This Article Abstract Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Services Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Download to citation manager patientINFORMation Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Meissner, H. I. Articles by Vernon, S. W. Search for Related Content PubMed PubMed Citation Articles by Meissner, H. I. Articles by Vernon, S. W.

Patterns of Colorectal Cancer Screening Uptake among Men and Women in the United States

¹ Division of Cancer Control and Population Sciences, National Cancer Institute, Bethesda, Maryland and ² School of Public Health, University of Texas Houston, Houston, Texas

Requests for reprints: Helen I. Meissner, Applied Cancer Screening Research Branch, Behavioral Research Program, Division of Cancer Control and Population Sciences, National Cancer Institute, Executive Plaza North, Room 4102, 6130 Executive Boulevard, MSC 7331, Bethesda, MD 20892-7331. Phone: 301-435-2836; Fax: 301-480-6637. E-mail: hm36d{at}nih.gov

	Abstract

Top Abstract Introduction Materials and Methods Results Discussion References

 
Objective: The purpose of this report is to examine (a) gender-specific correlates of colorectal cancer test use using recent national data from 2003 and (b) patterns of colorectal cancer screening by gender and test modality over time.

Methods: We analyze data from the 1987, 1992, 1998, 2000, and 2003 National Health Interview Surveys. Our sample consists of men and women 50 years never diagnosed with colorectal cancer and who reported a recent fecal occult blood test and/or endoscopy.

Results: In 2003, both men and women reported higher rates of colonoscopy (32.2% and 29.8%, respectively) than use of FOBT (16.1% and 15.3%, respectively) or sigmoidoscopy (7.6% and 5.9%, respectively). Men reported higher use of endoscopy than women if they had a usual source of health care, had talked to a general doctor, and had two to five visits to the doctor in the past year. Men and women 65 years and older had higher rates of any recommended colorectal cancer test (55.8% and 48.5%, respectively) than persons 50 to 64 years (males, 41.0%; females, 31.4%). Use of colorectal cancer tests also was higher among both genders if they were not Hispanic, had higher educational attainment, were former smokers, had health insurance or a usual source of care, or if they talked to a general doctor. Recent use of colorectal cancer tests has increased since 2000 for both women and men largely due to increased use of colonoscopy.

Conclusions: Colorectal cancer testing is increasing for both men and women, although the prevalence of testing remains higher in men. Our data support previous findings documenting socioeconomic disparities in colorectal cancer test use. Access barriers to screening could be particularly difficult to overcome if colonoscopy becomes the preferred colorectal cancer screening modality. (Cancer Epidemiol Biomarkers Prev 2006;15(2):389–94)

	Introduction

Top Abstract Introduction Materials and Methods Results Discussion References

 
Despite expert consensus and national guidelines (1) endorsing colorectal cancer screening as an effective strategy for reducing colorectal cancer incidence and mortality, uptake of screening has remained relatively low. In 2000, less than half (42%) of U.S. age-eligible adults reported receiving any of the recommended colorectal cancer screening tests (2). This relatively low rate of use has left many wondering why we have not witnessed the same steep increase in colorectal cancer screening that was observed with mammography after evidence-based recommendations for breast cancer screening were published. All the elements were in place by 2000 for the takeoff. The U.S. Preventive Services Task Force first published guidelines recommending colorectal cancer screening in 1996 (3). Two years later, colorectal screening became a covered Medicare benefit (http://healthservices.cancer.gov/seermedicare/considerations/testing.html). In 2000, most health plans in the United States covered at least one of the recommended colorectal cancer screening modalities (4). Nevertheless, rates of colorectal cancer screening remain low.

Correlates of colorectal cancer test use are similar to those observed for mammography and Papanicolaou tests and include race; ethnicity; age; education; income; and having health insurance coverage, a usual source of health care, a recent physician visit, use of other cancer screening tests, and a recommendation from a physician for screening (2, 5, 6). However, other characteristics of colorectal cancer screening distinguish it from breast and cervical screening, including a range of test modalities from which patients and physicians can choose [fecal occult blood testing (FOBT), sigmoidoscopy, colonoscopy, and double-contrast barium enema], patient responsibility in preparing for or completing the test, and the fact that this preventive service is recommended for both men and women.

Differences in colorectal cancer test use by gender have been documented. In general, studies have shown that men are more likely than women to be tested for colorectal cancer (7, 8) and that patterns of use by gender differ by test modality. For example, Seeff et al. (2) reported greater use of FOBT by women compared with men in 2000, but found that men had endoscopy more often than women. That colorectal cancer test use is higher in men than women is surprising because, in general, men tend to have lower use of medical services than women (9). One also would expect that high rates of breast and cervical cancer screening (5) would translate into greater opportunities for women to learn about and receive recommendations for colorectal cancer screening. Having seen a physician in the past year is strongly associated with colorectal cancer test use and increases with increasing numbers of physician visits (2). Furthermore, men have more colonic adenomas than do women (10) and there is a belief that colorectal cancer is a man's disease. This belief, coupled with years of publicity focusing women's attention on breast rather than colon cancer, may have contributed to the slower uptake of colorectal cancer screening among women compared with men (11, 12).

Trends in colorectal cancer test use to date suggest that patterns of use by gender and test modality may be changing. The purpose of this report is to examine (a) gender-specific correlates of colorectal cancer test use using recent national data from 2003 and (b) patterns of colorectal cancer screening by gender and test modality over time. We report national trends for colorectal cancer test use for any purpose and for screening.

	Materials and Methods

Top Abstract Introduction Materials and Methods Results Discussion References

 
We analyze data from the 1987, 1992, 1998, 2000, and 2003 National Health Interview Surveys (NHIS). The NHIS is the leading source of health information on the civilian, noninstitutionalized population in the United States (13). It is an in-person household survey that collects demographic and health information on an annual basis. The NHIS survey design oversamples Hispanics and African Americans to improve the precision of estimates for those populations (14, 15).

The NHIS includes questions on the use of FOBT and colorectal endoscopy, but the questions evolved over time to accommodate new technologies and research. The 2000 NHIS was the first time that questions specifically distinguished home from office FOBT and that questions distinguished among endoscopic tests (sigmoidoscopy, colonoscopy, and proctoscopy). Test descriptions were read to all eligible respondents for the first time in the 2003 NHIS.

Our sample consists of men and women age 50 years, reflecting the recommended starting age for colorectal cancer screening among persons at average risk. Because patterns in colorectal cancer test use over time were similar when stratified by age (50-64 and 65+), we display trends for both age groups combined. We report recent test use at intervals in compliance with published guidelines (1). Respondents who said that they had the test for follow-up or for a specific problem were classified as not having a recent test for screening purposes.

	Results

Top Abstract Introduction Materials and Methods Results Discussion References

 
Table 1 shows recent use of home FOBT, sigmoidoscopy, colonoscopy, and any recommended colorectal cancer test for men and women by selected sociodemographic variables. In 2003, both men and women reported higher rates of recent colonoscopy use (32.2% and 29.8%, respectively) than use of FOBT or sigmoidoscopy. There were no significant differences in the prevalence of FOBT by gender. Uptake of endoscopic tests was fairly comparable between men and women, with a few exceptions. Men with a usual source of health care, who had seen or talked to a general doctor, and who had two to five visits to the doctor in the past year reported higher use of sigmoidoscopy and colonoscopy than their female counterparts. Recent use of sigmoidoscopy was significantly greater for men overall (7.6% for men versus 5.9% for women) and for non-Hispanic men (7.8% for men versus 6.1% for women). Men ages 65 years and older reported greater use of colonoscopy than women the same age (39.5% versus 33.7%). Having any recent colorectal cancer tests was significantly different for men and women overall (46.5% versus 43.1%) and by non-Hispanic ethnicity, age 65 years or older, married, public health insurance coverage, having a usual source of health care, seen or talked to a general doctor, and having two to five physician visits in the past year.

Figure 1 displays trends in recent use of colorectal cancer tests from 1987 to 2003 for women and men. The broken lines between 1998 and 2000 represent changes in the survey questions that were redesigned to more accurately distinguish between recommended screening tests. As can be seen, colorectal cancer testing rates have increased since 2000 for both women and men, and this increase is largely driven by a steep increase in colonoscopy use. Recent use of sigmoidoscopy has declined since 2000. Likewise, rates of home FOBT use among women (not shown in figure) declined from 17.5% in 2000 to 15.4% in 2003. Among men, rates of home FOBT in the past year were similar in 2000 and 2003 (16.6% and 16.3%, respectively).

View larger version (18K): [in this window] [in a new window]   Figure 1. Recent use of colorectal cancer tests: 1987, 1992, 1998, 2000, and 2003. Percentages are standardized to the 2000 projected U.S. population by 5-year age groups. The relevant survey questions were redesigned after 1998; broken lines represent these changes. *, 1998 and before includes home or office FOBT, and colonoscopy, protoscopy, and sigmoidoscopy because we cannot adequately distinguish between tests during these years. Post 1998 includes home FOBT and sigmoidoscopy and colonoscopy. Source: NHIS.

View larger version (32K): [in this window] [in a new window]   Figure 2. Recent colorectal cancer test use for any reason and for screening purposes. Respondents are age 50+ years. All percentages are standardized to the 2000 projected U.S. population by 5-year age groups. FOBT includes tests within the past year. Recent endoscopy includes tests within the past 5 years (also includes colonoscopies in the past 10 years for 2000 and 2003). Source: NHIS.

	Discussion

Top Abstract Introduction Materials and Methods Results Discussion References

With the exception of age, correlates of colorectal cancer tests are similar to those for use of Papanicolaou tests and mammograms.

Increased use of colonoscopy is driving the increase in colorectal cancer testing. The extension of Medicare coverage for screening colonoscopy to average-risk beneficiaries in 2000 has likely contributed to this increase and is supported by our data. Test use rates among men and women ages 65 years and older are significantly higher than for those ages 50 to 64 years. Uptake of colonoscopy has also been influenced by media attention, professional endorsement of colonoscopy, and reimbursement. Katie Couric's televised colonoscopy on the Today Show in March 2000 was associated with a temporal increase in use of that test (16). The American College of Gastroenterology recommendation in 2000 of colonoscopy as the preferred colorectal cancer screening test for average-risk patients (17) and the greater profitability of colonoscopy compared with sigmoidoscopy also are probable contributors to the surge in colonoscopy. The current average Medicare reimbursement for both facility and professional fees is over thrice higher for screening colonoscopy than for screening sigmoidoscopy.³ Low-profit margins make it difficult for most primary care physicians to incorporate sigmoidoscopy in practice (18) and many consequently refer their patients for colorectal endoscopy (19).

The menu of colorectal cancer screening tests allows for flexibility, but can render decisions about recommending or choosing a particular test difficult. Each test has tradeoffs in terms of efficacy, complications, discomfort, frequency, time, and cost. Which test is best is a matter of personal preference that should be considered when recommendations for screening are made (20). It is not possible for us to assess with these data whether the increasing trend in colonoscopy use and the concurrent decline in sigmoidoscopy and FOBT reflect patient or provider preferences.

Our study is limited by the fact that NHIS data are cross-sectional and limited to self-report of selected individual correlates of colorectal test use. Self-reports of screening could lead to overestimates of adherence (21). We are unable to explore the influence of other potentially important correlates of screening, such as provider characteristics and practices, patient-provider communication, health plan policies regarding colorectal cancer tests, and geographic capacity for screening. Furthermore, the redesign of relevant survey questions to ask about endoscopic tests separately after 1998 may exaggerate the rate at which sigmoidoscopy declined and colonoscopy rose since 1998. Nevertheless, the recent national data do indicate that prevalence of colorectal cancer test use is higher than in previous years and that recent colonoscopy accounts for most of colorectal test use.

That the increase in colorectal cancer test use is almost exclusively driven by colonoscopy has implications for public health practice in the United States. Colonoscopy is an expensive, invasive, relatively time-consuming test that currently must be done by a physician. Even assuming that capacity exists to perform screening colonoscopy for every age-eligible person at recommended frequency (18, 22), promotion of colonoscopy as the "preferred" colorectal cancer screening test may widen socioeconomic disparities. Our data support previous findings that there are disparities in the use of screening by educational attainment, household income, health insurance coverage, and having a usual source of health care (2, 23). These barriers to screening could be particularly difficult to overcome if colonoscopy becomes the preferred colorectal cancer screening modality. Clinicians, health advocates, and policy-makers alike need to carefully consider the messages that are communicated to the public about colorectal cancer test options. Reliance on colonoscopy alone may be insufficient for high participation in colorectal cancer screening at a population level, which will be required to effectively reduce morbidity and mortality from colorectal cancer.

	Acknowledgments

 
We thank Tim McNeel and William Waldron of Information Management Services, Silverspring, MD for expert programming.

	Footnotes

 
Grant support: National Cancer Institute grants CA 76330 and CA 97263 (S.W. Vernon).

The costs of publication of this article were defrayed in part by the payment of page charges. This article must therefore be hereby marked advertisement in accordance with 18 U.S.C. Section 1734 solely to indicate this fact.

³ G.M. Brooks, Center for Medicaid and Medicare Services, personal communication, July 21, 2005.

Received 8/30/05; revised 11/10/05; accepted 12/15/05.

	References

Top Abstract Introduction Materials and Methods Results Discussion References

 

1. Agency for Healthcare Research and Quality. Colorectal cancer—screening. Guide to clinical preventive services, 3rd ed.: periodic updates. http://www.ahrq.gov/clinic/uspstf/uspscolo.htm; 2002.
2. Seeff LC, Nadel MR, Klabunde CN, et al. Patterns and predictors of colorectal cancer test use in the adult U.S. population. Cancer 2004;100:2093–103.[CrossRef][Medline]
3. U.S. Preventive Services Task Force. Guide to clinical preventive services. Alexandria (Virginia): International Medical Publishing; 1996.
4. Klabunde CN, Riley GF, Mandelson MT, Frame PS, Brown ML. Health plan policies and programs for colorectal cancer screening: a national profile. Am J Manag Care 2004;10:273–9.[Medline]
5. Swan J, Breen N, Coates RJ, Rimer BK, Lee NC. Progress in cancer screening practices in the United States: results from the 2000 National Health Interview Survey. Cancer 2003;97:1528–40.[CrossRef][Medline]
6. Cokkinides VE, Chao A, Smith RA, Vernon SW, Thun MJ. Correlates of underutilization of colorectal cancer screening among U.S. adults, age 50 years and older. Prev Med 2003;36:85–91.[CrossRef][Medline]
7. Brawarsky P, Brooks DR, Mucci LA. Correlates of colorectal cancer testing in Massachusetts men and women. Prev Med 2003;36:659–68.[CrossRef][Medline]
8. Etzioni DA, Ponce NA, Babey SH, et al. A population-based study of colorectal cancer test use: results from the 2001 California Health Interview Survey. Cancer 2004;101:2523–32.[CrossRef][Medline]
9. Green CA, Pope CR. Gender, psychosocial factors and the use of medical services: a longitudinal analysis. Soc Sci Med 1999;48:1363–72.
10. Villavicencio RT, Rex DK. Colonic adenomas: prevalence and incidence rates, growth rates, and miss rates at colonoscopy. Semin Gastrointest Dis 2005;11:185–93.
11. Burke W, Beeker C, Kraft JM, Pinsky L. Engaging women's interest in colorectal cancer screening: a public health strategy. J Womens Health Gend Based Med 2000;9:363–71.[CrossRef][Medline]
12. Donovan JM, Syngal S. Colorectal cancer in women: an underappreciated but preventable risk. J Womens Health 1998;7:45–8.[Medline]
13. National Research Council. Toward a national health care survey. A data system for 21st century. Washington (District of Columbia): National Academy Press; 1992.
14. Data file documentation, National Health Interview Survey, 2000 [machine readable data file and documentation]. Hyattsville (Maryland): National Center for Health Statistics; 2001.
15. Botman SL, Moore TF, Moriarity CL, Parsons VL. Design and estimation for the National Health Interview Survey, 1995-2004. Vital Health Stat 2000;2.
16. Cram P, Fendrick AM, Inadomi J, Cowen ME, Carpenter D, Vijan S. The impact of a celebrity promotional campaign on the use of colon cancer screening—The Katie Couric effect. Arch Intern Med 2003;163:1601–5.[Abstract/Free Full Text]
17. Rex DK. Colorectal cancer prevention 2000: screening recommendations of the American College of Gastroenterology. Am J Gastroenterol 2000;95:868–77.[Medline]
18. Brown ML, Klabunde CN, Mysliwiec P. Current capacity for endoscopic colorectal cancer screening in the United States: data from the National Cancer Institute Survey of Colorectal Cancer Screening Practices. Am J Med 2003;115:129–33.[CrossRef][Medline]
19. Klabunde C, Frame PS, Meadow A, Jones E, Nadel M, Vernon SW. A national survey of primary care physicians' colorectal cancer screening recommendations and practices. Prev Med 2003;36:352–62.[CrossRef][Medline]
20. Leard LE, Savides TJ, Ganiats TG. Patient preferences for colorectal cancer screening. J Fam Pract 1997;45:211–8.[Medline]
21. Gordon NP, Hiatt RA, Lampert DI. Concordance of self-reported data and medical record audit for 6 cancer screening procedures. J Natl Cancer Inst 1993;85:566–70.[Abstract/Free Full Text]
22. Seeff LC. Is there endoscopic capacity to provide colorectal cancer screening to the unscreened population in the United States? Gastroenterology 2004;127:1661–9.[CrossRef][Medline]
23. Breen N, Wagener DK, Brown ML, Davis WW, Ballard-Barbash R. Progress in cancer screening over a decade: results of cancer screening from the 1987, 1992, and 1998 National Health Interview Surveys. J Natl Cancer Inst 2001;93:1704–13.[Abstract/Free Full Text]

Find additional patient-related information at:

Colon Cancer Screening Rates on the Upswing

This article has been cited by other articles:

				D. A. Ahlquist, D. J. Sargent, C. L. Loprinzi, T. R. Levin, D. K. Rex, D. J. Ahnen, K. Knigge, M. P. Lance, L. J. Burgart, S. R. Hamilton, et al. Stool DNA and Occult Blood Testing for Screen Detection of Colorectal Neoplasia Ann Intern Med, October 7, 2008; 149(7): 441 - 450. [Abstract] [Full Text] [PDF]

				E. P. Whitlock, J. S. Lin, E. Liles, T. L. Beil, and R. Fu Screening for Colorectal Cancer: A Targeted, Updated Systematic Review for the U.S. Preventive Services Task Force Ann Intern Med, October 6, 2008; (2008) 0000605-200811040-00245. [Abstract] [Full Text]

				P. Lance Colorectal Cancer Screening: Confusion Reigns Cancer Epidemiol. Biomarkers Prev., September 1, 2008; 17(9): 2205 - 2207. [Full Text] [PDF]

				A. McQueen, J. A. Tiro, and S. W. Vernon Construct Validity and Invariance of Four Factors Associated with Colorectal Cancer Screening across Gender, Race, and Prior Screening Cancer Epidemiol. Biomarkers Prev., September 1, 2008; 17(9): 2231 - 2237. [Abstract] [Full Text] [PDF]

				N. K. Shokar, C. A. Carlson, and S. C. Weller Factors Associated with Racial/Ethnic Differences in Colorectal Cancer Screening J Am Board Fam Med, September 1, 2008; 21(5): 414 - 426. [Abstract] [Full Text] [PDF]

				A. E. Maxwell, L. L. Danao, C. M. Crespi, C. Antonio, G. M. Garcia, and R. Bastani Disparities in the Receipt of Fecal Occult Blood Test versus Endoscopy among Filipino American Immigrants Cancer Epidemiol. Biomarkers Prev., August 1, 2008; 17(8): 1963 - 1967. [Abstract] [Full Text] [PDF]

				L. M. Crawley, D. K. Ahn, and M. A. Winkleby Perceived Medical Discrimination and Cancer Screening Behaviors of Racial and Ethnic Minority Adults Cancer Epidemiol. Biomarkers Prev., August 1, 2008; 17(8): 1937 - 1944. [Abstract] [Full Text] [PDF]

				J. A. Shapiro, L. C. Seeff, T. D. Thompson, M. R. Nadel, C. N. Klabunde, and S. W. Vernon Colorectal Cancer Test Use from the 2005 National Health Interview Survey Cancer Epidemiol. Biomarkers Prev., July 1, 2008; 17(7): 1623 - 1630. [Abstract] [Full Text] [PDF]

				A. F. Jerant, J. J. Fenton, and P. Franks Determinants of Racial/Ethnic Colorectal Cancer Screening Disparities Arch Intern Med, June 23, 2008; 168(12): 1317 - 1324. [Abstract] [Full Text] [PDF]

				R.-N. Gao, C. I. Neutel, and E. Wai Gender differences in colorectal cancer incidence, mortality, hospitalizations and surgical procedures in Canada J. Public Health Med., June 1, 2008; 30(2): 194 - 201. [Abstract] [Full Text] [PDF]

				B. Levin, D. A. Lieberman, B. McFarland, R. A. Smith, D. Brooks, K. S. Andrews, C. Dash, F. M. Giardiello, S. Glick, T. R. Levin, et al. Screening and Surveillance for the Early Detection of Colorectal Cancer and Adenomatous Polyps, 2008: A Joint Guideline from the American Cancer Society, the US Multi-Society Task Force on Colorectal Cancer, and the American College of Radiology CA Cancer J Clin, May 1, 2008; 58(3): 130 - 160. [Abstract] [Full Text] [PDF]

				R. A. Smith, V. Cokkinides, and O. W. Brawley Cancer Screening in the United States, 2008: A Review of Current American Cancer Society Guidelines and Cancer Screening Issues CA Cancer J Clin, May 1, 2008; 58(3): 161 - 179. [Abstract] [Full Text] [PDF]

				S. W. Vernon, J. A. Tiro, R. W. Vojvodic, S. Coan, P. M. Diamond, A. Greisinger, and M. E. Fernandez Reliability and Validity of a Questionnaire to Measure Colorectal Cancer Screening Behaviors: Does Mode of Survey Administration Matter? Cancer Epidemiol. Biomarkers Prev., April 1, 2008; 17(4): 758 - 767. [Abstract] [Full Text] [PDF]

				K. Fiscella and K. Holt Impact of Primary Care Patient Visits on Racial and Ethnic Disparities in Preventive Care in the United States J Am Board Fam Med, November 1, 2007; 20(6): 587 - 597. [Abstract] [Full Text] [PDF]

				K. Glanz, A. D. Steffen, and L. A. Taglialatela Effects of Colon Cancer Risk Counseling for First-Degree Relatives Cancer Epidemiol. Biomarkers Prev., July 1, 2007; 16(7): 1485 - 1491. [Abstract] [Full Text] [PDF]

				A. McQueen, S. W. Vernon, R. E. Myers, B. G. Watts, E. S. Lee, and B. C. Tilley Correlates and Predictors of Colorectal Cancer Screening among Male Automotive Workers Cancer Epidemiol. Biomarkers Prev., March 1, 2007; 16(3): 500 - 509. [Abstract] [Full Text] [PDF]

				R. A. Smith, V. Cokkinides, and H. J. Eyre Cancer Screening in the United States, 2007: A Review of Current Guidelines, Practices, and Prospects CA Cancer J Clin, March 1, 2007; 57(2): 90 - 104. [Abstract] [Full Text] [PDF]

				N. J. Meropol and K. A. Schulman Cost of Cancer Care: Issues and Implications J. Clin. Oncol., January 10, 2007; 25(2): 180 - 186. [Abstract] [Full Text] [PDF]

				T. D. Denberg, J. M. Coombes, T. E. Byers, A. C. Marcus, L. E. Feinberg, J. F. Steiner, and D. J. Ahnen Effect of a Mailed Brochure on Appointment-Keeping for Screening Colonoscopy: A Randomized Trial Ann Intern Med, December 19, 2006; 145(12): 895 - 900. [Abstract] [Full Text] [PDF]

This Article Abstract Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Services Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Download to citation manager patientINFORMation Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Meissner, H. I. Articles by Vernon, S. W. Search for Related Content PubMed PubMed Citation Articles by Meissner, H. I. Articles by Vernon, S. W.