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Screening for Colorectal Cancer -- United States, 1997

Colorectal cancer is the second leading cause of cancer-related deaths in the United States (1). During 1999, approximately 129,400 new cases of colorectal cancer will be diagnosed, and 56,600 persons will die from the disease (1). In 1996, the U.S. Preventive Services Task Force (USPSTF) recommended the use of specific screening tests (i.e., annual fecal-occult blood testing {FOBT} and/or periodic flexible sigmoidoscopy for persons aged greater than or equal to 50 years) to reduce colorectal cancer-related mortality (2). In 1997, the American Cancer Society and an interdisciplinary task force developed guidelines that recommend one test or a combination of several tests for colorectal cancer screening (3,4). To estimate the proportion of the U.S. population that received colorectal cancer screening tests, CDC analyzed data from the 1997 Behavioral Risk Factor Surveillance System (BRFSS) on the use of a home-administered blood stool test, or FOBT, and sigmoidoscopy/proctoscopy. This report summarizes the results of this analysis, which documents low rates of use of colorectal cancer screening tests.

In 1997, all 50 states, the District of Columbia, and Puerto Rico participated in the BRFSS, a population-based, random-digit-dialed telephone survey of the noninstitutionalized, U.S. population aged greater than or equal to 18 years. A total of 52,754 persons aged greater than or equal to 50 years were asked whether they had ever had a blood stool test (FOBT) using a home kit and whether they had ever had a sigmoidoscopy or proctoscopy, and when the last test had been performed. Responses coded as "Don't know/Not sure" or "Refused" were excluded from the analyses (approximately 3%). Data were weighted to the age, sex, and racial/ethnic distribution of each state's adult population using 1990 census or intercensal estimates. Proportions, standard errors, and 95% confidence intervals were calculated using SAS and SUDAAN. Data were aggregated across states. Aggregated and state-level data are presented for the proportion of respondents aged greater than or equal to 50 years who reported receiving FOBT or sigmoidoscopy/proctoscopy.

Overall, 39.7% of respondents reported ever having had FOBT, and 41.7% reported ever having had sigmoidoscopy/proctoscopy. For this report, all results refer to tests received during the recommended time period (e.g., during the preceding year for FOBT and during the preceding 5 years for sigmoidoscopy/proctoscopy).

A total of 19.8% of respondents reported having had FOBT during the preceding year, and 30.4% reported having had a sigmoidoscopy/proctoscopy during the preceding 5 years (Table_1). The proportion of all respondents who reported having had either test or both tests within the recommended time interval was 40.9% and 9.5%, respectively. Men were more likely than women to report having had a sigmoidoscopy/proctoscopy (35.1% and 26.7%, respectively), and women were more likely than men to report having had FOBT (20.9% and 18.3%, respectively). The proportion of American Indians/Alaskan Natives and Asians/Pacific Islanders who reported having had FOBT was less than that of whites and blacks (Table_1). Respondents identifying themselves as of Hispanic origin were less likely to report having had either test than respondents identifying themselves as non-Hispanic. The proportion of respondents who reported having had either test increased with each age group until age 70-79 years, then decreased among persons aged greater than or equal to 80 years.

For both screening modalities, the proportion of respondents who reported having had a test increased with increasing education and income level (Table_1). The proportion of respondents who reported having had a test was greater for those with health-care coverage than for those without coverage. For persons without health-care coverage, 8.2% and 16.3% of respondents reported having had FOBT and sigmoidoscopy/proctoscopy, respectively, and 20.6% and 31.4% of those with health-care coverage reported having had the tests.

By state, the proportion of respondents who reported having had FOBT during the preceding year ranged from 9.2% (Mississippi) to 28.4% (Maine) (Table_2). The proportion of respondents who reported having had sigmoidoscopy/proctoscopy during the preceding 5 years ranged from 15.5% (Oklahoma) to 41.5% (District of Columbia).

Reported by: State Behavioral Risk Factor Surveillance System coordinators. Epidemiology and Health Svcs Research Br, Div of Cancer Prevention and Control, National Center for Chronic Disease Prevention and Health Promotion; and an EIS Officer, CDC.

Editorial Note

Editorial Note: Although screening can reduce mortality from colorectal cancer (2-4), the findings in this report indicate low use of sigmoidoscopy/proctoscopy and FOBT, particularly within the recommended time intervals. Persons with health-care coverage, higher incomes, and more years of education were more likely to report having had these tests.

The 1997 BRFSS was the first time questions about use of FOBT specified that the test was conducted at home using a kit. Previous survey questions did not address whether samples were obtained at home using a kit or as part of a digital rectal examination. The home kit is the recommended method of obtaining a stool sample (3,5,6). Use of the home kit allows for collection of multiple samples and should be performed in conjunction with dietary restrictions to decrease the possibility of false-positive or false-negative results from certain foods and medications (4,6).

Previous estimates of the prevalence of colorectal cancer screening practices using the 1993 BRFSS demonstrated that the rates of use of colorectal cancer screening tests were low (7). Although direct comparison between these two analyses is not possible because the wording of the survey questions differed, the current analysis demonstrates continued underuse of sigmoidoscopy/proctoscopy. Both patient and provider barriers have contributed to the low rates of screening. Patient barriers may include lack of knowledge of screening recommendations, access to health care, anticipated discomfort, and embarrassment. Provider barriers may include lack of skills and lack of time to counsel patients (2,8).

The findings in this report are subject to at least three limitations. First, because the BRFSS is administered as a telephone survey, only persons with telephones are represented. Second, results are based on self-reports and have not been validated. However, self-report of certain colorectal cancer screening tests appears to be valid (9). Third, because the BRFSS questionnaire did not distinguish between tests conducted for diagnostic or screening purposes, the rates of use of these tests for screening purposes were probably lower than reported.

Activities relating to colorectal cancer screening are increasing at both the state and national levels. In 1997, the American Cancer Society and CDC established the National Colorectal Cancer Roundtable, a collaboration of state health departments, professional and medical societies, private industry, consumers, and cancer survivors to promote colorectal cancer screening awareness and activities. In 1998, the Health Care Financing Administration expanded Medicare coverage to include colorectal cancer screening. For average-risk persons aged greater than or equal to 50 years, coverage will be provided for annual FOBT and sigmoidoscopy every 4 years, and for high-risk persons, coverage will be provided for colonoscopy every 2 years. Double-contrast barium enema may be substituted for either sigmoidoscopy or colonoscopy if requested in writing by the provider. Some commercial health plans also cover colorectal cancer screening.

The findings in this report underscore the need for efforts to increase screening for colorectal cancer. In response to low rates of use of screening tests, CDC is beginning a comprehensive health communication campaign to educate consumers and health-care providers about the importance of colorectal cancer screening and to encourage patients to discuss screening options with their providers. Public health officials, health-care providers, and commercial health plans need to intensify efforts to increase awareness of the effectiveness of screening and to promote the widespread use of colorectal cancer screening tests.

References

  1. American Cancer Society. Cancer facts and figures, 1999. Atlanta: American Cancer Society, 1999; publication no. 5008.99.
  2. US Preventive Services Task Force. Guide to clinical preventive services. 2nd ed. Baltimore: Williams and Wilkins, 1996.
  3. Byers T, Levin B, Rothenberger D, Dodd GD, Smith RA. American Cancer Society guidelines for screening and surveillance for early detection of colorectal polyps and cancer: update 1997. CA Cancer J Clin 1997;47:154-60.
  4. Winawer SJ, Fletcher RH, Miller L, et al. Colorectal cancer screening: clinical guidelines and rationale. Gastroenterology 1997;112:594-642.
  5. Mandel JS, Bond JH, Church TR, et al. Reducing mortality from colorectal cancer by screening for fecal occult blood. N Engl J Med 1993;328:1365-71.
  6. Ransohoff DF, Lang CA. Screening for colorectal cancer with the fecal occult blood test: a background paper. Ann Intern Med 1997;126:811-22.
  7. CDC. Screening for colorectal cancer -- United States, 1992-1993, and new guidelines. MMWR 1996;45:107-10.
  8. McCarthy BD, Moskowitz MA. Screening flexible sigmoidoscopy: patient attitudes and compliance. J Gen Intern Med 1993;8:120-5.
  9. Montano DE, Phillips WR. Cancer screening by primary care physicians: a comparison of rates obtained from physician self-report, patient survey, and chart audit. Am J Public Health 1995;85:795-800.



Table_1
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TABLE 1. Percentage of respondents aged >=50 years who reported having had
colorectal cancer screening tests within recommended time intervals, by selected
characteristics -- United States, Behavioral Risk Factor Surveillance System, 1997
=================================================================================================================
                                     Fecal occult blood test                   Sigmoidoscopy/proctoscopy
                                      during preceding year                    during preceding 5 years
                                ---------------------------------        -------------------------------------
Characteristic                  No.*           (%)      (95% CI+)         No.              (%)        (95% CI)
--------------------------------------------------------------------------------------------------------------
Sex
 Men                            3,432         (18.3)    (+/-0.8)          6,639           (35.1)      (+/-1.0)
 Women                          6,400         (20.9)    (+/-0.7)          8,039           (26.7)      (+/-0.8)

Race
 White                          8,755         (20.1)    (+/-0.6)         13,068           (30.9)      (+/-0.7)
 Black                            681         (20.4)    (+/-2.1)          1,020           (29.8)      (+/-2.2)
 Asian/Pacific Islander           158         (11.5)    (+/-3.7)            224           (25.9)      (+/-7.1)
 American Indian/Alaskan
  Native                           75         (12.1)    (+/-4.3)          139             (24.4)      (+/-6.7)

Ethnicity
 Hispanic                         378         (12.7)    (+/-1.9)            574           (25.5)      (+/-2.9)
 Non-Hispanic                   9,420         (20.3)     (+0.6)          14,043           (30.8)      (+/-0.6)

Age group (yrs)
 50-59                          2,815         (15.5)    (+/-0.8)          4,106           (23.6)      (+/-1.0)
 60-69                          3,201         (21.8)    (+/-1.0)          4,667           (33.2)      (+/-1.2)
 70-79                          2,843         (23.7)    (+/-1.2)          4,383           (37.0)      (+/-1.3)
   >=80                           973         (20.1)    (+/-1.7)          1,522           (31.6)      (+/-2.0)

Education
 Less than high school          1,691         (16.2)    (+/-1.1)          2,743           (27.5)      (+/-1.4)
 High school graduate           3,285         (19.3)    (+/-0.9)          4,737           (28.0)      (+/-1.0)
 Some college/technical
  school                        2,375         (20.5)    (+/-1.1)         3,490            (31.2)      (+/-1.3)
 College graduate               2,454         (22.8)    (+/-1.2)          3,679           (35.9)      (+/-1.4)

Annual income
        <$10,000                  706         (16.1)    (+/-1.8)          1,020           (24.9)      (+/-2.3)
 $10,000-$24,999                2,709         (18.4)    (+/-1.0)          4,155           (28.4)      (+/-1.1)
 $25,000-$74,999                3,678         (20.4)    (+/-0.9)          5,524           (32.1)      (+/-1.1)
       >=$75,000                  863         (23.0)    (+/-2.0)          1,378           (36.8)      (+/-2.3)

Health-care coverage
 Yes                            9,553         (20.6)    (+/-0.6)         14,179           (31.4)      (+/-0.6)
 No                               275         ( 8.2)    (+/-1.5)            490           (16.3)      (+/-2.1)

Total                           9,832         (19.8)    (+/-0.5)         14,678           (30.4)      (+/-0.6)
--------------------------------------------------------------------------------------------------------------
* Numbers may not add to total because of missing data.
+ Confidence interval.
=================================================================================================================


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Table_2
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TABLE 2. Percentage of respondents aged >=50 years who reported having had
colorectal cancer screening tests within recommended time intervals, by area --
United States, Behavioral Risk Factor Surveillance System, 1997
===================================================================================================================
                                   Fecal occult blood test                      Sigmoidoscopy/proctoscopy
                                    during preceding year                        during preceding 5 years
                            --------------------------------------       ---------------------------------------
Area                          No.              (%)       (95% CI*)          No.              (%)        (95% CI)
----------------------------------------------------------------------------------------------------------------
Alabama                       124            (14.3)       (+/-2.6)          251            (29.6)       (+/-3.4)
Alaska                         53            (15.4)       (+/-5.1)          138            (33.0)       (+/-6.7)
Arizona                       136            (16.9)       (+/-3.7)          244            (31.3)       (+/-4.5)
Arkansas                       97            (13.4)       (+/-2.7)          168            (22.9)       (+/-3.3)
California                    261            (16.4)       (+/-2.0)          533            (35.4)       (+/-2.7)
Colorado                      157            (24.0)       (+/-3.6)          207            (30.7)       (+/-3.8)
Connecticut                   193            (24.2)       (+/-3.3)          284            (35.1)       (+/-3.8)
Delaware                      231            (22.5)       (+/-2.9)          370            (37.1)       (+/-3.2)
District of Columbia          123            (25.6)       (+/-4.4)          192            (41.5)       (+/-5.1)
Florida                       385            (24.0)       (+/-2.3)          459            (28.6)       (+/-2.5)
Georgia                       112            (14.8)       (+/-2.8)          269            (38.5)       (+/-4.0)
Hawaii                        177            (21.6)       (+/-3.5)          280            (39.7)       (+/-4.2)
Idaho                         333            (17.6)       (+/-2.2)          478            (26.1)       (+/-2.5)
Illinois                       74            (14.4)       (+/-3.3)          147            (29.2)       (+/-4.3)
Indiana                       129            (16.0)       (+/-3.0)          207            (23.9)       (+/-3.3)
Iowa                          282            (18.6)       (+/-2.2)          399            (27.9)       (+/-2.6)
Kansas                        165            (23.0)       (+/-3.3)          226            (29.9)       (+/-3.5)
Kentucky                      283            (18.2)       (+/-2.2)          378            (25.3)       (+/-2.5)
Louisiana                     100            (16.9)       (+/-3.2)          157            (26.2)       (+/-3.8)
Maine                         184            (28.4)       (+/-3.7)          206            (32.0)       (+/-3.8)
Maryland                      403            (25.1)       (+/-2.7)          386            (25.8)       (+/-2.8)
Massachusetts                 150            (28.1)       (+/-4.2)          164            (31.0)       (+/-4.4)
Michigan                      186            (22.4)       (+/-3.1)          296            (34.6)       (+/-3.4)
Minnesota                     378            (21.9)       (+/-2.1)          669            (39.7)       (+/-2.5)
Mississippi                    68            ( 9.2)       (+/-2.2)          173            (25.7)       (+/-3.7)
Missouri                      148            (17.2)       (+/-2.9)          219            (29.6)       (+/-3.7)
Montana                       117            (16.6)       (+/-3.0)          182            (25.4)       (+/-3.3)
Nebraska                      214            (17.8)       (+/-2.5)          268            (24.1)       (+/-3.0)
Nevada                        109            (10.7)       (+/-4.5)          228            (29.1)       (+/-6.2)
New Hampshire                 143            (26.8)       (+/-4.4)          163            (33.4)       (+/-4.4)
New Jersey                    200            (21.7)       (+/-3.0)          271            (29.6)       (+/-3.3)
New Mexico                     99            (15.0)       (+/-3.0)          178            (27.0)       (+/-3.7)
New York                      291            (24.8)       (+/-2.8)          357            (31.7)       (+/-2.9)
North Carolina                370            (27.2)       (+/-2.6)          423            (30.8)       (+/-2.8)
North Dakota                  110            (14.7)       (+/-2.8)          222            (30.2)       (+/-3.6)
Ohio                          261            (18.4)       (+/-2.6)          433            (30.1)       (+/-3.0)
Oklahoma                       96            (10.9)       (+/-2.3)          139            (15.5)       (+/-2.7)
Oregon                        315            (23.9)       (+/-2.7)          399            (30.8)       (+/-2.8)
Pennsylvania                  294            (22.0)       (+/-2.5)          421            (31.9)       (+/-2.8)
Puerto Rico                   150            (16.1)       (+/-2.6)          183            (20.5)       (+/-2.8)
Rhode Island                  151            (21.1)       (+/-3.2)          220            (32.7)       (+/-3.8)
South Carolina                141            (15.5)       (+/-2.6)          187            (21.2)       (+/-3.0)
South Dakota                  133            (15.0)       (+/-2.5)          243            (27.9)       (+/-3.4)
Tennessee                     190            (15.9)       (+/-2.3)          303            (26.5)       (+/-2.8)
Texas                         154            (19.6)       (+/-3.1)          224            (27.5)       (+/-3.4)
Utah                          106            (14.7)       (+/-3.3)          256            (30.2)       (+/-4.0)
Vermont                       301            (26.6)       (+/-2.8)          314            (28.5)       (+/-2.9)
Virginia                      240            (19.8)       (+/-3.4)          392            (33.5)       (+/-3.9)
Washington                    306            (24.4)       (+/-2.6)          373            (31.1)       (+/-2.8)
West Virginia                 139            (11.9)       (+/-2.1)          266            (24.8)       (+/-2.7)
Wisconsin                     147            (17.2)       (+/-3.0)          271            (34.3)       (+/-3.8)
Wyoming                       123            (14.3)       (+/-2.5)          262            (30.0)       (+/-3.3)

Total                        9,832           (19.8)       (+/-0.5)        14,678           (30.4)       (+/-0.6)
----------------------------------------------------------------------------------------------------------------
* Confidence interval.
===================================================================================================================


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