Nancy Breen

Progress in cancer screening practices in the United States: Results from the 2000 National Health Interview Survey

Understanding differences in cancer screening among population groups in 2000 and successes or failures in reducing disparities over time among groups is important for planning a public health strategy to reduce or eliminate health disparities, a major goal of Healthy People 2010 national cancer screening objectives. In 2000, the new cancer control module added to the National Health Interview Survey (NHIS) collected more detailed information on cancer screening compared with previous surveys.

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

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)

Changes in the use of screening mammography: evidence from the 1987 and 1990 National Health Interview Surveys.

OBJECTIVES Mammography rates reported by women in the National Health Interview Surveys of 1990 and 1987 are examined. Why this screening modality is not more frequently used is explored. METHODS Data from the 1987 and 1990 National Health Interview Surveys, conducted by the National Center for Health Statistics, are cross-tabulated and compared. RESULTS In 1987, approximately 17% of women over 40 years of age reported having had a screening mammogram in the previous year. In 1990, the rate doubled. Race declined in importance; income and education remained strong, positive predictors of screening. CONCLUSIONS Despite this dramatic increase, two thirds of women are not having screening mammograms. Use was not higher primarily because women did not realize that screening mammography tests for breast cancer in asymptomatic women. Primary care physicians are the main source of health education for screening mammography. The data suggest that public health programs to promote screening mammography should especially target primary care physicians and women with low incomes and education. Likewise, health care providers should ensure that their patients are referred to facilities that deliver high-quality mammography at low cost to make the procedure more accessible.

Barriers to colorectal cancer screening: A comparison of reports from primary care physicians and average-risk adults

Background:Barriers to colorectal cancer (CRC) screening are not well understood. Objectives:We sought to compare barriers to CRC screening reported by primary care physicians (PCPs) and by average-risk adults, and to examine characteristics of average-risk adults who identified lack of provider recommendation as a major barrier to CRC screening. Research Design:This was a comparative study using data from the 1999–2000 Survey of Colorectal Cancer Screening Practices and the 2000 National Health Interview Survey (NHIS). Subjects:We recruited nationally representative samples of PCPs (n= 1235) from the SCCSP and average-risk adults (n = 6497) from the NHIS. Measures:We measured barriers to CRC screening identified by PCPs and average-risk adults who were not current with screening. Results:Both PCPs and average-risk adults identified lack of patient awareness and physician recommendation as key barriers to obtaining CRC screening. PCPs also frequently cited patient embarrassment/anxiety about testing and test cost/lack of insurance coverage, but few adults identified these as major barriers. Of adults not current with testing, those who had visited a doctor in the past year or had health insurance were more likely to report lack of physician recommendation as the main reason they were not up-to-date compared with their counterparts with no doctor visit or health insurance. Only 10% of adults not current with testing and who had a doctor visit in the past year reported receiving a screening recommendation. Conclusions:A need exists for continued efforts to educate the public about CRC and the important role of screening in preventing this disease. Practice-based strategies to systematically prompt health care providers to discuss CRC screening with eligible patients also are required.

Cancer knowledge and disparities in the information age

Increasing information flow often leads to widening gaps in knowledge between different socioeconomic status (SES) groups as higher SES groups are more likely to acquire this new information at a faster rate than lower SES groups. These gaps in knowledge may offer a partial but robust explanation for differential risk behaviors and health disparities between different social groups. Drawing on the Health Information National Trends Survey (HINTS 2003), a national survey of communication behaviors conducted by the National Cancer Institute (NCI), we examine the relationship between publicity and knowledge gaps on two cancer topics that received different levels of publicity: knowledge about tobacco and sun exposure and their respective links to cancer. Analyses of the HINTS 2003 data suggest that differential knowledge levels of causes of cancer between SES groups are one potential explanation of cancer disparities that have been extensively reported in the literature. It is evident that high income and high education are associated with awareness about causes of major cancers such as lung and skin, and may allow people to protect themselves and minimize their risks. The data also show that heavier media attention could attenuate the knowledge gaps though moderate publicity or lack of news coverage may actually widen them. Last, the findings in this article suggest that it is necessary to take into account the SES variation within different racial and ethnic groups rather than mask them by treating the groups as one.

Reported drop in mammography : is this cause for concern?

Timely screening with mammography can prevent a substantial number of deaths from breast cancer. The objective of this brief was to ascertain whether recent use of mammography has dropped nationally.

The association between health care coverage and the use of cancer screening tests. Results from the 1992 National Health Interview Survey.

OBJECTIVES The authors investigated whether utilization of six different cancer screening tests (mammography, clinical breast exam, Pap smear, Fecal Occult Blood Test, and Digital rectal exam) varied according to type of health care coverage. METHODS Data on the use of cancer screening tests and coverage in two age groups from a 1992 nationally representative cross-sectional survey of approximately 9,400 adults were analyzed. Multiple logistic regression analysis was used to estimate proportions of persons screened according to type and extent of coverage, adjusted for socioeconomic, demographic, and health status characteristics. RESULTS Persons aged 40 to 64 years with Medicaid coverage were equally as likely to receive five of six cancer screening tests as those with private fee-for-service coverage, and both groups were much more likely to be screened (70% higher for all six tests) than those who had no coverage. In contrast, persons aged 65 years and older who had supplemental private fee-for-service insurance in addition to Medicare were more likely to receive five of six tests than those with Medicare and Medicaid or those with Medicare only. For all six screening tests, managed care enrollees at all ages were approximately 10% more likely to be screened than persons enrolled in private fee-for-service plans. Fecal Occult Blood Test (25% versus 20%) and digital rectal exams (44% versus 38%) in persons aged 40 to 64 years and mammography (59% versus 48%) and Fecal Occult Blood Test screening (38% versus 30%) in the elderly were significantly more frequent for persons in managed care plans. CONCLUSIONS The extent of fee-for-service insurance coverage in the traditional indemnity US health care system was positively associated with the use of cancer screening tests. The authors found less difference in use of cancer screening between managed care and fee-for-service care in 1992 than we expected based on earlier research comparing use of preventive services in health maintenance organizations with fee-for-service care.

Trends in Colorectal Cancer Test Use among Vulnerable Populations in the United States

Background: Evaluating trends in colorectal cancer (CRC) screening use is critical for understanding screening implementation, and whether population groups targeted for screening are receiving it, consistent with guidelines. This study examines recent national trends in CRC test use, including among vulnerable populations. Methods: We used the 2000, 2003, 2005, and 2008 National Health Interview Survey to examine national trends in CRC screening use overall and for fecal occult blood test (FOBT), sigmoidoscopy, and colonoscopy. We also assessed trends by race/ethnicity, educational attainment, income, time in the United States, and access to health care. Results: During 2000 to 2008, significant declines in FOBT and sigmoidoscopy use and significant increases in colonoscopy use and in the percentages of adults up-to-date with CRC screening occurred overall and for most population subgroups. Subgroups with consistently lower rates of colonoscopy use and being up-to-date included Hispanics; people with minimal education, low income, or no health insurance; recent immigrants; and those with no usual source of care or physician visits in the past year. Among up-to-date adults, there were few subgroup differences in the type of test by which they were up-to-date (i.e., FOBT, sigmoidoscopy, or colonoscopy). Conclusions: Although use of CRC screening and colonoscopy increased among U.S. adults, including those from vulnerable populations, 45% of adults aged 50 to 75—or nearly 35 million people—were not up-to-date with screening in 2008. Impact: Continued monitoring of CRC screening rates among population subgroups with consistently low utilization is imperative. Improvement in CRC screening rates among all population groups in the United States is still needed. Cancer Epidemiol Biomarkers Prev; 20(8); 1611–21. ©2011 AACR.

An Overview of Methods for Monitoring Social Disparities in Cancer with an Example Using Trends in Lung Cancer Incidence by Area-Socioeconomic Position and Race-Ethnicity, 1992–2004

The authors provide an overview of methods for summarizing social disparities in health using the example of lung cancer. They apply four measures of relative disparity and three measures of absolute disparity to trends in US lung cancer incidence by area-socioeconomic position and race-ethnicity from 1992 to 2004. Among females, measures of absolute and relative disparity suggested that area-socioeconomic and race-ethnic disparities increased over these 12 years but differed widely with respect to the magnitude of the change. Among males, the authors found substantial disagreement among summary measures of relative disparity with respect to the magnitude and the direction of change in disparities. Among area-socioeconomic groups, the index of disparity increased by 47% and the relative concentration index decreased by 116%, while for race-ethnicity the index of disparity increased by 36% and the Theil index increased by 13%. The choice of a summary measure of disparity may affect the interpretation of changes in health disparities. Important issues to consider are the reference point from which differences are measured, whether to measure disparity on the absolute or relative scale, and whether to weight disparity measures by population size. A suite of indicators is needed to provide a clear picture of health disparity change.

Trends in Area-Socioeconomic and Race-Ethnic Disparities in Breast Cancer Incidence, Stage at Diagnosis, Screening, Mortality, and Survival among Women Ages 50 Years and Over (1987-2005)

Background: Breast cancer is the most commonly diagnosed cancer and the second leading cause of cancer death among women in the United States and varies systematically by race-ethnicity and socioeconomic status. Previous research has often focused on disparities between particular groups, but few studies have summarized disparities across multiple subgroups defined by race-ethnic and socioeconomic position. Methods: Data on breast cancer incidence, stage, mortality, and 5-year cause-specific probability of death (100 − survival) were obtained from the Surveillance, Epidemiology, and End Results program and data on mammography screening from the National Health Interview Survey from 1987 to 2005. We used four area-socioeconomic groups based on the percentage of poverty in the county of residence (<10, 10-15, 15-20, +20%) and five race-ethnic groups (White, Black, Asian, American Indian, and Hispanic). We used summary measures of disparity based on both rate differences and rate ratios. Results: From 1987 to 2004, area-socioeconomic disparities declined by 20% to 30% for incidence, stage at diagnosis, and 5-year cause-specific probability of death, and by roughly 100% for mortality, whether measured on the absolute or relative scale. In contrast, relative area-socioeconomic disparities in mammography use increased by 161%. Absolute race-ethnic disparities declined across all outcomes, with the largest reduction for mammography (56% decline). Relative race-ethnic disparities for mortality and 5-year cause-specific probability of death increased by 24% and 17%, respectively. Conclusions: Our analysis suggests progress towards race-ethnic and area-socioeconomic disparity goals for breast cancer, especially when measured on the absolute scale. However, greater progress is needed to address increasing relative socioeconomic disparities in mammography and race-ethnic disparities in mortality and 5-year cause-specific probability of death. (Cancer Epidemiol Biomarkers Prev 2009;18(1):121–31)