Age-related disparities in cancer screening: analysis of 2001 Behavioral Risk Factor Surveillance System data

Internal and external validation of an updated ICD-10-CA to AIS-2005 update 2008 algorithm

BACKGROUND

Administrative data are a powerful tool for population-level trauma research but lack the trauma-specific diagnostic and injury severity codes needed for risk-adjusted comparative analyses. The objective of this study was to validate an algorithm to derive Abbreviated Injury Scale (AIS-2005 update 2008) severity scores from Canadian International Classification of Diseases (ICD-10-CA) diagnostic codes in administrative data.

METHODS

This was a retrospective cohort study using data from the 2009 to 2017 Ontario Trauma Registry for the internal validation of the algorithm. This registry includes all patients treated at a trauma center who sustained a moderate or severe injury or were assessed by a trauma team. It contains both ICD-10-CA codes and injury scores assigned by expert abstractors. We used Cohen's kappa (𝜅) coefficient to compare AIS-2005 Update 2008 scores assigned by expert abstractors to those derived using the algorithm and the intraclass correlation coefficient to compare assigned and derived Injury Severity Scores. Sensitivity and specificity for detection of a severe injury (AIS score, ≥ 3) were then calculated. For the external validation of the algorithm, we used administration data to identify adults who either died in an emergency department or were admitted to hospital in Ontario secondary to a traumatic injury (2009-2017). Logistic regression was used to evaluate the discriminative ability and calibration of the algorithm.

RESULTS

Of 41,869 patients in the Ontario Trauma Registry, 41,793 (99.8%) had at least one diagnosis matched to the algorithm. Evaluation of AIS scores assigned by expert abstractors and those derived using the algorithm demonstrated a high degree of agreement in identification of patients with at least one severe injury (𝜅 = 0.75; 95% confidence interval [CI], 0.74-0.76). Likewise, algorithm-derived scores had a strong ability to rule in or out injury with AIS ≥ 3 (specificity, 78.5%; 95% CI, 77.7-79.4; sensitivity, 95.1; 95% CI, 94.8-95.3). There was strong correlation between expert abstractor-assigned and crosswalk-derived Injury Severity Score (intraclass correlation coefficient, 0.80; 95% CI, 0.80-0.81). Among the 130,542 patients identified using administrative data, the algorithm retained its discriminative properties.

CONCLUSION

Our ICD-10-CA to AIS-2005 update 2008 algorithm produces reliable estimates of injury severity and retains its discriminative properties with administrative data. Our findings suggest that this algorithm can be used for risk adjustment of injury outcomes when using population-based administrative data.

LEVEL OF EVIDENCE

Diagnostic Tests/Criteria; Level II.

The impact of neighborhood disadvantage on colorectal cancer screening among African Americans in Chicago

Historically, colorectal cancer (CRC) screening rates have been lower among African Americans. Previous studies that have examined the relationship between community characteristics and adherence to CRC screening have generally focused on a single community parameter, making it challenging to evaluate the overall impact of the social and built environment. In this study, we will estimate the overall effect of social and built environment and identify the most important community factors relevant to CRC screening. Data are from the Multiethnic Prevention and Surveillance Study (COMPASS), a longitudinal study among adults in Chicago, collected between May 2013 to March 2020. A total 2,836 African Americans completed the survey. Participants' addresses were geocoded and linked to seven community characteristics (i.e., community safety, community crime, household poverty, community unemployment, housing cost burden, housing vacancies, low food access). A structured questionnaire measured adherence to CRC screening. Weighted quantile sum (WQS) regression was used to evaluate the impact of community disadvantages on CRC screening. When analyzing all community characteristics as a mixture, overall community disadvantage was associated with less adherence to CRC screening even after controlling for individual-level factors. In the adjusted WQS model, unemployment was the most important community characteristic (37.6%), followed by community insecurity (26.1%) and severe housing cost burden (16.3%). Results from this study indicate that successful efforts to improve adherence to CRC screening rates should prioritize individuals living in communities with high rates of insecurity and low socioeconomic status.

Socioeconomic Disparity Trends in Cancer Screening Among Women After Introduction of National Quality Indicators

PURPOSE

Primary care physicians have an important role in encouraging adequate cancer screening. Disparities in cancer screening by socioeconomic status (SES) may affect presentation stage and cancer survival. This study aimed to examine whether breast, colorectal, and cervical cancer screening rates in women differed by SES and age, and whether screening rates and SES disparities changed after introduction of a primary care-based national quality indicator program.

METHODS

This repeated cross-sectional study spanning 2002-2017 included all female Israeli residents in age ranges appropriate for each cancer screening assessed. SES was measured both as an individual-level variable based on exemption from copayments and as an area-level variable using census data.

RESULTS

In 2017, the most recent year in the study period, screening rates among 1,529,233 women were highest for breast cancer (70.5%), followed by colorectal cancer (64.3%) and cervical cancer (49.6%). Women in the highest area-level SES were more likely to undergo cervical cancer screening compared with those in the lowest (odds ratio = 3.56; 99.9% CI, 3.47-3.65). Temporal trends showed that after introduction of quality indicators for breast and colorectal cancer screening in 2004 and 2005, respectively, rates of screening for these cancers increased, with greater reductions in disparities for the former. The quality indicator for cervical cancer screening was introduced in 2015, and no substantial changes have occurred yet for this screening.

CONCLUSIONS

We found increased uptake and reduced socioeconomic disparities after introduction of cancer screening indicators. Recent introduction of a cervical cancer screening indicator may increase participation and reduce disparities, as has occurred for breast and colorectal cancer screening. These findings related to Israel's quality indicators program highlight the importance of primary care clinicians in increasing cancer screening rates to improve outcomes and reduce disparities.

Nonlinear Relationship Between Age and Likelihood of Undergoing Prostate-Specific Antigen Testing, and the Predictive Factors of Testing at Different Ages

OBJECTIVE

To investigate the nonlinear relationship between age and the likelihood of undergoing prostate-specific antigen (PSA) testing, and the difference of factors influencing the test likelihood among subjects aged 40-54, 55-69, and ≥70 years.

METHODS

Data were extracted from the 2018 Behavioral Risk Factor Surveillance System, with the primary outcome defined as receipt of a PSA test within the previous 12 months. Restricted cubic splines were used to assess the relationship between age and the likelihood of undergoing PSA testing. Backward conditional logistic regression analyses were used to identify the predictors of undergoing PSA testing among subjects aged 40-54, 55-69, and ≥70 years.

RESULTS

Finally, 92,177 people were identified. The likelihood of PSA testing increased up to around 71 years old and then decreased rapidly for higher ages, showing a clear nonlinear inverted U-shaped relationship with age (p < .001). Insurance status, shared decision-making, whether a recommendation for PSA testing had been accepted, income level, smoking status, and age were the common predictors of testing in the three age groups. However, the predictors differed somewhat among the three groups: being overweight or obese was only positively associated with increased testing among people aged 40-54 and ≥70 years, being retired only greatly impacted the test likelihood among those aged 40-54 years, and the general health status, marital status, and race affected people aged ≥55 years.

CONCLUSION

The factors influencing PSA screening differ with age, which should be fully considered when screening different target age groups.

A Novel Curriculum on Using Life Expectancy to Inform Cancer Screening in Older Adults

BACKGROUND

Many older adults with limited life expectancy still receive cancer screening. One potential contributor is that primary care providers (PCP) are not trained to incorporate life expectancy in cancer screening recommendations. We describe the development and evaluation of a novel curriculum to address this need.

METHODS

We developed and implemented a web-based learning module within a large Maryland group practice with PCPs for older adults. We assessed attitude, knowledge, self-efficacy, and self-reported behavior outcomes before the module, immediately after completing the module, and 6 months afterwards.

RESULTS

Of 172 PCPs who were invited, 86 (50%) completed the module and of these, 50 (58.1%) completed the 6-months follow up survey. Immediately after the module, there was a significant increase in perceived importance of life expectancy (increase of 0.50 point on 10-point scale, 95% confidence intervals (CI) = 0.27-0.73), confidence in predicting life expectancy (increase of 2.32 points on 10-point scale, 95% CI = 1.95-2.70) and confidence in discussion screening cessation (increase of 1.69 points on 10-point scale, 95% CI = 1.37-2.02). Knowledge in patient-preferred communication strategies improved from 55% correct response to 97% (P < .001). However, most of these improvements dissipated by 6 months and there was no change in self-reported behavior at 6 months compared to baseline (P = .34).

CONCLUSION

Although the module resulted in significant short-term improvement in attitude, knowledge, and self-efficacy, the changes were not sustained over time. Educational interventions such as this can be coupled with ongoing reinforcing strategies and/or decision support interventions to improve cancer-screening practices in older adults.

Predictors of overall and test-specific colorectal Cancer screening adherence

This study investigated predictors of overall and test-specific colorectal cancer screening (CRCS). Stool blood test (SBT) and/or colonoscopy screening were offered to primary care patients in two randomized controlled trials which assessed the impact of behavioral interventions on screening. Data were obtained through surveys and electronic medical records. Among 1942 participants, 646 (33%) screened. Exposure to interventions was associated with higher overall CRCS by twofold to threefold; older age, African American race, being married, and having a higher screening decision stage were also associated with higher overall CRCS (odds ratios = 1.30, 1.31, 1.34, and 5.59, respectively). Intervention, older age, female gender, and being married were associated with higher SBT adherence, while preference for colonoscopy was associated with lower SBT adherence. Intervention and higher decision stage were associated with higher colonoscopy adherence, while preference for SBT was associated with lower colonoscopy adherence. Among older individuals, African Americans had higher overall CRCS than whites, but this was not true among younger individuals (interaction p = .041). The higher screening adherence of African Americans over whites was due to stronger screening with a non-preferred test, i.e., higher SBT adherence only among individuals who preferred colonoscopy and higher colonoscopy adherence only among individuals who preferred SBT. Intervention exposure, sociodemographic background, and screening decision stage predicted overall CRCS adherence. Gender and test preference also affected test-specific screening adherence. Interactions involving race and test preference suggest that it is important to provide both colonoscopy and SBT screening options to patients, particularly African Americans.

Age, Race, and Income Are Associated With Lower Screening Rates at a Safety Net Hospital

BACKGROUND

While lung cancer screening improves cancer-specific mortality and is recommended for high-risk patients, barriers to screening still exist. We sought to determine our institution's (an urban safety net hospital) screening rate and to identify socioeconomic barriers to lung cancer screening.

METHODS

We identified 8935 smokers 55 to 80 years of age evaluated by a primary care physician between March 2015 and March 2017 at our institution. We randomly selected one-third of these (n = 2978) to review for eligibility using the U.S. Preventive Services Task Force criteria for lung cancer screening. Using our institution's Lung Cancer Screening Program clinical tracking database, we identified patients who were screened from March 2015 to March 2017. We collected demographic information (race, primary language, education status, and median income) and evaluated possible associations with screening.

RESULTS

Among our institution population, 99 patients meeting U.S. Preventive Services Task Force screening criteria underwent screening computed tomography, whereas 516 eligible patients were not screened, making our institution's estimated screening rate 16.1%. Comparing the unscreened population with those who received screening at our institution, the unscreened population was significantly older (median age of screened patients was 63 years, of unscreened patients was 66 years; P < .001). African Americans had a lower screening rate (37.6% of the screened population and 47.5% of the unscreened population; P < .001). Unscreened patients had a lower annual household income.

CONCLUSIONS

The lung cancer screening rate at our hospital is 16.1%. Unscreened patients were older, were more likely to be African American, and had a lower median income. These findings highlight possible screening barriers and potential areas for targeted strategies to decrease disparities in lung cancer screening.

Developing a Tool for Evaluating Ageism in Nursing Care of Older People in Kashan/Iran

Ageism implies negative views and attitudes towards older people. These unconscious behaviors could make the elderly feel as if they were no longer useful for the family and community. Ageism is common in healthcare services. The objective of this study was to develop a tool to assess ageism in nursing care in Kashan/Iran 2015. This psychometric study was carried out in four stages: literature review for item generation; content validity testing; exploratory factor analysis (EFA) for evaluation of construct validity; and reliability assessment. The data analyzed with SPSS version 16. The final questionnaire had 24 items. The total CVI and CVR were 0.88 and 0.57. Explanatory factor analysis identified 3 factors of respecting older adult in nursing care (14 items); age discrimination and negative views towards older adults (5 items); attention to older adult and their basic caring needs (5 items). The three factors could explain 49.54% of variance. The test-re-test correlation stood at 0.9. The internal consistency of the questionnaire was Cronbach's alpha =0.85. A valid and reliable instrument for the evaluation of ageism in nursing care was developed in this study.

Health literacy and use of preventive health services among North Korean defectors in the Republic of Korea

It is known that some groups of immigrants can have low health literacy and it may affect their health. Although the number of North Korean defectors in the Republic of Korea has increased, little is known about their health literacy and health behavior. Adult North Korean defectors (n = 399) in this study were surveyed on health literacy, using the Korean Health Literacy Scale, and on the use of preventive services. Those with better health literacy scores were more likely to have vaccination than the lower scoring group (adjusted OR = 2.44; 95% CI, 1.19–5.00). However, undergoing medical check-up may not be associated with health literacy. In subgroup analysis, among defectors who lived alone (P = 0.032) or who had longer time in other countries before entering (P = 0.007), the vaccination coverage was associated with their health literacy scores. This study provides evidence for an association between health literacy and influenza vaccination coverage among North Korean defectors even though they may have fewer language barriers than other immigrants. Further research is needed to develop interventions for improving health literacy and their preventive health behavior.

Short-term survival after colorectal cancer in a screened versus unscreened population

Aims: United States' (US) colorectal cancer (CRC) screening and treatment practices seek to reduce mortality. We examined the survival of US patients compared with patients in the virtually unscreened Norwegian population. Methods: We compared short-term survival after CRC between the US and Norway using relative survival (RS) and excess mortality (EMR) analyses. The CRC patients were aged 50 and older diagnosed in the US (Surveillance, Epidemiology and End Results registry, 2004, N=9511) and in Norway (Cancer Registry of Norway, 2003-2005, N=8256). Results: Death occurred within three years for 39% of the CRC patients. Stage distributions were more favorable for US patients. Stage-specific survival was similar for localized and regional cancers, but more favorable for US distant cancers. In multivariate models of patient, tumor and treatment characteristics, patients (especially below age 80) in the US experienced longer survival (EMR 0.9, CI 0.8-0.9). Stage-specific analyses showed, however, that survival for localized cancers was relatively shorter in the US than in Norway (EMR 1.4, CI 1.1-1.8), but longer for distant cancers (EMR 0.8, CI 0.7-0.8). Conclusions: The enhanced survival for US CRC patients likely reflects a screening-related earlier diagnostic stage distribution, as well as prioritized life extension for patients with metastatic cancers, reflecting vastly different health care systems in the two countries. CRC screening is currently under consideration in Norway. For survival outcomes, the current findings do not discourage such an implementation. Other screening-related aspects such as feasibility and cost-benefit are, however, also relevant and warrant further research within a socialized health system.

Diet, Alcohol Use, and Colorectal Cancer Screening among Black Church-goers

OBJECTIVES

Interventions for colorectal cancer (CRC) prevention among black adults are needed. Connections between CRC screening non-adherence and other health risk behaviors may inform intervention development.

METHODS

Associations between red meat (RM) and fruit and vegetable (FV) consumption, at-risk alcohol use, and CRC ever-screening were examined using adjusted logistic regressions among 520 church-going black adults in Houston, Texas, aged >50.

RESULTS

In the final adjusted model, being younger, uninsured, eating more RM and engaging in at-risk alcohol use were associated with lower likelihood of CRC ever-screening.

CONCLUSIONS

Church-based interventions to increase CRC screening among black adults might capitalize on associations with RM consumption and alcohol use behaviors as part of a broader wellness promotion initiative.

Socioeconomic Disparities in Colorectal Cancer Screening in Korea: A Nationwide Cross-Sectional Study

Colorectal cancer (CRC) is a common cancer worldwide. The incidence and mortality rates of CRC are higher among lower socioeconomic status (SES) populations. We investigated the association between different indicators of SES and CRC screening rates in Korea. The eligible study population included males and females aged 50 to 74 years who participated in a nationwide cross-sectional survey (2010-2012). The "compliance with recommendation" category was applicable to participants who had undergone a fecal occult blood test (FOBT), double-contrast barium enema, or colonoscopy within 1, 5, or 10 years, respectively. In total, 6221 subjects (51.4% female, 55.6% aged 50 years) were included in the final analysis. Lower household income was significantly negatively related to compliance with screening recommendations (P for trend < 0.01) and marginally significantly related to noncompliance with recommendations (P for trend = 0.07). Older age and poor self-reported health were associated with the screening rate using the FOBT; male sex, older age, higher household income, having supplemental insurance, family history of cancer, and poor self-reported health were associated with a higher screening rate using colonoscopy. Lower household income was associated with a higher screening rate using the FOBT and with a lower screening rate using colonoscopy. To increase the rate of CRC screening using colonoscopy, efforts should be made toward improving the education and promotion of screening to the low household income target population.

Mammography interval and breast cancer mortality in women over the age of 75

The purpose of this study is to evaluate the relationship between mammography interval and breast cancer mortality among older women with breast cancer. The study population included 1,914 women diagnosed with invasive breast cancer at age 75 or later during their participation in the Women's health initiative, with an average follow-up of 4.4 years (3.1 SD). Cause of death was based on medical record review. Mammography interval was defined as the time between the last self-reported mammogram 7 or more months prior to diagnosis, and the date of diagnosis. Multivariable adjusted hazard ratios (HR) and 95 % confidence intervals (CIs) for breast cancer mortality and all-cause mortality were computed from Cox proportional hazards analyses. Prior mammograms were reported by 73.0 % of women from 7 months to ≤2 year of diagnosis (referent group), 19.4 % (>2 to <5 years), and 7.5 % (≥5 years or no prior mammogram). Women with the longest versus shortest intervals had more poorly differentiated (28.5 % vs. 22.7 %), advanced stage (25.7 % vs. 22.9 %), and estrogen receptor negative tumors (20.9 % vs. 13.1 %). Compared to the referent group, women with intervals of >2 to <5 years or ≥5 years had an increased risk of breast cancer mortality (HR 1.62, 95 % CI 1.03-2.54) and (HR 2.80, 95 % CI 1.57-5.00), respectively, p trend = 0.0002. There was no significant relationship between mammography interval and other causes of death. These results suggest a continued role for screening mammography among women 75 years of age and older.

Factors associated with compliance with recommendations for liver cancer screening in Korea: a nationwide survey in Korea

To investigate the factors associated with compliance with recommendations regarding liver cancer screening intervals and methods among individuals at high-risk for liver cancer in the Republic of Korea. We used data from the fourth Korean National Health and Nutrition Examination Survey (KNHANES IV), a representative cross-sectional nationwide survey conducted between 2007 and 2009. The liver cancer screening rate and factors associated with compliance with recommended screening intervals (6 months) and methods (both abdominal ultrasonography and serum alpha-fetoprotein testing) among individuals at high risk for liver cancer such as hepatitis B virus (HBV) carriers were investigated. Out of 24,871 KNHANES IV participants, 604 HBV carriers aged ≥20 years were included in our analysis. 39.6% of our study sample reported attending liver cancer screening at least once in their lifetime, 12.3% had attended within the previous 6 months, and 14.6% were screened using both recommended methods. Older age was associated with increased compliance with screening intervals (P-trend 0.011) and methods (40–49 year: OR = 3.25, 95% CI: 1.62–6.51; 50–59 years: OR = 3.09, 95% CI: 1.44–6.66; 60–69 years: OR = 3.17, 95% CI: 1.28–7.82). Unawareness of HBV infection status was negatively related to compliance with screening intervals and methods (OR = 0.30, 95% CI: 0.17–0.53; OR = 0.45, 95% CI: 0.26–0.79). Female sex (OR = 0.45, 95% CI: 0.25–0.78), lower household income (P-trend 0.011), and routine and manual occupations (OR = 0.46, 95% CI: 0.22–0.97) were associated with decreased compliance with screening methods. The liver cancer screening rate among high-risk individuals is much less suboptimal. Considering that those unaware of their HBV infection status got regular and complete liver cancer screening much less often, efforts should be made not only to decrease sociodemographic disparities, but also to better identify the high-risk population.

Shared decision-making about colorectal cancer screening: a conceptual framework to guide research

OBJECTIVE

To develop a conceptual framework to guide research on shared decision-making about colorectal cancer (CRC) screening among persons at average risk and their providers.

METHODS

Based upon a comprehensive review of empirical literature and relevant theories, a conceptual framework was developed that incorporated patient characteristics, cultural beliefs, provider/health care system variables, health belief/knowledge/stage of adoption variables, and shared decision-making between patients and providers that may predict behavior. Relationships among concepts in the framework, shared decision-making process and outcomes, and CRC screening behavior were proposed. Directions for future research were presented.

RESULTS

Many of the concepts in the proposed framework have been examined in prior research. However, these elements have not been combined previously to explain shared decision-making about CRC screening.

CONCLUSION

Research is needed to test the proposed relationships and hypotheses and to refine the framework.

PRACTICE IMPLICATIONS

Findings from future research guided by the proposed framework may inform clinical practice to facilitate shared decision-making about CRC screening.

Provision of counseling on diabetes self-management: are there any age disparities?

OBJECTIVE

To determine whether there are any age-related disparities in the frequency of provision of counseling and education for diabetes care in a large HMO in Central Texas.

METHODS

EMR search from 13 primary care clinics on patients aged ≥18 years (n=1300) who had been diagnosed with type 2 diabetes.

RESULTS

There were no significant age differences in the frequency of provision of counseling about HBGM, diet, smoking or diabetes education. However, there were significant age differences in the provision of exercise counseling. Patients aged ≥75 were significantly less likely to have been provided exercise counseling than those aged <65 (adjusted OR=0.60; 95% CI=0.37-0.98). The mean HbA1c for patients aged ≥75 and 65-74 were significantly lower than that of patients aged <65 (8.9 vs. 9.0 vs. 9.7; P<0.001).

CONCLUSION

While age-related variations in self-management protocols were not found, the provision of formal diabetes education was low (29.4%). The persistence of key risk factors in later life (e.g., obesity) underscores the need for better self-management protocols for older adults.

PRACTICE IMPLICATIONS

Additional efforts on strategies to increase counseling about lifestyle habits and diabetes self-management care by appropriate health care providers is needed. Diabetes counseling should be individually tailored in older population.

Are United States and Canadian cancer screening rates consistent with guideline information regarding the age of screening initiation?

OBJECTIVE

To understand whether US and Canadian breast, colorectal and prostate cancer screening test utilization is consistent with US and Canadian cancer screening guideline information with respect to the age of screening initiation.

DESIGN

Cross-sectional, regression discontinuity.

SETTING

Canada and the US.

PARTICIPANTS

Canadian and American women of ages 30-60 and men of ages 40-60.

INTERVENTIONS

None. Main Outcomes Measures Mammography, prostate-specific antigen (PSA) and colorectal cancer test use within the past 2 years.

METHODS

We identify US and Canadian compliance with age screening information in a novel manner, by comparing test utilization rates of individuals who are immediately on either side of the guideline recommended initiation ages.

RESULTS

US mammography utilization within the last 2 years increased from 33% at age 39 to 48% at age 40 and 60% at age 41. US colorectal cancer test utilization, within the last 2 years, increased from 15% at age 49 to 18% at age 50 and 28% at age 51. US PSA utilization within the last 2 years increased from 37% at age 49 to 44% at age 50 and 54% at age 51. In Canada, mammography utilization within the last 2 years increased from 47% at age 49 to 57% at age 50 and 66% at age 51.

CONCLUSION

American and Canadian cancer screening utilization is generally consistent with each country's guideline recommendations regarding age. US and Canadian differences in screening due to guidelines can potentially explain cross-country differences in breast cancer mortality and affect interpretation of international comparisons of cancer statistics.

Breast cancer risk assessment in women aged 70 and older

Although the benefit of screening mammography for women over 69 has not been established, it is generally agreed that screening recommendations for older women should be individualized based on health status and breast cancer risk. However, statistical models to assess breast cancer risk have not been previously evaluated in this age group. In this study, the original Gail model and three more recent models that include mammographic breast density as a risk factor were applied to a cohort of 19,779 Vermont women aged 70 and older. Women were followed for an average of 7.1 years and 821 developed breast cancer. The predictive accuracy of each risk model was measured by its c-statistic and associations between individual risk factors and breast cancer risk were assessed by Cox regression. C-statistics were 0.54 (95% CI = 0.52-0.56) for the Gail model, 0.54 (95% CI = 0.51-0.56) for the Tice modification of the Gail model, 0.55 (95% CI = 0.53-0.58) for a model developed by Barlow and 0.55 (95% CI = 0.53-0.58) for a Vermont model. These results indicate that the models are not useful for assessing risk in women aged 70 and older. Several risk factors in the models were not significantly associated with outcome in the cohort, while others were significantly related to outcome but had smaller relative risks than estimated by the models. Age-related attenuation of the effects of some risk factors makes the prediction of breast cancer in older women particularly difficult.

Factors influencing general practitioners in the referral of elderly cancer patients

BACKGROUND

A number of studies have identified advanced age as a barrier to accessing specialised oncological care. Many factors can influence the care provided for elderly patients after a diagnosis of cancer has been established or is suspected. Only one European study has analysed the decision processes leading general practitioners (GPs) to refer elderly patients with cancer to oncologists. The objectives of the current study are to describe the factors that influence these decisions and to identify the particular factors and GP characteristics that are associated with systematic referral of these patients in South-West France.

METHODS

This is a cross-sectional study on a representative sample of GPs in Aquitaine, South-West France. Questionnaire items were selected using a Delphi consensus approach and sent by post. Two logistic regression models were constructed to investigate GPs' decisions to refer these patients.

RESULTS

The response rate obtained was 30%. Half of the general practitioners reported "always" referring their elderly cancer patients to oncologists. More than 75% reported being influenced by patient-related elements (patient and/or family wishes, comorbid factors, unsuitability of invasive investigations, physical and mental autonomy), by cancer-related elements (severity of symptoms, expected side-effects) and an organisational element (whether the general practitioner was used to collaborating with oncologists). Logistic regression analysis showed that cancer site and organisational difficulties in patient management were significantly associated with the decision to refer elderly patients with early-stage cancer. For advanced stages, oncology training, patient age, organisational difficulties in patient management and stage of cancer were significantly associated with the decision to refer elderly patients.

CONCLUSIONS

Cancer-linked factors and organisational difficulties have been highlighted as influencing the decisions of GPs in the referral of elderly patients to a cancer team. These results highlight the need to implement continuous medical education specific for the management of elderly patients, to better apprehend the nature of these difficulties and to suggest solutions suited to local settings.

Use of the prostate-specific antigen test among men aged 75 years or older in the United States: 2006 Behavioral Risk Factor Surveillance System

INTRODUCTION

In 2008, the US Preventive Services Task Force (USPSTF) updated prostate cancer screening guidelines to recommend against screening for prostate cancer in men aged 75 years or older. We describe the prevalence of prostate-specific antigen (PSA) testing in this population and identify factors that may be correlated with the use of this test.

METHODS

Data came from the 2006 Behavioral Risk Factor Surveillance System. We assessed the status of PSA testing in the past year among 9,033 US men aged 76 or older who had no history of prostate cancer. We conducted descriptive and multiple logistic regression analyses to assess associations of PSA testing with certain sociodemographic and psychosocial factors.

RESULTS

Overall, 60% of men aged 76 or older reported having a PSA test in the past year. Men who had health insurance, were satisfied with life, or always had emotional support were significantly more likely to report having a PSA test in the past year. However, men who had no routine health checkup; were divorced, widowed, or separated; or had less than a high school education were significantly less likely to report having had a PSA test.

CONCLUSION

PSA testing is common among men aged 75 or older in the United States. Certain sociodemographic and psychosocial factors were associated with receipt of this test. This study may not only provide baseline data to evaluate acceptance and implementation of the USPSTF screening guidelines but may also help physicians and public health providers better understand these sociodemographic and psychosocial factors in this population.

Population-based prevalence estimates of history of colonoscopy or sigmoidoscopy: review and analysis of recent trends

BACKGROUND

Lower GI endoscopy, such as colonoscopy or sigmoidoscopy, is thought to have a substantial impact on colorectal cancer incidence and mortality through detection and removal of precancerous lesions and early cancers. We aimed to review prevalence estimates of history of colonoscopy or sigmoidoscopy in the general population and to analyze recent trends.

METHODS

A systematic review of the medical literature, including MEDLINE (1966 to August 2008) and EMBASE (1980 to August 2008), was undertaken, supplemented by searches of the European Health Interview & Health Examination Surveys database and bibliographies. Detailed age-specific and sex-specific prevalence estimates from the United States were obtained from the Behavioral Risk Factor Surveillance System surveys 2002, 2004, and 2006.

RESULTS

The search yielded 55 studies that met our inclusion criteria. The majority of the reports (43) originated from the United States. Other countries of origin included Australia (2), Austria (2), Canada (5), France (1), Germany (1), and Greece (1). Estimates from the United States were generally increasing over time up to 56% (2006) for lifetime use of colonoscopy or sigmoidoscopy in people aged 50 years and older. Analysis of national survey data showed higher prevalences among men aged 55 years and older than for women of the same age. Prevalences were highest for people aged 70 to 79 years.

CONCLUSION

Data from outside the United States were extremely limited. Prevalence estimates from the United States indicate that a considerable and increasing proportion of the population at risk has had at least 1 colonoscopy or sigmoidoscopy in their lives, although differences between age and sex groups persist. Prevalences of previous colonoscopy or sigmoidoscopy need to be taken into account in the interpretation of time trends in, and variation across, populations of colorectal cancer incidence and mortality.

Uptake of colorectal cancer screening: system, provider and individual factors and strategies to improve participation

Colorectal cancer (CRC) accounts for 9% of all new cancer cases worldwide and affects over 1 million people each year. Screening can reduce the mortality associated with the disease, yet participation rates are suboptimal. Compliers with CRC screening are less deprived; they have higher education than noncompliers and tend to be male, white and married. Likely reasons for nonparticipation encompass several 'modifiable' factors that could be targeted in interventions aimed at increasing participation rates. Successful intervention strategies include organizational changes, such as increasing access to fecal occult blood test (FOBT) kits, providing reminders to healthcare providers or users about screening opportunities, and educational strategies to improve awareness and attitudes towards CRC screening. Multifactor interventions that target more than one level of the screening process are likely to have larger effects. The biggest challenge for future research will be to reduce inequalities related to socio-economic position and ethnicity in the uptake of screening.

Screening mammography utilization in Tennessee women: the association with residence

CONTEXT

Approximately 70% of US women over age 40 report mammography screening within 2 years. However, rates are likely to vary by age, income, educational level, and residence.

PURPOSE

To describe the prevalence of screening mammography and associated factors in women living in rural and urban areas of Tennessee.

METHODS

Using pooled data from the Tennessee Behavioral Risk Factor Surveillance System (BRFSS; 2001 and 2003), utilization of screening mammography within a 2-year period was examined for a sample of 1,922 women, 40 years and older. Demographic, behavior, and health-related variables were used to examine associations with utilization.

FINDINGS

The prevalence of screening mammography utilization (71.3% 95% CI 67.4-75.2) in women living in rural areas of Tennessee was significantly lower than utilization among women living in urban areas (78.3% 95% CI 75.9-80.7). Higher utilization was associated with having attained at least a high school education, having health insurance, identifying a personal health care provider, being a nonsmoker, recent use of alcohol, having had a recent clinical breast exam or Papanicolau (Pap) test done, and meeting the Healthy People 2010 (HP 2010) recommendation for physical activity. After controlling for all other factors, rural residence was not associated with utilization. For rural women, identifying a personal health care provider was significantly associated with increased likelihood of utilization.

CONCLUSIONS

Lower income and lower education, each associated with lower screening utilization, were more common in rural Tennessee women. The significance of a personal health care provider for utilization in rural women is meaningful for service providers.

Are U.S. cancer screening test patterns consistent with guideline recommendations with respect to the age of screening initiation?

BACKGROUND

U.S. cancer screening guidelines communicate important information regarding the ages for which screening tests are appropriate. Little attention has been given to whether breast, colorectal and prostate cancer screening test use is responsive to guideline age information regarding the age of screening initiation.

METHODS

The 2006 Behavioral Risk Factor Social Survey and the 2003 National Health Interview Surveys were used to compute breast, colorectal and prostate cancer screening test rates by single year of age. Graphical and logistic regression analyses were used to compare screening rates for individuals close to and on either side of the guideline recommended screening initiation ages.

RESULTS

We identified large discrete shifts in the use of screening tests precisely at the ages where guidelines recommend that screening begin. Mammography screening in the last year increased from 22% [95% CI = 20, 25] at age 39 to 36% [95% CI = 33, 39] at age 40 and 47% [95% CI = 44, 51] at age 41. Adherence to the colorectal cancer screening guidelines within the last year increased from 18% [95% CI = 15, 22] at age 49 to 19% [95% CI = 15, 23] at age 50 and 34% [95% CI = 28, 39] at age 51. Prostate specific antigen screening in the last year increased from 28% [95% CI = 25, 31] at age 49 to 33% [95% CI = 29, 36] and 42% [95% CI = 38, 46] at ages 50 and 51. These results are robust to multivariate analyses that adjust for age, sex, income, education, marital status and health insurance status.

CONCLUSION

The results from this study suggest that cancer screening test utilization is consistent with guideline age information regarding the age of screening initiation. Screening test and adherence rates increased by approximately 100% at the breast and colorectal cancer guideline recommended ages compared to only a 50% increase in the screening test rate for prostate cancer screening. Since information regarding the age of cancer screening initiation varies across countries, results from this study also potentially have implications for cross-country comparisons of cancer incidence and survival statistics.

Biological, psychological and behavioral, and social variables influencing colorectal cancer screening in African Americans

BACKGROUND

Provider recommendation of colorectal cancer (CRC) screening is an important predictor of screening in African Americans. Little is known about influences of screening in African Americans without provider recommendations.

OBJECTIVES

The objectives of this study were to test, using the biopsychosocial (BPS) model, the relative predictive strength for screening of variables grouped into biological, psychological and behavioral, and social system factors and to compare CRC screening predictors in African Americans with and without provider recommendations.

METHODS

Secondary analysis of the 2002 Maryland Cancer Survey data was done using (a) hierarchical logistic regression to examine the relative influence of factors on screening and (b) simultaneous logistic regression to examine predictors of screening in individuals with and without provider recommendations to screen. Factors included biological (age and gender), psychological and behavioral (mammogram, prostate specific antigen, body mass index, activity level, fruit and vegetable consumption, alcohol, smoking, and cancer perceptions), and social system (education, employment, insurance, and healthcare provider access).

RESULTS

The social system factor influenced CRC screening in the overall sample (n = 492). In African Americans with provider recommendations (n = 337), the very active were 2.43 (95% confidence interval [CI] = 1.11-5.28) times more likely to screen than were less active. Insured were 3.25 (95% CI = 1.14-9.31) times more likely to screen than were uninsured. In African Americans without provider recommendations (n = 155), 65- to 69-year-olds were 9.99 (95% CI = 2.31-43.32) times more likely to screen than were those 50- to 54-year-olds without screening.

DISCUSSION

The BPS model confirms social system factor strength in influencing CRC screening in African Americans. Identifying other social system variables that enhance healthcare provider access is critical to increase provider visits, which will generate recommendations and subsequent CRC screening.

Trends in cervical and breast cancer screening practices among women in rural and urban areas of the United States

OBJECTIVE

The objective of this study was to assess rural-urban differences in mammography and Papanicolaou (Pap) smear screening.

METHODS

Data from the Behavioral Risk Factor Surveillance System (1994-2000, 2002, 2004) were used to examine trends in these two tests by rural-urban residence location.

RESULTS

In 2004, 70.8 percent of rural and 75.7 percent of urban respondents had received timely mammography; this difference remained significant in adjusted analyses and was greatest for women in remote rural locations. Although overall participation in mammography increased over time, a persistent rural-urban gap was identified. In contrast, in 2004, while 83.1 percent of rural and 86.1 percent of urban respondents had received a timely Pap test, the adjusted difference was not significant and Pap testing did not improve over time. Advanced age and low socioeconomic status were associated with a lack of screening.

CONCLUSIONS

Over an 11-year interval, mammography screening improved nationally, but women living in rural locations remained less likely than their urban counterparts to receive this test. However, no secular improvement in Pap testing was found, and no significant rural-urban differences were observed.

POLICY IMPLICATIONS

Interventions to improve breast cancer screening are needed for rural women. Such efforts should target older women and those with low socioeconomic status.

The contribution of health literacy to disparities in self-rated health status and preventive health behaviors in older adults

PURPOSE

Health literacy is associated with a range of poor health-related outcomes. Evidence that health literacy contributes to disparities in health is minimal and based on brief screening instruments that have limited ability to assess health literacy. The purpose of this study was to assess whether health literacy contributes, through mediation, to racial/ethnic and education-related disparities in self-rated health status and preventive health behaviors among older adults.

METHODS

We undertook a cross-sectional study of a nationally representative sample of 2,668 US adults aged 65 years and older from the 2003 National Assessment of Adult Literacy. Multiple regression analysis was used to assess for evidence of mediation.

RESULTS

Of older adults in the United States, 29% reported fair or poor health status, and 27% to 39% reported not utilizing 3 recommended preventive health care services in the year preceding the assessment (influenza vaccination 27%, mammography 34%, dental checkup 39%). Health literacy and the 4 health outcomes (self-rated health status and utilization of the 3 preventive health care services) varied by race/ethnicity and educational attainment. Regression analyses indicated that, after controlling for potential confounders, health literacy significantly mediated both racial/ethnic and education-related disparities in self-rated health status and receipt of influenza vaccination, but only education-related disparities in receipt of mammography and dental care.

CONCLUSIONS

Health literacy contributes to disparities associated with race/ethnicity and educational attainment in self-rated health and some preventive health behaviors among older adults. Interventions addressing low health literacy may reduce these disparities.

Geographic variation and effect of area-level poverty rate on colorectal cancer screening

BACKGROUND

With a secular trend of increasing colorectal cancer (CRC) screening, concerns about disparities in CRC screening also have been rising. It is unclear if CRC screening varies geographically, if area-level poverty rate affects CRC screening, and if individual-level characteristics mediate the area-level effects on CRC screening.

METHODS

Using 2006 Missouri Behavioral Risk Factor Surveillance System (BRFSS) data, a multilevel study was conducted to examine geographic variation and the effect of area-level poverty rate on CRC screening use among persons age 50 or older. Individuals were nested within ZIP codes (ZIP5 areas), which in turn, were nested within aggregations of ZIP codes (ZIP3 areas). Six groups of individual-level covariates were considered as potential mediators.

RESULTS

An estimated 51.8% of Missourians aged 50 or older adhered to CRC screening recommendations. Nearly 15% of the total variation in CRC screening lay between ZIP5 areas. Persons residing in ZIP5 areas with > or = 10% of poverty rate had lower odds of CRC screening use than those residing in ZIP5 areas with <10% poverty rate (unadjusted odds ratio [OR], 0.69; 95% confidence interval [95% CI], 0.58-0.81; adjusted OR, 0.81; 95% CI, 0.67-0.98). Persons who resided in ZIP3 areas with > or = 20% poverty rate also had lower odds of following CRC screening guidelines than those residing in ZIP3 areas with <20% poverty rate (unadjusted OR, 0.66; 95% CI, 0.52-0.83; adjusted OR, 0.64; 95% CI, 0.50-0.83). Obesity, history of depression/anxiety and access to care were associated with CRC screening, but did not mediate the effect of area-level poverty on CRC screening.

CONCLUSION

Large geographic variation of CRC screening exists in Missouri. Area-level poverty rate, independent of individual-level characteristics, is a significant predictor of CRC screening, but it only explains a small portion of the geographic heterogeneity of CRC screening. Individual-level factors we examined do not mediate the effect of the area-level poverty rate on CRC screening. Future studies should identify other area- and individual-level characteristics associated with CRC screening in Missouri.

Gender, Social Ties, and Cancer Screening Among Elderly Persons

Objective: This study examines the association of social ties and cancer screening. Method: Data from the Longitudinal Study on Aging II include 4,419 respondents (70 to 85) who completed Wave 2. The dependent variable is receipt of screening within the past 2 years, measured at Wave 2. Social network variables include marital status, interaction with friends, relatives, and children, and church attendance. Results: Women were higher on most social tie measures, except marriage, and less likely to have mammography than men were to have prostate cancer screening. Also, the decline of screening with age was greater for women. For women, screening was related to contact with friends, relatives, and children but not marital status or church attendance. For men, screening was higher in the married and church attendees, but contact with friends, relatives, and children was not associated with screening. Discussion: Cancer screening interventions that use interpersonal communication channels should target distinct relationships for older women and men.

Health disparities in receipt of screening mammography in Latinas: a critical review of recent literature

BACKGROUND

Increased use of screening mammography is associated with lower death rates from breast cancer in the United States. Despite recommendations that women over 40 years of age should obtain regular screening mammography at least every 2 years, many women do not adhere to these guidelines. Historically, women from underserved and minority populations have been less likely to receive screening mammography.

METHODS

A critical review of recent research literature was conducted to evaluate whether Latinas are less likely to receive screening mammography, determine whether disparities in screening mammography persist when controlling for other variables, and examine what other variables are associated with screening mammography. The articles were obtained from a search of the PubMed database.

RESULTS

Fifteen published articles met the inclusion criteria and were critically reviewed. The unadjusted odds ratios (ORs) of the association between Hispanic ethnicity and screening mammography ranged from 0.40 to 0.93. For the most part, the ORs adjusted for other variables in multiple logistic regression analyses increased (range: 0.3 to 1.67). Age, education, income, health insurance, having a usual source of care, and having a recent visit to a physician were consistently related to screening mammography in multiple logistic regression analysis.

CONCLUSIONS

Hispanic ethnicity is a risk factor for lack of adherence to screening mammography. However, other demographic, socioeconomic, and health system variables account for some of the disparity related to Hispanic ethnicity.

Health insurance-related disparities in colorectal cancer screening in Virginia

BACKGROUND

Colorectal cancer (CRC) screening rates remain low in the United States. The effect of health insurance on CRC screening is not clear. We assessed the association between having health insurance and being screened for CRC and the factors that modify this association.

METHODS

We used data from the 2005 Virginia Behavioral Risk Factor Surveillance System to evaluate the association of self-reported insurance coverage on self-reported CRC screening among all men and women ages > or =50 years (N = 2,887). Prevalence odds ratios (POR) were estimated using unconditional logistic regression. All covariates were assessed for potential effect measure modification and confounding. All analyses accounted for the Behavioral Risk Factor Surveillance System complex survey sampling design.

RESULTS

Overall, participants who reported having insurance coverage were more than twice as likely to report being screened for CRC compared with those who reported having none [crude POR, 2.16; 95% confidence interval (95% CI), 1.26-3.68]. This relationship differed between men and women (POR(males), 3.37; 95% CI, 1.63-6.96; POR(females), 1.46; 95% CI, 0.74-2.89). After adjusting for age and income, self-reported insurance coverage had a positive association with report of being screened among men (POR, 2.02; 95% CI, 0.96-4.23) but not among women (POR, 0.81; 95% CI, 0.34-1.93).

CONCLUSIONS

Men who reported having health insurance were more likely to report having CRC screening than those who reported not having insurance coverage. However, this effect was not observed in women. These findings, if confirmed in other study populations, indicate that improving CRC screening coverage may require not only insurance status specifications but also gender-explicit considerations.

Health status and behavioral risk factors among persons with epilepsy in Ohio based on the 2006 Behavioral Risk Factor Surveillance System

In 2006, Ohio added questions to the Centers for Disease Control and Prevention's yearly Behavioral Risk Factor Surveillance System (BRFSS) survey to assess epilepsy prevalence. Ninety-seven of 5506 respondents reported a history of epilepsy, yielding a weight-adjusted prevalence rate of 1.48% (95% CI=0.9-2.1), which is supportive of previous state-based epidemiology estimates. Persons with a history of epilepsy report double the rate of cigarette smoking than the population without epilepsy. Persons with both active epilepsy and a history of epilepsy report poor physical and mental health. Health screening behaviors were comparable to or higher than those of the population without epilepsy. Data from previous BRFSS surveys are used to identify major risk factor trends, as well as to explore the health promotion implications for people with epilepsy. Assessments reveal a need for smoking cessation and increased physical activity for persons with a history of epilepsy in Ohio.

[How is prostate cancer screening perceived by men 50 to 70 years of age? Analysis based on 1,774 screened individuals]

INTRODUCTION

The rationale for mass screening for prostate cancer remains controversial. Apart from the scientific debate, we wanted to evaluate the opinion of prostate cancer screening candidates concerning the practical modalities of this screening and assess the impact of various personal, medical or social factors on their replies.

MATERIAL AND METHOD

Following a screening campaign in a French district, 1,774 men, 50 to 70 years of age, who completed screening were interviewed by questionnaire concerning the duration, frequency, mode of blood sampling and the cost of screening. Medical history, family history and lifestyle were also evaluated.

RESULTS

Among 1,774 candidates who returned an interpretable questionnaire during the screening campaign (participation rate: 31%), 27.1% of subjects interviewed declared that the personal financial cost would be an obstacle to screening, 5.1% considered that collection of a blood sample from the cubital fossa would be an obstacle to screening, 6.5% considered that one PSA per year was too frequent, and 8.1% considered that screening between the ages of 50 and 70 years was too long.

CONCLUSION

More than 90% of men who participated in a prostate cancer screening campaign appear to be in favour of continuation of screening according to the current modalities provided it is free of charge. The acceptance rate was better for men with a family history of prostate cancer, men who had already had a PSA assay, men living alone and men under 60 years of age.

Do physician recommendations for colorectal cancer screening differ by patient age?

Colorectal cancer screening is underutilized, resulting in preventable morbidity and mortality. In the present study, age-related and other disparities associated with physicians' delivery of colorectal cancer screening recommendations were examined. The present cross-sectional study included 43 physicians and 618 of their patients, aged 50 to 80 years, without past or present colorectal cancer. Of the 285 screen-eligible patients, 45% received a recommendation. Multivariate analyses revealed that, compared with younger nondepressed patients, older depressed patients were less likely to receive fecal occult blood test recommendations, compared with no recommendation (OR=0.31, 95% CI 0.09 to 1.02), as well as less likely to receive colonoscopy recommendations, compared with no recommendation (OR=0.14; 95% CI 0.03 to 0.66). Comorbidity and marital status were associated with delivery of fecal occult blood test and colonoscopy recommendations, respectively, compared with no recommendation. In summary, patient age and other characteristics appeared to influence physicians' delivery of colorectal cancer screening and choice of modality.

Health disparities in 30 indicators of recommended clinical care

This article examines variations in clinical practice for 30 clinical indicators. Patients' age, gender, and morbidity and certain characteristics of their physicians affected whether they received recommended care. Recommended care increased with patient age for 13 significant clinical indicators and decreased with age for 7 others. Males received recommended care more often for 12 of 13 clinical indicators. Recommended care varied by physician specialties for health screenings, disease management, and medication use. Patients seeing physicians who treated a high volume of patients generally received better care. The variations in recommended care suggest potential targets for healthcare quality improvements.

Breast and colorectal cancer screening and sources of cancer information among older women in the United States: results from the 2003 Health Information National Trends Survey

INTRODUCTION

The number of people in the United States aged 65 years and older is increasing. Older people have a higher risk of dying from cancer; however, recent information about breast and colorectal cancer screening rates among women aged 65 years and older and about sources of health information consulted by these women is limited.

METHODS

We examined data from the Health Information National Trends Survey for women aged 65 years and older who had no personal history of breast or colorectal cancer. Women whose self-reported race and ethnicity was non-Hispanic white, non-Hispanic black, or Hispanic were included in the analysis. The overall response rate for the 2003 survey was 34.5%.

RESULTS

Women aged 75 years and older had lower rates of recent mammography (mammogram in previous 2 years) than did women aged 65 to 74 years. In both age groups, rates were especially low for Hispanic women and women with a household income of less than $15,000 per year. Rates of recent colorectal cancer screening (fecal occult blood test in previous year or endoscopy in previous 5 years) were markedly lower for non-Hispanic black women aged 75 years and older than for other women in this age group, and for Hispanic women aged 65 to 74 years than for non-Hispanic women in this age group. Screening rates were lowest for women with an annual household income of less than $15,000, no family history of cancer, no usual health care provider, or 1 or no provider visits in the previous year. Differences were found in the groups' preferred channel for receiving health information. Women who had had a mammogram in the previous 2 years were more likely to pay attention to health information on the radio or in newspapers and magazines than were women who had not received a recent mammogram. Women who had had a recent colorectal cancer screening test were more likely to pay attention to health information in magazines or on the Internet than were those who had not. Personalized print and other publications were the most preferred channel for receiving health information.

CONCLUSION

The results from this analysis suggest that educational materials about routine breast and colorectal cancer screening appropriate for women aged 65 years and older (especially low-income women, Hispanic women, and those aged 65 to 74 years) may be helpful.

Understanding Patterns of Change over Time to Improve Mammography Rates

This retrospective cohort study determined trends and patterns of mammography rates during 5 years (1997-2001) among female Medicare beneficiaries ages 50 years and older in Connecticut to better understand changes in rates over time and to plan future interventions. Time series analysis and hierarchical Longitudinal logistic regression were used to assess changes over time. Mammography rates increased significantly during the 5-year period (p < .001). A cyclical pattern was observed for all age groups and counties, with dips and peaks in the spring and fall each year (average increase 8% per year), consistent with concentrated intervention activity at those times.

Effects of a tailored interactive multimedia computer program on determinants of colorectal cancer screening: a randomized controlled pilot study in physician offices

OBJECTIVE

Screening reduces colorectal cancer (CRC) mortality and is cost-effective, yet uptake is suboptimal. We developed and evaluated a personally tailored interactive multimedia computer program (IMCP) to encourage CRC screening.

METHODS

Randomized controlled pilot trial evaluating the effects of the personally tailored CRC screening IMCP as compared with a non-tailored IMCP ("electronic leaflet") control. The IMCP was tailored to patient preference, self-efficacy, barriers, and readiness and deployed in busy primary care offices before scheduled doctor visits. Main outcomes were: CRC screening knowledge, self-efficacy, benefits and barriers, and stage of readiness.

RESULTS

We enrolled 54 subjects; software glitches occurred in 5, leaving 49 subjects for analysis. In adjusted analyses, compared with control, the experimental group had a significant increase in CRC screening self-efficacy (p=0.049), a significantly greater likelihood of moving to a more advanced stage of readiness for screening (p=0.034), a trend toward fewer perceived barriers to screening (p=0.149), and no difference in perceived benefits or knowledge of screening.

CONCLUSION

Our personally tailored IMCP was significantly more effective than control in bolstering CRC screening readiness and self-efficacy.

PRACTICE IMPLICATIONS

If further streamlined, personally tailored IMCPs might be usefully deployed in busy primary care offices to improve uptake of CRC screening.

Trends in Treatment Costs for Localized Prostate Cancer

OBJECTIVE

We sought to obtain estimates of trends in initial treatment costs during the prostate-specific antigen (PSA) era that account for the changing patient case-mix associated with screening.

SUBJECTS

We used reimbursement claims for Medicare-eligible subjects diagnosed with nonmetastatic prostate cancer between 1991 and 1999. Patients were grouped by initial treatment, with 17,846 receiving radical prostatectomy (RP), 25,933 receiving external beam radiotherapy (XRT), and 4525 receiving brachytherapy (BT).

METHODS

Cancer-attributable costs were computed by subtracting noncancer costs from total Medicare reimbursements among newly diagnosed cancer patients. Noncancer costs were estimated in 2 ways: (1) average costs among age-matched, cancer-free control subjects (control method) and (2) projections based on claims from subjects before diagnosis (prediagnosis method). Adjusted annual percent change in cancer-attributable costs was calculated using multivariate generalized linear models.

RESULTS

Noncancer costs increased at a much lower rate among men prior to diagnosis (3.8% annually) than among the general Medicare population (10.9%). The 2 approaches yielded different results; RP costs declined by 2.4% annually (prediagnosis method) versus 6.2% (control method); XRT costs declined by 1.5% versus 5.8%; and BT costs declined by 4.1% versus 8.3%.

CONCLUSIONS

Because of self-selection of PSA screening, men diagnosed with prostate cancer today are now healthier overall than men in the general population and are considerably healthier than men diagnosed previously. Estimates of cancer-attributable costs that do not account for this healthy selection effect are likely to be biased. Declines in cancer-attributable treatment costs are evident even after accounting for a healthy screenee effect, suggesting that there has been a real reduction in cancer treatment costs.

Do socio-demographic factors influence mammography use of French women? Analysis of a French cross-sectional survey

The aim of this study was to analyse the independent role of socio-demographic factors on the use of mammography according to whether or not an organized breast cancer screening programme exists. The study sample of 2825 women aged 40-74 years was drawn from a cross-sectional population-based survey of French households. Among these women 46% lived in districts that offered a screening programme and 63% reported undergoing mammography in the previous 2 years. Living in a district that offered a screening programme was associated with increased use of mammography. According to both univariate and multivariate analysis, several socio-demographic characteristics, such as high monthly household income or high education level, increased the probability of using mammography. However, three factors had a major positive impact on its use: (1) having had a gynaecological examination in the previous 2 years, (2) living in a district where a screening programme was available, and (3) age. There was a significant interaction between the factors 2 and 3. Between 40 and 60 years, age had the same impact on the use of mammography whether or not women lived in a district with a screening programme. After the age of 60 years, the use of mammography collapsed among women living in a district without a screening programme and remained frequent among women living in the district that offered such a programme. Even if the overall level of mammography screening was high and the existence of a screening programme maintained a high level of mammography use among older women, the programme should target better the women of underprivileged spheres and reinforce the role of the general practitioner; in particular for women not followed by a gynaecologist.

Practice patterns in screening and management of prostate cancer in elderly men

OBJECTIVES

To determine the practice preferences for prostate cancer screening and treatment in men 75 years of age or older among healthcare providers in Iowa.

METHODS

Practice patterns were determined by an institutional review board-approved 15-item survey mailed to all 3105 Iowa healthcare providers who care for older men. A modified Dillman method was used for the survey. Actual prostate-specific antigen (PSA) testing practices derived from our institutional database were correlated with the survey data.

RESULTS

The survey yielded a response rate of 32% (997 respondents). Of the respondents, 96% of primary care physicians and 97% of urologists preferred to stop PSA-based prostate cancer screening by age 80. This was compatible with our institutional data that indicated a PSA testing rate of 5.2% in men 80 years or older. Most physicians used the digital rectal examination as the first test for screening and reported a lack of educational materials to provide to patients. Older physicians and family practitioners were more likely to continue prostate cancer screening beyond 75 years, and most consented to patient requests for screening.

CONCLUSIONS

The predilection for prostate cancer screening among healthcare providers declines with increasing patient age but persists for a small proportion of patients. The education of both patients and healthcare providers to more selectively screen men older than 75 years and the development of educational materials are needed. A consensus among healthcare providers would facilitate adoption of a tailored approach to managing prostate cancer in older men, thereby decreasing healthcare costs and morbidity while limiting the use of unnecessary therapy.