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RESEARCH |
Stephenie Lemon and Jane Zapka are with the Division of Preventive and Behavioral Medicine, and Roger Luckmann is with the Department of Family and Community Medicine, University of Massachusetts Medical School, Worcester. Elaine Puleo and Lisa Chasan-Taber are with the Department of Biostatistics and Epidemiology, University of Massachusetts School of Public Health, Amherst.
Correspondence: Requests for reprints should be sent to Jane Zapka, ScD, University of Massachusetts Medical School, Division of Preventive and Behavioral Medicine, 55 Lake Ave N, Worcester, MA 01655 (e-mail: jane.zapka{at}umassmed.edu).
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ABSTRACT |
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 TOP ABSTRACT INTRODUCTIONMETHODSRESULTSDISCUSSIONReferences |
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Objectives. The relation of personal characteristics, health and lifestyle behaviors, and cancer screening practices to current colorectal cancer (CRC) screening was assessed and compared with those factors' relation to current mammography screening in women and prostate-specific antigen (PSA) screening in men.
Methods. A cross-sectional random-digit-dialed telephone survey of 954 Massachusetts residents aged 50 and older was conducted.
Results. The overall prevalence of current CRC screening was 55.3%. Logistic regression results indicated that family history of CRC (odds ratio [OR] = 1.98; 95% confidence interval [CI] = 1.02, 3.86), receiving a regular medical checkup (OR = 3.07; 95% CI = 2.00, 4.71), current screening by mammography in women and PSA in men (OR = 4.40; 95% CI = 2.94, 6.58), and vitamin supplement use (OR = 1.87; 95% CI = 1.27, 2.77) were significant predictors of CRC screening.
Conclusions. Health and lifestyle behaviors were related to increased current CRC, mammography, and PSA screening. Personal factors independently related to CRC screening were not consistent with those related to mammography and PSA screening. This lack of consistency may reflect different stages of adoption of each type of screening by clinicians and the public.
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INTRODUCTION |
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TOPABSTRACTINTRODUCTIONMETHODSRESULTSDISCUSSIONReferences |
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The purpose of this study was to investigate the prevalence of current CRC screening in a population-based sample of Massachusetts adults, and to examine the relationship of demographic variables, family history of CRC, health insurance status, health services use, lifestyle behaviors, and other screening use to current CRC screening. We compare and contrast the prevalence and predictors of CRC screening with the prevalence and predictors of mammography screening in women and of PSA screening in men.
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METHODS |
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TOPABSTRACTINTRODUCTIONMETHODSRESULTSDISCUSSIONReferences |
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Data Collection and Survey Measures
Interviews were conducted with a computer-assisted telephone system. Interviewers received extensive training in instrument administration as well as technical aspects of the subject matter. As described below, measures were designed or adapted from previous work to capture screening and lifestyle and other personal characteristics. Pilot tests were conducted to refine the instrument.
Cancer Screening Practice Measures
The telephone interview collected information on participants' experiences with the fecal occult blood test kit completed at home and mailed back to the physician's office or laboratory for interpretation, with flexible sigmoidoscopy, with colonoscopy, and with the double-contrast barium enema. For the fecal occult blood test and flexible sigmoidoscopy, participants were asked if they had ever had the test, the length of time since their last test, and whether the test was for screening or diagnostic purposes. Persons who reported never receiving a fecal occult blood test were then asked if they had ever had a stool blood test in the physician's office and the time since their last test. Participants were asked if they had ever received a colonoscopy or double-contrast barium enema for screening or diagnostic purposes.
Owing to multiple screening options, it is difficult to determine CRC screening status. Persons were considered currently screened on the basis of recent guidelines15 if they reported having had 1 or more of the following: (1) a fecal occult blood test within the previous year; (2) flexible sigmoidoscopy within the previous 5 years; (3) colonoscopy within the previous 10 years; (4) a double-contrast barium enema within the previous 10 years. This definition included those who received a CRC test for screening as well as for diagnostic reasons. Those who reported being screened but beyond the time periods recommended by guidelines, and those who reported never being screened, were considered not current. Those who reported only receiving a fecal occult blood test performed by a physician during an office visit were considered not current, because this is not an acceptable screen according to guidelines.
For mammography and PSA screening, women and men were first asked if they had ever received the test appropriate for their sex. Those who answered yes reported the length of time since their most recent test. On the basis of accepted guidelines, for both procedures, being current was defined as having been screened within the previous year.16,17
Personal Measures
Demographic information collected included sex, education, race/ethnicity, income, age, and marital status. Family histories of CRC, and of breast cancer in women and prostate cancer in men, were each classified as yes or no. Insurance and entitlement coverage was hypothesized to be a potential predictor of CRC screening, as it is for mammography.18,19 Insurance status was classified as private, non–health maintenance organization (HMO) insurance with or without supplemental insurance; private, HMO insurance with or without supplemental insurance; Medicare, non-HMO; Medicare, HMO; Medicaid or other insurance; and uninsured.20
Health and Lifestyle Behavior Measures
Health service use and lifestyle behaviors were hypothesized to be associated with CRC screening. Access to a regular source of medical care enables other preventive services.21,22 Participants were asked if they received a regular medical checkup, and if so, how often. A regular checkup was defined as a checkup every year or more often. Smokers are less likely to use many preventive services.23–25 Participants were asked if they had ever smoked 100 cigarettes, and if so, if they were current or former smokers. Smoking status was classified as never, former, and current. Certain dietary supplements may have chemoprevention potential for some cancers.26 Although evidence is equivocal, the public has adopted considerable use of supplements,27 and participants were asked if they currently used any type of vitamin supplement (yes or no).
Statistical Analysis
Univariate analyses were used to describe the study sample and screening prevalence. Both in the total sample and in the analyses stratified by sex, bivariate 
2 statistics and odds ratios, with 95% confidence intervals, were used to document the crude relationship between each independent variable and CRC screening status. Analyses were repeated with mammography and PSA as the outcome variables.
Logistic regression was used to model the association between each outcome measure and health and lifestyle behavior. Personal characteristics were considered potential confounders if they were marginally associated with the outcome or the exposure variables in bivariate analyses or were strongly associated in prior literature. Variables demonstrating sex differences in relation to CRC screening were tested for statistical interaction. Covariates were retained in the model if they were independent predictors of the outcome variable or if their inclusion in the model changed the odds ratio associated with an exposure variable by more than 15%. Data manipulation and frequency estimates were conducted with SAS Version 6.12.28 All other analyses were conducted with SUDAAN Version 7.52.29 To account for the stratified sampling scheme, we weighted analyses to represent the sex, race/ethnicity, and education distributions of Massachusetts.
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RESULTS |
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TOPABSTRACTINTRODUCTIONMETHODSRESULTSDISCUSSIONReferences |
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Women who had had a mammogram in the past year were 4 times as likely (odds ratio [OR] = 4.01; 95% confidence interval [CI] = 2.26, 7.12) to be current for CRC screening as women who had not, while men who were current for PSA screening were almost 7 times as likely (OR = 6.73; 95% CI = 3.91, 11.57) to be current for CRC screening as men who were not (Table 2).
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. Although no personal characteristic achieved statistical significance, family history of the disease, lower education, and being a Medicare HMO member were associated with higher CRC screening rates. Receiving a regular checkup (OR = 4.22; 95% CI = 2.41, 7.41) and using vitamin supplements (OR = 2.12; 95% CI = 1.31, 3.41) were significantly associated with increased CRC screening. While smoking status did not reach statistical significance, current smokers had the lowest screening rate.
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Factors Associated With Screening in Men
Men aged 65 to 74 were more likely to be currently screened for CRC than men aged 50 to 65 (OR = 2.57; 95% CI = 1.39, 4.74) (Table 4). Lower educational level was associated with decreased likelihood of current CRC screening (OR = 0.40; 95% CI = 0.20, 0.81). Members of Medicare HMO plans had nonsignificantly higher CRC screening rates than men with private insurance. Men with a family history of CRC (OR = 2.78; 95% CI = 1.34, 5.77) and those who received a regular checkup (OR = 5.47; 95% CI = 3.06, 9.77) had higher screening rates. Vitamin supplement users had a nonsignificantly higher rate of screening. CRC screening was less likely among current smokers than among never smokers (OR = 0.36; 95% CI = 0.16, 0.82).
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Multivariate Analyses
CRC screening.
The final multivariate model is presented in Table 5. While neither sex nor education had an independent effect, an interaction between education and sex emerged. Compared with men with a college degree or higher, those with less than a high school diploma (OR = 0.11; 95% CI = 0.04, 0.32) and men with high school diplomas or some college or trade school (OR = 0.31; 95% CI = 0.15, 0.64) were less likely to be currently screened. It should be noted that odds ratios for the main effects of sex and education are not interpretable independently of the interaction odds ratio.32
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Men and women who were currently screened for PSA and mammography, respectively, were more likely to be screened for CRC than those who were not (OR = 4.40; 95% CI = 2.94, 6.58). Those who had a regular checkup (OR = 3.07; 95% CI = 2.00, 4.71) and vitamin supplement users (OR = 1.87; 95% CI = 1.27, 2.77) had higher screening rates. Sex-stratified models predicting current CRC screening were also fit; because no further differences were observed, these models are not presented.
Mammography and PSA screening. For mammography, women 75 years or older had a lower likelihood of current screening (OR = 0.45; 95% CI = 0.19, 1.02). Having a regular checkup was also associated with increased screening (OR = 5.67; 95% CI = 3.03, 10.61). There was a suggestion of increased likelihood of screening among vitamin supplement users and those having an annual household income of greater than $50 000.
For PSA, men aged 64 to 75 years were more likely to be screened than younger men (OR = 2.61; 95% CI = 1.45, 4.70). Receiving a regular checkup was significantly associated with increased screening (OR = 6.35; 95% CI = 3.30, 12.20). Although not statistically significant, vitamin supplement use was also associated with current PSA screening.
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DISCUSSION |
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TOPABSTRACTINTRODUCTIONMETHODSRESULTSDISCUSSIONReferences |
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In contrast, the issue of PSA screening for prostate cancer has been more controversial and driven largely by patient demand39,40 amid concern about prostate cancer as a major health issue, particularly for African Americans.41 While the effectiveness of PSA screening in improving prostate cancer survival continues to be debated, low cost, ease of performance, and fear of cancer have contributed to the popularity of the test.
Credible guidelines have only recently been developed and promoted for CRC screening, and the recommendations are complex, with numerous testing options. Health plan and provider performance is more difficult to measure, given the number of screening options and the fact that a person may be "currently screened" on the basis of a test conducted several years earlier for diagnostic purposes. While health plans aggressively educate members about mammography and have developed sophisticated in-reach (e.g., tracking and physician cuing) and outreach programs, similar efforts are not yet applied to CRC and prostate cancer detection in most plans. Patient perceptions of CRC screening are frequently negative, particularly in contrast to the ease of acceptance of the PSA blood test. Findings from this study must be viewed in the context of the distinct histories and characteristics of the 3 cancer screening efforts we investigated.
This study is among the first few to investigate the prevalence of CRC screening according to recent guidelines.15 Overall, the prevalence of current CRC screening was modest (55.3%). The prevalence of PSA screening among men in the sample was similar to the rate of CRC screening (52.4%), while the prevalence of mammography screening was considerably higher (73.9%). Estimates of rates of fecal occult blood testing, flexible sigmoidoscopy, and mammography in this study were similar to those observed in the Massachusetts Behavioral Risk Factor Surveillance System.8,9 No prevalence estimate is currently available for PSA screening in Massachusetts; however, other population-based studies10,11,42 have reported PSA screening rates of 25% to 31%. Given the absence of a consensus on PSA screening in the medical community,12,13 our findings suggest a strong consumer demand for the test.
We observed interesting similarities and differences among screens. As previously noted, a strong association was found between each cancer screen and receiving a regular checkup.10,43 Two explanatory factors are probably operating: similar attitudes and predisposing factors motivate people to get checkups and screening, and checkups provide clinicians with the opportunity to promote screening.
We found that family history of CRC is a powerful stimulus to screening for both men and women.44 Although receiving mammography screening was associated with family history of breast cancer in earlier studies,45 we did not find a significant association. This suggests a ceiling on the effect of family history when screening rates approach 70% among women without a family history. The absence of a substantial effect of a family history of prostate cancer on PSA screening may be due to the fact that family history has not been widely promoted as a risk factor.
In the bivariate analysis, higher income level was associated with mammography and PSA use, but not with CRC screening. The lack of significance of income in the multivariate models is probably due to the complex relationships among income, education, employment, and insurance coverage, which cannot be modeled precisely without a very large sample. The sample size was also inadequate to detect differences between racial/ethnic subgroups. Future study of these population subgroups is needed to assess possible differences.
We found that those 65 years or older in Medicare HMOs were most likely to be screened for CRC. Bivariate analyses demonstrated similarly high rates of screening for PSA for the Medicare HMO groups. This may reflect differences in patient mix among systems of care,46 organized administrative systems that enable screening,47 or benefits and copayment policies.48
Among men, age differences in CRC screening were attributable to high enrollment among men aged 65 to 74 years in Medicare HMO plans. For PSA, however, men aged 65 to 74 years had increased screening, possibly highlighting consumer-driven interest in this disease among this age group. The relatively low rate of PSA screening in the oldest group may reflect the general consensus among proponents of PSA that screening men older than 75 is not likely to improve survival.
Although there were no age differences among women with respect to CRC screening, the oldest women were less likely to be screened by mammography, a finding demonstrated previously.49 Among the oldest women in this study, there was a particularly strong association between participation in mammography and CRC screening. This, along with the similarity of screening prevalence for mammography and CRC among the oldest women, suggests one group of older women who adopt new screening technologies quickly and another group of women unlikely to accept screening even after years of exposure to promotional messages. If the diffusion of CRC screening follows the pattern of mammography, we might expect the rate among younger women to rise considerably and the rate in the oldest group to remain stable or increase more slowly.
In the overall sample, men and women had similar rates of CRC screening and there was no significant association between CRC screening and educational level. However, among men, there were differences in screening rates according to educational level, with decreasing educational level associated with less screening. No such association was observed among women. This issue is worthy of more investigation, as it may reflect patterns of care-seeking behavior or patient–clinician interactions that vary by combinations of sex and educational level.50
The findings related to health and lifestyle behavior suggest an overall constellation of health-promoting behavior, including supplement use and care seeking. We also found, as did Patterson et al.,27 that supplement use was an independent predictor of mammography and of PSA and CRC screening. Nonsmoking has been associated with mammography screening24,51; we identified modest but statistically insignificant higher rates of screening among nonsmokers for all 3 screening tests. Smoking behavior has been associated with less use of medical services.25,52 We found that whereas 76% of nonsmokers received regular checkups, only 64% of smokers did. However, future study that more precisely measures smoking intensity is needed to sufficiently address the question of how smoking status influences CRC screening behavior.
As with any random-digit-dialed survey, there are acknowledged limitations to this study. Relying on self-reported data yields possible bias due to underestimating the length of time since screening examinations and checkups,53–55 as well as inaccuracies in reports of type of insurance (e.g., HMO vs non-HMO).56 Social desirability could also result in bias in reporting lifestyle characteristics. As with other studies, we found it difficult to achieve a high response rate in this era of intrusive telephone marketing, answering machines, and public distrust.30
Overall, within sex groups, health and lifestyle behaviors affecting screening prevalence were similar for CRC and mammography and for CRC and PSA screening. Interest in prevention as measured by checkups, nonsmoking, and use of supplements defines a group of consistently health-conscious individuals very likely to adhere to screening. Differences based on personal characteristics may be attributable to differences based on the history of diffusion of the test or on peculiarities of the promotion of the test. Implications of our findings for public health and clinical practice are that screening may "beget" screening and that efforts to improve access to preventive care in general should be promoted. Working with individuals to accept one screening test may lead to a shift in attitudes, making them open to other tests.
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Acknowledgments |
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We acknowledge the thoughtful review of Stephen Erban, MD, and the assistance of Maureen Vickers-Lahti in data management and Kathee Sonner in manuscript preparation. We obtained approval from the Institutional Review Board of the University of Massachusetts Medical School before initiating the study.
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Footnotes |
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Accepted for publication August 23, 2000.
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References |
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A. Chao, C. J. Connell, V. Cokkinides, E. J. Jacobs, E. E. Calle, and M. J. Thun Underuse of Screening Sigmoidoscopy and Colonoscopy in a Large Cohort of US Adults Am J Public Health, October 1, 2004; 94(10): 1775 - 1781. [Abstract] [Full Text] [PDF]
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 A. F. Jerant, P. Franks, J. E. Jackson, and M. P. Doescher Age-Related Disparities in Cancer Screening: Analysis of 2001 Behavioral Risk Factor Surveillance System Data Ann. Fam. Med, September 1, 2004; 2(5): 481 - 487. [Abstract] [Full Text] [PDF]
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S. T. Hawley, S. W. Vernon, B. Levin, and B. Vallejo Prevalence of Colorectal Cancer Screening in a Large Medical Organization Cancer Epidemiol. Biomarkers Prev., February 1, 2004; 13(2): 314 - 319. [Abstract] [Full Text] [PDF]
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 J. M. McWilliams, A. M. Zaslavsky, E. Meara, and J. Z. Ayanian Impact of Medicare Coverage on Basic Clinical Services for Previously Uninsured Adults JAMA, August 13, 2003; 290(6): 757 - 764. [Abstract] [Full Text] [PDF]
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M. E. Gornick A Decade of Research on Disparities in Medicare Utilization: Lessons for the Health and Health Care of Vulnerable Men Am J Public Health, May 1, 2003; 93(5): 753 - 759. [Abstract] [Full Text] [PDF]
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J. M. E. Walsh and J. P. Terdiman Colorectal Cancer Screening: Clinical Applications JAMA, March 12, 2003; 289(10): 1297 - 1302. [Abstract] [Full Text] [PDF]
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