Elsevier

Preventive Medicine

Volume 41, Issue 2, August 2005, Pages 367-379
Preventive Medicine

Colorectal cancer screening: Physician recommendation is influential advice to Marylanders

https://doi.org/10.1016/j.ypmed.2005.01.008Get rights and content

Abstract

Background

In comparison to the United States, Maryland is facing a significantly higher burden of colorectal cancer incidence and mortality. The primary objective of this study was to determine the predictors of colorectal cancer screening use in Maryland.

Methods

We performed secondary analyses on Maryland Cancer Survey 2002 data from 2994 respondents to investigate important predictors for individual colorectal cancer screening tests. CRC screening 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.

Results

We found that clinician recommendation for a screening test is the best predictor in both age categories (50–64 years and 65+ years); it is a very strong indicator and consistently improves the odds of use by a factor of at least 8 for any screening test.

Conclusions

There remains a great need for improved colorectal cancer screening in Maryland. According to our results, it is clear that the most influential way to improve overall colorectal cancer screening for each test and both age groups is to increase clinician recommendation for these tests.

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

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