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Trends in Cancer Screening -- United States, 1987 and 1992

Screening methods and programs are critical strategies for the early detection and timely treatment of some cancers. Established methods for early detection of cancer include mammography, clinical breast examination (CBE), the Papanicolaou (Pap) test, proctosigmoidoscopy, fecal occult blood test (FOBT), and digital rectal examination (DRE) (1-4). To examine changes in the reported use of selected cancer screening tests, the National Cancer Institute analyzed data from CDC's National Health Interview Survey (NHIS) for 1987 and 1992 to calculate rates of use and compared these rates with the national health objectives for the year 2000 (5). This analysis suggests that, although the use of these tests increased, substantial progress is needed to meet the objectives.

The NHIS is a continuing nationwide household survey that collects information from a representative sample of the U.S. civilian, noninstitutionalized population aged greater than or equal to 18 years. The overall response rate for the 1987 and 1992 surveys was 95.3% (n=122,859) and 95.7% (n=128,412), respectively. In 1987 and 1992, questions were included to determine respondents' knowledge and practices regarding cancer screening. Respondents were asked whether they had ever had a Pap test, CBE, mammography, DRE, FOBT, or proctosigmoidoscopy. Respondents who answered "yes" to any of the questions were asked when their most recent test had been performed. Screening tests were defined as tests performed for any reason other than as the result of a health problem. For CBE, mammography, DRE, and FOBT, screening was considered recent if it had been performed during the year preceding the interview; for the Pap test and proctosigmoidoscopy, within the preceding 3 years. Data about CBE and mammography are presented for women aged greater than or equal to 40 years; for DRE, FOBT, and proctosigmoidoscopy, persons aged greater than or equal to 40 years, and for the Pap test, women aged greater than or equal to 18 years with an intact uterus. Race/ethnicity-specific data are presented because screening rates and death rates historically have varied by these categories; data are presented only for whites, blacks, and Hispanics because numbers for other racial groups were too small to calculate precise estimates. Race/ethnicity-specific data were weighted using SUDAAN (6), and population and standard errors were estimated.

From 1987 to 1992, the overall percentage of women aged greater than or equal to 18 years who reported having had a recent Pap test remained stable (Table_1). The percentage increased slightly for Hispanic women, and remained low for women aged greater than or equal to 70 years ((Table_1) and (Table_2)). The increase in the percentage of women ever tested was greater for women aged greater than or equal to 50 years (85% to 89%) than women aged less than 50 years (90% to 92%), and for black (88% to 92%) and Hispanic women (75% to 83%) than white women (91% to 92%).

During this period, the percentage of respondents who reported recent mammography increased at least twofold for women in every age and racial/ethnic group. The greatest increases were for black and Hispanic women; as a consequence, in 1992, screening rates were similar for white, black, and Hispanic women. However, women aged greater than or equal to 70 years in 1992 remained less likely to have had a recent screening and to have ever been tested than women aged less than 70 years. From 1987 to 1992, the percentage of respondents who reported having had a recent CBE also increased; in 1992, at least 75% of women in each age group reported ever having the test.

From 1987 to 1992, the percentage of respondents who reported ever having had a DRE increased from 49% to 54% for men and from 51% to 54% for women (Table_2). Although increases were greater for men than women, rates for recent DRE were lower for men than women (22% versus 21% in 1992). Rates of recent FOBT remained stable; however, the rate for black men increased more than twofold, from 7% to 15%. The overall percentages of respondents who reported ever having had proctosigmoidoscopy increased for men (24% to 30%) and for women (21% to 26%), and the percentage screened recently was higher for men than women in both 1987 and 1992 (7% and 11%, respectively, versus 5% and 7%, respectively).

Reported by: N Breen, PhD, L Kessler, PhD, Applied Research Br, National Cancer Institute, National Institutes of Health. Div of Cancer Prevention and Control, National Center for Chronic Disease Prevention and Health Promotion; National Center for Health Statistics, CDC.

Editorial Note

Editorial Note: The analysis described in this report estimates use of cancer screening tests based on a representative sample of the U.S. population, and four of these tests have been targeted as national health objectives for the year 2000 (objectives 16.11-16.14). Although the findings indicate an increase in the recent use of all cancer screening tests (except the Pap test) from 1987 to 1992, percentages are substantially lower than the national health objectives. For example, one national health objective is to increase the rate of mammography among women aged greater than or equal to 50 years to 60% every 2 years and among women aged greater than or equal to 40 years to 80% ever (objective 16.11). Based on this survey, the rate of recent mammography among women aged greater than or equal to 50 years was 44% in 1992 and ever having had mammography was 70% for women aged greater than or equal to 40 years.

The differences in the screening rates and the national health objectives may, in part, reflect for respondents a lack of 1) health insurance coverage, 2) a primary-care physician, or 3) clear communication between physicians and patients about the importance of routine screening. For example, the lower rate of mammography use by women aged greater than or equal to 50 years (who are at greatest risk for breast cancer) may reflect the finding that these women are less likely to visit gynecologists, and of all physician specialists, gynecologists are most likely to recommend mammograms (7). In addition, for women with low incomes, the mammography objectives are unlikely to be met because facilities that perform mammography may not accept women without a referral from a primary-care physician, and a disproportionate number of women with low incomes do not have a regular health-care provider. To promote mammography screening among older women, since 1990, Medicare has reimbursed the cost of biennial mammograms. Although the reimbursement fee is substantially less than the median price of mammograms in the United States, the fee is feasible if mammograms are delivered using more efficient methods and established mass-production techniques (8).

In the United States, managed care and the increased use of health maintenance organizations (HMOs) are likely to increase the use of all preventive-care services (including screening examinations), particularly if primary-care physicians are encouraged to screen patients routinely and recommend screening tests they currently do not perform. In addition, however, the importance of some screening examinations, such as the Pap test, may need to be emphasized regularly in public health messages.

References

  1. Miller AB, Lindsay J, Hill GB. Mortality from cancer of the uterus in Canada and its relationship to screening for cancer of the cervix. Int J Cancer 1976;17:602-12.

  2. Mandel JS, Bond JH, Church TR, et al. Reducing mortality from colorectal cancer by screening for fecal occult blood: Minnesota Colon Cancer Control Study. N Engl J Med 1993;328:1365-71.

  3. Selby JV, Friedman GD, Quesenberry CP Jr, Weiss NS. A case-control study of screening sigmoidoscopy and mortality from colorectal cancer. N Engl J Med 1992;326:653-7.

  4. Newcomb PA, Norfleet RG, Storer BE, Surawicz TS, Marcus PM. Screening sigmoidoscopy and colorectal cancer mortality. J Natl Cancer Inst 1992;84:1572-5.

  5. Public Health Service. Healthy people 2000: national health promotion and disease prevention objectives -- full report, with commentary. Washington, DC: US Department of Health and Human Services, Public Health Service, 1991; DHHS publication no. (PHS)91-50212.

  6. Shah BV, Folsom RE, Harrell FE, Dillard CN. Survey data analysis software for logistic regression. Research Triangle Park, North Carolina: Research Triangle Institute, 1984.

  7. Schappert SM. National Ambulatory Medical Care Survey: 1989 summary. Hyattsville, Maryland: US Department of Health and Human Services, Public Health Service, CDC, NCHS, 1992. (Vital and health statistics; series 13, no. 110).

  8. Physician Payment Review Commission. The cost of providing screening mammography: report to Congress. Washington, DC: Physician Payment Review Commission, 1989.



Table_1
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TABLE 1. Percentage of persons who reported ever or recently * having had
screening tests for cancer, by test, age group of respondent, and year
-- United States, National Health Interview Survey, 1987 and 1992 +
============================================================================
                    Persons ever tested      Persons tested recently
                   ----------------------   --------------------------------
                      1987         1992        1987        1992
Test/              ---------   ----------   ----------   -----------
 Age group (yrs)    %  (SE &)   %   (SE)      %   (SE)    %   (SE)
----------------------------------------------------------------------------
Papanicolaou test@
 18-29              84  (0.4)   85  (0.5)     70  (0.3)   73  (0.8)
 30-39              95  (0.5)   95  (0.2)     77  (0.7)   76  (0.8)
 40-49              94  (0.9)   97  (1.0)     71  (1.4)   71  (1.6)
 50-59              91  (1.0)   94  (0.6)     67  (1.5)   64  (1.1)
 60-69              88  (2.0)   92  (1.7)     57  (1.7)   59  (1.7)
  >=70              76  (0.2)   82  (1.9)     41  (0.5)   43  (1.7)

Clinical breast
 examination
 40-49              87  (0.7)   95  (0.7)     49  (0.9)   55  (1.5)
 50-59              86  (0.8)   94  (0.7)     47  (0.6)   55  (1.9)
 60-69              80  (1.4)   89  (1.5)     42  (1.3)   49  (2.4)
  >=70              70  (1.3)   80  (2.5)     35  (1.0)   37  (1.4)

Mammography
 40-49              41  (1.4)   70  (1.7)     17   (1.9)  35  (1.0)
 50-59              44  (0.6)   75  (2.2)     20   (0.6)  42  (2.7)
 60-69              38  (0.8)   68  (2.4)     17   (0.5)  39  (2.4)
  >=70              28  (1.2)   58  (1.9)     12   (0.8)  28  (0.8)

Digital rectal
 examination
 Men
  40-49             46  (3.0)   53  (1.2)     12   (0.8)  14  (1.7)
  50-59             48  (1.4)   55  (2.7)     17   (0.9)  22  (1.1)
  60-69             54  (1.6)   55  (1.3)     21   (1.4)  29  (2.1)
   >=70             51  (1.3)   53  (1.1)     23   (2.1)  31  (1.6)
 Women
  40-49             51  (0.7)   57  (0.6)     26   (0.7)  29  (1.9)
  50-59             53  (1.7)   60  (3.6)     25   (1.5)  34  (3.4)
  60-69             55  (2.5)   57  (1.0)     26   (1.7)  27  (1.0)
   >=70             46  (0.6)   43  (2.0)     18   (1.3)  18  (0.4)

Fecal occult
 blood test
 Men
  40-49             32  (1.8)   35  (0.3)      8   (1.3)   8  (0.9)
  50-59             37  (2.5)   42  (2.5)     12   (1.0)  15  (1.5)
  60-69             46  (2.2)   51  (3.6)     14   (2.2)  18  (2.2)
   >=70             38  (2.0)   56  (2.9)     15   (1.3)  20  (2.2)
 Women
  40-49             28  (1.4)   33  (0.6)     10   (1.1)   9  (0.8)
  50-59             42  (1.1)   45  (0.3)     16   (0.5)  17  (1.1)
  60-69             45  (0.8)   51  (1.3)     19   (1.0)  21  (1.8)
   >=70             39  (1.8)   48  (1.9)     15   (1.0)  16  (1.4)

Proctosigmoidoscopy
 Men
  40-49             15  (1.2)   20  (1.0)      4   (1.0)   6  (0.6)
  50-59             23  (1.1)   28  (1.3)      7   (1.2)  12  (2.0)
  60-69             33  (1.8)   37  (1.3)      9   (1.2)  13  (1.5)
   >=70             28  (1.7)   45  (2.0)      9   (0.6)  15  (2.0)
 Women
  40-49             21  (0.8)   15  (1.4)      2   (0.5)     4  (0.4)
  50-59             13  (0.7)   29  (1.5)      5   (0.8)     7  (1.2)
  60-69             24  (2.0)   31  (1.7)      7   (0.8)     9  (1.7)
   >=70             26  (0.8)   33  (0.8)      6   (0.8)     8  (0.6)
----------------------------------------------------------------------------
* For Papanicolaou and proctosigmoidoscopy, "recently" is defined as
  during the 3 years preceding the interview; for clinical breast
  examination, mammography, digital rectal examination, and fecal
  occult blood test, during the year preceding the interview.
+ For 1987, the sample size was 122,859 (response rate: 95.3%), and
  for 1992 was 128,412 (response rate: 95.7%).
& Standard error.
@ Excludes women who had had a hysterectomy.
============================================================================

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Table_2
Note: To print large tables and graphs users may have to change their printer settings to landscape and use a small font size.

TABLE 2. Percentage of persons who reported ever or recently * having had
screening tests for cancer, by test, race/ethnicity, + and year -- United
States, National Health Interview Survey, 1987 and 1992 &
============================================================================

                      Persons ever tested     Persons tested recently
                     ----------------------   -------------------------
                        1987        1992          1987        1992
Test/                -----------  ---------   -----------   -----------
  Race/Ethnicity      %   (SE @)   %   (SE)      %   (SE)    %   (SE)
---------------------------------------------------------------------------
Papanicolaou test **
  White               91  (0.2)    92  (0.6)     69  (0.2)   66  (0.3)
  Black               88  (0.3)    92  (0.8)     70  (0.7)   73  (1.3)
  Hispanic            75  (0.2)    83  (1.5)     59  (1.2)   66  (1.4)
  Total               88  (0.2)    90  (0.6)     67  (0.2)   67  (0.3)

Clinical breast
  examination
  White               84  (0.9)    91  (0.3)     44  (0.5)   50  (1.7)
  Black               74  (1.1)    85  (2.2)     46  (2.1)   51  (1.9)
  Hispanic            73  (2.1)    86  (3.0)     45  (1.7)   53  (4.0)
  Total               81  (0.8)    90  (0.7)     44  (0.2)   50  (1.3)

Mammography
  White               40  (0.5)    69  (1.3)     18  (0.8)   36 (1.7)
  Black               31  (2.0)    64  (1.6)     14  (1.3)   32 (1.4)
  Hispanic            28  (1.0)    70  (3.9)     13  (2.3)   38 (3.2)
  Total               38  (0.4)    68  (1.0)     17  (0.7)   36 (1.1)

Digital rectal
  examination
  Men
    White             52  (1.4)    57  (0.5)     18   (1.1)  23 (0.7)
    Black             38  (1.6)    43  (3.1)     16   (1.5)  19 (3.8)
    Hispanic          32  (1.7)    37  (6.1)      9   (1.9)  13 (2.5)
    Total             49  (1.2)    54  (1.0)     17   (1.0)  22 (1.0)

  Women
    White             54  (0.7)    56  (1.3)     25   (0.4)  28 (1.0)
    Black             44  (2.0)    51  (3.7)     22   (1.3)  25 (3.3)
    Hispanic          38  (2.0)    39  (0.7)     15   (2.4)  18 (1.5)
    Total             51  (0.7)    54  (0.9)     24   (0.6)  27 (1.0)
 Fecal occult
  blood test
  Men
    White             39  (1.7)    46  (1.2)     13   (0.9)  15 (0.9)
    Black             29  (2.3)    41  (4.9)      7   (0.9)  15 (2.1)
    Hispanic          30  (5.1)    32  (4.5)      7   (2.4)   6 (0.6)
  Total               38  (1.5)    44  (1.4)     12   (7.7)  14 (1.0)

  Women
    White             39  (0.9)    44  (0.8)     16   (0.6)  16 (1.1)
    Black             33  (1.4)    39  (2.1)     13   (1.8)  12 (1.8)
    Hispanic          28  (2.0)    39  (4.1)      9   (1.4)  11 (2.3)
  Total               38  (0.7)    43  (0.6)     15   (0.5)  15 (0.8)

Proctosigmoidoscopy
  Men
    White             25  (1.0)    32  (1.0)      7   (0.2)  11 (1.1)
    Black             15  (1.7)    27  (4.1)      5   (0.9)  11 (2.2)
    Hispanic          16  (2.9)    23  (0.9)      2   (1.3)   8 (1.7)
  Total               24  (0.9)    30  (1.1)      7   (0.2)  11 (1.1)

  Women
    White             23  (1.0)    27  (0.6)      5   (0.1)   6 (0.3)
    Black             12  (0.6)    21  (2.4)      3   (0.4)   8 (1.8)
    Hispanic          12  (1.8)    18  (2.7)      2   (0.9)   5 (1.5)
  Total               21  (0.8)    26  (0.5)      5   (0.2)   7 (0.4)
============================================================================
*  For Papanicolaou and proctosigmoidoscopy, "recently" is defined as
   during the 3 years preceding the interview; for clinical breast
   examination, mammography, digital rectal examination, and fecal occult
   blood test, during the year preceding the interview.
+  Data are presented only for blacks, whites, and Hispanics because numbers
   for other racial groups were too small to calculate precise estimates.
&  For 1987, the sample size was 122,859 (response rate: 95.3%), and for
   1992 was 128,412 (response rate: 95.7%).
@  Standard error.
** Excludes women who had had a hysterectomy.
============================================================================

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