Colorectal Cancer Testing and Screening in a Multiethnic Population
Colorectal cancer (CRC) screening is strongly supported by evidence and widely recommended, but remains underutilized. This study reports the prevalence of CRC diagnostic testing and CRC screening in three racial/ethnic groups attending the same primary care clinic. A cross-sectional survey was conducted to elicit past history of CRC testing, including test type, indication and timing. A comparable number of African American, Hispanic and non-Hispanic white patients aged 50-80 were recruited. 560 surveys were completed: mean age was 63.4 years, 64% reported minority race/ethnicity, and 96.8% had insurance. Overall, 62.5% [95% CI: 58.5%, 66.5%] of patients were current with any type of CRC test, when diagnostic and screening procedures were included. However, 48.6% [95% CI: 44.5%, 52.7%] of the sample was current with CRC screening, when only procedures performed for screening in asymptomatic patients were included. Patients least likely to be current with testing were those of minority race/ethnicity (48.2% of Hispanics, 56.7% of African Americans and 67.5% of non Hispanic whites, p < 0.05), younger age, (57.6% of those aged 50-64, and 71.4% of those aged 65-80, p < 0.005), and those with private insurance alone (56.0% private, 67.7% public and 68.1% mixed, p < 0.05). Our findings indicate that racial/ethnic and age related disparities in CRC screening exist even in a patient population that has the same source of health care and no differences in insurance status. These results underline the need for providers to emphasize CRC screening in their practices to minority patients and those younger than 65 years of age.
Colorectal cancer (CRC) is the second leading cause of cancer related deaths in the U.S; with the American Cancer Society estimating 145,290 new cases and 56,290 deaths in 2005. The incidence of disease rises dramatically from age 50 with African Americans having the highest mortality of all groups. Based on accumulating evidence, CRC screening is now widely accepted by all major professional organizations. Current guidelines state that all asymptomatic, average risk individuals aged 50 years of age and older should be screened with one of five different screening options: an annual fecal occult blood test (FOBT), a flexible sigmoidoscopy (SIG) every 3-5 years, or an annual FOBT and SIG every 3-5 years, or a colonoscopy (COL) every 10 years, or double contrast barium enema (DCBE) every 5-10 years. Medicare and other payors have expanded their coverage to include payment for all CRC screening test options, in average risk individuals.
However, despite the recommendations and the Healthy People 2010 target for at least half of eligible patients to be screened for CRC, national screening prevalence data indicate that CRC screening levels are below these targets, and are much lower than screening rates for other cancers. National figures (2001) reveal 41.0% of males and 37.5% of females (over 50 years of age) reported being up to date with CRC testing for any reason.(22) More recent figures (2004) reveal that the overall current CRC testing rate is 52%. However, these surveys may overestimate screening rates because they also count procedures performed for diagnosis, in addition to those performed solely for screening. It is currently unclear what proportions of overall CRC tests are attributable to screening as opposed to diagnosis in subjects with symptoms. The distinction between tests performed for diagnosis versus screening is an important one because diagnostic testing is likely to make a fixed contribution to the overall CRC testing rate, as patients continue to present to their physicians with symptoms that indicate the appropriate test. The overall testing rate for CRC cancer will only increase if more tests are ordered for screening in asymptomatic patients. Therefore an accurate understanding of the relative contribution of the two indications is an important baseline measure.
National data also reveal that self-reported testing rates are lowest amongst minority groups. The most up to date national information about testing rates amongst different minority groups comes from the 2000 National Health Interview Survey (NHIS), which reveals that CRC testing rates are 42.5% for non-Hispanic whites, 40.3% for African Americans and 27.3% for Hispanics. However, the greatest disparities observed were in patients without insurance or a usual source of care. Although studies have reported screening prevalence in mixed populations, to our knowledge, there have been no studies examining the prevalence of screening in populations comprising all three major racial/ethnic groups residing in the US, who have the same source of health care.
The purpose of our study, therefore, was to determine whether racial/ethnic disparities in CRC screening occur in a population of African American, Hispanic and non-Hispanic white patients that attend the same primary care clinic. A second purpose was to determine the proportion of tests that were performed for screening versus diagnosis.
Colorectal cancer (CRC) screening is strongly supported by evidence and widely recommended, but remains underutilized. This study reports the prevalence of CRC diagnostic testing and CRC screening in three racial/ethnic groups attending the same primary care clinic. A cross-sectional survey was conducted to elicit past history of CRC testing, including test type, indication and timing. A comparable number of African American, Hispanic and non-Hispanic white patients aged 50-80 were recruited. 560 surveys were completed: mean age was 63.4 years, 64% reported minority race/ethnicity, and 96.8% had insurance. Overall, 62.5% [95% CI: 58.5%, 66.5%] of patients were current with any type of CRC test, when diagnostic and screening procedures were included. However, 48.6% [95% CI: 44.5%, 52.7%] of the sample was current with CRC screening, when only procedures performed for screening in asymptomatic patients were included. Patients least likely to be current with testing were those of minority race/ethnicity (48.2% of Hispanics, 56.7% of African Americans and 67.5% of non Hispanic whites, p < 0.05), younger age, (57.6% of those aged 50-64, and 71.4% of those aged 65-80, p < 0.005), and those with private insurance alone (56.0% private, 67.7% public and 68.1% mixed, p < 0.05). Our findings indicate that racial/ethnic and age related disparities in CRC screening exist even in a patient population that has the same source of health care and no differences in insurance status. These results underline the need for providers to emphasize CRC screening in their practices to minority patients and those younger than 65 years of age.
Colorectal cancer (CRC) is the second leading cause of cancer related deaths in the U.S; with the American Cancer Society estimating 145,290 new cases and 56,290 deaths in 2005. The incidence of disease rises dramatically from age 50 with African Americans having the highest mortality of all groups. Based on accumulating evidence, CRC screening is now widely accepted by all major professional organizations. Current guidelines state that all asymptomatic, average risk individuals aged 50 years of age and older should be screened with one of five different screening options: an annual fecal occult blood test (FOBT), a flexible sigmoidoscopy (SIG) every 3-5 years, or an annual FOBT and SIG every 3-5 years, or a colonoscopy (COL) every 10 years, or double contrast barium enema (DCBE) every 5-10 years. Medicare and other payors have expanded their coverage to include payment for all CRC screening test options, in average risk individuals.
However, despite the recommendations and the Healthy People 2010 target for at least half of eligible patients to be screened for CRC, national screening prevalence data indicate that CRC screening levels are below these targets, and are much lower than screening rates for other cancers. National figures (2001) reveal 41.0% of males and 37.5% of females (over 50 years of age) reported being up to date with CRC testing for any reason.(22) More recent figures (2004) reveal that the overall current CRC testing rate is 52%. However, these surveys may overestimate screening rates because they also count procedures performed for diagnosis, in addition to those performed solely for screening. It is currently unclear what proportions of overall CRC tests are attributable to screening as opposed to diagnosis in subjects with symptoms. The distinction between tests performed for diagnosis versus screening is an important one because diagnostic testing is likely to make a fixed contribution to the overall CRC testing rate, as patients continue to present to their physicians with symptoms that indicate the appropriate test. The overall testing rate for CRC cancer will only increase if more tests are ordered for screening in asymptomatic patients. Therefore an accurate understanding of the relative contribution of the two indications is an important baseline measure.
National data also reveal that self-reported testing rates are lowest amongst minority groups. The most up to date national information about testing rates amongst different minority groups comes from the 2000 National Health Interview Survey (NHIS), which reveals that CRC testing rates are 42.5% for non-Hispanic whites, 40.3% for African Americans and 27.3% for Hispanics. However, the greatest disparities observed were in patients without insurance or a usual source of care. Although studies have reported screening prevalence in mixed populations, to our knowledge, there have been no studies examining the prevalence of screening in populations comprising all three major racial/ethnic groups residing in the US, who have the same source of health care.
The purpose of our study, therefore, was to determine whether racial/ethnic disparities in CRC screening occur in a population of African American, Hispanic and non-Hispanic white patients that attend the same primary care clinic. A second purpose was to determine the proportion of tests that were performed for screening versus diagnosis.
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