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Colorectal Cancer Screening --- United States, 2002, 2004, 2006, and 2008

Sun Hee Rim, MPH

Djenaba A. Joseph, MD

C. Brooke Steele, DO

Trevor D. Thompson

Laura C. Seeff, MD

National Center for Chronic Disease Prevention and Health Promotion, CDC

Corresponding author: Laura C. Seeff, MD, Division of Cancer Prevention and Control, 1600 Clifton Road, NE, MS K-52, Atlanta, GA 30333. Telephone: 770-488-3223; Fax: 770-488-4760; E-mail: lvs3@cdc.gov.

Of the types of cancer that affect both men and women, colorectal cancer is the second leading cause of cancer-related deaths in the United States (1). Screening reduces colorectal cancer incidence and mortality (2). The U.S. Preventive Services Task Force recommended in 2008 that persons aged 50--75 years at average risk for colorectal cancer be screened for the disease by using one or more of the following methods: fecal occult blood testing (FOBT) every year, sigmoidoscopy every 5 years (with high-sensitivity FOBT every 3 years), or colonoscopy every 10 years (1).

To estimate disparities in rates of use of colorectal cancer tests and evaluate changes in test use, CDC compared data from the 2002, 2004, 2006, and 2008 Behavioral Risk Factor Surveillance System (BRFSS) surveys (3). BRFSS is a state-based, random-digit--dialed telephone survey of the noninstitutionalized, U.S. civilian population aged ≥18 years. Survey data were available for all 50 states (except for Hawaii in 2004) and the District of Columbia. The median response rate, based on Council of American Survey and Research Organizations (CASRO) guidelines,* was 58.3% in 2002, 52.7% in 2004, 51.4% in 2006, and 53.3% in 2008 (3). The median cooperation rate, based on CASRO guidelines, was 76.7% in 2002, 74.3% in 2004, 74.5% in 2006, and 75.0% in 2008 (3). Respondents who refused to answer, had a missing answer, or did not know the answer to a question were excluded from analysis of that specific question. Of persons aged ≥50 years who responded, approximately 3% of 108,028 persons were excluded from 2002 results, approximately 3% of 146,794 were excluded from 2004 results, approximately 4.5% of 195,318 were excluded from 2006 results, and approximately 4.1% of 251,623 were excluded from 2008 results.

Survey questions and response options were identical for survey years 2002, 2004, and 2006. Respondents aged ≥50 years were asked if they had ever used a "special kit at home to determine whether the stool contains blood (FOBT)," whether they had ever had "a tube inserted into the rectum to view the colon for signs of cancer or other health problems (sigmoidoscopy or colonoscopy)," and when these tests were last performed. In 2008, respondents also were asked whether their most recent test had been a sigmoidoscopy or a colonoscopy. For this report, as in previous reports (4--6), sigmoidoscopy and colonoscopy rates are measured and reported as a combined measure and described as lower endoscopy. Percentages were estimated for persons aged ≥50 years who reported receiving an FOBT within 1 year preceding the survey or lower endoscopy within 10 years preceding the survey, the recommended interval for colonoscopy for persons at average risk. For this analysis, all persons aged ≥50 years were included based on consideration of the screening recommendations during survey years and other age-related influences on screening (e.g., Medicare benefits for persons aged ≥65 years). States were categorized into poverty quartiles by using data from the 2009 Current Population Survey (available at http://cps.ipums.org/cps/sda), and aggregate screening rates per quartile were calculated. Respondents were defined as having a disability if they responded yes when asked whether they were limited in any way in any activities because of physical, mental, or emotional problems. Aggregate percentages and 95% confidence intervals were calculated by selected characteristics. Data were weighted according to the sex, racial/ethnic, and age distribution of the adult population of each state by using intercensal estimates and were age standardized to the 2008 BRFSS population aged ≥50 years. The Wald F test was used to determine the significance of differences among the four surveys.

In 2008, a total of 64.2% of respondents aged ≥50 years reported having had an FOBT within 1 year preceding the survey or lower endoscopy within 10 years preceding the survey, compared with 60.7% in 2006, 56.7% in 2004, and 53.8% in 2002 (Table 1). For all survey years, the proportions of persons aged ≥50 years who reported having had either test within recommended intervals was greater among persons aged ≥65 years than among those aged 50--64 years. The proportion was greater for non-Hispanic whites compared with all other races; men compared with women, persons with a disability compared with those with no disability, and persons with health insurance compared with those with no health insurance. The difference in proportions also increased with time among those with health insurance, compared with those with no health insurance (55.8% versus 33.0% in 2002, respectively, and 66.6% versus 37.5%, respectively, in 2008). Reported rates of test use increased with increasing education level and increasing household income. By composite state quartiles, reported screening rates decreased with increasing levels of poverty (Table 2).

The findings in this analysis indicate that although overall use of colorectal cancer tests increased from 2002 to 2008, disparities exist in the prevalence of colorectal cancer test use among certain groups. Although colorectal cancer test use increased among racial/ethnic minorities, those without health insurance, those with lower household incomes (<$35,000 annually), and those with less than a high school education, these four groups had a substantially lower prevalence of test use than did the comparison groups surveyed. However, the difference between the white and black populations was substantially less than the difference between whites and other racial/ethnic populations. Although rates of use of colorectal cancer tests increased among both those with and those without disabilities, rates were lower among persons without disabilities than among those with disabilities. Decreasing family income was associated with decreasing colorectal cancer screening rate.

Although colorectal cancer test use increased by approximately 11 percentage points among white and black populations from 2002 to 2008, only an approximate 4 percentage point increase in test use occurred among American Indian/Alaska Native populations. Those without health insurance had a 4.5 percentage point increase, compared with a 10.8 percentage point increase in screening rates among those with insurance. These differences might indicate that interventions are disproportionally reaching populations or have varying effects among different groups, an area in which additional research is needed (7). Factors that also might contribute to disparities in colorectal cancer test use include lack of awareness of the need for screening, lack of recommendation for screening from a physician, lack of health insurance, and lack of a usual source of care, all factors that can be more pronounced among underserved populations (6,8,9).

Previous studies have documented a greater prevalence of colorectal cancer test use among men compared with women (6,8). Available data indicate that the difference in use between men and women decreased during 2002--2006 but increased during 2006--2008. Respondents aged ≥65 years had a greater prevalence of colorectal cancer test use, compared with those aged 50--64 years, which might be associated with the availability of Medicare coverage for colorectal cancer screening after age 65 years (6,8). Variations in prevalence of test use by state might result from variations in demographic characteristics, insurance coverage, and availability of providers to perform endoscopy (10,11). Additional contributing factors might be increased public awareness of the importance of screening (8) and adoption of the Healthcare Effectiveness Data and Information Set (HEDIS) measure in 2004 that encourages health plans to cover colorectal screening tests (12). Furthermore, multiple state and federal initiatives have focused on increasing colorectal cancer test use, including the following: a statewide colorectal cancer screening program in Maryland supported through tobacco restitution funds; a statewide endoscopy screening program in Colorado funded by the state tobacco tax; the Colorectal Cancer Screening and Prostate Initiative Program in the state of New York, which has provided colorectal cancer screening to uninsured or underinsured residents since 2001; the CDC-funded Colorectal Cancer Screening Demonstration Program (CRCSDP), which supported state and local screening programs during 2005--2009; and the new CDC Colorectal Cancer Control Program (CRCCP), which provides funds to 25 states and four tribal organizations to increase population-level screening rates (13,14).

The CDC colorectal cancer screening programs were established specifically to address disparities in colorectal cancer screening rates and to improve access to underserved populations. The CDC CRCSDP provided services for low-income men and women aged ≥50 years with inadequate or no colorectal cancer screening insurance coverage at five sites across the country, including Baltimore, Maryland; St. Louis, Missouri; Nebraska (statewide); Suffolk County, New York; and Clallam, Jefferson, and King counties in Washington (13). Two of the programs focused on racial minorities (blacks in St. Louis; American Indians/Alaska Natives and blacks in the state of Washington).

On the basis of the success of implementing and sustaining CRCSDP, CDC received funds to establish CRCCP in 2009, with a goal of increasing screening rates among those aged ≥50 years to 80% in each of the participating states and tribal nations by 2014 (14). The majority of program funds are dedicated to screening promotion, with CRCCP programs using evidence-based strategies recommended by the Task Force on Community Preventive Services (http://www.thecommunityguide.org) to increase population-level screening, with a limited proportion of funds used to provide screening and follow-up care to low-income men and women aged 50--64 years who are underinsured or uninsured for screening (14). When possible, screening services of this program are integrated with other publicly funded health programs (e.g., the CDC National Breast and Cervical Early Detection Program [available at http://www.cdc.gov/cancer/nbccedp], the CDC WISEWOMAN Program [available http://www.cdc.gov/wisewoman], and the federally funded health centers of the Health Resources and Service Administration [available at http://bphc.hrsa.gov]).

CDC also provides funds to programs that are part of the National Comprehensive Cancer Control Program. Sixty-nine programs, which include all 50 U.S. states, the District of Columbia, seven tribes, and seven territories, are funded, all of which address nonservice delivery components of colorectal cancer control in their state, tribal, and territorial cancer control plans (15).

The findings in this report are subject to at least four limitations. First, the results might underestimate or overestimate actual colorectal cancer screening test rates because BRFSS does not determine the indication for the test (screening versus diagnostic use) and does not determine whether the tests were conducted according to the U.S. Preventive Services Task Force's recommended timeline, particularly with regards to the combined lower endoscopy measure. Second, BRFSS excludes certain populations, including persons in institutions and persons without landline telephones. Certain populations are more likely to be represented in households without landline telephones (e.g., younger, Hispanic, and lower-income adults) (16). Therefore, the results might not be generalizable to the entire U.S. adult population. Third, responses are self-reports and not validated by medical record review. Finally, participation rates for random-digit--dialed health surveys have been decreasing. However, although BRFSS has a low median response rate, the BRFSS weighting procedure partially corrects for nonresponse.

As with cancer screening rates, disparities are evident in cancer incidence. Although colorectal cancer incidence is decreasing in the United States among the total population, incidence rates are higher among blacks and lower among American Indians/Alaska Natives than among other racial/ethnic populations (17,18). Coordinated efforts by CDC and other federal agencies, state and local health departments, and the medical community to address barriers to and disparities in screening should be continued so that the incidence of and comorbidities associated with colorectal cancer can be reduced among all populations.

Acknowledgments

This report is based, in part, on data contributed by the state and territorial BRFSS coordinators.

References

  1. US Preventive Services Task Force. Screening for colorectal cancer: recommendation statement. Rockville, MD: US Department of Health and Human Services, Agency for Healthcare Research and Quality; 2008. AHRQ publication no. 08-05124-EF-3. Available at http://www.ahrq.gov/clinic/uspstf08/colocancer/colors.htm.
  2. US Cancer Statistics Working Group. United States cancer statistics: 1999--2006 incidence and mortality pre-release data. Atlanta, GA: US Department of Health and Human Services, CDC and the National Cancer Institute; 2010.
  3. CDC. Behavioral Risk Factor Surveillance System. Atlanta, GA: US Department of Health and Human Services, CDC; 2010. Available at http://www.cdc.gov/brfss.
  4. CDC. Vital signs: colorectal cancer screening among adults aged 50--75 years---United States, 2008. MMWR 2010;59:808--12.
  5. CDC. Use of colorectal cancer tests---United States, 2002, 2004, and 2006. MMWR 2008;57:253--8.
  6. CDC. Increased use of colorectal cancer tests---United States, 2002 and 2004. MMWR 2006;55:308--11.
  7. Baron RC, Rimer BK, Breslow RA, et al. Client-directed interventions to increase community demand for breast, cervical, and colorectal cancer screening a systematic review. Am J Prev Med 2008;35(Suppl 1):S34--55.
  8. Shapiro JA, Seeff LC, Thompson TD, Nadel MR, Klabunde CN, Vernon SW. Colorectal cancer test use from the 2005 National Health Interview Survey. Cancer Epidemiol Biomarkers Prev 2008;17:1623--30.
  9. Agency for Healthcare Research and Quality (AHRQ). National healthcare disparities report: 2009. Washington, DC: US Department of Health and Human Services, AHRQ; 2010. Available at http://www.ahrq.gov/qual/nhdr09/nhdr09.pdf.
  10. Meissner HI, Breen N, Klabunde CN, Vernon SW. Patterns of colorectal cancer screening uptake among men and women in the United States. Cancer Epidemiol Biomarkers Prev 2006;15:389--94.
  11. Wolf RL, Basch CE, Brouse CH, Shmukler C, Shea S. Patient preferences and adherence to colorectal cancer screening in an urban population. Am J Pub Health 2006;96:809--11.
  12. National Committee for Quality Assurance. What is HEDIS? HEDIS and Quality Compass. Washington, DC: National Committee for Quality Assurance; 2010. Available at http://www.ncqa.org/tabid/187/Default.aspx.
  13. Seeff LC, DeGroff A, Tangka F, et al. Development of a federally funded demonstration colorectal cancer screening program. Prev Chronic Dis 2008;5:A64. Epub March 15, 2008. Available at http://www.cdc.gov/pcd/issues/2008/apr/07_0206.htm.
  14. CDC. Colorectal Cancer Control Program (CRCCP). Atlanta, GA: US Department of Health and Human Services, CDC, National Center for Chronic Disease Prevention and Health Promotion, Division of Cancer Prevention and Control; 2010. Available at http://www.cdc.gov/cancer/crccp/about.htm.
  15. CDC. National Comprehensive Cancer Control Program (NCCCP). Atlanta, GA: US Department of Health and Human Services, CDC, National Center for Chronic Disease Prevention and Health Promotion, Division of Cancer Prevention and Control; 2010. Available at http://www.cdc.gov/cancer/ncccp/.
  16. CDC. Wireless substitution: early release of estimates from the National Health Interview Survey, January--June 2009. US Department of Health and Human Services, CDC, National Center for Health Statistics; 2009.
  17. Rim SH, Seeff L, Ahmed F, King JB, Coughlin SS. Colorectal cancer incidence in the United States, 1999--2004: an updated analysis of data from the National Program of Cancer Registries (NPCR) and the Surveillance, Epidemiology, and End Result (SEER) Program. Cancer 2009;115:1967--76.
  18. Edwards BK, Ward E, Kohler BA, et al. Annual report to the nation on the status of cancer, 1975--2006, featuring colorectal cancer trends and impact of interventions (risk factors, screening, and treatment) to reduce future rates. Cancer 2010;116:544--73.

* Available at http://www.cdc.gov/brfss/technical_infodata/quality.htm. The response rate is the percentage of persons who completed interviews among all eligible persons, including those who were not successfully contacted. The cooperation rate is the percentage of persons who completed interviews among all eligible persons who were contacted.


TABLE 1. Percentage of respondents aged ≥50 years who reported receiving a fecal occult blood test within 1 year or a lower endoscopy* within 10 years, by selected characteristics --- Behavioral Risk Factor Surveillance System, United States, 2002, 2004, 2006, and 2008

Characteristic

2002

2004

2006

2008

%

(95% CI)

%

(95% CI)

%

(95% CI)

%

(95% CI)

Age (yrs)

50--64

47.9

(47.1--48.6)

50.3

(49.6--51.0)

54.8

(54.1--55.4)

58.2

(57.6--58.7)

≥65

62.2

(61.4--63.0)

65.8

(65.1--66.5)

69.2

(68.6--69.8)

72.8

(72.3--73.3)

Sex

Male

55.1

(54.2--55.9)

57.9

(57.1--58.7)

61.4

(60.7--62.1)

65.1

(64.5--65.6)

Female

52.9

(52.2--53.6)

55.8

(55.2--56.4)

60.3

(59.7--60.8)

63.6

(63.1--64.0)

Race/Ethnicity

White, non-Hispanic

55.3

(54.8-55.8)

58.2

(57.7-58.7)

62.5

(62.0-62.9)

66.2

(65.9-66.5)

Black, non-Hispanic

51.8

(49.6-54.0)

55.3

(53.3-57.2)

58.9

(57.2-60.6)

62.9

(61.5-64.3)

Asian/Pacific Islander

50.9

(37.8-63.9)

39.6

(27.8-52.7)

57.0

(45.2-68.0)

62.9

(52.3-72.3)

American Indian/Alaska Native

54.1

(47.8-60.3)

45.2

(40.2-50.4)

50.5

(45.5-55.5)

57.8

(54.1-61.5)

Other, non-Hispanic

50.4

(46.4-54.3)

56.0

(52.3-59.7)

58.0

(54.5-61.4)

57.9

(55.1-60.7)

Hispanic

43.8

(40.4-47.1)

46.0

(43.0-49.0)

47.1

(44.4-49.8)

51.2

(49.2-53.3)

Education level

Less than high school

40.8

(39.1--42.5)

43.8

(42.0--45.6)

45.3

(43.6--47.0)

48.6

(47.1--50.0)

High school graduate or GED

50.5

(49.6--51.4)

52.7

(51.9--53.6)

56.5

(55.7--57.2)

59.7

(59.1--60.4)

Some college or technical school

56.3

(55.3--57.3)

58.3

(57.3--59.3)

62.5

(61.6--63.3)

65.3

(64.6--66.0)

College graduate

61.9

(60.9--62.9)

64.7

(63.8--65.5)

68.6

(67.8--69.3)

72.1

(71.5--72.6)

Annual household income ($)

<15,000

43.2

(41.4--45.1)

44.9

(43.2--46.6)

48.3

(46.6--50.0)

49.4

(48.1--50.8)

15,000--34,999

48.9

(47.9--49.9)

51.0

(50.0--52.0)

53.7

(52.7--54.7)

56.6

(55.8--57.4)

35,000--49,999

55.9

(54.5--57.2)

58.5

(57.3--59.7)

61.8

(60.6--62.9)

64.2

(63.2--65.1)

50,000--74,999

59.2

(57.2--61.1)

61.9

(60.5--63.3)

67.0

(65.9--68.1)

68.8

(67.9--69.7)

≥75,000

64.7

(63.1--66.3)

67.9

(66.6--69.1)

70.2

(69.2--71.2)

74.8

(74.1--75.4)

Disability

Yes

57.5

(55.5--59.4)

59.5

(58.5--60.4)

62.7

(61.8--63.5)

66.3

(65.7--67.0)

No

52.2

(51.0--53.4)

55.8

(55.2--56.4)

59.9

(59.4--60.4)

63.3

(62.8--63.7)

Health insurance

Yes

55.8

(55.2--56.3)

58.8

(58.2--59.3)

62.9

(62.4--63.3)

66.6

(66.2--66.9)

No

33.0

(30.6--35.3)

34.5

(32.1--37.0)

36.5

(34.1--38.9)

37.5

(35.4--39.5)

Total§

53.8

(53.2--54.3)

56.7

(56.2--57.2)

60.7

(60.2--61.1)

64.2

(63.8--64.5)

Abbreviations: CI = confidence interval; GED = general equivalency diploma.

* Sigmoidoscopy or colonoscopy.

Age-standardized to the 2008 Behavioral Risk Factor Surveillance System population aged ≥50 years.

§ Wald F test of significance for differences across the survey years, p<0.001.


TABLE 2. Colorectal cancer screening rates, by state poverty-level quartile --- Behavioral Risk Factor Surveillance System, United States, 2008

State/Area

Population in poverty (%)

Fecal occult blood test within 1 year or lower endoscopy* during preceding 10 years

%

(95% CI)

Quartile 1

New Hampshire

7.1

73.3

(71.7--74.9)

Utah

7.8

66.3

(64.0--68.5)

Connecticut

8.2

70.6

(68.7--72.5)

Alaska

8.3

57.8

(53.6--61.8)

Maryland

8.9

72.2

(70.6--74.7)

Vermont

9.2

71.0

(69.5--72.5)

New Jersey

9.3

61.9

(60.3--63.5)

Delaware

9.7

74.3

(71.9--76.5)

Iowa

9.7

64.5

(62.7--66.3)

Minnesota

9.9

70.1

(68.1--71.9)

Wisconsin

9.9

67.0

(64.8--69.1)

Hawaii

10.1

62.7

(60.6--64.7)

Wyoming

10.2

57.7

(56.3--59.2)

Composite

---

67.2

(66.6--67.9)

Quartile 2

Virginia

10.5

71.3

(69.2--73.4)

Washington

10.6

67.8

(66.9--68.8)

Nebraska

10.7

60.1

(58.5--61.6)

Oregon

10.8

66.8

(64.9--68.6)

Nevada

10.9

55.4

(52.5--58.3)

Pennsylvania

11.1

63.6

(62.0--65.2)

Colorado

11.2

64.7

(63.4--66.0)

Massachusetts

11.3

73.6

(72.4--74.8)

North Dakota

12

59.2

(57.4--61.1)

Maine

12.1

74.5

(73.0--76.0)

Idaho

12.4

56.7

(54.7--58.7)

Illinois

12.4

59.8

(57.6--61.8)

Rhode Island

12.9

71.8

(69.9--73.6)

Composite

---

65.3

(64.6--65.9)


TABLE 2. Continued. Colorectal cancer screening rates, by state poverty-level quartile --- Behavioral Risk Factor Surveillance System, United States, 2008

State/Area

Population in poverty (%)

Fecal occult blood test within 1 year or lower endoscopy* during preceding 10 years

%

(95% CI)

Quartile 3

Kansas

13

63.2

(61.8--64.6)

Michigan

13.1

68.5

(67.0--69.9)

Montana

13.2

58.8

(57.0--60.5)

Florida

13.3

66.0

(64.0--68.0)

South Dakota

13.4

63.2

(61.4--64.9)

Missouri

13.5

61.8

(59.5--63.9)

Ohio

13.8

61.9

(60.6--63.3)

Oklahoma

13.8

55.2

(53.5--56.8)

North Carolina

14.1

68.0

(66.7--69.2)

South Carolina

14.1

66.1

(64.3--67.9)

New York

14.3

67.3

(65.6--69.1)

Alabama

14.4

61.1

(59.1--63.0)

Indiana

14.4

60.0

(57.7--62.2)

Composite

---

64.8

(64.2--65.4)

Quartile 4

West Virginia

14.6

56.6

(54.5--58.7)

California

14.7

63.1

(61.5--64.6)

Tennessee

15.3

62.1

(59.9--64.3)

Arkansas

15.4

55.8

(53.8--57.7)

Georgia

15.6

65.6

(63.5--67.5)

Texas

15.9

58.3

(56.6--60.1)

District of Columbia

16.8

69.8

(67.4--72.0)

Kentucky

17.2

63.9

(62.1--65.6)

Arizona

18.1

64.1

(61.0--67.0)

Mississippi

18.3

57.9

(56.2--59.5)

Louisiana

18.4

56.6

(54.6--58.4)

New Mexico

19.3

57.8

(55.8--59.7)

Composite

---

61.4

(60.6--62.1)

Abbreviation: CI = confidence interval.

* Sigmoidoscopy or colonoscopy.

Composite screening percentage: the weighted number of persons who received a test divided by the estimated population total of all the states within the quartile of interest.



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