Are we doing enough to screen for colorectal cancer? Findings from the 1999 Behavioral Risk Factor Surveillance System

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Original Research

Are we doing enough to screen for colorectal cancer? Findings from the 1999 Behavioral Risk Factor Surveillance System

J Fam Pract. 2002 September;51(9):761-766

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References

1. American Cancer Society. Cancer facts and figures, 2002. Atlanta: American Cancer Society, Inc., 2002. Publication 02-250M-No. 5008.02.

2. Mandel JS, Church TR, Bond JH, et al. The effect of fecal occultblood screening on the incidence of colorectal cancer. N Engl J Med 2000;343:1603-7.

3. Mandel JS, Bond JH, Church TR, et al. Reducing mortality from col-orectal cancer by screening for fecal occult blood. N Engl J Med 1993;328:1365-71.

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

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

6. Hardcastle JD, Chamberlain JO, Robinson MH, et al. Randomised controlled trial of faecal-occult-blood screening for colorectal cancer. Lancet 1996;348:1472-1477.

7. Kronborg O, Fenger C, Olsen J, Jorgensen OD. Sondergaard. Randomised study of screening for colorectal cancer with faecal-occult-blood test. Lancet 1996;348:1467-1.

8. Mandel JS, Church TR, Ederer F, Bond JH. Colorectal cancer mortality: Effectiveness of biennial screening for fecal occult blood. J Natl Cancer Inst 1999;91:434-7.

9. U.S.Preventive Services Task Force. Guide to clinical preventive services. 2nd ed. Baltimore: Williams and Wilkins, 1996.

10. Winawer SJ, Fletcher RH, Miller L, et al. Colorectal cancer screening: clinical guidelines and rationale. Gastroenterology 1997;112:594-642.

11. Smith RA, von Eschenbach AC, Wender R, et al. American Cancer Society guidelines for the early detection of cancer: update of early detection guidelines for prostate, colorectal, and endometrial cancers. CA Cancer J Clin 2001;51:38-75.

12. Shapiro JA, Seeff LC, Nadel MR. Colorectal cancer-screening tests and associated health behaviors. Am J Prev Med 2001;21:132-7.

13. SAS statistical analysis software. Cary, NC: SAS Institute, 1996.

14. SUDAAN software for the statistical analysis of correlated data. Research Triangle Park, NC: Research Triangle Institute, 1997.

15. Centers for Disease Control and Prevention. Behavioral Risk Factor Surveillance System, 1999. BRFSS Summary Quality Control Report. Atlanta: National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, U.S. Department of Health and Human Services, 1999.

16. Fenlon HM, Nunes DP, Schroy PC, III, Barish MA, Clarke PD, Ferrucci JT. A comparison of virtual and conventional colonoscopy for the detection of colorectal polyps. N Engl J Med 1999;341:1496-503.

17. Ahlquist DA, Skoletsky JE, Boynton KA, et al. Colorectal cancer screening by detection of altered DNA in stool: feasibility of a mul-titarget assay panel. Gastroenterology 2000;119:1219-27.

18. Vernon SW. Participation in colorectal cancer screening: A review. J Natl Cancer Inst 1997;89:1406-22.

19. Peterson SK, Vernon SW. A review of patient and physician adherence to colorectal cancer screening guidelines. Semin Colon Rectal Surg 2000;11:58-72.

20. McCarthy BD, Moskowitz MA. Screening flexible sigmoidoscopy: patient attitudes and compliance. J Gen Intern Med. 1993;8:120-5.

21. Lewis JD, Asch DA. Barriers to office-based screening sigmoi-doscopy: does reimbursement cover costs? Ann Intern Med 1999;130:525-30.

22. Anderson JE, Nelson DE, Wilson RW. Telephone coverage and measurement of health risk indicators: data from the National Health Interview Survey. Am J Public Health 1998;88:1392-5.

23. Baier M, Calonge N, Cutter G, et al. Validity of self-reported col-orectal cancer screening behavior. Cancer Epidemiol Biomarkers Prev 2000;9:229-32.

The 1999 BRFSS questions regarding use of sigmoidoscopy were modified from previous questionnaires. As the scientific evidence supporting CRC screening tests has grown, BRFSS CRC survey questions have changed. The 1997 survey, described previously,¹² was the first survey to collect information regarding the use of home-administered FOBT and sigmoidoscopy from all 50 states, the District of Columbia, and Puerto Rico. In 1997, respondents were asked if they had received a sigmoidoscopy or proctoscopy. Proctoscopy, performed with a shorter instrument than a sigmoidoscope, is not recommended as a CRC screening test. In 1999, the term “sigmoidoscopy/proctoscopy” was replaced with “sigmoidoscopy/colonoscopy.” Colonoscopy evaluates the entire colon and is recommended once every 10 years in some guidelines.^10,11For this report, the terms “sigmoidoscopy/proctoscopy” and “sigmoidoscopy/colonoscopy” will each be referred to as “sigmoidoscopy” unless otherwise specified.

TABLE 1
Questions used in the 1999 Behavioral Risk Factor Surveillance System to assess usage of colorectal cancer screening tests

A sigmoidoscopy or colonoscopy is when a tube is inserted in the rectum to view the bowel for signs of cancer and other health problems. Have you ever had this exam?
When did you have your last sigmoidoscopy or colonoscopy?
A blood stool test is a test that may use a special kit at home to determine whether the stool contains blood. Have you ever had this test using a home kit?
When did you have your last blood stool test using a home kit?

Results

The age-adjusted proportion of overall respondents who reported ever receiving CRC screening tests in 1999 was 40.3% for FOBT and 43.8% for sigmoidoscopy (data not shown).

The 1999 age-adjusted CRC screening test rates are presented by demographic subgroups for reported use within recommended time intervals: FOBT within the year preceding the survey, sigmoidoscopy within the past five years, or at least one of the two tests (Table 2). Less than half of the population surveyed reported having either FOBT or sigmoidoscopy within the recommended time interval. In 1999, 20.6% of respondents reported having had FOBT within the previous year; 33.6% reported having had a sigmoidoscopy within the previous 5 years; 44.0% reported having had either FOBT within the previous year or a sigmoidoscopy within the previous 5 years. There was little difference in test use between blacks and whites. Rates of use by Asian/Pacific Islanders and American Indian/Alaska Natives were calculated from small respondent samples and should be interpreted cautiously. Respondents of Spanish or Hispanic origin reported lower rates of FOBT and sigmoidoscopy than respondents who were not of Hispanic origin. Reported test use rose with increasing age of the respondents, up to age 70–79, and then declined for those over 80 years of age. Reported test use increased with education and with annual house hold income. Respondents who had health care coverage were almost twice as likely to have had CRC screening tests as respondents without health care coverage.

CRC screening test rates increased slightly from 1997 to 1999. In 1997, 19.6% of respondents reported having had an FOBT within the previous year and 30.3% reported having had a sigmoidoscopy within the previous 5 years.

We compared 1999 BRFSS usage rates for FOBT and sigmoidoscopy or colonoscopy with those for mammography and Papanicolaou (Pap) smear (Figure). These are not direct comparisons but, rather, comparisons of the rates of testing within recommended time intervals among appropriate demographic groups. The proportion of persons who used CRC screening tests within recommended time intervals was lower than those for other cancer screening tests.

TABLE 2
Respondents aged 50 years or older who reported colorectal cancer screening tests within recommended time intervals, by demographic variables¹

	Fecal occult blood test within previous year			Sigmoidoscopy/colonoscopy within previous 5 years			Either test within recommended time interval
	n2	%	(95% CI)	n	%	(95% CI)	N	%	(95% CI)
Total	61,952	20.6	(20.1–21.2)	61,953	33.6	(33.0–34.2)	61,537	44.0	(43.3–44.6)
Gender
Male	23,919	19.1	(18.2–19.9)	23,850	37.9	(36.8–38.9)	23,724	45.9	(44.9–47.0)
Female	38,033	22.0	(21.3–22.7)	38,103	30.4	(29.6–31.1)	37,813	42.6	(41.7–43.4)
Race⁴
White	55,139	21.0	(20.5–21.6)	55,170	33.6	(33.0–34.3)	54,804	44.2	(3.5–44.9)
Black	4,075	20.7	(18.8–22.6)	4,046	32.6	(30.3–34.9)	4,020	43.3	(40.9–45.7)
Asian/Pacific Islander	739	10.3	(6.9–13.6)	739	35.4	(28.4–42.5)	735	40.1	(33.3–46.9)
American Indian/ Alaska Native	725	18.2	(12.7–23.7)	725	36.0	(29.4–42.5)	723	43.0	(36.5–49.6
Spanish or Hispanic origin
Yes	3,664	11.2	(9.4–12.9)	3,667	28.6	(25.6–31.5)	3,635	33.9	(30.9–37.0)
No	57,993	21.4	(20.9–21.9)	57,999	34.0	(33.4–34.6)	57,620	44.8	(44.1–45.5)
Age (group)
50–59 years	23,758	15.5	(14.7–16.2)	23,803	26.1	(25.1–27.0)	23,667	34.7	(33.7–35.7)
60–69 years	17,680	23.0	(22.0–24.0)	17,651	36.9	(35.7–38.1)	17,574	48.1	(46.9–49.3)
70–79 years	14,427	25.8	(24.6–27.0)	14,412	40.7	(39.3–42.1)	14,306	52.7	(51.4–54.1)
≤80 years	6,087	21.6	(19.8–23.4)	6,087	36.1	(34.0–38.2)	5,990	46.9	(44.7–49.1)
Education
< 12 years	11,928	15.0	(13.8–16.1)	11,889	27.5	(25.9–29.1)	11,756	35.6	(33.9–37.3)
High school graduate	21,183	19.7	(18.8–20.6)	21,176	30.6	(29.6–31.6)	21,049	41.2	(40.1–42.3)
Some college/ technical school	14,167	23.5	(22.3–24.7)	14,162	35.9	(34.6–37.3)	14,102	47.9	(46.5–49.2)
College graduate	14,503	24.3	(23.2–25.5)	14,560	41.1	(39.8–42.5)	14,466	51.4	(50.1–52.7)
Income (annual household)
<$20,000	15,204	15.3	(14.3–16.3)	15,154	29.1	(27.7–30.5)	15,029	37.0	(35.5–38.4)
$20,000–34,999	14,354	20.8	(19.7–21.9)	14,362	32.5	(31.2–33.8)	14,288	43.0	(41.7–44.4)
$35,000–49,999	7,721	23.3	(21.6–24.9)	7,718	37.0	(35.1–39.0)	7,703	48.2	(46.3–50.1)
≥$50,000	11,967	24.2	(22.7–25.6)	12,002	41.7	(39.9–43.4)	11,949	51.7	(50.0–53.5)
Health care coverage
Yes	57,551	21.3	(20.8–21.9)	57,561	34.7	(34.1–35.4)	57,169	45.4	(44.7–46.1)
No	4,331	12.1	(9.8–14.5)	4,326	18.7	(15.6–21.7)	4,304	25.7	(22.2–29.2)
¹From the Behavioral Risk Factor Surveillance System (BRFSS), 1999; estimates are age-adjusted.
²Sample size for each question; sample sizes may not sum to totals because of missing data.
³Confidence interval.
⁴Sample sizes for racial categories do not add up to column totals. “Other” racial category not presented here.

FIGURE
Comparison of use of colorectal cancer screening tests with other screening tests, BRFSS 1999

Discussion

Currently, 4 widely accepted tests are available for CRC screening, and several new tests are under investigation.^16,17 Not enough evidence exists to determine which of the available tests is most appropriate when efficacy, cost-effectiveness, availability, patient acceptability, and safety are taken into consideration. The 1999 BRFSS monitored the use of 3 of these tests: FOBT and sigmoidoscopy or colonoscopy. Our results show that less than half of the US population aged 50 years and older is being screened for CRC with these methods. Persons with health care coverage and with higher education and income levels were more likely to have had CRC tests. Since 1997, the proportion of the U.S. population being screened for CRC has increased slightly, but it remains low and lags far behind the use of other recommended cancer screening tests (Figure). While use of barium enema, one of the recommended colorectal cancer screening tests, is not monitored in the 1999 BRFSS, data from a recent national primary care physician survey suggest that barium enemas are infrequently recommended for colorectal cancer screening (Carrie Klabunde, National Cancer Institute, personal/written communication, 2002).