Colorectal cancer screening: Physician recommendation is influential advice to Marylanders
Introduction
Colorectal cancer (CRC) is the second most common fatal malignancy in Maryland [1]. According to the Maryland Cigarette Restitution Fund's 2003 Annual Cancer Report, 2778 new CRC cases were diagnosed and 1158 deaths due to CRC were recorded in Maryland during 2000. In comparison to the United States, Maryland is facing a significantly higher burden of CRC incidence and mortality. Effective CRC screening procedures allow for the detection and removal of precursor lesions and facilitate earlier identification of malignancies at stages that are more amenable to treatment [2], [3]. The burden of CRC can be reduced by increased colorectal cancer screening and adherence to guidelines such as those issued by the American Cancer Society (ACS) [4]. For average risk individuals ages 50 years and older, the ACS lists the following as acceptable options for CRC screening: (1) annual fecal occult blood test, (2) flexible sigmoidoscopy every 5 years, or (3) colonoscopy every 10 years with the caveat that completion of timely fecal occult blood test and sigmoidoscopy is preferred over the individual tests alone. In practice, however, the tests are conducted in different settings and at different times.
According to 2001 BRFSS results for Maryland, 44.4% of residents 50 years and older reported FOBT use within the past 2 years and 52.2% reported ever having had a sigmoidoscopy or colonoscopy [1]. Fifty-eight percent of Maryland Cancer Survey 2002 (MCS) responders 50 years of age or older reported ever having had a sigmoidoscopy or colonoscopy [5], [6]. This indicates that at least 42% of residents age 50 or older have not been screened by a method that visualizes the colon. The primary objective of this study was to determine the predictors of CRC screening test use among Marylanders 50 years or older. Additionally, we sought to assess and quantify the outstanding need for CRC screening by individual CRC test and age.
Section snippets
Background
Studies have previously shown an association between many factors and CRC screening. The literature suggests that age and sex influence screening behavior. Thomas et al. found peak compliance for annual FOBT to be around age 70 with lower screening seen among the youngest (55 years or younger) and the oldest (80 years or older) [7]. Lemon et al. found that men aged 65–74 were more likely to be currently CRC screened than men aged 50–64 [8]. Women perceive themselves to be at lower risk for CRC
Data source
The Maryland Cigarette Restitution Fund, created in 2000 with tobacco settlement money by the Maryland State Legislature, established the Cancer Prevention, Education, Screening, and Treatment (CPEST) Program under the Center for Cancer Surveillance and Control at the Department of Health and Mental Hygiene (DHMH). The Surveillance and Evaluation Unit of the CPEST Program commissioned the MCS, a population-based, random digit dial, computer-assisted land line telephone interview utilizing
Design
We obtained the MCS data set [6] and performed secondary analyses to investigate CRC screening usage in accordance with ACS screening guidelines for fecal occult blood test (FOBT), sigmoidoscopy, and colonoscopy. The three screening tests were evaluated independently and respondents reporting use of more than one test were counted more than once. Survey questions did not allow a dual response to sigmoidoscopy and colonoscopy use, however. Several distinct factor groups were considered and
Data analysis
CRC screening test outcomes were defined as (1) FOBT within the past year, (2) sigmoidoscopy within the past 5 years, or (3) colonoscopy within the past 10 years. CRC screening test outcomes were determined using survey variables that indicated whether FOBT, sigmoidoscopy, and/or colonoscopy had been performed, and if so, the time since each exam was done.
Respondent observations where race was missing were not included in the initial data set since this variable was required for assigning a
Respondent characteristics
Weighted respondent characteristics are provided in Table 1 by age. In the 50–64 year group, 85 respondents (5.30%) reported having had a timely FOBT and timely sigmoidoscopy; 240 respondents (13.80%) reported having had a timely FOBT and timely colonoscopy. In the 65+ year group, 75 respondents (6.08%) reported having had a timely FOBT and timely sigmoidoscopy; 275 respondents (23.38%) reporting having had a timely FOBT and timely colonoscopy. Of the timely colonoscopies, 23.29% and 33.03%
Discussion
The main objective of this analysis was to determine what factors were the primary predictors of CRC screening test use in Maryland. This study was able to take a comprehensive approach to understanding the factors that influence CRC screening test use. We found that clinician recommendation for a screening test is the best predictor for all forms of screening in both age categories; it is a very strong indicator and consistently improves the odds of use by a factor of at least 8 in all
Conclusions
In summary, the most compelling conclusion is that clinician recommendation is the best predictor of CRC screening use. There is a unique profile for each type of screening test (FOBT, sigmoidoscopy, or colonoscopy), and these profiles differ by age group (50–64 years and 65+ years). Research suggests that the perceived benefits and barriers of screening differ by type of screening test, thereby influencing use [26]. Nevertheless, clinician advice is a strong factor in these data and may be
Acknowledgments
We would like to thank Ebenezer Israel1, Eileen Steinberger1, Annette Hopkins1, Min Zhan1, and Carmela Groves2 for designing, collecting, and weighting the MCS data. We would also like to acknowledge Helio Lopez2, Scott Zeger3, and Michael Griswold3 for
References (27)
- et al.
Which colon cancer screening test: a comparison of costs, effectiveness, and compliance
Am. J. Med.
(2001) - et al.
Risk and reluctance: understanding impediments to colorectal cancer screening
Prev. Med.
(2001) - et al.
Impact of a breast cancer screening community intervention
Prev. Med.
(1993) - Maryland Department of Health and Mental Hygiene. Annual cancer report. Available at:...
- et al.
Cost-effectiveness of screening for colorectal cancer in the general population
JAMA
(2001) - et al.
American cancer society guidelines for the early detection of cancer, 2003
CA Cancer J. Clin.
(2003) - Steinberger1 E, Israel1 E, Hopkins1 A, Zhan1 M, Uman1 J, Glover1 M, Groves2 C, Bienia2 M, Dwyer2 D. Maryland Cancer...
- Steinberger1 E, Israel1 E, Hopkins1 A, Zhan1 M, Groves2 C. Maryland Cancer Survey 2002. 1Department of Epidemiology and...
- et al.
Longitudinal compliance with annual screening for fecal occult blood. Minnesota colon cancer control study
Am. J. Epidemiol.
(1995) - et al.
Colorectal cancer screening participation: comparisons with mammography and prostate-specific antigen screening
Am. J. Public Health
(2001)
Racial differences in the elderly's use of medical procedures and diagnostic tests
Am. J. Public Health
Colorectal cancer screening
JAMA
Chronic disease as a barrier to breast and cervical cancer screening
J. Gen. Int. Med.
Cited by (68)
Limited English proficiency and reported receipt of colorectal cancer screening among adults 45–75 in 2019 and 2021
2024, Preventive Medicine ReportsBarriers and facilitators of colorectal cancer screening using the 5As framework: A systematic review of US studies
2023, Preventive Medicine ReportsFecal immunological blood test is more appealing than the guaiac-based test for colorectal cancer screening
2017, Digestive and Liver Disease