Friday, December 28, 2007

Colorectal cancer exam use—Maryland, 2002-2006

During 2000-2004, Maryland had the thirteenth top mortality rate for colorectal cancer (CRC) among the 50 states and the District of Columbia (1). The American Cancer Society (ACS), the U.S. Preventive Services Task Force, and other organizations recommend that adults originate CRC screening at age 50 years if they are at average risk for CRC and before age 50 years if they are at increased risk (2,3). For those at average risk, ACS recommend screening with 1) a fecal occult blood check (FOBT) or fecal immunochemical test (FIT) every year, 2) flexible sigmoidoscopy every 5 years, 3) an annual FOBT or FIT combined beside flexible sigmoidoscopy every 5 years, * 4) double-contrast barium enema (DCBE) every 5 years, or 5) colonoscopy every 10 years (2). In 2002, the Maryland Department of Health and Mental Hygiene initiated the Maryland Cancer Survey (MCS) to assess testing prevalence and risk behaviors for seven types of cancer, including CRC. Reducing CRC mortality and disparities in CRC incidence and mortality are goal described in Maryland's Comprehensive Cancer Control Plan (MCCCP) (4). As milestones toward these goal, Maryland set the following targets for 2008 for folks aged [greater than or equal to] 50 years: 1) decrease the percentage of Maryland residents who hold never been screen for CRC to [less than or equal to] 15% (from a 2002 baseline of 25.9%); 2) increase the percentage of residents who are up to date with CRC screening (per ACS guidelines) to [greater than or equal to] 73% (from a 2002 baseline of 63.8%); and 3) increase the percentage of residents who own been screen with any colonoscopy in the recent past 10 years, or FOBT in days gone by year plus flexible sigmoidoscopy in olden times 5 years, to [greater than or equal to] 57% (from a baseline of 46.5% in 2002). This report describes trends in CRC test use base on results from MCS surveys completed in 2002, 2004, and 2006.t The results indicated a significant decline (6.1 percentage points) in the percentage of Maryland residents aged [greater than or equal to] 50 years who have never been tested for CRC, a 5.4 percentage-point increase in prevalence of up-to-date trialling by any method, and a 13.9 percentage-point increase in prevalence of either colonoscopy surrounded by the past 10 years or FOBT surrounded by the past year plus flexible sigmoidoscopy surrounded by the past 5 years. However, Maryland residents who be neither white nor black (i.e., persons of other races) have a significantly lower prevalence of ever having a CRC tryout, as did persons short health insurance or those lacking a recent checkup. Although overall increases in CRC testing echo substantial progress in Maryland, extramural measures are needed to increase CRC testing among cultural minority groups and the medically underserved.


MCS is a biennial, population-based, statewide survey of cancer test use and behavioral risk factor among Maryland residents. MCS follows the methodology of the Behavioral Risk Factor Surveillance System (BRFSS) but focuses on adults aged [greater than or equal to] 40 years, the population most at risk for cancer. ([section]) The survey is conducted by telephone using random-digit dialing near computer-assisted telephone interviewing and list-assisted, disproportionate, stratified sampling. Respondents be eligible to participate contained by the survey if they were aged [greater than or equal to] 40 years, resided surrounded by a private residence in Maryland, and be able to respond to the interview question. For the purposes of sampling, Maryland was divided into two geographic strata, urban and rural, next to oversampling of rural telephone numbers. In 2002 and 2004, the survey be offered only contained by English. In 2006, participants be able to respond contained by English or Spanish.


Reported prevalence data be weighted to the Maryland population in the corresponding year according to BRFSS protocol (5). A total of 5,040, 5,004, and 5,149 those completed the interviews in 2002, 2004, and 2006, respectively. Council of American Survey Research Organizations (CASRO) response rates were 38.4% (2002), 38.3% (2004), and 39.7% (2006). Of those individuals surveyed in 2002, 2004, and 2006, a total of 3,436, 3,556, and 3,776 respondents, respectively, be aged [greater than or equal to] 50 years.


Respondents first were asked whether they have ever used a home FOBT or blood stool test and how long it have been since the second home test. After audible range a description of sigmoidoscopy and colonoscopy, respondents were asked whether they have ever had any test, which one be the most recent, and how long it had be since the last try-out. Questions regarding DCBE be not included in the questionnaire because DCBE is not commonly used as a first-line CRC screening test. Persons be considered to have up-to-date CRC trialling if they reported any one of the following: an FOBT within olden times year, a sigmoidoscopy within times past 5 years, an FOBT in days gone by year combined with a sigmoidoscopy contained by the past 5 years, or a colonoscopy in the past 10 years. Respondents whose responses be outside these parameters be considered not up to date, as were those who did not know when their closing test occur (6.8% of persons categorized as not up to date). The analysis is base on respondents aged [greater than or equal to] 50 years who were competent to report whether they had received any CRC test and were competent to distinguish whether their last lower gastrointestinal (GI) endoscopy be a sigmoidoscopy or colonoscopy (3,400 in 2002, 3,506 within 2004, and 3,748 in 2006; 99% of respondents aged [greater than or equal to] 50 years for respectively year). ([paragraph])


The estimated percentage of adults aged [greater than or equal to] 50 years who had never have a CRC test decrease from 25.9% in 2002 to 19.8% within 2006, a decline of 6.1 percentage points (Figure). The percentage of respondents who were up to date beside CRC testing by ACS guidelines increased by 5.4 percentage points during the study spell, from 63.8% in 2002 to 69.2% contained by 2006. On the basis of 2006 MCS background, the percentage of Maryland residents who reported being up to date next to colonoscopy or FOBT plus sigmoidoscopy has already exceeded the 2008 target of 57%. The prevalence of self-reported up-to-date colonoscopy (within times gone by 10 years) increased from 41.2% in 2002 to 58.7% in 2006. Accompanying the increase in colonoscopy during the study period be a decrease within the proportion of adults aged >50 years who were up to date by FOBT (within olden times year) and sigmoidoscopy (in the past 5 years). The percentage of adults who be tested but were not up to date remained stable at 10.3%, 10.1%, and 11.0%, respectively, in the three survey years.


[FIGURE OMITTED]


The estimated percentage of Maryland residents never tested for CRC decline significantly (p<0.05, by chi-square test) during the study period by nearly adjectives subject characteristics examined, except for respondents of other race (i.e., nonwhite and nonblack), those who have not had a routine checkup traditionally 2 years, and those without form insurance coverage (Table). Persons with lower tutorial attainment (i.e., high academy diploma or less) were significantly smaller amount likely to hold ever been tested within each study year, but this disparity decrease over time. Persons who reported having a routine checkup in the past 2 years be more likely than those in need a recent checkup to have ever be tested. Approximately 55% of the uninsured persons contained by each survey year have never been tested, compared next to 24.7% (2002), 21.1% (2004), and 18.4% (2006) among persons near health insurance.


Editorial Note. MCS results indicate that the percentage of Maryland residents aged [greater than or equal to] 50 years who reported ever man tested for CRC increased by 6.1 percentage points from 2002 to 2006. Extrapolated to the state population aged [greater than or equal to] 50 years (6), this finding translates into an estimated 90,000 previously untested Maryland residents who received CRC testing during that extent.


The observed prevalences in MCS of ever have any CRC tests are consistent next to those reported in the Maryland BRFSS. The 2006 BRFSS indicated that 77.1% of Maryland residents aged [greater than or equal to] 50 years have ever been tested for CRC, compared near 80.2% in the 2006 MCS. However, MCS, unlike BRFSS, asks respondents to specify which type of lower GI endoscopy be used in their most recent CRC testing. Thus, MCS results have be able to call attention to a trend toward increasing use of colonoscopy in recent years, with corresponding decline in carrying out tests with FOBT and sigmoidoscopy.


The increase in CRC exam use in common and colonoscopy in unusual likely is attributable to recent change in health-insurance coverage and to increased skill among the general public on the subject of CRC test procedures. Since July 2001, Medicare have provided payment for adjectives types of CRC screening tests, including colonoscopy, which might tale, in bit, for the increase in testing among adults aged [greater than or equal to] 65 years. Since 2001, the state of Maryland have required certain health-care insurers, health-maintenance organization, and nonprofit health-services plans to provide CRC screening in accordance with ACS guidelines (7). In decoration, since 2000, 23 of 24 Maryland jurisdictions hold used funds from the Cigarette Restitution Fund Program to provide CRC education to health-care providers and the public or to provide CRC trialling to qualified, low-income, uninsured residents (8).


The MCS results also indicate that not all segment of the Maryland population have participate equally in these increases. Persons of other race (e.g., Asian, Native Hawaiian or other Pacific Islander, American Indian/Alaska Native, multiple race, and unspecified race), the medically underserved (i.e., those short health insurance), and folks without a routine checkup in times gone by 2 years have a substantially superior prevalence of never having have CRC testing.


The findings here report are subject to at least four limitations. First, findings from MCS are base on self-report and are not verified by medical chart review. Therefore, responses might be subject to social-desirability and recall bias. In adornment, although the procedures of sigmoidoscopy and colonoscopy are described to survey respondents, certain respondents might not accurately identify their most recent exam. Second, response rates in the MCS be low; however, they were comparable to those reported within the Maryland BRFSS (9). For survey years 2002-2006, CASRO rates ranged from 38.3% to 39.7% within the MCS and 36.8% to 44.0% in the Maryland BRFSS. The effect of nonresponse on survey estimates is difficult to determine because it depends on the extent to which nonrespondents differ from respondents and the nonspecific population. To reduce potential bias from nonresponse, interviewers made numerous send for attempts and, when necessary, arranged appointments next to respondents for more convenient times. Third, because MCS is a telephone survey, it excludes people without landline telephone. The rates of cancer test use from receiver surveys might be overestimated because persons in need landline telephones are smaller amount likely to enjoy health insurance (10). Finally, the three survey sample consisted nearly entirely of English speakers. In 2002 and 2004, households that were reach by telephone but be unable to respond surrounded by English were excluded. However, surrounded by 2006, when the survey was offered within Spanish, only 0.4% of respondents chose to respond within Spanish.


MCS elicits from respondents the specific type of lower GI endoscopy used contained by their most recent CRC test. Knowing whether the most recent endoscopy be a sigmoidoscopy or colonoscopy allows for better assessment of CRC testing practices. In Maryland, CRC carrying out tests rates have increased in recent years, near increases in up-to-date testing and a shift toward use of colonoscopy. Although these change in CRC trialling likely will hold a substantial public health impact contained by Maryland (e.g., via the detection of premalignant lesions and early-stage CRC), second measures are needed to eliminate remaining disparities in CRC carrying out tests and to increase testing among the medically underserved.


References


(1.) Ries LAG, Melbert D, Krapcho M, et al, eds. SEER cancer statistics review, 1975-2004. Bethesda, MD: National Cancer Institute; 2007. Available at http://seer.cancer.gov/csr/1975_2004.


(2.) Smith RA, Cokkinides V, Eyre HJ. Cancer screening in the United States, 2007: a review of current guidelines, practices, and prospects. CA Cancer J Clin 2007;57:90-104.


(3.) US Preventive Services Task Force. Screening for colorectal cancer: recommendation and rationale. Rockville, MD: Agency for Healthcare Research and Quality; 2002. Available at http://www.ahrq.gov/clinic/ 3rduspstf/colorectal/colorr.htm.


(4.) Maryland Department of Health and Mental Hygiene. The 2004-2008 Maryland Comprehensive Cancer Control Plan: our call to dealing. Baltimore, MD: Center for Cancer Surveillance and Control; 2004. Available at http://www.fha.state.md.us/cancer/cancerplan/html/ theplan.cfm.


(5.) CDC. Behavioral Risk Factor Surveillance System. Technical information and data. BRFSS weighting formula. Available at http:// www.cdc.gov/brfss/technical_infodata/weighting.htm.


(6.) Maryland Department of Health and Mental Hygiene. Vital statistics annual report, 2002. Baltimore, MD: Vital Statistics Administration; 2003. Available at http://www.vsa.state.md.us/html/reports.html.


(7.) National Conference of State Legislatures. Colorectal cancer screening: what are states doing? Available at http://www.ncsl.org/programs/ health/colonrectal.htm.


(8.) Maryland Cigarette Restitution Fund Program. Available at http:// www.crf.state.md.us/index.cfm.


(9.) CDC. Behavioral Risk Factor Surveillance System. Technical information and data, summary data standard reports for 2002, 2004, and 2006. Available at http://www.cdc.gov/brfss/technical_infodata/ quality.htm.


(10.) Blumberg SJ, Luke JV, Cynamon ML. Telephone coverage and vigour survey estimates: evaluating the need for concern almost wireless substitution. Am J Pub Health 2006;96:926-31.


* An annual FOBT or FIT combined with flexible sigmoidoscopy every 5 years is preferred over any of these options alone.


([dagger]) Results of 2002 and 2004 MCS surveys are available at http://fha.state.md.us/ cancer/surveillance/html/data_reports.cfm. Results of the 2006 survey are within press.


([section] MCS is conducted independendy of the Maryland BRFSS. The Maryland BRFSS is available at http://www.flaa.state.md.us/cphs/html/brfss.cfm.


([paragraph]) In this report, CRC tests perform for screening purposes are not differentiated from those performed for nonscreening reason (e.g., diagnostic testing as follow-up to another tryout or because of symptoms). Therefore, the broader term "testing" is used in lieu of "screening" to imitate CRC tests perform for any indication.


TABLE. Estimated percentage * of population aged [greater than or
equal to]50 years never tested for colorectal cancer, by selected
characteristics--Maryland Cancer Survey, 2002-2006

2002

Characteristic % (95% CI)
[dagger]
Overall 25.9 (24.1-27.6)
Age group (yrs)
50-64 30.6 (28.1-33.0)
[greater than or equal to] 65 19.5 (17.2-21.7)
Sex
Male 26.3 (23.4-29.2)
Female 25.5 (23.4-27.7)
Race
White 23.8 (22.0-25.6)
Black 29.5 (25.2-33.8)
Other see 40.3 (29.0-51.7)
Geographic area
Urban 25.2 (23.1-27.2)
Rural 28.5 (25.6-31.3)
Education smooth
High school diploma or smaller quantity 32.2 (29.4-35.0)
Any college or more 21.1 (18.9-23.3)
Time since last routine checkup ([paragraph])
<2 yrs 24.0 (22.3-25.8)
[greater than or equal to] 2 yrs 50.3 (42.6-58.0)
Health-insurance coverage **
Yes 24.7 (22.9-26.4)
No 53.8 (44.3-63.2)

2004

Characteristic % (95% CI)

Overall 22.8 (21.1-24.5)
Age group (yrs)
50-64 26.0 (23.6-28.5)
[greater than or equal to] 65 18.1 (15.8-20.3)
Sex
Male 22.1 (19.2-25.1)
Female 23.3 (21.3-25.4)
Race
White 20.2 (18.4-21.9)
Black 27.7 (23.6-31.9)
Other see 44.1 (30.8-57.4)
Geographic area
Urban 22.5 (20.4-24.6)
Rural 23.9 (21.1-26.7)
Education rank
High school diploma or smaller quantity 29.5 (26.6-32.4)
Any college or more 18.6 (16.5-20.7)
Time since last routine checkup ([paragraph])
<2 yrs 20.7 (18.9-22.4)
[greater than or equal to] 2 yrs 56.2 (48.0-64.3)
Health-insurance coverage **
Yes 21.1 (19.4-22.8)
No 59.1 (49.1-69.1)

2006

Characteristic % (95% CI)

Overall 19.8 (18.3-21.4)
Age group (yrs)
50-64 23.8 (21.6-26.0)
[greater than or equal to] 65 13.8 (11.6-15.9)
Sex
Male 19.4 (16.8-22.0)
Female 20.2 (18.3-22.2)
Race
White 18.4 (16.8-20.0)
Black 22.3 (18.1-26.4)
Other see 31.4 (21.1-41.7)
Geographic area
Urban 19.2 (17.3-21.1)
Rural 22.3 (19.8-24.7)
Education even
High school diploma or smaller amount 24.1 (21.2-26.9)
Any college or more 17.4 (15.5-19.3)
Time since last routine checkup ([paragraph])
<2 yrs 17.1 (15.5-18.7)
[greater than or equal to] 2 yrs 50.6 (43.8-57.4)
Health-insurance coverage **
Yes 18.4 (16.9-20.0)
No 52.5 (43.0-62.0)

Characteristic p pro ([section])

Overall <0.001
Age group (yrs)
50-64 <0.001
[greater than or equal to] 65 0.001
Sex
Male 0.003
Female 0.001
Race
White <0.001
Black 0.04
Other race 0.31
Geographic nouns
Urban <0.001
Rural 0.004
Education level
High university diploma or less <0.001
Any college or more 0.04
Time since ultimate routine checkup ([paragraph])
<2 yrs <0.001
[greater than or equal to] 2 yrs 0.50
Health-insurance coverage **
Yes <0.001
No 0.59

* Percentage weighted to Maryland population in each survey year.

([dagger]) Confidence interval.

([section]) Based on chi-square question paper of significance for differences
across the three survey years.

([paragraph]) Based on response to survey question, "About how long have
it been since you end visited a doctor for a routine checkup?"

** Based on response to survey put somebody through the mill, "Do you have any humane of
health-care coverage?"

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