Are people being screened for colorectal cancer as recommended? Results from the National Health Interview Survey

BACKGROUND: The evidence is now compelling that colorectal cancer incidence and mortality can be reduced by screening, and medical organizations recommend regular screening among persons of average risk aged 50 years or older. We sought to determine whether appropriate screening has become more widespread now that consensus over its value has been achieved. METHODS: We analyzed data from the 1992 and 1998 National Health Interview Survey, an in-person survey of a nationally representative sample of the U.S. population. Persons aged > or =50 years (4428 in 1992, 12,629 in 1998) were questioned about their use of colorectal cancer screening. RESULTS: Self-reported use of fecal occult blood testing and proctoscopy increased slightly from 1992 to 1998. In 1998, however, only an estimated 22.9% of Americans aged > or =50 years had been screened with either the home-administered fecal occult blood testing in the past year or proctoscopy within 5 years. Nearly half of fecal occult blood testings were performed with a sample taken during an in-office physical examination rather than with the recommended home kit. CONCLUSION: Most eligible persons are still not meeting the screening recommendations for colorectal cancer. Education is needed for both the public and health care providers to increase their compliance with current guidelines.     

Skin cancer screening among U.S. adults from 1992, 1998, and 2000 National Health Interview Surveys

BACKGROUND: Relatively little is known about the prevalence of skin cancer screening in the context of inconsistent skin cancer screening recommendations. METHODS: To determine the prevalence and predictors of skin cancer screening rates in the U.S. adult population, we used self-reported data from the 1992, 1998, and 2000 National Health Interview Surveys, a nationally representative survey of civilian noninstitutionalized adults. RESULTS: The percentage of the U.S. adult population who had ever had a skin examination conducted by a doctor was 20.6% in 1992, 20.9% in 1998, and 14.5% in 2000. The percentage with a recent skin examination was 10.3% in 1992, 11.0% in 1998, and 8.0% in 2000. White non-Hispanics reported being screened more frequently than persons in other racial or ethnic groups. Recent skin cancer screening exams were more common among white persons who had a family history of melanoma, had higher education, had usual place of care, and were older (> or =50 years). Frequent use of sunscreen and hats was associated with a recent skin cancer exam. CONCLUSIONS: In the past decade, skin cancer screening rates have been consistently low. Continued monitoring of skin cancer examination is important given conflicting current research results and potentially evolving science.     

Good laboratory practices for biochemical genetic testing and newborn screening for inherited metabolic disorders

Biochemical genetic testing and newborn screening are essential laboratory services for the screening, detection, diagnosis, and monitoring of inborn errors of metabolism or inherited metabolic disorders. Under the Clinical Laboratory Improvement Amendments of 1988 (CLIA) regulations, laboratory testing is categorized on the basis of the level of testing complexity as either waived (i.e., from routine regulatory oversight) or nonwaived testing (which includes tests of moderate and high complexity). Laboratories that perform biochemical genetic testing are required by CLIA regulations to meet the general quality systems requirements for nonwaived testing and the personnel requirements for high-complexity testing. Laboratories that perform public health newborn screening are subject to the same CLIA regulations and applicable state requirements. As the number of inherited metabolic diseases that are included in state-based newborn screening programs continues to increase, ensuring the quality of performance and delivery of testing services remains a continuous challenge not only for public health laboratories and other newborn screening facilities but also for biochemical genetic testing laboratories. To help ensure the quality of laboratory testing, CDC collaborated with the Centers for Medicare & Medicaid Services, the Food and Drug Administration, the Health Resources and Services Administration, and the National Institutes of Health to develop guidelines for laboratories to meet CLIA requirements and apply additional quality assurance measures for these areas of genetic testing. This report provides recommendations for good laboratory practices that were developed based on recommendations from the Clinical Laboratory Improvement Advisory Committee, with additional input from the Secretary's Advisory Committee on Genetics, Health, and Society; the Secretary's Advisory Committee on Heritable Disorders in Newborns and Children; and representatives of newborn screening laboratories. The recommended practices address the benefits of using a quality management system approach, factors to consider before introducing new tests, establishment and verification of test performance specifications, the total laboratory testing process (which consists of the preanalytic, analytic, and postanalytic phases), confidentiality of patient information and test results, and personnel qualifications and responsibilities for laboratory testing for inherited metabolic diseases. These recommendations are intended for laboratories that perform biochemical genetic testing to improve the quality of laboratory services and for newborn screening laboratories to ensure the quality of laboratory practices for inherited metabolic disorders. These recommendations also are intended as a resource for medical and public health professionals who evaluate laboratory practices, for users of laboratory services to facilitate their collaboration with newborn screening systems and use of biochemical genetic tests, and for standard-setting organizations and professional societies in developing future laboratory quality standards and practice recommendations. This report complements Good Laboratory Practices for Molecular Genetic Testing for Heritable Diseases and Conditions (CDC. Good laboratory practices for molecular genetic testing for heritable diseases and conditions. MMWR 2009;58 [No. RR-6]) to provide guidance for ensuring and improving the quality of genetic laboratory services and public health outcomes. Future recommendations for additional areas of genetic testing will be considered on the basis of continued monitoring and evaluation of laboratory practices, technology advancements, and the development of laboratory standards and guidelines.     

Participation in annual skin cancer screening among women seeking routine mammography

BACKGROUND: Early detection of skin cancer is associated with improved prognosis. The American Cancer Society's current skin cancer screening (SCS) recommendation states that adults over the age of 40 should receive an annual skin examination conducted by a health professional. However, little is known about the psychosocial factors related to participation in annual SCS, which remains relatively low among the general public. METHODS: Data were collected from women, aged 50 and older, seeking routine mammography at a large, urban, breast diagnostic facility. RESULTS: A total of 253 eligible women completed the survey. Overall, 20.2% of women reported receiving annual clinical SCS. Physician recommendation, self-efficacy, perceived susceptibility, and age were significantly associated with participation in annual skin screening. CONCLUSIONS: Similar to previously reported findings in the literature, our rates of participation in annual clinical skin screening were lower than reported rates for other types of cancer screening. Among older women, multiple covariates for participation in annual skin cancer screening were determined and may serve to guide future health education interventions to promote screening. Our findings suggest that participation could improve through increasing physician recommendation, screening self-efficacy, and individuals' sense of perceived susceptibility to skin cancer.     

Incidental Findings in a Federally-Sponsored Cancer Screening Program

The volume of non-cancer related clinical services and referrals for medical care of women as a consequence of their enrollment in a federally-sponsored breast and cervical cancer screening program was examined. We randomly sampled 100 medical records from among 389 individuals who received cancer screening services through the Connecticut Breast and Cervical Cancer Early Detection Program. Medical record audits tabulated occasions when women were offered or received diagnostic or therapeutic procedures as a by product of their program participation. Breast screening was provided to 100 women and 49 individuals received cervical cancer screening. In addition, 87 percent of the sample were offered or received one or more non-cancer related health services. Physical exams were provided to 86 women, laboratory tests were ordered for 11 individuals and 55 referrals were made to address a myriad of specific medical needs that were uncovered incidental to breast and cervical cancer screening. Among 26 women who did not heed recommendations for follow-up care, cost, inconvenience and beliefs that medical problems were not immediate concerns were cited. Local screening program sponsors should be cognizant that the health care needs and limited resources of some target populations may be substantial. Mechanisms to assure that needed health care is available to individuals should be built and into all categorical health service programs.     

Surveillance for use of preventive health-care services by older adults, 1995-1997.

PROBLEM/CONDITION: In 1995, a total of 55 million persons aged > or =55 years lived in the United States. The members of this large and growing segment of the population are major consumers of health care. Their access to medical and dental preventive services contributes to their likelihood of healthy later years and influences their long-term impact on the health-care delivery system. REPORTING PERIOD: 1995-1997. DESCRIPTION OF SYSTEMS: This report summarizes data from the National Health Interview Survey (NHIS), the state-based Behavioral Risk Factor Surveillance System (BRFSS), and the Medicare Current Beneficiary Study (MCBS) to describe national, regional, and state-specific patterns of access to and use of preventive services among persons aged > or =55 years. RESULTS: During 1995-1997, approximately 90% of persons aged > or =55 years living in the United States reported having a regular source of health-care services. However, only 75%-80% reported receiving a routine checkup during the preceding 2 years. The estimated percentage of persons who reported not being able to receive medical care because of cost was highest for those aged 55-64 years. Within this age group, the percentage was highest among Hispanics (4%) and persons without a high school diploma. Approximately 11% of Medicare beneficiaries reported delaying care be cause of cost or because they had no particular source of care. Percentage estimates varied according to age, race/ethnicity, and sociodemographic status. Approximately 95% of persons aged > or =55 years reported having their blood pressure checked during the preceding 2 years, but only 85%-88% had received a cholesterol evaluation during the preceding 5 years. The percentage of women receiving breast and cervical cancer screening decreased with increasing age, and the percentage of persons aged > or =55 years who had received some form of screening for colorectal cancer was low approximately 25% for fecal occult blood testing (FOBT) and 45% for endoscopy. State-specific rates of compliance with vaccination recommendations among persons aged > or =65 years were higher for influenza vaccine (range: 54%-74%) than for pneumococcal vaccine (range: 32%-59%), and compliance increased with advancing age. State-specific estimates of the percentage of annual dental visits varied 40%-75%, and 41%-88% of persons aged > or =65 years reported not having dental insurance. INTERPRETATION: Access to medical services among adults living in the United States is greater for persons aged > or =65 years, compared with those aged <65 years, presumably because of Medicare coverage. In contrast, use of dental services decreased, despite increased need for preventive and restorative dental care. Although Medicare covers many medical services for older adults, financial, personal, and physical barriers to both medical and dental care create racial, regional, and sociodemographic disparities in health status and use of health services in the United States. PUBLIC HEALTH ACTION: Continued surveillance of access to and use of health services among older adults (i.e., persons aged > or =65 years), as well as among persons aged 55-64 years, will help health-care providers target underserved groups, make Medicare coverage decisions, and develop public health programs to ensure equitable access to services and improve the health of older adults.     

Predictors of Colorectal Screening in Rural Colorado: Testing to Prevent Colon Cancer in the High Plains Research Network

CONTEXT: Colorectal cancer is the second leading cause of cancer death in the United States, yet screening rates are well below target levels. Rural communities may face common and unique barriers to health care, particularly preventive health care. PURPOSE: To establish baseline attitudinal, knowledge, belief, and behavior measures on colorectal cancer screening and to identify barriers to or predictors of colorectal cancer screening. METHODS: As part of a controlled trial using a quasi-experimental, pretest, post-test design, we conducted a baseline telephone survey of 1,050 rural eastern Colorado residents aged 50 years and older. Smaller counties were over-sampled to ensure a minimum of 30 completed interviews per county. FINDINGS: Seventy-seven percent reported they ever had a colorectal cancer screening test and 59% were up-to-date on at least 1 test. The most important independent predictors of being up-to-date were having visited a doctor or other health care practitioner for a checkup in the past year, having personal or family history of colon polyps or cancer, and having asked for a colorectal cancer screening test. Financial concerns were reported reasons for not obtaining fecal occult blood testing by 18% and colonoscopy by 21%. CONCLUSIONS: This study suggests that health care providers should be vigilant in counseling their patients 50 and older to have a colorectal cancer test. Community programs designed to promote colon cancer screening should encourage residents to have regular contact with their primary care physician and ask their doctor for a screening test. Additionally, programs should provide financial assistance for testing for low-income and uninsured patients.     

Correlates of cervical cancer screening among underserved Hispanic and African-American women

BACKGROUND: Substantial subgroups of American women, specifically those of ethnic minorities, have not been screened for cervical cancer or are not screened at regular intervals. The rates for receipt of female-related cancer screening tests remain far below the goals set forth in Healthy People 2010. OBJECTIVE: This study applied a well-known, recently revised theoretical model of health care access and utilization, the Behavioral Model for Vulnerable Populations, to examine the correlates of the adherence to cervical cancer screening guidelines among publicly housed Hispanic and African-American women, two of the most vulnerable segments of our population. METHODS: This study conducted a cross-sectional survey of a community-based random sample of 230 African-American and Latino female heads of household, from a geographically defined area, the three urban public housing communities in Los Angeles County, CA. RESULTS: Only 62% of our sample had received a screening for cervical cancer within the past year. Yet, 29% of the sample claimed that no health care provider had ever told them that they needed a screening test for cervical cancer. Hispanic and older women are by far less likely to adhere to screening guidelines; in this study, 51% of Hispanics and 22% of African-Americans reported no screening within the last year. Multivariate analysis shows that affordability, continuity of care, and receiving advice from health care providers regarding a Papanicolaou (Pap) smear were significant predictors of up-to-date to cervical cancer screening. CONCLUSION: This study documents a significant disparity in screening for cervical cancer among underserved minorities, particularly Hispanic, uninsured, and older women. The continuity of obtaining medical services and receiving recommendations from physicians remain the core factors that are significantly associated with obtaining cervical cancer screening. These results underscore the need for continued efforts to ensure that medically underserved minority women have access to cancer screening services.     

A comparison of screening for disease detection and screening for risk factors

This paper distinguishes between traditional screening programswhich seek to detect persons with treatable diseases such asbreast cancer, and recent screening programs which seek to identifyand counsel persons with reducible risk factors, particularlybehavioral factors such as smoking or not exercising. Screeningto detect disease is based on a biomedical model, and screeningfor risk factors on a general susceptibility model. The twotypes of program can differ in goals, procedures and outcomes.An examination of these differences highlights the importanceof health education in screening for behavioral risk factors,especially those which predict cardiovascular diseases. A failureto appreciate these differences has impaired the design andevaluation of risk factor screening programs.     

Physicians’ recommendations for colon cancer screening in women: Too much of a good thing?

Background:Expert groups support periodic colorectal cancer (CRC) screening for persons aged 50 and older but not for persons younger than 50. We were interested in community primary care physicians’ recommendations to women for fecal occult blood tests (FOBT), flexible sigmoidoscopy (SIG), and colonoscopy (COL).Methods:In a mailed survey of 1,292 community primary care physicians in North Carolina, we queried physicians regarding their recommendations to women for CRC screening.Results:Analysis was performed on 508 respondents (39%). Recommendation for FOBT (96%) and SIG (69%) for women >50 years old was high among all subgroups of physicians. Recommendation for women < 50 years old was high for FOBT (82%) but lower for SIG (28%). Overall, 19% of physicians recommended COL. Recommendation for FOBT, SIG, and COL varied by physician specialty, physician age, perceived patient demand, physician need for additional CRC screening information, practice size, and location.Conclusions:Although increasing physician recommendation for CRC screening is important, primary care physicians report recommending earlier and more aggressive screening than that supported by national guidelines.     

The potential benefits and harms of screening for colorectal cancer

Abstract: Australian guidelines for colorectal cancer screening for average-risk populations vary from recommendations for annual screening by faecal occult blood testing for those over 40 years to recommendations that screening may be appropriate if requested by an informed patient aged 50 to 75 years. There are five large screening trials, of which three have published mortality data. A meta-analysis of the mortality data suggests a 19 per cent reduction in colorectal cancer mortality (95 per cent confidence intervals 0.68 to 0.96) with Hemoccult screening. Because of the width of the confidence interval, decisions about the magnitude of the effect of screening should await further trial results, which should be available in the next few years. In the interim, we should examine issues of harm and costs in Australia. For example, in the major trials, over 80 per cent of positive results have been falsely positive and have required invasive investigation. Estimates of the cost-effectiveness of screening for the Australian health system are not yet available and are essential. If the benefits of screening outweigh the harms and costs, a successful screening program would require provision of screening infrastructure and appropriate information to target populations, quality control for screening tests and investigations, recall mechanisms to ensure appropriate follow-up of persons with positive results and the active participation of the Australian public and health practitioners.     

Colorectal cancer screening differential costs for younger versus older Americans

BACKGROUND: Colorectal cancer (CRC) incidence rises with age, and most CRC arises from adenomatous polyps. It was therefore hypothesized that increased use of CRC screening and polypectomy in younger persons might yield CRC-related savings later in life for payers such as Medicare. METHODS: Using a decision analytic Markov model, the impact of increased CRC screening uptake on healthcare payers for younger Americans versus payers for older Americans, such as Medicare, was projected. RESULTS: As screening uptake increased, CRC incidence and mortality decreased, and annual costs related to CRC care and testing increased for younger persons, but decreased for older persons. Compared with current screening uptake of 40%, screening 75% of the U.S. population aged 50 to 80 increased annual costs related to CRC care and testing from 3.6 billion US dollars to 5.0 billion US dollars for 50- to 64-year-olds, but decreased annual costs from 5.9 billion US dollars to 5.6 billion US dollars for those aged 65 years and older. Sensitivity analyses suggest that future costs for other diseases could offset CRC care savings in older Americans that are attributable to screening. However, even without net cost savings for any age group, screening remained relatively cost-effective. CONCLUSIONS: Investments in screening and polypectomy in younger persons may decrease CRC-related costs, including screening and surveillance, for healthcare payers for older Americans, including Medicare. While these savings could potentially be offset by future health costs for other diseases, screening would still be cost-effective. Widespread CRC screening beginning at age 50 must remain a national priority.     

Cancer screening among Latino subgroups in the United States

BACKGROUND: Relying upon the Health Belief Model and a behavioral model of health care utilization, the purpose of this study was to examine current adherence to cancer screening among Latino subgroups. METHODS: Using data from the 2000 National Health Interview Survey, 5377 Latinos were surveyed for their use of Pap smear, mammogram, breast self-examination and the clinical breast exam among women, prostate specific antigen test among men, and the fecal occult blood test, sigmoidoscopy, colonoscopy, and proctoscopy among both men and women. Using sampling weights, multivariate logistic regression models were used to assess screening use. RESULTS: Dominican women had 2.4 times greater likelihood of having had mammography than other Latinos. In addition, Latinas aged 50-69, who had more years of education, a personal history of cancer, who were not current smokers, had health insurance, had visited a primary care provider over the past 12 months, and had at least one other screening test had greater use of mammography. Younger age, marriage, greater acculturation, visits to a primary care provider, health insurance, and the use of other cancer screening tests predicted the uptake of the Pap smear. Latinas were more likely to use a CBE if they were younger, had a Bachelor's degree, a personal history of cancer, were more acculturated, had visits to a primary care provider over the past 12 months, and used other cancer screening tests. Puerto Ricans, Central or South Americans had half the likelihood of having colorectal cancer screening than other groups. Ages between 50 and 69, male sex, marriage, history of visiting a health care provider, and use of other screening tests predicted use of the FOBT. Older age, greater education, male sex, history of visiting a health care provider in the previous year, use of other screening tests, and better health status influenced the uptake of endoscopy for colorectal cancer screening. Cuban males had fivefold greater utilization of PSA testing. Additionally, PSA use among Latinos was predicted by older age, history of visiting a primary care provider in the past 12 months, and use of other screening tests. CONCLUSIONS: Cancer screening programs must take into account differences among Latinos in age, gender, educational levels, marital status, cancer history, risk behaviors, insurance, health status and health services utilization.     

Primary care providers human papillomavirus vaccine recommendations for the medically underserved: A pilot study in U.S. Federally Qualified Health Centers

Introduction

In the United States, Federally Qualified Health Centers (FQHCs) are safety-net clinics that provide cervical cancer screening and human papillomavirus (HPV) vaccination to medically underserved women, some of whom may be at risk for developing cervical cancer. National guidelines recommend against using screening test results or sexual history to determine vaccine eligibility. Documenting HPV vaccine recommendations and beliefs of primary care providers in FQHCs may aid in promoting evidence-based practices and prioritizing health interventions for vulnerable populations.

Methods

Between 2009 and 2010, we collected data from 98 primary care providers in 15 FQHC clinics in IL, USA using a cross-sectional survey. Questions assessed provider and practice characteristics, HPV vaccine recommendations, and provider's belief about whether their screening and management procedures would change for women who were vaccinated.

Results

93% of providers recommended the HPV vaccine, most frequently for females aged 13–26 years (98%). Some providers reported sometimes to always using HPV test results (12%), Pap test results (7%), and number of sexual partners (33%) to determine vaccine eligibility. More than half of providers (55%) reported they will not change their screening and management practices for vaccinated females, yet believe vaccination will yield fewer abnormal Pap tests (71%) and referrals for colposcopy (74%).

Conclusion

Study providers routinely recommended the HPV vaccine for their patients. However, providers made fewer recommendations to vaccinate females ages 9–12 years (which includes the target age for vaccination) compared to older females, and used pre-vaccination assessments not recommended by U.S. guidelines, such as screening test results and number of sexual partners. In order to maximize the public health benefit of the HPV vaccine to prevent cervical cancer, adherence to guidelines is necessary, especially in settings that provide care to medically underserved women.     

Visual Inspection with Acetic Acid (VIA) Screening Program: 7 Years Experience in Early Detection of Cervical Cancer and Pre-Cancers in Rural South India

Cervical cancer continues to be a major public health problem in India in the absence of wide spread organised cervical screening programs. Visual inspection of the cervix with acetic acid (VIA) is an effective, inexpensive screening test that can be combined with simple treatment procedures for early cervical lesions, provided by trained health workers. We report 7 years experience in early detection of cervical cancer and pre-cancers using the VIA test in a community-based program in rural Andhra Pradesh, India where there are no existing organised cervical screening programs.

Materials and Methods:

Eligible women aged between 26 and 60 were opportunistically screened by trained health wor kers using the VIA test. Women who tested positive were further evaluated and those with cervical lesions were treated either by cryotherapy in the screening clinic or referred to a higher center.

Results:

A total of 18,869 women were screened by a single round of VIA testing with a positive rate of 10.75%. Biopsy proven high-grade squamous intraepithelials (HSILs) were 90 (0.48%) and low-grade squamous intraepithelials (LSILs) were 43 (0.28%). The overall prevalence of cervical intraepithelial neoplasia (CIN) 2+ lesion rate is 1.05%. A total of 312 (1.65%) cryotherapies were done and 49 women underwent hysterectomy.

Conclusions:

VIA by trained female health workers is a safe, acceptable, and effective test that can save lives from cervical cancer even in remote areas with few resources. These results have important implications for efficient service delivery in cervical screening programs in low-resourced settings.     

National trends in the use of preventive health care by women.

This study investigates national changes between 1973-74 and 1985 in women's use of three preventive health services based on data from the National Health Interview Survey. Smoothed proportions of women with recent preventive care were estimated using weighted least squares for subgroups categorized by age (20-39, 40-59, 60-79), race (White, Black), income (poor, nonpoor), and year of interview. Older women and Black women experienced the largest increases in recent use of clinical breast examinations and Pap tests. Between 1973 and 1985 changes in recent breast examination ranged from zero for White women ages 20-39 years to a 23 percentage point increase (95% CI = 17,30) for Black women ages 60-79 years. A similar pattern was found for Pap testing. Changes between 1974 and 1985 in recent blood pressure testing ranged from zero for women ages 20-39 years to an 8 percentage point increase (95% CI = 6, 10) for women ages 60-79 years. Despite the increases among older women, in 1985 recent use of breast exams and Pap tests remained lower among older women. Further, the poor remained less likely than the nonpoor to have recent preventive care (except blood pressure testing among older women). Most women without recent cancer screening tests had a recent physician contact, highlighting the need for greater emphasis on cancer prevention by health care providers.     

Evolution of cervical cancer screening and prevention in United States and Canada: Implications for public health practitioners and clinicians

Objective

Declines in cervical cancer incidence and mortality in Canada and in the United States have been widely attributed to the introduction of the Papanicolaou (Pap) test. This article reviews changes in screening and introduction of HPV vaccination.

Method

Sentinel events in cervical cancer screening and primary prevention through HPV vaccination in the US and Canada are described.

Results

Despite commonalities, cervical cancer screening and prevention differ between the two countries. Canada has a combination of opportunistic and organized programs at the provincial and territorial level, while the US has opportunistic screening and vaccination systems. In the US, the HPV test along with the Pap test (co-testing) is part of national recommendations for routine cervical cancer screening for women age 30 and older. Co-testing is not being considered anywhere in Canada, but primary HPV testing is currently recommended (but not implemented) in one province in Canada.

Conclusion

Many prevention strategies are available for cervical cancer. Continued public health efforts should focus on increasing vaccine coverage in the target age groups and cervical cancer screening for women at appropriate intervals. Ongoing evaluation will be needed to ensure appropriate use of health resources, as vaccinated women become eligible for screening.     

Colorectal cancer screening attitudes and practices in the general population: a risk-adjusted survey.

OBJECTIVES: To characterize self-reported colorectal cancer (CRC) screening behavior, and to identify characteristics of CRC screening practices, stratified by risk. METHODS: Using random-digit-dial methodology, we conducted telephone surveys in US adults 50 years of age and older. Respondents provided data on utilization of CRC screening tests; demographic characteristics; and awareness, concerns, attitudes and beliefs about the tests, CRC, and health care. On the basis of available guidelines, three definitions of adequate screening were considered. RESULTS: Among persons reporting having ever had a CRC screening exam, the exam was more likely to have been a fecal occult blood test than a radiologic or endoscopic exam (p < .0001). Subjects at increased CRC risk were more likely to have met the screening criteria (p < .001) compared with average-risk subjects. Receipt of information or advice about cancer screening tests, male gender, and concern about managed care were positively associated with adequate screening. Smoking, low health self-monitoring, and an average risk for CRC reduced the probability of CRC screening. CONCLUSIONS: Lack of awareness about screening remains common, regardless of CRC risk. Providing information and advice about cancer screening may be the single most important tool available to improve screening rates.