Validation of self-reported colorectal cancer screening behavior from a mixed-mode survey of veterans

Provincial variation in colorectal cancer screening adherence in Canada; evidence from the Canadian Partnership for Tomorrow's Health

Introduction

Although colorectal cancer (CRC) screening program is proven to reduce CRC incidence and mortality, understanding patterns and predictors of suboptimal adherence in screening program requires further investigation in Canada.

Methods

We used self-reported data from five regional cohorts of the Canadian Partnership for Tomorrow's Health (CanPath), namely the BC Generations Project (BCGP), Alberta's Tomorrow Project (ATP), the Ontario Health Study (OHS), Quebec's CARTaGENE, and the Atlantic Partnership for Tomorrow's Health Study (Atlantic PATH). We stratified participants into the following four risk categories: 1) age 50-74 years, 2) family history in a first-degree relative, 3) personal history of chronic inflammatory bowel disease and/or polyps, and 4) co-existence of personal risk and family history. Multivariable logistic regression was used to identify predictors of adherence to the screening guidelines.

Results

Adherence to CRC screening varied considerably between regions, ranging from 16.6% in CARTaGENE to 47.7% in OHS. Compared to the largest cohort OHS, the likelihood of non-adherence to CRC screening was significantly higher in BCGP (OR 1.15, 95% CI 1.11-1.19), the Atlantic PATH (OR 1.90, 95% CI 1.82-1.99) and CARTaGENE (OR 5.10, 95% CI 4.85-5.36). Low physical activity, current smoking, presence of personal risk, family history of CRC significantly reduced the likelihood of adherence to screening recommendations.

Discussion/conclusion

Compared to the national target of ≥ 60% for participation in CRC screening, adherence to regular CRC screening was suboptimal in this cohort of Canadians and varied by region. Further efforts are needed to identify the specific barriers to screening adherence in different provinces and across risk categories.

Community Health Workers to Increase Cancer Screening: 3 Community Guide Systematic Reviews

INTRODUCTION

Many in the U.S. are not up to date with cancer screening. This systematic review examined the effectiveness of interventions engaging community health workers to increase breast, cervical, and colorectal cancer screening.

METHODS

Authors identified relevant publications from previous Community Guide systematic reviews of interventions to increase cancer screening (1966 through 2013) and from an update search (January 2014-November 2021). Studies written in English and published in peer-reviewed journals were included if they assessed interventions implemented in high-income countries; reported screening for breast, cervical, or colorectal cancer; and engaged community health workers to implement part or all of the interventions. Community health workers needed to come from or have close knowledge of the intervention community.

RESULTS

The review included 76 studies. Interventions engaging community health workers increased screening use for breast (median increase=11.5 percentage points, interquartile interval=5.5‒23.5), cervical (median increase=12.8 percentage points, interquartile interval=6.4‒21.0), and colorectal cancers (median increase=10.5 percentage points, interquartile interval=4.5‒17.5). Interventions were effective whether community health workers worked alone or as part of a team. Interventions increased cancer screening independent of race or ethnicity, income, or insurance status.

DISCUSSION

Interventions engaging community health workers are recommended by the Community Preventive Services Task Force to increase cancer screening. These interventions are typically implemented in communities where people are underserved to improve health and can enhance health equity. Further training and financial support for community health workers should be considered to increase cancer screening uptake.

Impact of Health Care-Associated Cost Concerns on Mammography Utilization: Cross-Sectional Survey Results From the National Health Interview Survey

PURPOSE

Health care-related cost concerns and financial toxicity are increasingly recognized barriers along the breast cancer care continuum. The purpose of this study was to evaluate the association between patient-reported cost concerns and screening mammography utilization.

METHODS

Survey participants aged 40 to 74 years from the 2018 National Health Interview Survey without personal history of breast cancer were included (response rate: 64%). Respondents were queried if they had experienced specific access-related health care barriers. Multiple variable logistic regression analyses were performed to evaluate the association between barriers to care and patient-reported screening mammography utilization.

RESULTS

Of survey respondents, 7,511 women were included. Of this group, 68.9% reported receiving a screening mammogram within the last 2 years and 52.2% reported receiving a screening mammogram within the last year. Of all survey respondents, 48.4% reported worry paying medical bills. Patients who reported worry about paying medical bills (odds ratio [OR] 0.86; 95% confidence interval [CI]: 0.76-0.97; P = .01), challenges affording dental care (OR 0.65; 95% CI: 0.54-0.77; P < .01), and challenges affording eyeglasses (OR 0.67; 95% CI: 0.54-0.84; P < .01) were less likely to report screening mammography use than their respective counterparts. Patients who skipped medication doses (OR 0.69; 95% CI: 0.52-0.91; P < .01), took less medication, (OR 0.63; 95% CI: 0.48-0.82; P < .01), and delayed filling prescriptions (OR 0.71; 95% CI: 0.56-0.90; P < .01) to save money were also less likely to report receiving mammography screening.

CONCLUSION

Patient-reported cost-related barriers are associated with decreased utilization of routine mammography.

Colorectal Cancer Screening Prevalence and Adherence for the Cancer Prevention Project of Philadelphia (CAP3) Participants Who Self-Identify as Black

Introduction

Colorectal cancer is the third leading cause of cancer-related deaths among Black men and women. While colorectal cancer screening (CRCS) reduces mortality, research assessing within race CRCS differences is lacking. This study assessed CRCS prevalence and adherence to national screening recommendations and the association of region of birth with CRCS adherence, within a diverse Black population.

Methods

Data from age-eligible adults, 50–75 years, (N = 357) participating in an ongoing, cross-sectional study, was used to measure CRCS prevalence and adherence and region of birth (e.g., Caribbean-, African-, US-born). Prevalence and adherence were based on contemporaneous US Preventive Services Task Force guidelines. Descriptive statistics were calculated and adjusted prevalence and adherence proportions were calculated by region of birth. Adjusted logistic regression models were performed to assess the association between region of birth and overall CRCS and modality-specific adherence.

Results

Respondents were 69.5% female, 43.3% married/living with partner, and 38.4% had <$25,000 annual income. Overall, 78.2% reported past CRCS; however, stool test had the lowest prevalence overall (34.6%). Caribbean (95.0%) and African immigrants (90.2%) had higher prevalence of overall CRCS compared to US-born Blacks (59.2%) (p-value <0.001). African immigrants were five times more likely to be adherent to overall CRCS compared to US-born Blacks (OR = 5.25, 95% CI 1.34–20.6). Immigrants had higher odds of being adherent to colonoscopy (Caribbean OR = 6.84, 95% CI 1.49–31.5; African OR = 7.14, 95% CI 1.27–40.3) compared to US-born Blacks.

Conclusions

While Caribbean and African immigrants have higher prevalence and adherence of CRCS when compared US-born Blacks, CRCS is still sub-optimal in the Black population. Efforts to increase CRCS, specifically stool testing, within the Black population are warranted, with targeted interventions geared towards US-born Blacks.

Screening for Colorectal Cancer in the United States: Correlates and Time Trends by Type of Test

BACKGROUND

It is strongly recommended that adults aged 50-75 years be screened for colorectal cancer. Recommended screening options include colonoscopy, sigmoidoscopy, CT colonography, guaiac fecal occult blood testing (FOBT), fecal immunochemical testing (FIT), or the more recently introduced FIT-DNA (FIT in combination with a stool DNA test). Colorectal cancer screening programs can benefit from knowledge of patterns of use by test type and within population subgroups.

METHODS

Using 2018 National Health Interview Survey (NHIS) data, we examined colorectal cancer screening test use for adults aged 50-75 years (N = 10,595). We also examined time trends in colorectal cancer screening test use from 2010-2018.

RESULTS

In 2018, an estimated 66.9% of U.S. adults aged 50-75 years had a colorectal cancer screening test within recommended time intervals. However, the prevalence was less than 50% among those aged 50-54 years, those without a usual source of health care, those with no doctor visits in the past year, and those who were uninsured. The test types most commonly used within recommended time intervals were colonoscopy within 10 years (61.1%), FOBT or FIT in the past year (8.8%), and FIT-DNA within 3 years (2.7%). After age-standardization to the 2010 census population, the percentage up-to-date with CRC screening increased from 61.2% in 2015 to 65.3% in 2018, driven by increased use of stool testing, including FIT-DNA.

CONCLUSIONS

These results show some progress, driven by a modest increase in stool testing. However, colorectal cancer testing remains low in many population subgroups.

IMPACT

These results can inform efforts to achieve population colorectal cancer screening goals.

National Survey of Patient Factors Associated with Colorectal Cancer Screening Preferences

Recommended colorectal cancer screening modalities vary with respect to safety, efficacy, and cost. Better understanding of the factors that influence patient preference is, therefore, critical for improving population adherence to colorectal cancer screening. To address this knowledge gap, we conducted a panel survey focused on three commonly utilized colorectal cancer screening options [fecal immunochemical test or guaiac-based fecal occult blood test (FIT/gFOBT), multi-target stool DNA (mt-sDNA) test, and colonoscopy] with a national sample of U.S. adults, ages 40-75 years and at average risk of colorectal cancer, in November 2019. Of 5,097 panelists invited to participate, 1,595 completed the survey (completion rate, 31.3%). Our results showed that when presented a choice between two colorectal cancer screening modalities, more respondents preferred mt-sDNA (65.4%) over colonoscopy, FIT/gFOBT (61%) over colonoscopy, and mt-sDNA (66.9%) over FIT/gFOBT. Certain demographic characteristics and awareness of and/or experience with various screening modalities influenced preferences. For example, uninsured people were more likely to prefer stool-based tests over colonoscopy [OR, 2.53; 95% confidence interval (CI), 1.22-5.65 and OR, 2.73; 95% CI, 1.13-7.47]. People who had heard of stool-based screening were more likely to prefer mt-sDNA over FIT/gFOBT (OR, 2.07; 95% CI, 1.26-3.40). People who previously had a stool-based test were more likely to prefer FIT/gFOBT over colonoscopy (OR, 2.75; 95% CI, 1.74-4.41), while people who previously had a colonoscopy were less likely to prefer mt-sDNA or FIT/gFOBT over colonoscopy (OR, 0.39; 95% CI, 0.24-0.63 and OR, 0.40; 95% CI, 0.26-0.62). Our survey demonstrated broad patient preference for stool-based tests over colonoscopy, contrasting the heavy reliance on colonoscopy for colorectal cancer screening in clinical practice and highlighting the importance of considering patient preference in colorectal cancer screening recommendations. PREVENTION RELEVANCE: Our national survey demonstrated broad patient preference for stool-based tests over colonoscopy, contrasting the heavy reliance on colonoscopy for colorectal cancer screening in clinical practice and highlighting the importance of considering patient preference in colorectal screening recommendations.

A stepped randomized trial to promote colorectal cancer screening in a nationwide sample of U.S. Veterans

BACKGROUND

Colorectal cancer (CRC) screening (CRCS) facilitates early detection and lowers CRC mortality.

OBJECTIVES

To increase CRCS in a randomized trial of stepped interventions. Step 1 compared three modes of delivery of theory-informed minimal cue interventions. Step 2 was designed to more intensively engage those not completing CRCS after Step 1.

METHODS

Recruitment packets (60,332) were mailed to a random sample of individuals with a record of U.S. military service during the Vietnam-era. Respondents not up-to-date with CRCS were randomized to one of four Step 1 groups: automated telephone, telephone, letter, or survey-only control. Those not completing screening after Step 1 were randomized to one of three Step 2 groups: automated motivational interviewing (MI) call, counselor-delivered MI call, or Step 2 control. Intention-to-treat (ITT) analyses assessed CRCS on follow-up surveys mailed after each step.

RESULTS

After Step 1 (n = 1784), CRCS was higher in the letter, telephone, and automated telephone groups (by 1%, 5%, 7%) than in survey-only controls (43%), although differences were not statistically significant. After Step 2 (n = 516), there were nonsignificant increases in CRCS in the two intervention groups compared with the controls. CRCS following any combination of stepped interventions overall was 7% higher (P = 0.024) than in survey-only controls (55.6%).

CONCLUSIONS

In a nationwide study of Veterans, CRCS after each of two stepped interventions of varying modes of delivery did not differ significantly from that in controls. However, combined overall, the sequence of stepped interventions significantly increased CRCS.

An examination of socioeconomic and racial/ethnic disparities in the awareness, knowledge and utilization of three colorectal cancer screening modalities

While colorectal cancer (CRC) mortality rates have been decreasing, disparities by socioeconomic status (SES) and race/ethnicity persist. CRC screening rates remain suboptimal among low SES and racial/ethnic minority populations, despite the availability of multiple screening modalities. Understanding awareness, knowledge, and utilization of common screening modalities within different racial/ethnic and SES groups is critical to inform efforts to improve population screening uptake and reduce disparities in CRC-related health outcomes. Through the theoretical lenses of diffusion of innovation and fundamental cause theory, we examined the associations of race/ethnicity and SES with awareness, knowledge, and utilization of three guideline recommended CRC screening strategies among individuals at average risk for CRC. Data were obtained from a survey of a nationally representative panel of US adults conducted in November 2019. The survey was completed by 31.3% of invited panelists (1595 of 5097). Analyses were focused on individuals at average risk for CRC, aged 45–75 for awareness and knowledge outcomes (n = 1062) and aged 50–75 for utilization outcomes (n = 858). Analyses revealed racial/ethnic and SES disparities among the three CRC screening modalities, with more racial/ethnic and SES differences observed in the awareness, knowledge, and utilization of screening colonoscopy and mt-sDNA than FIT/gFOBT. Patterns of disparities are consistent with previous research showing that inequities in social and economic resources are associated with an imbalanced adoption of medical innovations. Our findings demonstrate a need to increase awareness, knowledge, and access of various CRC screening modalities in specific populations defined by race/ethnicity or SES indicators. Efforts to increase CRC screening should be tailored to the needs and social-cultural context of populations. Interventions addressing inequalities in social and economic resources are also needed to achieve more equitable adoption of CRC screening modalities and reduce disparities in CRC-related health outcomes.

•

Socioeconomic status linked to screening method awareness gap, notably mt-sDNA.

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Screening modalities with low demand on patient resources more likely to be adopted.

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Screening education needs to emphasize uniform starting age for all modalities.

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Tailoring education to low resource communities may improve screening uptake.

Leveraging Emergency Department Encounters to Improve Cancer Screening Adherence

OBJECTIVE

We aimed to estimate the proportion of patients visiting the emergency department (ED) who were not up to date with cancer screening guidelines to assess the scope of need and potential impact of ED-based cancer screening interventions.

METHODS

Adult participants from the 2015 National Health Interview Survey were included. Among patients nonadherent to national breast, colorectal, or lung cancer screening guidelines, the proportion of patients reporting an ED visit within the last year was estimated, accounting for complex survey sampling design features. Multiple variable logistic regression analyses were then conducted to evaluate the association between sociodemographic characteristics and screening adherence.

RESULTS

Of screening eligible respondents, 17.2% of women nonadherent to mammography screening, 16.9% of patients nonadherent to colorectal cancer screening, and 25.0% of patients nonadherent to lung cancer screening reported at least one ED visit in the preceding year. Patients visiting the ED with postsecondary school education were more likely to be up to date with mammography screening than those without advanced education (odds ratio [OR] 1.45; 95% confidence interval [CI]: 1.21-1.74; P = .01). Patients without insurance were less likely than those with insurance to report being up to date with both mammography screening (OR 0.31; 95% CI: 0.21-0.48; P = .01) and colorectal cancer screening (OR 0.56; 95% CI: 0.34-0.93; P = .03).

DISCUSSION

Opportunities to improve cancer screening adherence exist through ED-based preventative care interventions, which leverage multidisciplinary partnerships, including radiologists, to reach large volumes of patients who are not engaged in cancer screening.

Hereditary colorectal cancer screening: A 10-year longitudinal cohort study following an educational intervention

Family history (FH) of a first-degree relative with colorectal cancer (CRC) is associated with two to fourfold increased risk, yet screening uptake is suboptimal despite proven mortality reduction. We developed a FH-based CRC Risk Triage/Management tool for family physicians (FPs), and educational booklet for patients with CRC FH. This report describes physician referral and patient screening behavior 5 and 10 years post-educational intervention, and factors associated with screening. Longitudinal cohort study. FPs/patients in Ontario and Newfoundland, Canada were sent questionnaires at baseline (2005), 5 and 10 years (2015) following tool/booklet receipt. FPs were asked about CRC screening, patients about FH, screening type and timing. "Correct" screening was concordance with tool recommendations. Results reported for 29/121 (24%) FPs and 98/297 (33%) patients who completed all 3 questionnaires. Over 10 years 2/3 patients received the correct CRC screening test at appropriate timing (baseline 75%, 5-year 62%, 10-year 65%). About half reported their FP recommended CRC screening (5-year 51%, 10-year 63%). Fewer than half the patients correctly assessed their CRC risk (44%, 40%, 41%). Patients were less likely to have correct screening timing if female (RR 0.78; 95% CI 0.61, 0.99; p = 0.045). Patients were less likely to have both correct test and timing if moderate/high CRC risk (RR 0.66; 95% CI 0.47, 0.93; p = 0.017) and more likely if their physician recommended screening (RR1.69; 95% CI 1.15, 2.49; p = 0.007). Physician discussion of CRC risk and screening can positively impact patient screening behavior. Efforts are particularly needed for women and patients at moderate/high CRC risk.

Sex differences in the impact of Affordable Care Act Medicaid expansion on colorectal cancer screening

Access to care varies by sex such that interactions with insurance status result in mixed patterns of preventive services utilization. We examined sex-specific effects of ACA Medicaid expansions on receipt of CRC screening. We used Behavioral Risk Factor Surveillance System data (2008-2016) for adults aged 50-64 years with household income ≤138% of federal poverty level to examine self-reported lifetime use of guideline-recommended CRC screening services overall and by screening modality. We employed difference-in-difference models comparing changes in CRC screening in 20 Medicaid expansion states before and after the ACA to changes in 18 states that did not expand Medicaid during our study period. We divided the expansion period into implementation (2014) and post-expansion (2016) periods to account for possible lagged effects. We observed time-varying effects of Medicaid expansion that revealed relative increases in CRC screening occurring during the post-expansion period. Heterogeneous effects by sex and by screening modality were also observed: there was a significant relative increase of 16.2 percentage points (95% CI [2.2, 30.2]; p-value = 0.023) in lifetime colonoscopy use among women in expansion states relative to non-expansion states in the post-expansion period. There were no significant effects of Medicaid expansion among men. Health insurance expansion had a lagged but significant effect on CRC screening among low-income non-elderly women in Medicaid expansion states, but no effect for men. The observed increase in CRC screening among women suggests that barriers to CRC screening may differ by sex, and tailored interventions to increase CRC screening improve outcomes.

Evaluating Lung Cancer Screening Uptake, Outcomes, and Costs in the United States: Challenges With Existing Data and Recommendations for Improvement

The National Lung Screening Trial (NLST) reported substantial reduction in lung cancer mortality among high-risk individuals screened annually with low-dose helical computed tomography (LDCT). As a result, the US Preventive Services Task Force issued a B recommendation for annual LDCT in high-risk individuals, which requires private insurers to cover it without cost-sharing. The Medicare program also covers LDCT for high-risk beneficiaries without cost-sharing. However, the NLST findings may not be generalizable to the community setting because of differences in patients, providers, and practices participating in the NLST. Thus, examining uptake of LDCT screening in community practice is critical, as is evaluating the immediate and downstream outcomes of screening, including false-positive scans, follow-up examinations and adverse events, costs, stage of disease at diagnosis, and survival. This commentary presents an overview of the landscape of the data resources currently available to evaluate the uptake, outcomes, and costs of LDCT screening in the United States. We describe the strengths and limitations of existing data sources, including administrative databases, surveys, and registries. Thereafter, we provide recommendations for improving the data infrastructure pertaining to three overarching research areas: receipt of guideline-consistent screening and follow-up, weighing benefits and harms of screening, and costs of screening.

Affective components of perceived risk mediate the relation between cognitively-based perceived risk and colonoscopy screening

Perceived risk is a common component of health decision making theory. When affective components of risk are assessed as predictors of a behavior, they are usually examined separately from cognitive components. Less frequently examined are more complex interplays between affect and cognition. We hypothesized that cognitive and affective risk components would both have direct effects on colonoscopy behavior/intentions and that affective components would mediate the relationship of cognitively-based perceived risk to colonoscopy screening. In two secondary analyses, participants reported their cognitive and affective perceived risk for colorectal cancer, past colonoscopy behavior, and future screening intentions. In both studies, cognitive and affective risk components were associated with increased screening behavior/intentions and cognitive risk components were mediated through affective risk. Given the impact of early detection on colorectal cancer prevention, educational strategies highlighting both components of risk may be important to increase screening rates.

Colorectal cancer screening: Understanding the health literacy needs of hispanic rural residents

Purpose

Hispanics residing in rural areas are among those who are least likely to be screened for colorectal cancer (CRC) and more likely to present with late stage CRC than other racial or ethnic groups. We conducted a pilot study utilizing a mixed-method approach to explore perceptions of CRC and CRC screening among Hispanic adults residing in South Texas rural communities and to identify health literacy needs associated with CRC screening uptake.

Methods

A convenience sample of 58 participants, aged 35–65, were recruited to complete questionnaires and participate in focus groups, ranging in size from 4 to 13 participants. Six focus groups were conducted across 3 adjacent rural counties. A semi-structured moderator's guide was designed to elicit discussion about participants' experiences, knowledge, and perceptions of CRC and CRC screening.

Findings

Lack of knowledge of CRC and CRC screening as cancer prevention was a common theme across focus groups. A majority, 59%, reported never been screened. Thirty-nine percent reported they had been screened for colon cancer and 5% reported they did not know if they had been screened. Participants with lower educational levels perceived themselves at high risk for developing CRC polyps, would not want to know if they had CRC, and if they did have CRC, would not want to know until the very end. Limited information about CRC and CRC screening, a lack of specialized providers, limited transportation assistance, and compromised personal privacy in small-town medical facilities were perceived to be barriers to CRC screening.

Conclusions

Low screening rates persist among rural Hispanics. Improving CRC screening literacy and addressing factors unique to rural Hispanics may be a beneficial strategy for reducing screening disparities in this at-risk population.

Nationwide, Longitudinal Trends in CT Colonography Utilization: Cross-Sectional Survey Results From the 2010 and 2015 National Health Interview Survey

PURPOSE

Colon cancer screening reduces deaths from colorectal cancer. Screening rates have plateaued; however, studies have found that giving patients a choice between different screening tests improves adherence. CT colonography is a minimally invasive screening test with high sensitivity for colonic polyps (>1 cm). With increasing insurance coverage of CT colonography nationwide, there are limited estimates of CT colonography utilization over time. Our purpose was to estimate CT colonography utilization over time using nationally representative cross-sectional survey data.

METHODS

We utilized 2010 and 2015 National Health Interview Survey cross-sectional data. Participants between ages 50 and 75 without colorectal cancer history were included. Accounting for complex survey design elements, logistic regression analyses evaluated changes in CT colonography utilization over time, adjusted for potential confounders, and stratified by insurance and age.

RESULTS

Overall, 21,686 respondents were included (8,965 in 2010, 12,721 in 2015). Reported CT colonography utilization decreased from 1.2% to 0.9% (odds ratio [OR] 0.92, 95% confidence interval [CI] 0.86-0.98). Stratified analyses revealed no changes in utilization in patients with private insurance (P = .35) and in patients younger than 65 (P = .07). Overall awareness of CT colonography decreased from 20.5% to 15.9% (OR 0.93, 95% CI 0.91-0.95). Reported optical colonoscopy utilization increased from 57.9% to 63.6% (OR 1.03, 95% CI 1.02-1.05).

CONCLUSION

Despite increasing self-reported utilization of optical colonoscopy from 2010 to 2015, survey results suggest that CT colonography awareness (∼16%) and utilization (∼1%) remain low. Improved public awareness and coverage expansion to Medicare-aged populations will promote improved CT colonography utilization and overall colorectal cancer screening rates.

Designing a randomized controlled trial to evaluate a community-based narrative intervention for improving colorectal cancer screening for African Americans

OBJECTIVE

To describe the methodology of a 2-arm randomized controlled trial that compared the effects of a narrative and didactic version of the Witness CARES (Community Awareness, Reach, & Empowerment for Screening) intervention on colorectal cancer screening behavior among African Americans, as well as the cognitive and affective determinants of screening.

METHODS

Witness CARES targeted cognitive and affective predictors of screening using a culturally competent, community-based, narrative or didactic communication approach. New and existing community partners were recruited in two New York sites. Group randomization allocated programs to the narrative or didactic arm. Five phases of data collection were conducted: baseline, post-intervention, three-month, six-month, and qualitative interviews. The primary outcome was screening behavior; secondary outcomes included cognitive and affective determinants of screening.

RESULTS

A total of 183 programs were conducted for 2655 attendees. Of these attendees, 19.4% (N=516) across 158 programs (50% narrative; 50% didactic) were study-eligible and consented to participate. Half (45.6%) of the programs were delivered to new community partners and 34.8% were delivered at faith-based organizations. Mean age of the total sample was 64.7years and 75.4% were female.

CONCLUSION

The planned number of programs was delivered, but the proportion of study-eligible attendees was lower than predicted. This community-based participatory research approach was largely successful in involving the community served in the development and implementation of the intervention and study.

Self-perceived Mental Health Status and Uptake of Fecal Occult Blood Test for Colorectal Cancer Screening in Canada: A Cross-Sectional Study

BACKGROUND

While colorectal cancer (CRC) is one of the most preventable causes of cancer mortality, it is one of the leading causes of cancer death in Canada where CRC screening uptake is suboptimal. Given the increased rate of mortality and morbidity among mental health patients, their condition could be a potential barrier to CRC screening due to greater difficulties in adhering to behaviours related to long-term health goals. Using a population-based study among Canadians, we hypothesize that self-perceived mental health (SPMH) status and fecal occult blood test (FOBT) uptake for the screening of CRC are associated.

METHODS

The current study is cross-sectional and utilised data from the Canadian Community Health Survey 2011-2012. Multinomial logistic regression analysis was undertaken to assess whether SPMH is independently associated with FOBT uptake among a representative sample of 11 386 respondents aged 50-74 years.

RESULTS

Nearly half of the respondents reported having ever had FOBT for CRC screening, including 37.28% who have been screened within two years of the survey and 12.41% who had been screened more than two years preceding the survey. Respondents who reported excellent mental health were more likely to have ever been screened two years or more before the survey (adjusted odds ratio [AOR] = 2.08; 95% CI, 1.00-4.43) and to have been screened in the last two years preceding the survey (AOR = 1.53; 95% CI, 0.86-2.71) than those reported poor mental health status.

CONCLUSION

This study supports the association between SPMH status and FOBT uptake for CRC screening. While the efforts to maximize CRC screening uptake should be deployed to all eligible people, those with poor mental health may need more attention.

Results of a Health Education Message Intervention on HPV Knowledge and Receipt of Follow-up Care among Latinas Infected with High-risk Human Papillomavirus

A clinic-based intervention study was conducted among high-risk human papillomavirus (HPV)-infected Latinas aged 18-64 years between April 2006 and May 2008 on the Texas-Mexico border. Women were randomly assigned to receive a printed material intervention (n=186) or usual care (n=187) and were followed at three months, six months, and 12 months through telephone surveys and review of medical records. The HPV knowledge of nearly all women had increased greatly, but only two-thirds of women reported they had received follow-up care within one year of diagnosis regardless of additional health education messaging. Our findings suggest that, regardless of type of health education messaging, Latinas living on the Texas-Mexico border are aware that follow-up care is recommended, but they may not receive this care. Individual, familial and medical care barriers to receipt of follow-up care may partially account for the higher rates of cervical cancer mortality in this region.

Racial and Ethnic Disparities in Colonoscopic Examination of Individuals With a Family History of Colorectal Cancer

BACKGROUND & AIMS

Guidelines recommend that persons with a high-risk family history of colorectal cancer (CRC) undergo colonoscopy examinations every 5 years, starting when they are 40 years old. We investigated factors associated with colonoscopy screening of individuals with a family history of CRC, focusing on race and ethnicity.

METHODS

In a retrospective study, we analyzed data from the 2009 California Health Interview Survey on persons 40-80 years old with a first-degree relative (mother, father, sibling, or child) with CRC who had visited a physician within the past 5 years. Our study included an unweighted and population-weighted sample of 2539 and 870,214 individuals with a family history of CRC, respectively. We performed a survey-weighted logistic regression analysis to adjust for relevant demographic and socioeconomic variables and used estimates to calculate relative risks and 95% confidence intervals (CIs) for colonoscopy examination within the past 5 years.

RESULTS

In the weighted sample, 60.0% of subjects received a colonoscopy within the past 5 years. A physician recommendation for CRC screening increased the odds that an individual would undergo colonoscopy examination (relative risk, 1.89; 95% CI, 1.61-2.24). Latinos were 31% less likely to receive colonoscopies than whites (95% CI, 7%-55%). Among individuals 40-49 years old, blacks were 71% less likely to have had a colonoscopy than whites (95% CI, 13%-96%).

CONCLUSION

On the basis of an analysis of data from the California Health Interview Survey, less than two-thirds of individuals with a family history of CRC reported receiving guideline-recommended colonoscopy examinations within the past 5 years. We observed racial and ethnic disparities in colonoscopy screening of this high-risk group; Latinos and blacks were less likely to have had a colonoscopy than whites.

Beyond the black box: a systematic review of breast, prostate, colorectal, and cervical screening among native and immigrant African-descent Caribbean populations

Cancer screening disparities between black and white groupings are well-documented. Less is known regarding African-descent subpopulations despite elevated risk, distinct cultural backgrounds, and increasing numbers of Caribbean migrants. A systematic search of Medline, Web of Science, PubMed and SCOPUS databases (1980-2012) identified 53 studies reporting rates of breast, prostate, cervical, and colorectal screening behavior among immigrant and non-immigrant Caribbean groups. Few studies were conducted within the Caribbean itself; most work is US-based, and the majority stem from Brooklyn, New York. In general, African-descent Caribbean populations screen for breast, prostate, colorectal, and cervical cancers less frequently than US-born African-Americans and at lower rates than recommendations and guidelines. Haitian immigrants, in particular, screen at very low frequencies. Both immigrant and non-immigrant African-descent Caribbean groups participate in screening less frequently than recommended. Studying screening among specific Caribbean groups of African-descent may yield data that both clarifies health disparities between US-born African-Americans and whites and illuminates the specific subpopulations at risk in these growing immigrant communities.

Against Colorectal Cancer in Our Neighborhoods, a Community-Based Colorectal Cancer Screening Program Targeting Low-Income Hispanics

Background. Colorectal cancer is the second leading cause of cancer-related death in the United States. Despite universal screening recommendations, screening rates in the United States remain suboptimal, especially among the poor, the uninsured, recent immigrants, and Hispanics. This article describes the development of a large community-based colorectal cancer screening program designed to address these disparities. Method. The Against Colorectal Cancer in our Neighborhoods program is a bilingual, evidence-based, theory-guided, multicomponent community screening intervention, targeting the uninsured and developed using a systematic planning process. It combines community health worker–led outreach, bilingual and culturally tailored community education, and no-cost screening with provision of the fecal immunochemical test or colonoscopy and navigation services. A detailed process and outcome evaluation is planned. Program development cost calculated prospectively (in 2011 dollars) using a societal perspective and micro-costing methods was $243,278, of which $180,344 was direct cost. Discussion. The detailed description of the development processes and costs of this health promotion program targeting low-income Hispanics will inform health program decision makers about the resource requirements for planning and developing new programs to reduce disease burden in communities.

Examining Adherence With Recommendations for Follow-Up in the Prevention Among Colorectal Cancer Survivors Study

PURPOSE/OBJECTIVES

To explore the impact of health professionals' recommendations for medical follow-up among colorectal cancer (CRC) survivors.

DESIGN

Cross-sectional survey.

SETTING

Mailed surveys and telephone interviews with CRC survivors in California.

SAMPLE

593 adults diagnosed with a primary CRC six to seven years before the time of the study.

METHODS

Participants were identified through California Cancer Registry records and invited to take part in a survey delivered via mail or through telephone interview.

MAIN RESEARCH VARIABLES

The survey assessed cancer history, current preventive health practices, health status, demographics, and other cancer-related experiences.

FINDINGS

More than 70% of CRC survivors received recommendations for routine checkups, surveillance colonoscopy, or other cancer screenings after completing CRC treatment, and 18%-22% received no such recommendations. Recommendations were sometimes given in writing. Receiving a recommendation for a specific type of follow-up was associated with greater adherence to corresponding guidelines for routine checkups, colonoscopy, mammography, and Papanicolaou testing. Receiving written (versus unwritten) recommendations led to greater adherence only for colonoscopy.

CONCLUSIONS

Most CRC survivors reported receiving recommendations for long-term medical follow-up and largely adhered to guidelines for follow-up. Receiving a health professional's recommendation for follow-up was consistently associated with patient adherence, and limited evidence showed that recommendations in written form led to greater adherence than unwritten recommendations.

IMPLICATIONS FOR NURSING

Given the increasingly important role of the oncology nurse in survivorship care, nurses can be instrumental in ensuring appropriate surveillance and follow-up care among CRC survivors. Conveying recommendations in written form, as is done in survivorship care plans, may be particularly effective.

Association between self-reported depression and screening colonoscopy participation

The impact of depression on participation in screening colonoscopy is poorly characterized. This study attempts to understand this relationship by conducting a cross-sectional analysis on a nationally representative sample of adults aged 50 to 75 years without a history of colorectal cancer or inflammatory bowel disease from the 2009 Medical Expenditures Panel Survey. Multivariable analysis shows that the odds of having a current colonoscopy is 1.3 times higher for individuals with depression compared with those without depression (odds ratio = 1.3; 95% confidence interval = 1.1-1.7). These findings suggest that depression may not be a risk factor for underutilization of CRC screening.

Disgusted, embarrassed, annoyed: affective associations relate to uptake of colonoscopy screening

BACKGROUND

Uptake of colorectal cancer screening is lower than desired. Screening decision making research has traditionally focused on benefits and barriers to screening. This study examines the relation of affective associations with screening (feelings and emotions associated with screening) to colonoscopy screening uptake.

METHODS

Participants were 103 African American community adults. Participants completed a structured interview assessing perceived benefits of and barriers to colonoscopy screening, affective associations with colonoscopy, colonoscopy screening behavior, and intentions for future screening.

RESULTS

Higher positive and lower negative affective associations with screening were both significant predictors of colonoscopy uptake. Affective associations fully mediated the relation of perceived benefits and barriers to screening uptake. Affective associations were associated with intentions for future screening.

CONCLUSIONS

Incorporation of affective associations into models of screening decision making and intervention approaches to address screening compliance has utility for advancing our understanding of screening adherence as well as increasing screening rates.

Agreement Between Self-Report and Medical Record Prevalence of 16 Chronic Conditions in the Alaska EARTH Study

The gold standard for health information is the health record. Hospitalization and outpatient diagnoses provide health systems with data on which to project health costs and plan programmatic changes. Although health record information may be reliable and perceived as accurate, it may not include population-specific information and may exclude care provided outside a specific health care facility. Sole reliance on medical record information may lead to underutilization of health care services and inadequate assessment of population health status. In this study, we analyzed agreement, without assuming a gold standard, between self-reported and recorded chronic conditions in an American Indian/Alaska Native cohort. Self-reported health history was collected from 3821 adult participants of the Alaska EARTH study during 2004-2006. Participant medical records were electronically accessed and reviewed. Self-reported chronic conditions were underreported in relation to the medical record and both information sources reported the absence more reliably than the presence of conditions (across conditions, median positive predictive value = 64%, median negative predictive value = 94%). Agreement was affected by age, gender, and education. Differences between participant- and provider-based prevalence of chronic conditions demonstrate why health care administrators and policy makers should not rely exclusively on medical record-based administrative data for a comprehensive evaluation of population health.

Agreement between self-reported and registered colorectal cancer screening: a meta-analysis

This random-effects meta-analysis investigates the accuracy of self-reported colorectal cancer screening history as a function of screening mode (colonoscopy, flexible sigmoidoscopy, faecal occult blood testing - FOBT, double-contrast barium enema - DCBE) and survey mode (written, telephone, face-to-face). Summary estimates of sensitivity, specificity, positive predictive value (PPV) and area under the receiver operating characteristic curve (AUC) were calculated. Medical record data were used as reference. We included 23 studies comprising 11,592 subjects. Colonoscopy yielded higher AUC [0.948, 95% confidence interval (CI) = 0.918, 0.968] than flexible sigmoidoscopy (0.883, 95% CI = 0.849, 0.911) and FOBT (0.869, 95% CI = 0.833, 0.898). Colonoscopy showed the highest sensitivity (0.888, 95% CI = 0.835, 0.931), whereas specificity was comparable between screening modes (ranging from 0.802 for FOBT to 0.904 for DCBE). AUC was not significantly different between survey modes. Prevalence of screening history correlated positively with sensitivity and negatively with specificity, possibly because of errors in the medical records. In conclusion, the accuracy of self-reported cancer screening is generally moderate, and higher for colonoscopy than for sigmoidoscopy and FOBT.

Survey mode and asking about future intentions did not impact self-reported colorectal cancer screening accuracy

BACKGROUND

Self-reported colorectal cancer (CRC) screening behavior is often subject to over-reporting bias. We examined how the inclusion of a future intention to screen item (viz. asking about future intentions to get screened before asking about past screening) and mode of survey administration impacted the accuracy of self-reported CRC screening.

METHODS

The target population was men and women between 49 and 85 years of age who lived in Olmsted County, MN, for at least 10 years at the time of the study. Eligible residents were randomized into four groups representing the presence or absence the future intention to screen item in the questionnaire and administration mode (mail vs. telephone). A total of 3,638 cases were available for analysis with 914, 838, 956, and 930 in the mail/future intention, mail/no future intention, telephone/future intention, and telephone/no future intention conditions, respectively. False positives were defined as self-reporting being screened among those with no documented history of screening in medical records and false negatives as not self-reporting screening among those with history of screening.

RESULTS

Comparing false positive and false negative reporting rates for each specific screening test among the responders at the bivariate level, regardless of mode, there were no statistically significant differences by the presence or absence of a preceding future intention question. When considering all tests combined, the percentage of false negatives within the telephone mode was slightly higher for those with the future intention question (6.7% vs 4.2%, p = 0.04). Multivariate models that considered the independent impact of the future intention question and mode, affirmed the results observed at the bivariate level. However, individuals in the telephone arm (compared to mail) were slightly (though not significantly) more likely to report a false positive (36.4% vs 31.8%, OR = 1.11, p = 0.55).

CONCLUSION

It may be that in the context of a questionnaire that is clearly focused on CRC and with specific descriptions of the various CRC screening tests, certain design features such as including intention to screen items or mode of administration will have very little impact on the accuracy of self-reported CRC screening.

Surveillance instructions and knowledge among African American colorectal cancer survivors

INTRODUCTION

African Americans are less likely than other racial/ethnic groups to receive appropriate surveillance, an important component of care to achieve better long-term outcomes and well-being after colorectal cancer (CRC) treatment. This study explored survivors' understanding of surveillance instructions and purpose.

PATIENTS AND METHODS

Interviews with 60 African American CRC survivors were recorded and transcribed. Compliance with surveillance guidelines was defined by disease stage and self-reported tests. Four coders (blind to compliance status) independently reviewed transcripts. Frequency of themes was reported by compliance status.

RESULTS

Survivors (4 to 6 years postdiagnosis; women, 57%; age ≥ 65 years, 60%; rural location, 57%; early-stage disease, 62%) were 48% noncompliant. Most survivors reported receiving surveillance instructions from providers (compliant, 80%; noncompliant, 76%). There was variation in recommended frequency of procedures (eg, every 3 or 12 months) and in importance of surveillance stressed by physicians. Most survivors understood the need for follow-up (compliant, 87%; noncompliant, 79%). Lack of knowledge of/interest in surveillance was more common among noncompliant individuals (compliant, 32%; noncompliant, 52%).

CONCLUSION

Patients' limited understanding about the importance of CRC surveillance and procedures may negatively affect compliance with recommendations in African American CRC survivors. Clear and enhanced communications about post-treatment recommendations in this population are warranted.

Decision Aid to Technologically Enhance Shared decision making (DATES): study protocol for a randomized controlled trial

BACKGROUND

Clinicians face challenges in promoting colorectal cancer screening due to multiple competing demands. A decision aid that clarifies patient preferences and improves decision quality can aid shared decision making and be effective at increasing colorectal cancer screening rates. However, exactly how such an intervention improves shared decision making is unclear. This study, funded by the National Cancer Institute, seeks to provide detailed understanding of how an interactive decision aid that elicits patient's risks and preferences impacts patient-clinician communication and shared decision making, and ultimately colorectal cancer screening adherence.

METHODS/DESIGN

This is a two-armed single-blinded randomized controlled trial with the target of 300 patients per arm. The setting is eleven community and three academic primary care practices in Metro Detroit. Patients are men and women aged between 50 and 75 years who are not up to date on colorectal cancer screening. ColoDATES Web (intervention arm), a decision aid that incorporates interactive personal risk assessment and preference clarification tools, is compared to a non-interactive website that matches ColoDATES Web in content but does not contain interactive tools (control arm). Primary outcomes are patient uptake of colorectal cancer screening; patient decision quality (knowledge, preference clarification, intent); clinician's degree of shared decision making; and patient-clinician concordance in the screening test chosen. Secondary outcome incorporates a Structural Equation Modeling approach to understand the mechanism of the causal pathway and test the validity of the proposed conceptual model based on Theory of Planned Behavior. Clinicians and those performing the analysis are blinded to arms.

DISCUSSION

The central hypothesis is that ColoDATES Web will improve colorectal cancer screening adherence through improvement in patient behavioral factors, shared decision making between the patient and the clinician, and concordance between the patient's and clinician's preferred colorectal cancer screening test. The results of this study will be among the first to examine the effect of a real-time preference assessment exercise on colorectal cancer screening and mediators, and, in doing so, will shed light on the patient-clinician communication and shared decision making 'black box' that currently exists between the delivery of decision aids to patients and subsequent patient behavior.

TRIAL REGISTRATION

ClinicalTrials.gov ID NCT01514786.

Effectiveness of a theory-based intervention to increase colorectal cancer screening among Iranian health club members: a randomized trial

Colorectal cancer is the third most commonly diagnosed cancer and the fourth leading cause of death in the world. There are few published studies that have used theory-based interventions designed to increase colorectal cancer screening in community lay health organizations. The present study was guided by the theoretical concepts of the preventive health model. Twelve health clubs of a municipal district in Tehran were randomized to two study groups with equal ratio. The control group received usual services throughout the study while the intervention group also received a theory-based educational program on colorectal cancer screening plus a reminder call. Screening behavior, the main outcome, was assessed 4 months after randomization. A total of 360 members aged 50 and older from 12 health clubs completed a baseline survey. Participants in the intervention group reported increased knowledge of colorectal cancer and screening tests at 4 months follow-up (p's < .001). Moreover, exposure to the theory-based intervention significantly improved self-efficacy, perceived susceptibility, efficacy of screening, social support, and intention to be screened for colorectal cancer, from baseline to 4 months follow-up (p's < .001). The screening rate for colorectal cancer was significantly higher in the intervention group compared to the control group (odds ratio = 15.93, 95% CI = 5.57, 45.53). Our theory-based intervention was found to have a significant effect on colorectal cancer screening use as measured by self-report. The findings could have implications for colorectal cancer screening program development and implementation in primary health care settings and through other community organizations.

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

OBJECTIVES

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

DESIGN AND SAMPLE

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

MEASURES

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

RESULTS

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

CONCLUSIONS

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

Systems intervention to promote colon cancer screening in safety net settings: protocol for a community-based participatory randomized controlled trial

BACKGROUND

Colorectal cancer is a leading cause of cancer mortality. Screening can be effective but is underutilized. System- or multi-level interventions could be effective at increasing screening, but most have been implemented and evaluated in higher-resource settings such as health maintenance organizations. Given the disparities evident for colorectal cancer and the potential for screening to improve outcomes, there is a need to expand this work to include diverse settings, including those who treat economically disadvantaged patients. This paper describes the study protocol for a trial designed to increase colorectal cancer screening in those 'safety-net' health centers that serve underinsured and uninsured patients. This trial was designed and is being implemented using a community-based participatory approach.

METHODS/DESIGN

We developed a practical clinical cluster-randomized controlled trial. We will recruit 16 community health centers to this trial. This systems-level intervention consists of a menu of evidence-based implementation strategies for increasing colorectal cancer screening. Health centers in the intervention arm then collaborate with the study team to tailor strategies to their own setting in order to maximize fit and acceptability. Data are collected at the organizational level through interviews, and at the provider and patient levels through surveys. Patients complete a survey about their healthcare and screening utilization at baseline, six months, and twelve months.

OUTCOMES

The primary outcome is colorectal cancer screening by patient self-report, supplemented by a chart-audit in a subsample of patients. Implementation outcomes informed by the Reach, Efficacy/Effectiveness, Adoption, Implementation, and Maintenance (RE-AIM) conceptual framework will be measured at patient, provider, and practice levels.

DISCUSSION

Our study is one of the first to integrate community participatory strategies to a randomized controlled trial in a healthcare setting. The multi-level approach will support the ability of the intervention to affect screening through multiple avenues. The participatory approach will strengthen the chance that implementation strategies will be maintained after study completion and, supports external validity by increasing health center interest and willingness to participate.

TRIAL REGISTRATION

NCT01299493.

Patients' short-term knowledge of personal polyp history inadequate despite systematic notification of results after polypectomy

OBJECTIVES

Patients' memories of personal polyp characteristics have been shown to be inadequate when compared with the medical record. An accurate polyp history is necessary to adhere to guidelines. We sought to determine whether systematically informing patients of the results of their colonoscopy and pathology in a multifaceted manner could increase their knowledge of their personal polyp history.

METHODS

We conducted a prospective pilot study of 240 consecutive patients undergoing screening colonoscopy with polypectomy by a single endoscopist (B.J.H.) at a tertiary care center. All of the patients were provided with a verbal report of findings immediately after the procedure, an endoscopy report specifying polyp size and number, and a mailed letter specifying the pathology results of their polyps. Telephone contact was attempted for all of the patients. Patients were asked to recall the size, number, and histology of their polyps.

RESULTS

One hundred (42%) of the patients completed the telephone survey. Forty patients remembered the polyp number; five remembered their polyp histology, and one recalled the polyp size. None of the patients recalled all three factors, although patients who recalled telling a family member the results of the colonoscopy were more likely to recall at least one polyp descriptor (relative risk 2.62 [95% confidence interval 1.01-6.83]). No other variables were associated with polyp recall.

CONCLUSIONS

Patients' knowledge of personal polyp characteristics, even after systematic notification, does not seem adequate for determining the best guideline-based colonoscopy surveillance interval. Discussing results with family members may help.

Individual- and provider-level factors associated with colorectal cancer screening in accordance with guideline recommendation: a community-level perspective across varying levels of risk

BACKGROUND

Participation rates in colorectal cancer screening (CRC) are low. Relatively little is known about screening uptake across varying levels of risk and across population groups. The purpose of the current study was to identify factors associated with (i) ever receiving colorectal cancer (CRC) testing; (ii) risk-appropriate CRC screening in accordance with guidelines; and (iii) recent colonoscopy screening.

METHODS

1592 at-risk persons (aged 56-88 years) were randomly selected from the Hunter Community Study (HCS), Australia. Participants self-reported family history of CRC was used to quantify risk in accordance with national screening guidelines.

RESULTS

1117 participants returned a questionnaire; 760 respondents were eligible for screening and analysis. Ever receiving CRC testing was significantly more likely for persons: aged 65-74 years; who had discussed with a doctor their family history of CRC or had ever received screening advice. For respondents "at or slightly above average risk", guideline-appropriate screening was significantly more likely for persons: aged 65-74 years; with higher household income; and who had ever received screening advice. For respondents at "moderately or potentially high risk", guideline-appropriate screening was significantly more likely for persons: with private health insurance and who had discussed their family history of CRC with a doctor. Colonoscopy screening was significantly more likely for persons: who had ever smoked; discussed their family history of CRC with a doctor; or had ever received screening advice.

CONCLUSIONS

The level of risk-appropriate screening varied across populations groups. Interventions that target population groups less likely to engage in CRC screening are pivotal for decreasing screening inequalities.

Correlates of self-reported colorectal cancer screening accuracy in a multi-specialty medical group practice

PURPOSE

We assessed whether accuracy of self-reported screening for colorectal cancer (CRC) varied by respondent characteristics or healthcare utilization.

METHODS

From 2005 to 2007, 857 respondents aged 51 - 74 were recruited from a multi-specialty medical group practice to answer a questionnaire about their CRC screening (CRCS) behaviors. Self-reports were compared with administrative and medical records to assess concordance, sensitivity, specificity, and report-to-records ratios for overall CRCS (fecal occult blood test, sigmoidoscopy, and/or colonoscopy).

RESULTS

Concordance was good (≥0.8 to <0.9) or fair (≥0.7 to <0.8) for most subgroups; respondents with >5 visits outside the clinic had poor (<0.7) concordance. Sensitivity estimates were mostly excellent (≥0.9) or good but poor for respondents whose healthcare provider did not advise a specific CRCS test. Specificity was poor for the following respondents: 65+ years, males, college graduates, family history of CRC, >5 visits outside of the clinic, or whose healthcare provider advised a specific CRCS test. Respondents 65+ years and with >5 outside visits over-reported CRCS.

CONCLUSIONS

With few exceptions, self-reports of CRCS in an insured population is reasonably accurate across subgroups. More work is needed to replicate these findings in diverse settings and populations to better understand subgroup differences and improve measures of CRCS.

Levels and variation in overuse of fecal occult blood testing in the Veterans Health Administration

BACKGROUND

Policy-makers have called for efforts to reduce overuse of cancer screening tests, including colorectal cancer screening (CRCS). Overuse of CRCS tests other than colonoscopy has not been well documented.

OBJECTIVE

To estimate levels and correlates of fecal occult blood test (FOBT) overuse in a national Veterans Health Administration (VHA) sample.

DESIGN

Observational

PARTICIPANTS

Participants included 1,844 CRCS-eligible patients who responded to a 2007 CRCS survey conducted in 24 VHA facilities and had one or more FOBTs between 2003 and 2009.

MAIN MEASURES

We combined survey data on race, education, and income with administrative data on region, age, gender, CRCS procedures, and outpatient visits to estimate overuse levels and variation. We coded FOBTs as overused if they were conducted <10 months after prior FOBT, <9.5 years after prior colonoscopy, or <4.5 years after prior barium enema. We used multinomial logistic regression models to examine variation in overuse by reason (sooner than recommended after prior FOBT; sooner than recommended after colonoscopy, barium enema, or a combination of procedures), adjusting for clustering of procedures within patients, and patients within facilities.

KEY RESULTS

Of 4,236 FOBTs received by participants, 885 (21 %) met overuse criteria, with 323 (8 %) sooner than recommended after FOBT, and 562 (13 %) sooner than recommended after other procedures. FOBT overuse varied across facilities (9-32 %, p<0.0001) and region (12-23 %, p< .0012). FOBT overuse after prior FOBT declined between 2003 and 2009 (8 %-5 %, p= .0492), but overuse after other procedures increased (11-19 %, p= .0002). FOBT overuse of both types increased with number of outpatient visits (OR 1.15, p<0.001), but did not vary by patient demographics. More than 11 % of overused FOBTs were followed by colonoscopy within 12 months.

CONCLUSIONS

Many FOBTs are performed sooner than recommended in the VHA. Variation in overuse by facility, region, and outpatient visits suggests addressing FOBT overuse will require system-level solutions.

Patterns of colorectal cancer test use, including CT colonography, in the 2010 National Health Interview Survey

BACKGROUND

Recommended colorectal cancer (CRC) screening tests for adults ages 50 to 75 years include home fecal occult blood tests (FOBT), sigmoidoscopy with FOBT, and colonoscopy. A newer test, computed tomographic (CT) colonography, has been recommended by some, but not all, national organizations.

METHODS

We analyzed 2010 National Health Interview Survey data, including new CT colonography questions, from respondents ages 50 to 75 years (N = 8,952). We (i) assessed prevalence of CRC test use overall, by test type, and by sociodemographic and health care access factors and (ii) assessed reported reasons for not having a CRC test.

RESULTS

The age-standardized percentage of respondents reporting FOBT, sigmoidoscopy, or colonoscopy within recommended time intervals was 58.3% [95% confidence interval (CI), 57.0-59.6]. Colonoscopy was the most commonly reported test [within past 10 years: 54.6% (95% CI, 53.2-55.9)]. Home FOBT and sigmoidoscopy with FOBT were less frequently used [FOBT within past year: 8.8% (95% CI, 8.1-9.6); sigmoidoscopy within past 5 years with FOBT within past 3 years: 1.3% (95% CI, 1.0-1.6)]. CT colonography was rare: 1.3% (95% CI, 1.0-1.7). Increasing age, education, income, having health care insurance, and having a usual source of health care were associated with higher CRC test use. Test use within recommended time intervals was particularly low among individuals ages 50 to 64 years without health care insurance [21.2% (95% CI, 18.3-24.4)]. The most common reason for nonuse was "no reason or never thought about it."

CONCLUSIONS

About 40% of Americans ages 50 to 75 years do not meet the recommendations for having CRC screening tests.

IMPACT

Expanded health care coverage and greater awareness of CRC screening are needed to further decrease CRC mortality.

Colorectal cancer testing in the national Veterans Health Administration

BACKGROUND

Colorectal cancer (CRC) screening is a priority for the Veteran's Health Administration (VHA). Optimizing fecal occult blood testing (FOBT) is integral to CRC screening in health care systems.

AIMS

The purpose of this study was to characterize the utilization of CRC testing in a large integrated health care system (VHA), determine current rates of CRC testing by FOBT and examine factors associated with lack of FOBT card return.

METHODS

The VHA Office of Quality and Performance (OQP) collected data from a national sample of Veterans from October 2008 to September 2009. Rates and modality of CRC testing for eligible Veterans were calculated. Among those offered FOBT, bivariate analyses were performed to describe population characteristics by FOBT return. Logistic regression was used to determine factors independently associated with lack of FOBT return.

RESULTS

A total of 36,336 Veterans were included. On weighted analysis, 80.4% of Veterans received a form of CRC screening. The majority underwent colonoscopy in the prior 10 years (71.6%), followed by FOBT in the prior year (24.0%). A total of 31.0% did not return FOBT cards that were provided. Factors associated with a lack of FOBT return included: younger age, female gender, non-Caucasian race, living in the Northeast, current smoking and lack of influenza vaccination.

CONCLUSIONS

Overall rates of CRC screening in VHA are high. Systems-based practices within VHA likely play a role in successful CRC screening. CRC screening is most often via colonoscopy, followed by FOBT. Characteristics associated with non-adherence with FOBT may inform future quality improvement initiatives in health care systems.

Overutilization of endoscopic surveillance in nondysplastic Barrett's esophagus: a multicenter study

BACKGROUND

Guidelines suggest that patients with nondysplastic Barrett's esophagus (BE) undergo endoscopic surveillance every 3 to 5 years, but actual use of surveillance endoscopy and the determinants of variation in surveillance intervals are not known.

OBJECTIVE

To measure use of surveillance endoscopy and its variation in patients with nondysplastic BE.

DESIGN

Multicenter, cross-sectional study.

SETTING

Three sites in Arizona, Minnesota, and North Carolina.

PATIENTS

This study involved patients who had prevalent BE without a history of high-grade dysplasia or esophageal adenocarcinoma.

INTERVENTION

Participants were given validated measures of quality of life, numeracy, and cancer risk perception, and the total number of prior endoscopic surveillance examinations was measured.

MAIN OUTCOME MEASUREMENTS

Oversurveillance was defined as >1 surveillance examination per 3-year period.

RESULTS

Among 235 patients with nondysplastic BE, 76% were male and 94% were white. The average (± standard deviation [SD]) duration of BE was 6.5 ± 5.9 years. The mean (± SD) number of endoscopies per 3-year period was 2.7 ± 2.6. Oversurveillance was present in 65% of participants, resulting in a mean of 2.3 excess endoscopies per patient. Neither numeracy skills nor patient perception of cancer risk were associated with oversurveillance.

LIMITATIONS

Endoscopies were measured by patient report, which is subject to error. Results may be generalizable only to patients seen in academic centers.

CONCLUSION

Most patients with nondysplastic BE had more surveillance endoscopic examinations than is recommended by published guidelines. Patient factors did not predict oversurveillance, indicating that other factors may influence decisions about the interval and frequency of surveillance examinations.

Relationship of colorectal cancer awareness and knowledge with colorectal cancer screening

AIM

The aim was to describe the association of awareness and knowledge with participation in colorectal cancer (CRC) screening.

MATERIALS & METHODS

Telephone survey research was conducted with South Carolina (USA) residents aged 50-75 years using a 144-item instrument. Data were analyzed with SAS and Stata. Adjusted odds ratios are reported.

RESULTS

Respondents (n = 1302) had heard of CRC screening (96%) and exhibited high levels of CRC awareness and knowledge; only 74% had ever been screened. Higher levels of knowledge were associated with a greater likelihood of having ever been screened (odds ratio: 1.05; 95% CI: 1.02-1.41; p < 0.001).

CONCLUSION

Results showed high levels of awareness and knowledge, but modest participation in CRC. Transforming awareness and knowledge into CRC screening participation should be a priority.

Is the accuracy of self-reported colorectal cancer screening associated with social desirability?

BACKGROUND

Self-reported cancer screening behaviors are often overreported and may lead to biased estimates of prevalence and of subgroup differences in screening. We examined whether the tendency to give socially desirable responses was associated with concordance between self-reported colorectal cancer (CRC) screening behaviors and medical records.

METHODS

Primary care patients (n = 857) age 50 to 74 years completed a mail, face-to-face, or telephone survey that assessed CRC screening and social desirability measured by a short version of the Marlowe-Crowne scale. We used medical records to verify self-reports of fecal occult blood testing (FOBT), sigmoidoscopy, colonoscopy, and barium enema.

RESULTS

Social desirability scores were lower for whites versus African Americans, college graduates, and patients reporting no prior screening tests; they were higher for telephone versus mail or face-to-face survey respondents. In univariable logistic regression analysis, social desirability scores were not associated with concordance for FOBT (OR = 1.03, 95% CI = 0.94-1.13), sigmoidoscopy (OR = 0.95, 95% CI = 0.86-1.04), or colonoscopy (OR = 0.99, 95% CI = 0.88-1.11); however, lower social desirability scores were associated with increased concordance for barium enema (OR = 0.87, 95% CI = 0.77-0.99). In multivariable analyses, no associations were statistically significant.

CONCLUSION

Social desirability as measured by the Marlowe-Crowne scale was not associated with accuracy of self-reported CRC tests in our sample, suggesting that other explanations for overreporting need to be explored.

IMPACT

By understanding sources of response bias, we can improve the accuracy of self-report measures.

A population-based study of prevalence and adherence trends in average risk colorectal cancer screening, 1997 to 2008

BACKGROUND

Increasing colorectal cancer screening (CRCS) is important for attaining the Healthy People 2020 goal of reducing CRC-related morbidity and mortality. Evaluating CRCS trends can help identify shifts in CRCS, and specific groups that might be targeted for CRCS.

METHODS

We utilized medical records to describe population-based adherence to average-risk CRCS guidelines from 1997 to 2008 in Olmsted County, MN. CRCS trends were analyzed overall and by gender, age, and adherence to screening mammography (women only). We also carried out an analysis to examine whether CRCS is being initiated at the recommended age of 50.

RESULTS

From 1997 to 2008, the size of the total eligible sample ranged from 20,585 to 21,468 people. CRCS increased from 22% to 65% for women and from 17% to 59% for men (P < 0.001 for both) between 1997 and 2008. CRCS among women current with mammography screening increased from 26% to 74%, and this group was more likely to be adherent to CRCS than all other subgroups analyzed (P < 0.001).The mean ages of screening initiation were stable throughout the study period, with a mean age of 55 years among both men and women in 2008.

CONCLUSION

Although overall CRCS tripled during the study period, there is still room for improvement.

IMPACT

Working to decrease the age at first screening, exploration of gender differences in screening behavior, and targeting women adherent to mammography but not to CRCS seem warranted.

Validity of self-reported colorectal cancer test use in different racial/ethnic groups

OBJECTIVE

Prevalence of colorectal cancer (CRC) screening is ascertained by self-reported screening, yet little is known about the accuracy of this method across different racial/ethnic groups, particularly Hispanics. The purpose of this study was to compare the accuracy of CRC self-report measures across three racial/ethnic groups.

METHODS

During 2004 and 2005, 271 white, African-American and Hispanic participants were recruited from a primary care clinic in Southeast Texas, and their CRC testing history based on self-report and medical record (the 'gold standard') were compared.

RESULTS

Over-reporting was prevalent. Overall, up-to-date CRC test use was 57.6% by self-report and 43.9% by medical record. Racial/ethnic group differences were most pronounced for Hispanics in whom sensitivity was significantly lower for any up-to-date testing, fecal occult blood testing, flexible sigmoidoscopy and double contrast barium enema. There were no statistically significant differences across groups for over-reporting, specificity or concordance.

CONCLUSIONS

Self-report prevalence data are overestimating CRC test use in all groups; current measures are less sensitive in Hispanics.

The Family Health Promotion Project (FHPP): design and baseline data from a randomized trial to increase colonoscopy screening in high risk families

Colorectal cancer (CRC) is a significant cause of mortality and morbidity in the United States, much of which could be prevented through adequate screening. Consensus guidelines recommend that high-risk groups initiate screening earlier with colonoscopy and more frequently than average risk persons. However, a large proportion of high risk individuals do not receive regular colonoscopic screening. The Family Health Promotion Project (FHPP) is a randomized-controlled trial to test the effectiveness of a telephone-based counseling intervention to increase adherence to risk-appropriate colonoscopy screening in high risk individuals. Unaffected members of CRC families from two national cancer family registries were enrolled (n=632) and randomized to receive either a single session telephone counseling intervention using Motivational Interviewing techniques or a minimal mail-out intervention. The primary endpoint, rate of colonoscopy screening, was assessed at 6, 12 and 24 months post-enrollment. In this paper, we describe the research design and telephone counseling intervention of the FHPP trial, and report baseline data obtained from the two high risk cohorts recruited into this trial. Results obtained at baseline confirm the need for interventions to promote colonoscopy screening among these high risk individuals, as well as highlighting several key opportunities for intervention, including increasing knowledge about risk-appropriate screening guidelines, and providing both tailored risk information and barriers counseling.

The many faeces of colorectal cancer screening embarrassment: preliminary psychometric development and links to screening outcome

OBJECTIVES

Although embarrassment may be among the most easily modified discrete emotional barriers to patients seeking health care or testing, work in the area of colorectal cancer (CRC) has been restricted by the absence of suitable instrumentation. The current report describes the development and validation of a self-report instrument assessing two specific aspects of CRC screening embarrassment and their links to screening outcomes.

DESIGN

Convenience sampling was used to recruit 245 European American, African-American, and immigrant Caribbean community-dwelling men and women (aged 45-75 years) living in Brooklyn, New York.

METHODS

Participants completed the measure of CRC screening embarrassment, an array of convergent and divergent validity measures including dispositional embarrassment, general medical embarrassment, neuroticism, trait emotion, social desirability, previous treatment avoidance because of embarrassment, relevant health characteristics, and a brief CRC screening history.

RESULTS

As expected, CRC screening embarrassment was not unidimensional and had two reliable and distinct components, one concentrated on faecal/rectal embarrassment and the other on embarrassment arising from unwanted intimacy during examinations. In addition to demonstrating patterns of convergent and divergent validity consistent with their separation, multivariate analyses indicated that faecal/rectal embarrassment (but not intimacy concerns) predicted CRC screening frequency.

CONCLUSIONS

The current report extends current understanding by identifying the specific sources of embarrassment that may contribute to patients' avoidance of CRC screening. Directions for future study and implications for clinical practice and interventions are discussed.

Colorectal cancer mortality prevented by use and attributable to nonuse of colonoscopy

BACKGROUND

Use of colonoscopy is thought to reduce colorectal cancer (CRC) mortality, but its impact at the population level is unclear.

OBJECTIVE

To estimate the effect of current colonoscopy use on CRC mortality and its further potential in reducing CRC mortality.

DESIGN

Population-level analysis was performed by using the concepts of prevented and attributable fractions, by using data from the National Health Interview Survey, the Surveillance, Epidemiology and End Results Program, and estimates of the effectiveness of colonoscopy at reducing CRC mortality.

SETTING

The 2005 U.S. population aged 50 years and older.

EXPOSURE

Colonoscopy within 10 years or less.

MAIN OUTCOME MEASUREMENTS

Percentages and absolute numbers of CRC deaths prevented and potentially preventable by colonoscopy.

LIMITATIONS

Uncertainty in effectiveness estimates.

RESULTS

Overall, the proportions of CRC deaths in 2005 prevented by colonoscopy (ie, the prevented fractions) range from 13% (95% CI, 11%-15%) to 19% (95% CI, 12%-24%) across the estimates of colonoscopy effectiveness. Corresponding numbers of CRC deaths prevented range from 7314 (95% CI, 6010-8467) to 11,711 (95% CI, 7077-14,898). The proportions of CRC deaths attributable to nonuse of colonoscopy (ie, the attributable fractions) range from 28% (95% CI, 22%-33%) to 44% (95% CI, 24%-60%), depending on the assumed effectiveness. Corresponding numbers of CRC deaths attributed to nonuse of colonoscopy range from 13,796 (95% CI, 11,076-16,255) to 22,088 (95% CI, 12,189-29,947).

CONCLUSIONS

Although we estimate that colonoscopy has prevented substantial numbers of CRC deaths, many more deaths could have been prevented with more widespread use. These findings highlight the potential benefits from public health interventions to increase the use of screening colonoscopy.

Presence and correlates of racial disparities in adherence to colorectal cancer screening guidelines

OBJECTIVES

We examined the presence and correlates of Black/White racial disparities in adherence to guidelines for colorectal cancer screening (CRCS).

METHODS

The sample included 328 Black and 1827 White patients age 50-75 from 24 VA medical facilities who responded to a mailed survey with phone follow-up (response rate: 73% for Blacks and 89% for Whites). CRCS adherence and race were obtained through surveys and supplemented with administrative data. Logistic regressions estimated the contribution of demographic, health, cognitive, and environmental factors to racial disparities in adherence to CRCS guidelines.

RESULTS

In unadjusted analyses, Blacks had slightly lower rates of adherence to CRCS guidelines than Whites (72% versus 77%, p<0.05). This racial disparity in CRCS adherence was explained by race differences in demographic, health, and environmental factors but not by cognitive factors. Tests for interactions revealed that the association of race with adherence varied significantly across levels of income, education, and marital status. In particular, among those who were married with higher levels of education, CRCS adherence was significantly higher for Whites; whereas among those who were unmarried, with low levels of education, adherence was significantly higher for Blacks.

CONCLUSION

We found that disparities in CRCS are greatly attenuated in the VA system and both Whites and Blacks have substantially higher rates of CRCS than the national average. These results point to the success of the VA at implementing CRCS system-wide. Our findings also suggest additional initiatives may be needed for unmarried low income white men and higher income black men.

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

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