammography, reduced odds of late-stage diagnosis, and lower breast cancer and overall mortality. Prior mammography (and resultant earlier stage diagnosis) mediated these associations in part, but not completely. Similar results were seen for non-primary care physician visits. Results were similar when women with DCIS were included in the analysis.

CONCLUSIONS

Medicare beneficiaries with breast cancer had better outcomes if they made greater use of a primary care physician's ambulatory services. These findings suggest adequate primary medical care may be an important factor in achieving optimal breast cancer outcomes.

Body mass index and screening for colorectal cancer: gender and attitudinal factors

BACKGROUND

Overweight/obese women and men are at increased risk for colorectal cancer (CRC) incidence and mortality. Research examining body mass index (BMI) and CRC screening has had mixed results. A clearer understanding of the extent to which high-BMI subgroups are screened for CRC is needed to inform planning for CRC screening promotions targeting BMI.

METHODS

Data were obtained from a random, population-based sample of women and men at average-risk for CRC (aged 50-75 years) during 2004 (n = 1098). Multiple logistic regression analyses were conducted to evaluate whether BMI category was significantly associated with the probability of reporting recent CRC screening and with the probability of agreeing with statements denoting attitudes/perceptions about CRC and screening. Attitudes/perceptions about CRC and screening were evaluated as potential mediators and moderators of the association between BMI category and CRC screening.

RESULTS

After controlling for characteristics associated with CRC screening, overweight and obese women were each 40% less likely to have CRC screening than women with normal-BMI (OR = 0.6, 95% CI:0.4-0.9 and OR = 0.6, 95% CI:0.3-0.9). BMI category was unrelated to screening among men. Obese women (but not men) were less aware than normal-BMI women that obesity increased risk for CRC (OR = 0.5, 95% CI:0.3-0.9) and less worried about CRC (OR = 0.5, 95% CI:0.3-0.8). However, findings suggest that attitudes/perceptions about CRC and screening did not mediate or moderate the association between BMI category and CRC screening.

CONCLUSION

Overweight/obese women are at increased risk for CRC because of their greater BMI and their propensity not to screen for CRC. Study findings suggest that potentially modifiable perceptions, e.g., lack of awareness of risk for CRC and less worry about CRC, in this subgroup may not explain the relationship between BMI category and reduced screening.

Patients' experiences and reported barriers to colonoscopy in the screening context--a systematic review of the literature

OBJECTIVE

A systematic review of the literature was conducted to characterise patients' own experience of colonoscopy in the screening context.

METHODS

A search strategy was applied in MEDLINE, EMBASE and PSYCHinfo (1996-2009). Thematic analysis and narrative summary techniques were used.

RESULTS

Fifty-six studies met eligibility criteria and were included in the analysis. Seven studies examined patients' views after having colonoscopy. Forty-seven studies addressed patient-reported barriers to an anticipated primary colonoscopy. Most patients perceived the laxative bowel preparation to be the most burdensome part of colonoscopy. Other reported difficulties included anxiety, anticipation of pain, feelings of embarrassment and vulnerability. Inadequate knowledge and fear of finding cancer were identified as obstacles to the uptake of screening colonoscopy. Physician endorsement, having a family history, knowing someone with cancer, and perceived accuracy of the test were incentives to having a colonoscopy. Two studies focused on colonoscopy after faecal occult blood screening. Similar procedural, personal, and practical concerns were reported.

CONCLUSIONS

Bowel preparation, lack of awareness of the importance of screening, and feelings of vulnerability in women are all significant barriers to screening colonoscopy.

PRACTICE IMPLICATIONS

Patient reported obstacles and barriers to screening colonoscopy needs to be addressed to improve adherence.

Screening adherence for colorectal cancer among immigrant Hispanic women

PURPOSE

We sought to assess factors related to colorectal cancer (CRC) screening adherence among immigrant, Hispanic women in Harlem, New York City.

METHOD

Adherence for colonoscopy and fecal occult blood test (FQBT) screening was measured among 255 women based on self-reported screening behaviors using American Cancer Society guidelines.

RESULTS

Univariate results showed that age, language of the interview (English/Spanish), years in the United States, physician recommendation for either test, marital status (living alone/living with someone), and mammography adherence were associated with CRC screening adherence (p's < .05). In the multivariate analysis, having an age greater than 65 years, being interviewed in Spanish, having lived in the United States longer, having a regular doctor and a physician recommendation, and being currently adherent for mammography were associated with higher CRC screening adherence.

CONCLUSION

Among this sample, there proved to be differences between having ever been screened and adherence with a greater proportion of women having ever completed either colonoscopy and/or FOBT compared to women who were adherent (72.9% vs 58.8%). Therefore, it is important to determine factors associated with adherence, not just screening utilization, in order to design strategies to increase adherence among immigrant Hispanic women.

Colorectal cancer screening and prevention in women

Colorectal cancer (CRC) is the third most common cause of cancer in women. Screening for CRC increases early detection of cancer and premalignant polyps and decreases morbidity from this disease. However, adherence to the screening guidelines continues to remain inadequate both at the physician and patient levels. Several factors are of special importance to women. Presence of prior gynecological malignancies may increase the risk of CRC in women. Furthermore, new studies have shown other factors such as obesity and smoking to increase the risk of CRC in women. This article highlights issues unique to women with regards to CRC and outlines special considerations for determining screening intervals in women, identifies factors that make screening more difficult in women, and reviews studies that identify preventative strategies which, together with screening, may reduce the burden of CRC.

Development and Psychometric Testing of the Colonoscopy Embarrassment Scale

Colorectal cancer, the third leading cause of cancer-related death in the United States, could largely be prevented if more people had polyps removed via colonoscopies. Embarrassment is one important barrier to colonoscopy, but little is known about embarrassment in this context, and there were no reliable and valid measures of this construct. The purpose of this study was to develop a reliable and valid instrument to measure colonoscopy-related embarrassment. Transtheoretical Model of Behavior Change and Health Belief Model provided the theoretical basis for this study. Participants were health maintenance organization members aged 50 to 65 years ( N = 234). Using a cross-sectional, descriptive research design, data were collected using a mailed survey. Internal consistency (Cronbach’s α = .96) and construct validity of the 13-item instrument were demonstrated. This unidimensional scale shows promise as a valid and reliable instrument to measure colonoscopy-related embarrassment and to inform development of interventions to reduce embarrassment, leading to higher colonoscopy completion rates and lower mortality.

Issues related to colorectal cancer and colorectal cancer screening practices in women

Studies have shown that colorectal cancer (CRC) incidence is equal between men and women. However, several studies have demonstrated lower adenoma detection rates in women than in men. Many questions arise about differences in adenomas, CRC, and screening practices between men and women: should screening be the same for both sexes, are there differences in risk factors in the formation of colon cancer, should special groups of women be screened differently from the general population, are colonoscopies tolerated differently in women and why, and what determines if a woman will undergo colonoscopy? This article reviews these issues.

Rates of screening colonoscopy are not increased when women are offered a female endoscopist in a health promotion outreach program

BACKGROUND

In surveys, almost 50% of women prefer a female endoscopist (FE) to perform their screening colonoscopies (SCOs).

OBJECTIVE

To assess whether offering women an FE is associated with higher rates of SCOs.

DESIGN

Prospective cohort study.

SETTING

University of Colorado Hospital primary care clinics.

PATIENTS

Women of ages 50 to 69 years eligible for an SCO.

INTERVENTIONS

SCO offers through mail and telephone outreach, with and without an explicit FE option.

MAIN OUTCOME MEASUREMENTS

Outreach intervention differences in SCO completion rates and percentages of women requesting FE.

RESULTS

Of 396 women, 72 (18.2%) underwent SCO without difference by type of invitation. Women who received an FE invitation were more likely to request an FE than patients who received no invitation (44.2% and 4.8%, respectively, P < .001), but women who requested an FE were not more likely to undergo an SCO than those who did not.

LIMITATIONS

SCO was offered through an outreach program rather than through in-clinic referrals. The study used a nonrandomized trial comparison group.

CONCLUSIONS

Women offered an FE were not more likely to undergo an SCO than those who were not. This study is unique in describing outcomes associated with actual offers of an FE at the time of scheduling. More direct evidence is needed to support the notion that the absence of FEs is an important barrier to colorectal cancer screening among women.

Screening mammography use and chemotherapy among female stage II colon cancer patients: a retrospective cohort study

Background

Although chemotherapy is not a routine recommendation for stage II colon cancer by the U.S. national guidelines, 20-30% of patients have received chemotherapy. This study investigated whether screening mammography use before the cancer diagnosis was associated with chemotherapy use among female elderly patients with stage II colon cancer.

Methods

Retrospective cohort study on 2910 female stage II colon cancer patients aged 67-79 using the Surveillance, Epidemiology and End Results (SEER)-Medicare data (1996-2002). Screening mammography use and chemotherapy use were identified using Medicare claims data. Multivariate logistic regression and Kaplan-Meier curves were used.

Results

About 25% of female elderly patients received chemotherapy. The chemotherapy rates increased from 22% in 1996-1998 to 26% in 2001-2002. After adjusting for socio-demographic variables, tumor characteristics and Charlson index for comorbidities, the odds of receiving chemotherapy were 28% higher among those who had a screening mammogram before the cancer diagnosis than those who did not (OR: 1.28, 95% CI: 1.07-1.54). Those with a prior mammogram also received chemotherapy earlier than those without. In addition, patients with unfavorable tumor characteristics were more likely to receive chemotherapy. Mammography use before the cancer diagnosis was associated with favorable tumor characteristics.

Conclusions

Despite the controversy about the chemotherapy use among stage II colon cancer, female elderly patients still received chemotherapy at a high rate. Our findings suggest that patient's health beliefs and health care seeking behavior, together with physician's recommendation, play important roles in the cancer treatment decision.

Uptake of colorectal cancer screening: system, provider and individual factors and strategies to improve participation

Colorectal cancer (CRC) accounts for 9% of all new cancer cases worldwide and affects over 1 million people each year. Screening can reduce the mortality associated with the disease, yet participation rates are suboptimal. Compliers with CRC screening are less deprived; they have higher education than noncompliers and tend to be male, white and married. Likely reasons for nonparticipation encompass several 'modifiable' factors that could be targeted in interventions aimed at increasing participation rates. Successful intervention strategies include organizational changes, such as increasing access to fecal occult blood test (FOBT) kits, providing reminders to healthcare providers or users about screening opportunities, and educational strategies to improve awareness and attitudes towards CRC screening. Multifactor interventions that target more than one level of the screening process are likely to have larger effects. The biggest challenge for future research will be to reduce inequalities related to socio-economic position and ethnicity in the uptake of screening.

Sex differences in epidemiological, clinical and pathological characteristics of colorectal cancer

Sex significantly influences the clinical and pathological characteristics of colorectal cancer (CRC). These include differences in incidence and mortality rates, clinical presentations including age, emergency surgery for complications from CRC, screening participation rates, site, stage and treatment utilization, histopathology and survival. Environmental, behavioral and biological factors contribute to the differential risk. Recent advances in the molecular biology of CRC, specifically in microsatellite status, estrogen hormone and estrogen receptor beta, have led to greater understanding of the effect of estrogen in colorectal carcinogenesis. Estrogen may preferentially protect against microsatellite unstable cancers through its effect on selected molecular targets; however, the exact pathways have not been elucidated. Recognition of important sex disparities in these areas may lead to the implementation of specific measures to diminish these differences and facilitate equitable distribution of health resources. Identifying specific molecular targets on CRC that interact with estrogen may stimulate research to improve the overall outcomes of all patients with CRC.

Language use and the receipt of cancer screening recommendations by immigrant Chinese American women

BACKGROUND

Cancer screening rates are low among Chinese American women, a mostly immigrant minority population. This is possibly because they do not receive cancer screening recommendations from their physicians. The objective of this study was to determine if the rate at which physicians recommend cancer screening to older Chinese American women differs according to the language used during visits.

METHODS

Data for the cross-sectional study were collected from a telephone survey of older Chinese American women residing in the Washington, DC, area. A total of 507 asymptomatic Chinese American women aged > or =50 who had a regular physician participated in this study. The main outcome was women's self-reported perception of having received a recommendation from their physician for mammography, Pap tests, or colorectal cancer screening in the past 2 years. The main independent variable was the language used during visits (English vs. Chinese). Patient age, educational level, employment status, cultural views, physician specialty, physician gender, and length of relationship with the physician were included in the multiple logistic regression analyses.

RESULTS

Chinese women who communicated with their physicians in English were 1.71 (95% CI 1.00-2.96) and 1.73 (95% CI 1.00-3.00) times more likely to report having received mammography and colorectal cancer screening recommendations, respectively (p < 0.05). Physicians in family medicine or general practice were 2.11 (95% CI 1.31-3.40) and 1.70 (95% CI 1.06-2.48) times more likely to recommend cancer screening than those in other specialties.

CONCLUSIONS

Chinese American women who conversed with their physicians in Chinese were less likely to perceive receiving cancer screening recommendations. Future research is needed to identify physician-specific knowledge, attitude, and cultural barriers to recommending cancer screening.

The utility of an evidence-based lecture and clinical prompt as methods to improve quality of care in colorectal cancer screening

OBJECTIVES

Colorectal cancer screening can decrease both the incidence of and mortality from colorectal cancer. Unfortunately, participation rates remain suboptimal. We assessed whether an evidence-based lecture or a written clinical prompt at the time of a patient visit would independently increase colorectal cancer screening rates in an internal medicine resident clinic.

METHODS

Three-phase prospective cohort trial of 750 patients. The first phase assessed the baseline screening rate. The second phase assessed the screening rate after an evidenced-based lecture. The third phase assessed the screening rate after the addition of written prompts to patient charts. All 50- to 80-year-old patients who met the criteria for colorectal cancer screening were included in the study. The first intervention was a 1-h evidence-based lecture addressing colorectal cancer screening. The second intervention was placing a written prompt on all eligible patients' charts, reminding physicians to assess whether their patient had been screened. Demographic characteristics were assessed for each cohort of 250 patients. The percentage of patients with documented intention to be screened was assessed for each cohort.

RESULTS

The evidence-based lecture did not significantly improve overall attempted screening rates or colon imaging rates relative to baseline. The clinical prompt significantly improved attempts at screening relative to baseline (39.6 to 67.6%) (P<0.0001). Ordering of colon imaging rates also significantly improved after instituting the prompt from 24 to 46% (P<0.0001).

CONCLUSIONS

Clinical prompts are superior to evidence-based lectures for improving physician colorectal cancer screening practices. These prompts are simple low-cost measures that can improve quality of care.

Influence of physician and patient characteristics on adherence to breast cancer screening recommendations

Identifying physician and patient characteristics is important in implementing effective, targeted strategies to improve breast cancer detection rates through increased screening recommendations and uptake. The purpose of this study was to determine whether Ontario physicians recommend breast screening using mammography every 2 years for women aged 50-69 as encouraged by the Ontario Breast Screening Program. This study also aimed to identify physician and patient characteristics that may influence adherence to these recommendations. The study design was a cross-sectional study. Using the Canadian Medical Directory-Ontario database, 3063 questionnaires were mailed to all active general and family practitioners. A response rate of 38% (N = 939) was achieved. Adherence to screening was defined as recommending screening to women aged 50-69 only, every 2 years as outlined by the Ontario Breast Screening Program. Bivariate analyses and unconditional logistic regression were used to assess physician adherence to screening guidelines. Only 38.9% of physicians followed recommended breast screening guidelines. After adjusting for physician sex and age, predictors of screening adherence include physicians working in academic or research centers (odds ratio 8.3, 95% confidence interval 1.7-39.7) and those reporting that over 31% of their patients to be of low-income (odds ratio 1.6, 95% confidence interval 1.1-2.4). Compared with physicians working in a rural/town setting (<10 000 people), those located in a large city (>100 000 people) were less likely to adhere to screening guidelines (odds ratio 0.5, 95% confidence interval 0.3-0.7). A low proportion of Ontario physicians adhere to recommended breast screening guidelines. Future research into effective strategies to increase adherence should take into account practice location, setting and patient characteristics.

Endoscopic follow-up of positive fecal occult blood testing in the Ontario FOBT Project

BACKGROUND

The Ontario FOBT Project is a pilot study of fecal occult blood testing (FOBT) for colorectal cancer screening conducted among age-eligible volunteers (50 to 75 years) in 12 of 37 public health regions in Ontario.

METHODS

Volunteers responded to invitations from primary care practitioners (PCPs) in six regions, and from public health programs in the remaining regions. FOBT collection kits were distributed from routine laboratory specimen collection sites, to which completed kits were returned. Results were sent to PCPs in all 12 regions, with copies sent to the study office at Cancer Care Ontario (Toronto, Ontario). Follow-up of positive results was at the discretion of the PCPs. The study files contained the unique Ontario Health Insurance Numbers, the date of the analyses, the number of satisfactory slides and the results for each slide. The Ontario Health Insurance Numbers were encrypted for each participant, and along with the study file, were linked to medical billing claims, hospital records and aggregate demographic data.

RESULTS

Among participants with positive results (men 3.5% and women 2.2%), the median time from date of FOBT analysis to date of colonoscopy was 121 days among men and 202 days among women. At the end of follow-up, after positive FOBT (six to 17 months), 73% of men and 56% of women had proceeded to colonoscopy.

CONCLUSION

Although colonoscopy appeared to be acceptable to the majority of participants with positive FOBT, accessibility problems was the likely explanation for lengthy intervals between the date of positive FOBT and its performance. Differences between the experiences of men and women require further investigation.

Correlates and predictors of colorectal cancer screening among male automotive workers

BACKGROUND

Most studies examining factors associated with colorectal cancer (CRC) screening (CRCS) are cross-sectional and thus temporal relationships cannot be determined. Furthermore, less attention has been paid to psychosocial predictors of CRCS. We examined both cross-sectional correlates of prior CRCS and predictors of prospective CRCS initiation and maintenance during The Next Step Trial, a 2-year worksite behavioral intervention to promote regular CRCS and dietary change.

METHOD

The sample included 2,693 White male automotive workers at increased occupational risk for, but no history of, CRC who completed a baseline survey. Stratified analyses were conducted for three dependent variables (prior CRCS, CRCS initiation, and CRCS maintenance). We also assessed prior CRCS as a moderator in prospective analyses. Multivariable logistic regression analyses with generalized linear mixed models were used to adjust for cluster sampling.

RESULTS

Except for education, cross-sectional correlates of prior CRCS including older age, family history of CRC or polyps, personal history of polyps, self-efficacy, family support, and intention were also significant prospective predictors of increased CRCS during the trial. Despite differences in the patterns of association for CRCS initiation and maintenance in stratified analyses, the only associations with prospective CRCS that were significantly moderated by prior CRCS were family history and CRCS availability.

CONCLUSIONS

Correlates of prior CRCS that also were prospective predictors of CRCS may be suitable targets for intervention. Additionally, intervention messages addressing psychosocial constructs may be relevant for both CRCS initiation and maintenance. However, studies with more diverse samples are needed to replicate the results reported here.

Uniquely women's issues in colorectal cancer screening

Colorectal cancer (CRC) is the third most common cause of cancer in women. Screening has been shown to increase detection and decrease morbidity from this disease, but compliance is poor. This paper reviews special considerations for determining screening intervals in women, factors making screening more difficult in women, and studies reviewing preventative strategies in addition to screening that may reduce CRC.

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.

Racial differences in colorectal cancer test use by Medicare consumers

BACKGROUND

Lower use of colorectal cancer (CRC) screening has been suggested as a factor in higher rates of CRC incidence and mortality among African Americans. Racial differences in colorectal cancer test use are not well understood.

METHODS

The study sample included respondents aged 50 to 80 to a 2001 telephone survey of Medicare consumers from two states. The analyses, initiated in 2004, were limited to respondents with no history of CRC (n = 1901). Three CRC tests were examined: fecal occult blood tests (FOBTs), sigmoidoscopy, and colonoscopy. Type of testing and testing according to Medicare coverage intervals by race were compared. Odds ratios (ORs) and 95% confidence intervals (CIs) were obtained from unadjusted and adjusted models to assess the independent associations between race and test use.

RESULTS

Adherence to the Medicare-covered intervals for CRC tests was low (56.8% for whites, 39.1% for African Americans), and did not significantly differ by race after adjustment. African Americans were, however, significantly less likely to have ever been tested (OR = 0.48, 95% CI = 0.33-0.70) and more likely to have had an endoscopic test than an FOBT (OR = 3.06, 95% CI = 1.70-5.51).

CONCLUSIONS

The type of test used to screen for colorectal cancer has important implications for compliance with recommended screening intervals. Understanding reasons for racial differences in CRC test use may help identify approaches to increasing test use in the Medicare population.

Colonoscopy issues related to women

Colonoscopy is the preferred method of screening for colorectal cancer in women. The longer, more redundant female colon is frequently more difficult for the endoscopist to navigate and most studies show longer insertion times, lower completion rates, and more discomfort associated with the procedure in women, all of which may be exacerbated by hysterectomy. To improve female patients' compliance with colorectal cancer screening we need to understand the barriers to participation prevalent among women. This article reviews the findings of several studies and discusses some steps to improve cancer screening for women.

Women patients' preference for women physicians is a barrier to colon cancer screening

BACKGROUND

The preference of women patients for women physicians has been shown in many specialties. Women patients awaiting a lower endoscopy have been shown to have a preference for women endoscopists. The reasons for this preference and the strength of this preference have not been studied in the primary care setting.

METHODS

A questionnaire was given to female patients who were waiting for primary care appointments at 4 offices. Patients reported sociodemographic characteristics, experiences with colorectal cancer (CRC), barriers to CRC screening, gender preference of their physician, the significance, and reasons for this preference.

RESULTS

A total of 202 women patients aged 40 to 70 years (mean 53 years) completed the questionnaire. Of these patients, 43% preferred a woman endoscopist, and of these, 87% would be willing to wait >30 days for a woman endoscopist, and 14% would be willing to pay more for one. The most common reason (in 75%) for this gender preference was embarrassment. Univariate analysis revealed that gender of the primary care physician (PCP), younger patient age, current employment, and no previous history of colonoscopy were predictors of preference for a woman endoscopist. Of these variables, only female gender of the PCP (OR 2.84: 95% CI[1.49, 5.40]) and employment (OR 2.4: 95% CI[1.23, 4.67]) were positive predictors for a woman endoscopist preference by multivariable analysis; 5% stated that they would not undergo a colonoscopy unless guaranteed a woman endoscopist. The sole independent factor associated with adherence to screening was PCP recommendation (OR 2.93: 95% CI[1.63, 5.39]).

CONCLUSIONS

Women patients frequently prefer a woman endoscopist, and this preference is reported as being strong enough to delay the procedure and to incur personal expense. It is an absolute barrier to endoscopy according to 5% in this subset of women surveyed. Interventions must be made in the primary care setting to address this issue and to increase the participation of women patients in CRC screening.

Colorectal cancer screening behavior and health insurance status (United States)

OBJECTIVE

The purpose of this study was to examine the association between health insurance status and CRC screening behavior among a diverse sample of ambulatory patients.

METHODS

Cross-sectional, retrospective study. Quota sampling techniques were used to recruit 52 insured/uninsured patients > or =age 50 from three Midwestern medical clinics (N=104). Data were collected by interviewer-administered CRC screening questionnaires.

RESULTS

Thirty-nine percent of the sample was in compliance with CRC testing guidelines. Insured compared to uninsured participants were significantly more likely to have ever completed any testing (77% versus 33%), and were more likely to have undertaken testing according to current US guidelines (62% versus 17%), all ps < 0.001. Insured participants also were significantly more likely than the uninsured to know about, receive physician recommendation to screen, and profess future intent to screen, ps < 0.001. Fewer uninsured participants were tested for routine reasons compared to insured participants. Significant group differences did not emerge on future preference for a particular screening methodology, if testing costs were equal.

CONCLUSIONS

Results suggest that CRC screening depends, in part, on health insurance status. Increasing insurance coverage or resources for low-cost, accurate tests may facilitate future screening.

Associations in breast and colon cancer screening behavior in women

RATIONALE AND OBJECTIVES

Gender-based psychosocial factors appear to influence colorectal cancer (CRC) screening adherence. Given its near-universal acceptance by the public, screening mammography represents a potential "teachable moment" for educating patients about the risk of CRC. Accordingly, to better understand screening behaviors among women, data from the Behavioral Risk Factors Surveillance Survey (BRFSS) were analyzed to identify potential relationships that would allow interventions to enhance CRC screening.

MATERIALS AND METHODS

Women 50 years and older who participated in the BRFSS 2001 survey were included in the analysis. Colorectal, breast, and cervical cancer screening adherence with American Cancer Society guidelines was determined. We identified the association between breast and cervical cancer screening adherence and general health and demographic characteristics with CRC screening adherence.

RESULTS

After adjustment for sociodemographic factors in a multivariate analysis, women 60-69 years old (adjusted odds ratio [OR], 1.50; P < .01) and 70-79 years old (adjusted OR, 1.39; P < .01), having achieved at least some high school (adjusted OR, 1.62; P < .01) or college (adjusted OR, 2.11; P < .01) education, having health coverage (adjusted OR, 1.67; P < .01) or a personal physician (adjusted OR, 1.60; P < .01), and adherence to screening mammography (adjusted OR, 2.42; P < .01) and Pap smear (adjusted OR, 1.70; P < .01) were independently associated with an increased likelihood CRC screening adherence. Women in self-reported good general health were less likely to have adhered to CRC screening guidelines (adjusted OR, 0.79; P < .01). Current smokers were also less likely to have adhered to CRC screening guidelines than were women who never smoked or formerly smoked (adjusted OR, 0.76; P < .01). Participants who adhered to both mammography and Pap smear guidelines were significantly more likely to adhere to CRC screening (51.5% CRC screening adherence) compared with women who adhered to neither screening test (8.2% CRC screening adherence), with an adjusted OR of 5.67 (P < .001). Participants who adhered to both mammography and Pap smear guidelines were significantly more likely to adhere to CRC screening than were women who adhered to either screening test (38.0% CRC screening adherence) with an adjusted OR of 1.94 (P < .001).

CONCLUSION

Women with up-to-date mammography and cervical cancer screening were more likely to be up-to-date with CRC screening. Regardless of the increased association between non-CRC-related cancer screening and CRC screening, rates of CRC screening utilization remained low in these otherwise compliant populations.

Effect of physician recommendation and patient adherence on rates of colorectal cancer testing

This study explored: (1) patient characteristics associated with physician recommendation for colorectal cancer (CRC) screening and patient adherence to recommendation, and (2) the combined effect of recommendation and adherence on CRC testing, broadly defined. Data were from the 1999 MA BRFSS and a call-back survey of 869 BRFSS participants, age 50 and older. Logistic regression was used to identify correlates of recommendation, adherence, and testing. Patient-physician factors were positively associated with recommendation, adherence and testing. Inadequate health insurance was negatively associated with recommendation (OR = 0.45, 95% CI = 0.27-0.78) and testing (OR = 0.64, 95% CI = 0.38-1.1). Men were not more likely to be recommended (OR = 1.1, 95% CI = 0.78-1.5), but were more likely to adhere (OR = 1.9, 95% CI = 1.2-2.0) and to be tested (OR = 1.4, 95% CI = 1.0-1.9). There were gender differences in recommendation when considering health and risk factor measures. Research is needed to understand differences in recommendation and adherence. Greater encouragement and follow-through may be needed for groups less likely to adhere.

Colon cancer screening practices in New York City, 2003

BACKGROUND

New York City (NYC) has one of the highest concentrations of gastroenterologists in the country, yet only 33% of colorectal cancers in NYC are diagnosed early, and approximately 1500 New Yorkers die from colorectal cancer each year.

METHODS

Using data from a large, local, random-digit dialed telephone survey (n = 9802), the authors of the current study described types of colorectal cancer screening modalities and characteristics of adults undergoing screening within a recommended timeframe. Multivariate analyses were used to examine demographic, behavioral, socioeconomic, and neighborhood-level predictors of screening participation, with particular attention to factors associated with colonoscopy, the recommended screening modality in NYC.

RESULTS

Fifty-five percent of NYC adults aged > or = 50 years reported a recent colorectal cancer screening test, and 42% reported a colonoscopy within the past 10 years. After multiple statistical adjustments, groups with the lowest likelihood of screening were the poor (odds ratio [OR], 0.66; 95% confidence interval [CI], 0.53-0.83) and uninsured (OR, 0.31; 95% CI, 0.20-0.48), as well as Asians (OR, 0.46; 95% CI, 0.29-0. 72), and current smokers (OR, 0.62; 95% CI, 0.50-0.78). Colonoscopy was less frequently reported by non-Hispanic Black New Yorkers and by women; both groups reported higher use of fecal occult blood tests. Less than 10% of adult New Yorkers reported a sigmoidoscopy in the past 5 years.

CONCLUSIONS

Low screening uptake in NYC leaves nearly 1 million New Yorkers, particularly poor and uninsured adults, at risk for undetected colorectal cancer. Colonoscopy screening programs in NYC should address health care and socioeconomic barriers and target racial and ethnic minorities and women.

Barriers to endoscopic colorectal cancer screening: are women different from men?

OBJECTIVES

The goals of this study were to compare women and men's understanding of screening flexible sigmoidoscopy (FS) and to identify predictors of endoscopic colorectal cancer (CRC) screening.

METHODS

We mailed a 36-item questionnaire to asymptomatic patients aged 50 years or older who were scheduled for routine health assessments at a large multispecialty health-care group. Data collection included demographics, health behaviors, psychosocial factors, and CRC screening compliance. We followed participants for 1 year and assessed completion of endoscopic CRC screening. Both cross-sectional results examining previous screening and prospective results examining screening 1 year later were evaluated.

RESULTS

554 (54%) of 998 patients responded to the survey. Responses of 13 patients were excluded in the analyses due to unverifiable screening outcome. The majority of the respondents were white, and their average age was 62 years. Women reported significantly more embarrassment and fear about having FS than men. Women were more willing to consider having a FS if a female endoscopist performed the procedure. Of the 334 participants who were eligible to have endoscopic CRC screening, 53 (16%) had the procedure within a year. The odds of having the endoscopic procedures increased with the length of time the patients were under the care of their primary care providers and how strongly patients believed that one should have an FS even without symptoms.

CONCLUSION

Our findings suggest some unique gender-specific attitudes and beliefs that act as potential barriers for CRC screening and further support the important role of primary care providers in facilitating timely completion of screening.