Has the use of cervical, breast, and colorectal cancer screening increased in the United States?

The role of organization of care in GPs' prevention practice

BACKGROUND

General practitioners (GPs) do not systematically include preventive recommendations in their practice, and some characteristics of health care organization are associated with more systematic prevention. But the characteristics of health care organization may act in a nonuniform manner depending on the type of preventive care. Thus, one characteristic can be positively associated with one type of preventive care and negatively associated with another. Our aim was to investigate the association between health care organization in general practice and different areas of preventive care (immunization and addiction prevention), in search of nonuniform associations.

METHODS

We used a representative survey of 1,813 French GPs conducted in 2009. Four preventive care practices were studied: immunization through flu and HPV vaccination, and prevention of addictive behaviors concerning tobacco and alcohol use.Characteristics of GPs' health care organization and the social context of their practice were collected (spatial accessibility to GPs and socioeconomic level of the area of practice). We constructed mixed models to study associations and interactions between the organization variables and preventive care.

RESULTS

Four out of five characteristics of GPs' organization have uneven impacts on different types of preventive care (p-interaction < 10-4). For example, number of daily consultations is associated with better immunization prevention but with poorer prevention counseling in addictive behaviors. In contrast, working with digital medical files is uniformly associated with both types of preventive care (OR = 1.29 [1.15-1.45]; P < 10-4).

CONCLUSION

An approach centered on specific types of preventive care should help deepen our understanding of prevention and possibly help to identify a new typology for preventive care.

Black and White Differences in Colorectal Cancer Screening and Screening Outcomes: A Narrative Review

Racial disparities in colorectal cancer incidence are widely documented. There are two potential mechanisms for these disparities: differences in access to screening, including screening follow-up, and differences in underlying risk of colorectal cancer. We reviewed the literature for evidence of these two mechanisms. We show that higher colorectal cancer incidence in blacks relative to whites emerged only after the dissemination of screening and describe evidence of racial disparities in screening rates. In contrast to the strong evidence for differences in colorectal cancer screening utilization, there is limited evidence for racial differences in adenoma prevalence. In general, black and white patients who are screened have similar adenoma prevalence, though there is some evidence that advanced adenomas and adenomas in the proximal colon are somewhat more likely in black than white patients. We conclude that higher rates of colorectal cancer incidence among black patients are primarily driven by lower rates of colorectal cancer screening. Our findings highlight the need to increase black patients' access to quality screening to reduce colorectal cancer incidence and mortality.

Projecting total costs and health consequences of increasing mt-sDNA utilization for colorectal cancer screening from the payer and integrated delivery network perspectives

Aims: To evaluate total costs and health consequences of a colorectal cancer (CRC) screening program with colonoscopy, fecal immunochemical tests (FIT), and expanded use of multitarget stool DNA (mt-sDNA) from the perspectives of Integrated Delivery Networks (IDNs) and payers in the United States.Materials and methods: We developed a budget impact and cost-consequence model that simulates CRC screening for eligible 50- to 75-year-old adults. A status quo scenario and an increased mt-sDNA scenario were modeled. The status quo includes the current screening mix of colonoscopy (83%), FIT (11%), and mt-sDNA (6%) modalities. The increased mt-sDNA scenario increases mt-sDNA utilization to 28% over 10 years. Costs for both the IDN and the payer perspectives incorporated diagnostic and surveillance colonoscopies, adverse events (AEs), and CRC treatment. The IDN perspective included screening program costs, composed of direct nonmedical (e.g. patient navigation) and indirect (e.g. administration) costs. It was assumed that IDNs do not incur the costs for stool-based screening tests or bowel preparation for colonoscopies.Results: In a population of one million covered lives, the 10-year incremental cost savings incurred by increasing mt-sDNA utilization was $16.2 M for the IDN and $3.3 M for the payer. The incremental savings per-person-per-month were $0.14 and $0.03 for the IDN and payer, respectively. For both perspectives, increased diagnostic colonoscopy costs were offset by reductions in screening colonoscopies, surveillance colonoscopies, and AEs. Extending screening eligibility to 45- to 75-year-olds slightly decreased the overall cost savings.Limitations: The natural history of CRC was not simulated; however, many of the utilized parameters were extracted from highly vetted natural history models or published literature. Direct nonmedical and indirect costs for CRC screening programs are applied on a per-person-per modality basis, whereas in reality some of these costs may be fixed.Conclusions: Increased mt-sDNA utilization leads to fewer colonoscopies, less AEs, and lower overall costs for both IDNs and payers, reducing overall screening program costs and increasing the number of cancers detected while maintaining screening adherence rates over 10 years.

Mobile Mammography Screening as an Opportunity to Increase Access of Rural Women to Breast Cancer Research Studies

Objectives

Rural women are underrepresented in cancer research. We hypothesized that providing access to a research study to rural, medically underserved women who were receiving their breast cancer screening using a mobile mammography unit would increase the representation of rural women in a cancer cohort study.

Design

This study is a cross-sectional study using a cohort of women who have been recruited to a breast cancer study in Arkansas.

Setting

Recruiters accompanied a mobile mammography unit, the MammoVan, to implement a novel method for reaching and recruiting underrepresented rural Arkansas women into the study. Participants include 5850 women recruited from 2010 through 2012 as part of the Arkansas Rural Community Health (ARCH) study.

Results

Participants recruited during their mammography screening on the MammoVan tended to be more rural, less educated, and more likely to be non-Hispanic than those recruited in other venues. A significant difference was not noted for race or age.

Conclusion

Collaboration with the MammoVan greatly aided the recruitment of rural participants. These strategies can facilitate the representation of this historically underserved and understudied rural population in future research studies.

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

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

Access and Attitudinal Factors Related to Breast and Cervical Cancer Rescreening: Why are Latinas Still Underscreened?

To identify access, attitudes, and health practices of Latina women undergoing regular mammography and Pap smear screening, 977 Latinas aged 40 to 74, residing in four California cities, answered a telephone interview. Forty-one percent of women had regular mammography, and 73% had regular Pap smear screening. Cancer screening maintenance was associated with having health insurance, a regular place of care, and fewer fatalistic attitudes about cancer. Regular mammography and Pap smear screening were also associated with ever being married, attending church, and having taken hormone replacement therapy. Being older than 50, residing in the United States a long time, and having had a hysterectomy predicted mammography maintenance. Pap smear screening maintenance was negatively associated with poverty, old age, and negative attitudes toward physicians. There are structural and attitudinal barriers to regular cancer screening among Latinas. Interventions that increase access to care and address women's attitudes about cancer are needed.

Predicting Incongruence between Self-reported and Documented Colorectal Cancer Screening in a Sample of African American Medicare Recipients

Assessments of colorectal cancer (CRC) screening rates typically rely on self-reported screening data, which are often incongruent with medical records. We used multilevel models to examine health-related, socio-demographic and psychological predictors of incongruent self-reports for CRC screening among Medicare-insured African Americans (N = 3,740). Results indicated that living alone decreased, and income increased, the odds of congruently self-reporting endoscopic CRC screening. Being male and having greater number of comorbidities decreased, and having less than a high school education increased, the odds of congruently self-reported fecal occult blood tests. Living alone, age and income had the most robust effects across classifications into one of four mutually exclusive categories defined by screening status (screened/unscreened) and congruence of self-reports. The results underscore the clinical importance of gathering socio-demographic data via patient interviews, and the relevance of these data for judging the veracity of self-reported CRC screenings behaviors.

Where can colorectal cancer screening interventions have the most impact?

BACKGROUND

Although colorectal cancer death rates in the United States have declined by half since 1970, large geographic disparities persist. Spatial identification of high-risk areas can facilitate targeted screening interventions to close this gap.

METHODS

We used the Getis-Ord Gi* statistic within ArcGIS to identify contemporary colorectal cancer "hotspots" (spatial clusters of counties with high rates) based on county-level mortality data from the national vital statistics system. Hotspots were compared with the remaining aggregated counties (non-hotspot United States) by plotting trends from 1970 to 2011 and calculating rate ratios (RR). Trends were quantified using joinpoint regression.

RESULTS

Spatial mapping identified three distinct hotspots in the contemporary United States where colorectal cancer death rates were elevated. The highest rates were in the largest hotspot, which encompassed 94 counties in the Lower Mississippi Delta [Arkansas (17), Illinois (16), Kentucky (3), Louisiana (6), Mississippi (27), Missouri (15), and Tennessee (10)]. During 2009 to 2011, rates here were 40% higher than the non-hotspot United States [RR, 1.40; 95% confidence interval (CI), 1.34-1.46], despite being 18% lower during 1970 to 1972 (RR, 0.82; 95% CI, 0.78-0.86). The elevated risk was similar in blacks and whites. Notably, rates among black men in the Delta increased steadily by 3.5% per year from 1970 to 1990, and have since remained unchanged. Rates in hotspots in west central Appalachia and eastern Virginia/North Carolina were 18% and 9% higher, respectively, than the non-hotspot United States during 2009 to 2011.

CONCLUSIONS

Advanced spatial analysis revealed large pockets of the United States with excessive colorectal cancer death rates.

IMPACT

These well-defined areas warrant prioritized screening intervention.

Mobile Mammography, Race, and Insurance: Use Trends Over a Decade at a Comprehensive Urban Cancer Center

PURPOSE

To assess the use of a mobile mammography unit (MMU) as it relates to race and insurance status in the largest county in Kentucky.

METHODS

We retrospectively reviewed 48,324 screening mammograms of 21,857 patients conducted over a 10-year period. Descriptive statistics for patient age, race, and insurance status were computed by entire cohort and within subsets of cohorts. This analysis was limited to trends in use by race and insurance status. To study the patterns of frequency distributions, indiscrete variables were performed using the Pearson χ(2) test. For continuous variable range, a 95% CI of mean was estimated. Comparisons with a P value less than .05 were considered statistically significant.

RESULTS

Self-reported blacks constituted significant use of the MMU (29% v census data demographic reports of 19%). Race significantly correlated with likelihood to screen ≥ three times, with blacks (30.5%) more likely, and whites (27.8%) and Hispanics (20.2%) less likely (P < .001). Insurance status also affected frequency of use (P < .001).

CONCLUSION

In this data set, blacks were more likely to repeat use of the MMU. Although preliminary, these data suggest outreach efforts of mobile mammography are appropriately reaching certain targeted populations.

Evaluating the impact of public health initiatives on trends in fecal occult blood test participation in Ontario

BACKGROUND

Since the publication of two randomized controlled trials (RCT) in 1996 demonstrating the effectiveness of fecal occult blood test (FOBT) in reducing colorectal cancer (CRC) mortality, several public health initiatives have been introduced in Ontario to promote FOBT participation. We examined the effect of these initiatives on FOBT participation and evaluated temporal trends in participation between 1994 and 2012.

METHOD

Using administrative databases, we identified 18 annual cohorts of individuals age 50 to 74 years eligible for CRC screening and identified those who received FOBT in each quarter of a year. We used negative binomial segmented regression to examine the effect of initiatives on trends and Joinpoint regression to evaluate temporal trends in FOBT participation.

RESULTS

Quarterly FOBT participation increased from 6.5 per 1000 in quarter 1 to 41.6 per 1000 in quarter 72 (January-March 2012). Segmented regression indicated increases following the publication of the RCTs in 1996 (Δ slope = 6%, 95% CI = 4.3-7.9), the primary care physician financial incentives announcement in 2005 (Δ slope = 2.2%, 95% CI = 0.68-3.7), the launch of the ColonCancerCheck (CCC) Program (Δ intercept = 35.4%, 95% CI = 18.3 -54.9), and the CCC Program 2-year anniversary (Δ slope = 7.2%, 95% CI = 3.9 - 10.5). Joinpoint validated these findings and identified the specific points when changes occurred.

CONCLUSION

Although observed increases in FOBT participation cannot be definitively attributed to the various initiatives, the results of the two statistical approaches suggest a causal association between the observed increases in FOBT participation and most of these initiatives.

Breast cancer stage at diagnosis among medically underserved women screened through the Texas Breast and Cervical Cancer Services

The Texas Breast and Cervical Cancer Services (BCCS) program was established to address the socioeconomic disparities in stage at diagnosis and outcomes among breast cancer patients. This study examines the impact of Texas BCCS on stage at diagnosis among low socioeconomic status (SES) breast cancer patients. This is a retrospective analysis of women aged 40-64 years who were screened and diagnosed with breast cancer through the Texas BCCS program (participants) as compared with similar women living in low-SES census tracts and diagnosed outside the program (comparison group) during 1995-2008. Incident cases among the participants were compared with the comparison group as well. Stage at diagnosis was also analyzed separately for the years 1995-2002 and 2003-2008 in order to estimate the effect of BCCS-related Medicaid expansion in 2002. Over the study period of 1995-2008, BCCS participants had a 1.23 (P value<0.0001) times higher odds, and BCCS incident cases had 40% (P value<0.0001) lower odds of advanced stage at diagnosis as compared with the comparison group. A statistically significant difference in stage at diagnosis between the participants and the comparison group only existed for the 2003-2008 (post-Medicaid) period (odds ratio: 1.39, P value<0.0001). Texas BCCS program acts as a source of diagnosis and treatment access to many suspected cancer cases, especially since the 2002 Medicaid expansion, leading to more advanced stage at diagnosis among the BCCS cases as compared with other low-SES cases. Significant expansion of the program to serve a higher proportion of the eligible population is needed to achieve its goals as a screening program.

The role of social capital in African-American women's use of mammography

Black/African-American women are more likely to get breast cancer at a young age and/or be diagnosed at a late disease stage, pointing to a greater need to promote mammography for Black women at earlier ages than are currently recommended. This study explores how perceived neighborhood social capital, that is, perceptions of how tight-knit a neighborhood is and what power that confers to neighborhood members, relates to use of mammography for Black women in Philadelphia. Living in a community with tight social ties (social cohesion) or that have a collective motivation for community change (collective efficacy) may increase the likelihood that an individual woman in that community will hear health messages from other community members and neighbors (diffusion of information) and will have access to health-related resources that allow them to engage in healthy behaviors. No prior studies have explored the role of social capital in decisions for mammography use. Using multilevel logistic regression, we analyzed self-report of mammography in the past year for 2586, Black women over age 40 across 381 Philadelphia, Pennsylvania USA census tracts. Our study included individual demographic and aggregates of individual-level social capital data from the Public Health Management Corporation's 2004, 2006, and 2008 Community Health Database waves, and 2000 US Census sociodemographic characteristics. Individual perceptions that a Black woman's neighborhood had high social capital, specifically collective efficacy, had a positive and statistically significant association with mammography use (OR = 1.40, CI: 1.05, 1.85). Our findings suggest that an individual woman's perception of greater neighborhood social capital may be related to increased mammography use. Although this analysis could not determine the direction of causality, it suggests that social capital may play a role in cancer preventive screening for African-American women in Philadelphia, which warrants further study.

Barriers to cervical cancer screening among middle-aged and older rural Appalachian women

Although cervical cancer rates in the United States have declined sharply in recent decades, certain groups of women remain at elevated risk, including middle-aged and older women in central Appalachia. Cross-sectional baseline data from a community-based randomized controlled trial were examined to identify barriers to cervical cancer screening. Questionnaires assessing barriers were administered to 345 Appalachian women aged 40-64, years when Papanicolaou (Pap) testing declines and cervical cancer rates increase. Consistent with the PRECEDE/PROCEED framework, participants identified barriers included predisposing, enabling, and reinforcing factors. Descriptive and bivariate analyses are reported, identifying (a) the most frequently endorsed barriers to screening, and (b) significant associations of barriers with sociodemographic characteristics in the sample. Recommendations are provided to decrease these barriers and, ultimately, improve rates of Pap tests among this traditionally underserved and disproportionately affected group.

Use of electronic clinical reminders to increase preventive screenings in a primary care setting: blueprint from a successful process in Kodiak, Alaska

PURPOSE

The Kodiak Area Native Association (KANA) provides primary health care in Kodiak, Alaska and 6 outlying villages. KANA sought to actively improve key preventive screening rates for its patients.

METHODS

KANA adopted an electronic health record in 2008 and deployed national clinical reminders from the Indian Health Service for 5 key preventive screenings: tobacco use, alcohol use, depression, intimate partner violence, and a comprehensive cardiovascular exam. Clinical reminders were deployed in a 5-step process: (a) establish clinical demand, (b) pilot test reminder, (c) expand reminder to all providers, (d) measure outcomes and share results, and (e) delegate clinical reminder follow-up (primarily to nurses).

RESULTS

Data from 2007-2011 show screening rates for all 5 measures improved considerably, to levels significantly above the national average for Indian Health Service facilities.

CONCLUSIONS

Clinical reminders have been a key part of a multistep process to improve screening for depression, tobacco cessation, intimate partner violence, alcohol use, and cardiovascular disease. If deployed correctly, reminders are valuable tools in identifying patients who are overdue for preventive health screenings.

Disparities in breast and cervical cancer screening in women with mental illness: a systematic literature review

CONTEXT

Breast and cervical cancer screening rates have improved substantially in the U.S. during the past decade. Cancer screening and other health outcomes in patients with mental illnesses, such as major depression and schizophrenia, remain suboptimal. Understanding the prevalence and root causes of these disparities is an essential first step toward developing effective interventions. This paper presents a systematic literature review of current evidence on breast and cervical cancer screening disparities in women with mental illness.

EVIDENCE ACQUISITION

A systematic PubMed/MEDLINE and PsycINFO search completed in May 2012 retrieved articles pertaining to cancer screening and mentally ill patients using pertinent search terms. Articles that met the inclusion criteria were appraised critically for evidence quality related to screening disparities using defined criteria. Articles that reported cancer screening rates in patients with mental illness were reviewed to determine whether any barriers to screening or factors that promote screening were identified.

EVIDENCE SYNTHESIS

Nineteen studies met the inclusion criteria. Many articles contributed to more than one of the identified areas of interest (i.e., screening utilization, barriers to screening, and factors that encourage screening).

CONCLUSIONS

Substantial evidence in the current literature confirms disparities in breast and cervical cancer screening rates among women with mental illness. However, the mentally ill population is more complex and diverse than many studies imply. Using a global functional indicator that measures the overall impact of mental illness may yield a more useful categorization of influences on cancer screening.

Value-based reengineering: twenty-first century chronic care models

The need for improved models of chronic care is great and will become critical over the next years as the Medicare-aged population doubles. Many promising models have been developed by outstanding groups across the country. This article reviews key strategies used by successful models in chronic disease management and discusses in detail how Geisinger has evolved and organized its cohesive delivery model.

The demographic, system, and psychosocial origins of mammographic screening disparities: prediction of initiation versus maintenance screening among immigrant and non-immigrant women

Disparities in breast screening are well documented. Less clear are differences within groups of immigrant and non-immigrant minority women or differences in adherence to mammography guidelines over time. A sample of 1,364 immigrant and non-immigrant women (African American, English Caribbean, Haitian, Dominican, Eastern European, and European American) were recruited using a stratified cluster-sampling plan. In addition to measuring established predictors of screening, women reported mammography frequency in the last 10 years and were (per ACS guidelines at the time) categorized as never, sub-optimal (<1 screen/year), or adherent (1+ screens/year) screeners. Multinomial logistic regression showed that while ethnicity infrequently predicted the never versus sub-optimal comparison, English Caribbean, Haitian, and Eastern European women were less likely to screen systematically over time. Demographics did not predict the never versus sub-optimal distinction; only regular physician, annual exam, physician recommendation, and cancer worry showed effects. However, the adherent categorization was predicted by demographics, was less likely among women without insurance, a regular physician, or an annual exam, and more likely among women reporting certain patterns of emotion (low embarrassment and greater worry). Because regular screening is crucial to breast health, there is a clear need to consider patterns of screening among immigrant and non-immigrant women as well as whether the variables predicting the initiation of screening are distinct from those predicting systematic screening over time.

Burden of invasive cervical cancer in North Carolina

OBJECTIVE

Cervical cancer causes over 4000 deaths yearly in the United States, although highly preventable through vaccination, screening, and early treatment. We aimed to determine demographic correlates for cervical cancer in North Carolina to identify target populations for interventions and to create a framework for state-level analyses.

METHOD

Data on all reported invasive cervical cancer cases from 1998 to 2007 were obtained from the North Carolina Central Cancer Registry. Age-adjusted incidence and mortality rates were estimated using population data from the National Center for Health Statistics.

RESULTS

Cervical cancer incidence and mortality rates varied greatly by county and were inversely associated with county prosperity. Hispanic women had the highest incidence rate, black women the highest mortality rate, although white women accounted for most cases. Incidence rates remained fairly steady above age 35 and mortality rates steadily increased with age. A later stage at diagnosis was more common for older women and for women without private insurance.

CONCLUSION

Registry-based assessment illustrates the economic, racial, and age disparities associated with cervical cancer. This localized focus on demographic correlates is an important step toward eliminating this preventable disease and offers a template for cervical cancer prevention programs in other states.

Screening and prevention in Swiss primary care: a systematic review

BACKGROUND AND OBJECTIVES

Prevention is a challenging area of primary care. In Switzerland, little is known about attitudes to and performance of screening and prevention services in general practice. To implement prevention services in primary care it is important to know about not only potential facilitators but also barriers. Primary care encompasses the activities of general practitioners, including those with particular interest and/or specializations (eg, pediatrics, gynecology). The aim of this study was to review all studies with a focus on prevention services which have been conducted in Switzerland and to reveal barriers and facilitators for physicians to participate in any preventive measures.

METHODS

The Cochrane Library, PubMed, EMBASE and BIOSIS were searched from January 1990 through December 2010. Studies focussing on preventive activities in primary care settings were selected and reviewed. The methodological quality of the identified studies was classified according to the guidelines in the Consolidated Standards of Reporting Trials (CONSORT) statement.

RESULTS

We identified 49 studies including 45 descriptive studies and four randomised controlled trials (RCTs). Twelve studies addressed the prevention of epidemics, eleven out of them vaccinations. Further studies focused on lifestyle changes, physical activity counselling, smoking cessation, cardiovascular prevention and cancer screening. Perceived lack of knowledge/training and lack of time were the most commonly stated barriers. Motivation, feasibility and efficiency were the most frequently reported supporting factors for preventive activities. The methodological quality was weak, only one out of four RCTs met the applied quality criteria.

CONCLUSION

Most studies focussing on screening and prevention activities in primary care addressed vaccination, lifestyle modification or cardiovascular disease prevention. Identified barriers and facilitators indicate a need for primary-care-adapted education and training which are easy to handle, time-saving and reflect the specific needs of general practitioners. If new prevention programs are to be implemented in general practices, RCTs of high methodological quality are needed to assess their impact.

Are United States and Canadian cancer screening rates consistent with guideline information regarding the age of screening initiation?

OBJECTIVE

To understand whether US and Canadian breast, colorectal and prostate cancer screening test utilization is consistent with US and Canadian cancer screening guideline information with respect to the age of screening initiation.

DESIGN

Cross-sectional, regression discontinuity.

SETTING

Canada and the US.

PARTICIPANTS

Canadian and American women of ages 30-60 and men of ages 40-60.

INTERVENTIONS

None. Main Outcomes Measures Mammography, prostate-specific antigen (PSA) and colorectal cancer test use within the past 2 years.

METHODS

We identify US and Canadian compliance with age screening information in a novel manner, by comparing test utilization rates of individuals who are immediately on either side of the guideline recommended initiation ages.

RESULTS

US mammography utilization within the last 2 years increased from 33% at age 39 to 48% at age 40 and 60% at age 41. US colorectal cancer test utilization, within the last 2 years, increased from 15% at age 49 to 18% at age 50 and 28% at age 51. US PSA utilization within the last 2 years increased from 37% at age 49 to 44% at age 50 and 54% at age 51. In Canada, mammography utilization within the last 2 years increased from 47% at age 49 to 57% at age 50 and 66% at age 51.

CONCLUSION

American and Canadian cancer screening utilization is generally consistent with each country's guideline recommendations regarding age. US and Canadian differences in screening due to guidelines can potentially explain cross-country differences in breast cancer mortality and affect interpretation of international comparisons of cancer statistics.

Screening prevalence and incidence of colorectal cancer among American Indian/Alaskan natives in the Indian Health Service

BACKGROUND

Studies on colorectal cancer (CRC) screening and incidence among American Indian/Alaska Natives (AI/AN) are few.

AIMS

Our aim was to determine CRC screening prevalence and to calculate CRC incidence among AI/AN receiving care within the Indian Health Service (IHS).

METHODS

A retrospective cohort study of AI/AN who utilized IHS from 1996 to 2004. AI/AN who were average-risk for CRC and received primary care within IHS were identified by searching the IHS Resource Patient Management System for selected ICD-9/CPT codes (n = 142,051). CRC screening prevalence was calculated and predictors of screening were determined for this group. CRC incidence rates were ascertained for the entire AI/AN population ages 50-80 who received IHS medical care between 1996 and 2004 (n = 283,717).

RESULTS

CRC screening was performed in 4.0% of average-risk AI/AN. CRC screening was more common among women than men (RR = 1.6, 95% CI 1.4-1.7) and among AI/AN living in the Alaska region compared to the Pacific Coast region (RR = 2.5, 95% CI 2.2-2.8) while patients living in the Northern Plains (RR = 0.4, 95% CI 0.3-0.4) were less likely to have been screened. CRC screening was less common among patients with a greater number of primary care visits. The age-adjusted CRC incidence among AI/AN ages 50-80 was 227 cancers per 100,000 person-years.

CONCLUSIONS

CRC was common among AI/AN receiving medical care within IHS. However, CRC screening prevalence was far lower than has been reported for the U.S. population.

Is breast cancer the same disease in Asian and Western countries?

A mini-symposium was held in Montreal, Canada, at the International Surgical Week for the Breast Surgical International in 2007 addressing the question whether breast cancer is the same disease in Asian and Western countries. Numerous investigators from Asian and Western countries presented the epidemiologic and clinical outcome data of women with breast cancer. Although there are significant similarities, the striking difference is that the peak age for breast cancer is between 40 and 50 years in the Asian countries, whereas the peak age in the Western countries is between 60 and 70 years. Also, the incidence of breast cancer in Asia is rising and is associated with increased mortality. In the West, although the incidence is increasing, the mortality rate is definitely decreasing. Future prospective data collection from Asian and Western countries may provide further interesting epidemiologic and outcome data regarding the outcome of women with breast cancer from Asian and Western countries.

BACKGROUND

Whether breast cancer is the same disease in Asian and Western countries was the topic of a 2007 Breast Surgery International symposium at International Surgical Week.

METHODS

Participating investigators from China, Taiwan, India, Japan, South Korea, Sweden, Canada, and the United States were asked beforehand to provide data on the epidemiology and treatment outcome of women in their countries.

RESULTS

Comparisons of the epidemiologic and clinical outcome data of women with breast cancer showed significant similarities, but the striking difference is that the peak age is between 40 and 50 years in Asian countries, but is between 60 and 70 years in Western countries. The incidence of breast cancer in Asia is rising and is associated with increased mortality. In the West, although the incidence is also increasing, the mortality rate is definitely decreasing.

DISCUSSION

Future prospective data collection from Asian and Western countries may provide further interesting epidemiologic and outcome data regarding the outcome of women with breast cancer from Asian and Western countries.

Mailed fecal-immunochemical test for colon cancer screening

Various interventions have been implemented to increase the rate of colon cancer screening. The purpose of this study was to determine if persons who are regular patients of a clinic, ages 50-64 years, and not up-to-date with colon cancer screening will complete the at-home fecal-immunochemical test (FIT) if it is mailed to them. This intervention was designed to have the subject avoid the signing of an informed consent and having to ask for the screening test; and, only one stool specimen was needed. Three hundred and fifty potential subjects were randomly selected from an electronic medical record database after meeting inclusion criteria. Eighty-seven fecal immunochemical tests were returned. Seven of the FIT kit results were positive for occult blood. Each respondent was sent a letter giving them their results. A minimal cue CRC screening intervention, a FIT kit sent in the mail without prerequisite of a signed informed consent, was offered to the study subjects. Twenty-six percent of the eligible persons were screened for colon cancer by this method. A mailed FIT kit or one handed to the patient at an office visit has minimal cost which can be recovered through insurance coverage. Commitment by health care providers is necessary for prevention. This method is one of several that could reach the hard to screen population.

Colon cancer screening update and management of the malignant polyp

Colorectal carcinoma is common, but screening for this cancer has found less acceptance with the public than screening for breast, prostate, and cervical cancer. Available methods include fecal occult blood tests (FOBTs), flexible sigmoidoscopy (FOS), double-contrast barium enema, colonoscopy, computed tomographic colography, and fecal DNA. Evaluation of these options demonstrates that colonoscopy at ages 55 and 65 offers the best combination of reduction in colorectal cancer at the lowest cost. However, when compliance with screening recommendations is very high, costs are high, and the proportion of cancers arising from adenomas is low, the combination of FOS and FOBT is most cost effective. Malignant polyps look friable and irregular and feel hard. Sessile malignant polyps need to be treated by formal resection. Patients with pedunculated polyps with favorable histology (clear margin, well or moderately differentiated, no lymphovascular invasion) can be observed, and those whose polyps show unfavorable histology should have the polyp-bearing segment of colon resected along with its draining lymph nodes.

Relationship among age, race, medical funding, and cervical cancer survival

OBJECTIVE

To examine the impact of age, race, and medical funding on cervical cancer survival.

MATERIALS AND METHODS

Study design was a retrospective chart review of cervical cancer patients. Charts were abstracted for demographic characteristics, Pap smear history, clinical presentation, treatment, and survival. Descriptive studies, Spearman correlation, and Cox's proportional hazards regression model were performed.

RESULTS

One hundred-twenty-five cervical cancer patients were included. Mean age at diagnosis was 46.1 +/- 13.2 years, and median survival time from cervical cancer was 31 months; 11.2% of the study population was aged greater than 65 years; 63.4% were African American; and 44.6% had no medical funding. Diagnosis at age of at least 65 years was significantly correlated with suboptimal cervical cancer screening pattern (r = 0.36, p = .0003). Women aged at least 65 years old had a 3.39 time increased hazard of death compared to younger patients (p = .02; OR, 3.39; 95% CI, 1.20-9.56) after adjusting for advanced stage of disease and treatment modality. There was no significant association between medical funding or race on cervical cancer screening pattern, stage at diagnosis, or survival.

CONCLUSION

Age at diagnosis (> or = 65 years), but not medical funding or race, was correlated with suboptimal cervical cancer screening pattern and poor survival.

The delivery of prevention programmes for cardiovascular disease and chronic obstructive pulmonary disease in Lodz by primary care physicians

INTRODUCTION

In Poland, the National Health Fund (NHF) has contracted preventative interventions in primary health care (PHC) delivered by family physicians, internists, paediatricians and other physicians. The aim of the study was determining whether there is a correlation between PHC physicians' specialisation and the rate of interventions delivered for the prevention of cardiovascular disease (CVD) and chronic obstructive pulmonary disease (COPD).

MATERIAL AND METHODS

A retrospective observational study of the NHF 2005 data related to the delivery of prevention programmes using Spearman's rank correlation coefficient (rho).

RESULTS

Out of 133 PHC providers in Lodz, 25 participated in the cardiovascular disease (CVD) prevention programme, 22 in the chronic obstructive pulmonary disease (COPD) prevention programme at a basic level, and 20 at an extended level (with contract completion rates respectively of 55.2, 47.8 and 51.5%). When all three prevention programmes were analysed together, the correlation between the rate of preventative interventions by physicians with a particular specialisation and the contract completion rate was positive (rho > 0) only for family physicians.

CONCLUSIONS

Participation of primary health care providers in preventative programmes and the rates of their delivery of interventions were low despite additional funding. The correlation between the proportion of physicians with a particular specialisation, involved in CVD and COPD prevention interventions delivery, and the rate of the programme accomplishment was the strongest for family physicians.

Race moderates the relationship between obesity and colorectal cancer screening in women

OBJECTIVE

To determine if the relationship between obesity and usage of colorectal cancer (CRC) screening in women varies when stratifying by race.

METHODS

Using nationally representative data from the 2005 National Health Interview Survey, we examined the relationship between obesity and CRC screening for white and African-American women aged 50 and older. Screening usage variables indicated if a woman was up-to-date for any CRC screening test, colonoscopy, or FOBT. We used multivariable logistic regression models that included interaction terms to determine if race moderates the obesity-screening relationship. We also calculated adjusted up-to-date colonoscopy rates using direct standardization to model covariates.

RESULTS

The relationship between obesity and screening differed by race for any CRC screening test (P = 0.04 for interaction) and for colonoscopy (P = 0.01 for interaction), but not for FOBT. Obese white women had a lower adjusted colonoscopy rate (30.2%, 95% CI 25.9-34.8) than non-obese white women (39.1%, 95% CI 36.1-42.2). Obese African-American women, on the other hand, had a higher adjusted colonoscopy rate (41.2%, 95% CI 31.6-51.4) than their non-obese counterparts (35.6%, 95% CI 28.3-43.6). Overall, adjusted colonoscopy rates were lowest among obese white women.

CONCLUSIONS

Obesity is associated with lower CRC screening rates in white, but not African-American women.

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSION

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

Faith Moves Mountains: an Appalachian cervical cancer prevention program

OBJECTIVE

To provide a conceptual description of Faith Moves Mountains (FMM), an intervention designed to reduce the disproportionate burden of cervical cancer among Appalachian women.

METHODS

FMM, a community-based participatory research program designed and implemented in collaboration with churches in rural, southeastern Kentucky, aims to increase cervical cancer screening (Pap tests) through a multiphase process of educational programming and lay health counseling.

RESULTS

We provide a conceptual overview to key elements of the intervention, including programmatic development, theoretical basis, intervention approach and implementation, and evaluation procedures.

CONCLUSIONS

After numerous modifications, FMM has recruited and retained over 400 women, 30 churches, and has become a change agent in the community.

Are U.S. cancer screening test patterns consistent with guideline recommendations with respect to the age of screening initiation?

BACKGROUND

U.S. cancer screening guidelines communicate important information regarding the ages for which screening tests are appropriate. Little attention has been given to whether breast, colorectal and prostate cancer screening test use is responsive to guideline age information regarding the age of screening initiation.

METHODS

The 2006 Behavioral Risk Factor Social Survey and the 2003 National Health Interview Surveys were used to compute breast, colorectal and prostate cancer screening test rates by single year of age. Graphical and logistic regression analyses were used to compare screening rates for individuals close to and on either side of the guideline recommended screening initiation ages.

RESULTS

We identified large discrete shifts in the use of screening tests precisely at the ages where guidelines recommend that screening begin. Mammography screening in the last year increased from 22% [95% CI = 20, 25] at age 39 to 36% [95% CI = 33, 39] at age 40 and 47% [95% CI = 44, 51] at age 41. Adherence to the colorectal cancer screening guidelines within the last year increased from 18% [95% CI = 15, 22] at age 49 to 19% [95% CI = 15, 23] at age 50 and 34% [95% CI = 28, 39] at age 51. Prostate specific antigen screening in the last year increased from 28% [95% CI = 25, 31] at age 49 to 33% [95% CI = 29, 36] and 42% [95% CI = 38, 46] at ages 50 and 51. These results are robust to multivariate analyses that adjust for age, sex, income, education, marital status and health insurance status.

CONCLUSION

The results from this study suggest that cancer screening test utilization is consistent with guideline age information regarding the age of screening initiation. Screening test and adherence rates increased by approximately 100% at the breast and colorectal cancer guideline recommended ages compared to only a 50% increase in the screening test rate for prostate cancer screening. Since information regarding the age of cancer screening initiation varies across countries, results from this study also potentially have implications for cross-country comparisons of cancer incidence and survival statistics.

Provider recommendation for colorectal cancer screening: examining the role of patients' socioeconomic status and health insurance

BACKGROUND

Provider recommendation for colorectal cancer (CRC) screening test has been shown as a strong predictor of patients' decision to be screened. Evidence of factors associated with provider recommendation remains limited and inconsistent. The present study sought to examine the association between provider recommendation for colorectal cancer screening and patients' socioeconomic status (SES) and insurance status using national survey data for 2005.

METHODS

Analyses were based on 2948 adult aged 50 and older who participated in the 2005 Health Information National Trend Survey (HINTS). Multivariate logistic regression models were used to determine whether the indicators of SES (income and educational level) and insurance status have any impact on provider recommendation.

RESULTS

Our study found a strong association between recall of health care provider recommendation and reported recent screening testing after controlling for other patient characteristics. When all the study population were included in the analysis, those who had lower than high school education and high school graduates were less likely to have received provider recommendation than those with higher than high school education (OR=0.49; 95%CI=0.32-0.73 and OR=0.60; 95%CI=0.47-0.78 respectively). Income and insurance were not significant predictors. Education remained significantly associated with provider recommendation when only those who had made one or more medical visits in the past year were included in the analyses.

CONCLUSIONS

Patient's educational level--but not income or insurance status--was related to provider recommendation for CRC screening. To increase awareness of colorectal cancer risks and the benefit of screening, health care providers need to make a concerted effort to recommend colorectal cancer screening to all relevant patients, regardless of socioeconomic status and other personal characteristics.

Initiation of health behavior discussions during primary care outpatient visits

OBJECTIVE

Despite the importance of health promotion, rates of health behavior advice remain low and little is known about how advice is integrated into routine primary care. This study examines how health behavior topics of diet, physical activity and smoking are initiated during outpatient visits.

METHODS

Audio recording of 187 adults visit to five purposefully selected physicians. An iterative analysis involved listening to and discussing cases to identify emergent patterns of initiation of health behavior talk and advice that followed.

RESULTS

Physicians initiated 65% of discussions and used two overarching strategies (1) Structured: a routine to ask about health behavior and (2) Opportunistic: use of a trigger to make a transition to talk about health behavior. Opportunistic strategies identified a greater proportion of patients at risk (50% vs. 34%) and led to a greater rate of advice (100% vs. 75%). Patients initiated one-third of health behavior discussions and were more likely to receive advice if they explicitly indicated readiness to change.

CONCLUSIONS

Opportunistic strategies show promise for a higher yield of identifying patients at risk and leading to advice.

PRACTICE IMPLICATIONS

Encouraging patients to be explicit about their readiness to change is likely to increase physician advice and assistance.

Factors influencing the uptake of screening services for breast and cervical cancer in Taiwan

AIMS

Cervical cancer and breast cancer have had the first and second highest occurrence rates among women in Taiwan since 1981 and have also been two of the leading causes of cancer death. In order to more effectively promote preventive medical care programs, it is important to identify the key determinants of women's behavior regarding their decisions to engage in screenings. This study aims to identify the major factors that affect the utilization of breast and cervical cancer screening among women in Taiwan, who are covered by universal National Health Insurance.

METHODS

Data were obtained from the 2001 National Health Interview Survey for the Taiwan area and targeted women between 30 and 75 years old. The sample size consisted of 5,611 individuals for Papanicolaou (Pap) tests and breast examinations by a doctor. For breast ultrasounds and mammograms, 3,875 individuals were included. The propensity among women in Taiwan to use the two types of screening services, i.e., Pap test and breast examinations, were estimated by maximum likelihood probit regressions.

RESULTS

The findings in this study show that the likelihood of a woman receiving a Pap test or a clinical breast examination depends on a variety of factors such as age, marital status, income level, education, and health status. Women with lower socioeconomic status were found to be much less likely to undergo the freely available cancer screening services. In addition, healthy behavior, such as not smoking and engaging in exercise, had a positive effect on the uptake of screening.

CONCLUSIONS

The results of this study enable us to understand more thoroughly the characteristics of women who undergo a Pap test and breast examination, as well as the factors that influence them in Taiwan. The findings can help formulate related policies that are directed at removing the barriers to accessing medical care and targeting those at-risk groups. This analysis provides new evidence of the factors affecting the utilization of preventive care among women in a developing country, which are comparable to those of other countries, and may shed further light on the issue of promoting cancer screening and women's health.

Dissemination of a breast and cervical cancer early detection program through a network of community-based organizations

ENCORE (plus) , a breast and cervical cancer outreach, education, and screening referral program, was implemented by the YWCA of the United States and funded by Avon's Breast Cancer Awareness Crusade. ENCORE (plus) was designed to address the educational and access needs of low socioeconomic status and minority women who experience substantial barriers to breast and cervical cancer screening. This article describes the dissemination of ENCORE (plus) to 78 YWCAs in 30 states. It illustrates the application of social cognitive theory and diffusion theory to increase program adoption, implementation, and maintenance among community organizations that have not traditionally provided public health related services. The article highlights elements of the program that enhanced its adoption and implementation and describes procedures for accelerating the diffusion of the program across the country.

Secular trends in mortality from common cancers in the United States by educational attainment, 1993-2001

Background

Death rates for the four major cancer sites (lung, breast, prostate, and colon and rectum) have declined steadily in the United States among persons aged 25–64 years since the early 1990s. We used national data to examine these trends in relation to educational attainment.

Methods

We calculated age-standardized death rates for each of the four cancers by level of education among 25- to 64-year-old non-Hispanic white and non-Hispanic black men and women for 1993 through 2001 using data on approximately 86% of US deaths from the National Center for Health Statistics, education level as recorded on the death certificate, and population data from the US Bureau of Census Current Population Survey. Annual percent changes in age-adjusted death rates were estimated using weighted log-linear regression models. All statistical tests were two-sided.

Results

Death rates for each cancer decreased statistically significantly from 1993 to 2001 in people with at least 16 years of education in every sex and race stratum except lung cancer in black women, for whom death rates were stable. For example, colorectal cancer death rates among white men, black men, white women, and black women with at least 16 years of education decreased by 2.4% (P < .001), 4.8% (P = .011), 3.0% (P < .001), and 2.6% (P = .030) annually, respectively. By contrast, among people with less than 12 years of education, a statistically significant decrease in death rates from 1993 through 2001 was seen only for breast cancer in white women (1.4% per year; P = .029). Death rates among persons with less than 12 years of education over the same time interval increased for lung cancer in white women (2.4% per year; P < .001) and for colon cancer in black men (2.7% per year; P < .001) and were stable for the remaining race/sex/site strata. Temporal trends generally followed an educational gradient in which the slopes of the decreases in death rate became steeper with higher educational attainment.

Conclusion

The recent declines in death rates from major cancers in the United States mainly reflect declines in more highly educated individuals.

Patterns of diagnosis for colorectal cancer: screening detected vs. symptomatic presentation

PURPOSE

Colorectal cancer is a leading cause of cancer death in North America; studies have shown that screening improves survival. Conducted in British Columbia, Canada, this study was performed to identify the proportion of screening-eligible patients with sporadic colorectal cancer who are detected by screening tests vs. symptomatic presentation and to compare baseline patient and tumor characteristics of these two groups.

METHODS

This retrospective cohort study identified 571 consecutive patients referred to the British Columbia Cancer Agency at aged 50 years and older presenting with a first diagnosis of invasive colorectal cancer between November 2002 and April 2003. Questionnaires for self-completion were mailed to all patients to capture: previous screening history, screening vs. symptomatic presentation, and demographic information.

RESULTS

Of 212 eligible respondents (37 percent response), 14 patients (6.6 percent) with a new CRC were detected by screening vs. 198 patients (93.4 percent) presenting with symptoms. Respondents were 59 percent male, average age at diagnosis was 69 years, 91 percent white, 37 percent rectal, and 18 percent M1 at diagnosis. No significant differences in the age, gender, ethnicity, socioeconomic status, tumor stage, and site were detected between the screened vs. symptomatic cohorts. Only 33 of 212 patients (15.6 percent) reported ever having a screening test. Nineteen of 198 cancers (9.6 percent) were diagnosed by symptomatic presentation despite a compliant screening history.

CONCLUSIONS

Less than 7 percent of patients with a new diagnosis of CRC were detected via a screening test. Furthermore, only 15 percent of screening-eligible respondents had ever been screened. Significant effort is required to increase knowledge and compliance for CRC screening.

Is Minority Status a More Consistent Predictor of Disability Than Socioeconomic Status?

Applying the social and capabilities models of disability and using individuals as the unit of analysis, the authors examined the consistency of socioeconomic status and membership in a minority group as covariates of four dimensions of disability. Using the responses of 260,062 individuals to the 2003 Behavioral Risk Factor Surveillance System, the authors examined three binary variables identifying individuals who required assistive devices or experienced at least 1 day of limited activity because of physical, emotional, or mental problems or because of only physical problems. Among 55,026 respondents who experienced at least 1 day of limited activity, the authors examined variation in the number of disability days. After health needs, lifestyle risks, demographic attributes, and access to care were controlled, the results indicated that socioeconomic status is a more consistent predictor of disability than membership in a minority group.

Primary care physicians' assessments of older patients' health and psychological status and recommendation of mammography

BACKGROUND

Recommendation of mammography may be particularly important for older women; nevertheless, physicians are less likely to recommend mammography to older women. Our objective was to examine the characteristics of older patients for whom primary care physicians recommend mammography.

METHODS

Two hundred sixteen women aged 65 to 80 years were screened for depressive symptoms in primary care offices and invited to participate. They then completed a baseline in-home assessment between 2001 and 2003. At the time of the baseline in-home assessment, mammogram use and psychological status were assessed with commonly used and validated standard questionnaires. At the time of the index visit, physicians were asked to provide assessments of the patients.

RESULTS

Patient-reported physician recommendation of mammography was more likely among patients the physicians rated as anxious than among patients the physicians rated as not being anxious (unadjusted odds ratio, 2.08; 95% confidence interval, 1.10-3.94). In multivariate models that controlled for physician ratings of knowledge of the patient, the association between physician rating of anxiety with patient-reported physician recommendation of mammography remained significant. Patient-reported physician recommendation of mammography was not significantly more likely among patients the physicians rated as depressed than among patients the physicians rated as not being depressed (unadjusted odds ratio, 1.57; 95% confidence interval, 0.86-2.85).

CONCLUSIONS

Identification of anxiety may influence the recommendation of mammography among primary care physicians. An understanding of factors that influence the recommendation of mammography by primary care physicians may have important implications for interventions to improve rates of mammography use among older women.

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

Colorectal cancer (CRC) screening is strongly supported by evidence and widely recommended, but remains underutilized. This study reports the prevalence of CRC diagnostic testing and CRC screening in three racial/ethnic groups attending the same primary care clinic. A cross-sectional survey was conducted to elicit past history of CRC testing, including test type, indication and timing. A comparable number of African American, Hispanic and non-Hispanic white patients aged 50-80 were recruited. 560 surveys were completed: mean age was 63.4 years, 64% reported minority race/ethnicity, and 96.8% had insurance. Overall, 62.5% [95% CI: 58.5%, 66.5%] of patients were current with any type of CRC test, when diagnostic and screening procedures were included. However, 48.6% [95% CI: 44.5%, 52.7%] of the sample was current with CRC screening, when only procedures performed for screening in asymptomatic patients were included. Patients least likely to be current with testing were those of minority race/ethnicity (48.2% of Hispanics, 56.7% of African Americans and 67.5% of non Hispanic whites, p < 0.05), younger age, (57.6% of those aged 50-64, and 71.4% of those aged 65-80, p < 0.005), and those with private insurance alone (56.0% private, 67.7% public and 68.1% mixed, p < 0.05). Our findings indicate that racial/ethnic and age related disparities in CRC screening exist even in a patient population that has the same source of health care and no differences in insurance status. These results underline the need for providers to emphasize CRC screening in their practices to minority patients and those younger than 65 years of age.

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

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

Interest in genetic counseling and testing for adolescent nicotine addiction susceptibility among a sample of adolescent medicine providers attending a scientific conference on adolescent health

PURPOSE

Preventing adolescents from smoking and becoming addicted to nicotine is an important public health issue. New research on the genetics of susceptibility to nicotine addition is emerging and may eventually help to identify adolescents at high risk. Over time, genetic counseling and testing for nicotine addiction susceptibility may become incorporated into tobacco control practice, and providers in primary care settings are likely to be at the forefront of these services. As such, it is important to understand the attitudes and practices of adolescent medicine providers toward tobacco control and genetic testing to anticipate better the needs and interests of these individuals and prepare for the future. This study describes adolescent medicine providers' interest, and correlates of their interest, in genetic counseling and testing for nicotine addiction susceptibility among their adolescent patients--a test that is not yet clinically available.

METHODS

Adolescent medicine providers attending a national scientific conference (N = 232) completed a survey about their patient tobacco control and other screening behaviors, perceptions of their patients' attitudes and beliefs toward tobacco control, and their own attitudes and beliefs about smoking and genetics.

RESULTS

Providers who engaged in more regular tobacco screening behaviors with their adolescent patients (odds ratio [OR] = 4.07, 95% confidence interval [CI] = 2.20, 7.751, p = .00) and those who were more optimistic that biobehavioral research would lead to significant improvements in adolescent smoking prevention and treatment (OR = 2.47, 95% CI = 1.40, 4.37, p = .00), were more interested in counseling and testing.

CONCLUSIONS

In the future, adolescent wellness visits may present an opportunity to offer genetic counseling and testing for nicotine addiction susceptibility. Implementation at the provider level may depend on tobacco screening behavior and research optimism. Educating providers about safe and effective adolescent tobacco control strategies incorporating genetics will be essential.

Rural access to vocational rehabilitation services: minority farmers' perspective

PURPOSE

The paper documents the need for, and obstacles to effective access to rehabilitation services by minority farmers. It draws from the findings of a study conducted in the Mississippi delta.

METHOD

Applying community-based participatory research approach (CBPR) the study trained farmers to conduct interviews and focus group discussions. They interviewed 1308 farmers and had 18 focus group discussions with 254 farmers. The study also interviewed 290 service providers and conducted 8 focus group discussions with 72 State Vocational Rehabilitation services (VR) counselors.

RESULTS

The study found an unmet need for VR services in this population. Farmers were not aware of VR services or how to access them and VR was not aware of farmers' needs. Farmers felt marginalized and afraid that access to VR services would diminish their ability to earn a living on the farm.

CONCLUSIONS

Collaboration between VR and rural organizations, agencies and with rural people would help close the information and gaping service gap. One-stop service centers in rural areas could improve access to services. CBPR is an invaluable research tool especially among marginalized people.

Gender differences in colorectal cancer screening barriers and information needs

CONTEXT

Several prior studies have found that women are less likely to be screened for colorectal cancer (CRC) than men. While the source of this screening differential is unknown, recent studies suggest gender differences in barriers to screening might explain the disparity.

OBJECTIVE

This formative study was designed to explore CRC screening barriers, attitudes and preferences by gender.

METHODOLOGY

Focus group interviews with groups stratified by gender and screening status. Participants included 27 females and 43 males between the ages of 50 and 75 years who receive primary care at the Minneapolis VA Medical Center. We conducted interpretive and grounded text analysis of semi-structured focus group interviews to assess how knowledge, experiences and sociocultural norms shape female and male preferences and barriers to current CRC screening guidelines.

RESULTS

Female and male participants reported similar preferences for CRC screening mode, but there were notable differences in the barriers and facilitators to screening. Key findings suggest that women viewed the preparation for endoscopic procedures as a major barrier to screening while men did not; women and men expressed different fears and information preferences regarding endoscopic procedures; and women perceive CRC as a male disease thus feeling less vulnerable to CRC. Gender-specific barriers may explain women's lower rate of screening for CRC.

CONCLUSION

Colorectal cancer screening promotion interventions, decision aids and clinical practice may benefit by being tailored by gender.

Clinical efficacy of human papillomavirus DNA detection in urine from patients with various cervical lesions

A considerable number of adult Korean women avoid a Pap smear due to fear and discomfort of the pelvic examination. A reliable but noninvasive and comfortable screening method would considerably increase the participation rate. To evaluate the clinical efficacy of urine-based human papillomavirus (HPV) detection by oligonucleotide microarray, the results of HPV test from matched cervical swab specimens were compared. HPV DNA was detected in 70 of 100 cervical samples. HPV 16 was the most prevalent type (38/70), followed by types 18, 58, 52, 33, 35, 31, and 51. HPV DNA was identified in 47 of 90 urine samples. HPV 16 was the most prevalent type (30/45), followed by types 18, 52, 35, 51, 58, 33, and 56. The HPV detection rates of the cervical swabs increased in accordance with the severity of the cytologic and histologic diagnosis. The type specific agreement of HPV DNA tests between cervical swabs and urine was good in HPV 16 (kappa index=0.64 [95% CI: 0.50-0.79]), 18, 52, and 58 and fair in HPV 33 and 35. We propose that a urine HPV test is a valuable adjunctive method for a conventional Pap smear and can be used in population screening for cervical cancer in countries where it is difficult to obtain colposcopic specimens for cultural or religious reasons.