Using colorectal trends in the U.S. to identify unmet primary care needs of vulnerable populations

Background

Colorectal cancer screening (CRC) disparities have worsened in recent years.

Objective

To examine progress toward Healthy People 2010 goals for CRC screening among ethnic/racial groups, including disaggregated Latino groups.

Methods

Multivariate logistic regressions examined associations between ethnicity/race and primary outcomes of self-reported guideline-concordant CRC screenings considering time trends for 65,947 respondents of the Medical Expenditure Panel Survey from 2000 to 2007 age 50-years and older from six groups (non-Latino White, non-Latino Black, Puerto Rican, Cuban, Mexican, and Other Latino). We also tested for modification effects by education, income, and health insurance.

Results

Most groups approached Healthy People 2010 CRC screening rate goals, including non-Latino Whites (47%), non-Latino Blacks (42%) and Puerto Ricans (40%), while Mexicans remained disparately lower (28%). Higher education, income and insurance coverage, partially attenuated this lower likelihood, but Mexican rates remained significantly lower than non-Latino Whites for receiving endoscopy in the past 5 years {OR(95% CI) = 0.68(0.59-0.77)} and having received any CRC screening {0.70(0.62-0.79)}.

Conclusions

Among ethnic/racial groups examined, only Mexicans met healthcare disparity criteria in CRC screening. Findings suggest that healthcare equity goals can be attained if resources affecting continuity of care or ability to pay for preventive services are available, and targeted populations are adequately identified.     

Feasibility and efficacy of pairing fecal immunochemical testing with mammography for increasing colorectal cancer screening among uninsured Latinas in northern Manhattan

Objectives

We evaluated the feasibility and efficacy of a program to promote colorectal cancer screening (CRC) among uninsured Latinas receiving mammography through a cancer screening clinic in northern Manhattan.

Methods

Between August 2009 and March 2010, unscreened, average CRC risk, uninsured Latinas, aged 50-64 years, undergoing mammography received a screening recommendation, education, and fecal immunochemical test (FIT). Socio-demographic information and level of acculturation was collected. Screening compliance was assessed.

Results

Of 651 Latinas evaluated, 210 were eligible and, of these, 94% (n = 197) consented to participate; 441 were excluded because they were up-to-date with CRC screening (n = 130), < 50 (n = 285) or > 64 (n = 26) years of age. After intervention, 177 (90%) completed FIT. Within 2 weeks, 87% completed the FIT, and 69% did so with no reminder calls. Acculturation was significantly lower among screeners (p = 0.014). Compared with non-screeners, screeners were more likely to be foreign-born (p = 0.009), to speak only Spanish (p = 0.043), and to prefer to read (p = 0.037), and think (p = 0.015) in Spanish.

Conclusion

This study suggests that pairing CRC education and screening with mammography is both feasible and efficacious.     

Behavioral mediators of colorectal cancer screening in a randomized controlled intervention trial

Background

Understanding mediators for behavioral change is important for the optimization of intervention strategies. This report examines mediators of change in the context of a randomized controlled intervention trial (Los Angeles, 2004-2009) that successfully increased colorectal cancer (CRC) screening among Filipino Americans.

Methods

The intervention, based on the Health Behavior Framework, targeted knowledge/awareness of CRC screening, communication with health care provider, health beliefs, social support and barriers to CRC screening. Health Behavior Framework variables were assessed at baseline and 6-month follow-up (N = 432). Variables targeted for change were tested as potential mediators of the primary outcome, self-reported receipt of CRC screening during the follow-up period, which was previously found to have increased significantly among intervention participants.

Results

Consistent with the Health Behavior Framework, knowledge/awareness of CRC screening and patient-provider communication mediated receipt of screening. Increase in knowledge/awareness of CRC screening accounted for 13% (95% confidence interval 2%-24%) of the total intervention effect size, while patient-provider communication accounted for 20% (5%-36%). Combined, these two variables accounted for 28% (10%-46%) of the total effect size.

Conclusion

Examining the roles of potential mediators in intervention trials may help identify constructs to target in order to enhance the effectiveness of interventions to increase screening.     

Impact of a community-based breast cancer screening program on Hopi women

Objective

To examine changes in breast cancer knowledge, attitudes, beliefs and behaviors following implementation of a tribal run CDC Breast and Cervical Cancer Program (BCCP), we report 2006 survey results from Hopi women and contrast findings with 1993 survey data and BCCP reports.

Methods

Community meetings, focus groups, and researchers jointly developed a culturally appropriate survey instrument. Hopi women randomly selected from Tribal enrollment lists were interviewed in-person by Hopi interviewers; 250 women ≥ age 18 participated (87% response) between June and December, 2006.

Results

Among women 40+, 77.5% reported ever having had a mammogram and 68.9% reported having done so within the past 2 years, an increase from 45.2% and 46% self-reported in 1993. Compared to 1993, more women in 2006 (88.1% vs. 59%) believed that a mammogram can detect cancer and more than 90% now believe that early detection of cancer can save lives. Women reported a preference (60%) for receiving health care at the Hopi BCCP. Survey results were validated using programmatic data which estimated 76.6% of Hopi women had received mammography screening.

Conclusion

Implementation of a tribal run BCCP has resulted in a substantial increase in mammography screening on the Hopi reservation.     

Text message reminders to promote human papillomavirus vaccination

Objective

To implement and evaluate text message reminders for the second (HPV2) and third (HPV3) vaccine doses.

Design

Site-based intervention.

Setting

Nine pediatric sites (5 academic and 4 private) located in New York City.

Participants

Parents of adolescents 9-20 years who received HPV1 or HPV2 during the intervention period, January-June 2009.

Intervention

Parents who enrolled received up to three weekly text message reminders that their daughter was due for her next vaccine dose.

Outcome measure

On-time receipt of the next vaccine dose, within one month of its due date.

Results

During the intervention period, of 765 eligible HPV vaccine events, 434 enrollment instructions were distributed to parents (56.7% of doses). Parents of 124 adolescent girls (28.6% of those handed instructions) activated text message reminders. Comparing children of parents who enrolled versus those who did not, on-time receipt of next HPV vaccine dose occurred among 51.6% (95% CI 42.8-60.4%) versus 35.0% (95% CI 29.6-40.2%) of adolescents (p = .001). Similarly, among a historical cohort of adolescents, receiving HPV1 or HPV2 in the six months prior to the intervention period, on-time receipt of next vaccine dose was noted for 38.1% (95% CI 35.2-41.0%) (p = .003). Increases in receipt of next vaccine dose among intervention subjects were sustained at 4 months following the vaccine due date. Using a logistic regression model, after controlling for insurance and site of care, intervention subjects were significantly more likely than either control population to receive their next HPV vaccine dose on-time.

Conclusion

Among those choosing to enroll, text message reminders were an effective intervention to increase on-time receipt of HPV2 or HPV3.     

Socioeconomic factors affecting colorectal, breast and cervical cancer screening in an Asian urban low-income setting at baseline and post-intervention

Background

Inequalities in cancer screening are little studied in Asian societies. We determined whether area and individual measures of socio-economic status (SES) affected cancer screening participation in Singapore and prospectively evaluated an access-enhancing community-based intervention.

Methods

The study population involved all residents aged > 40 years in two housing estates comprising of owner-occupied (high-SES area) and rental (low-SES area) flats. From 2009 to 2011, non-adherents to regular screening for colorectal/breast/cervical cancer were offered free convenient screening over six months. Pre- and post-intervention screening rates were compared with McNemar's test. Multi-level logistic regression identified factors of regular screening at baseline; Cox regression analysis identified predictors of screening post-intervention.

Results

Participation was 78.2% (1081/1383). In the low-SES area, 7.7% (33/427), 20.4% (44/216), and 14.3% (46/321) had regular colorectal, cervical and breast cancer screening respectively. Post-intervention, screening rates in the low-SES area rose significantly to 19.0% (81/427), 25.4% (55/216), and 34.3% (74/216) respectively (p < 0.001). Area SES was more consistently associated with screening than individual SES at baseline. Post-intervention, for colorectal cancer screening, those with higher education were more likely to attend (p = 0.004); for female cancer screening, the higher-income were less likely to attend (p = 0.032).

Conclusions

Access-enhancing community-based interventions improve participation among disadvantaged strata of Asian societies.     

Breast cancer screening for women ages 50 to 69 years a systematic review of observational evidence

Objective

To systematically review the observational evidence concerning the effect of screening on breast cancer mortality in actual populations of women ages 50-69 years.

Methods

We searched MEDLINE and multiple reference lists for relevant cohort and ecologic studies. At least 2 authors reviewed abstracts and full texts of studies meeting eligibility criteria. We rated each accepted study on standard quality criteria and developed a Summary Evidence Table.

Results

Seventeen studies met eligibility criteria. Five studies found no to small effect of screening (0-12% relative risk reduction [RRR] in breast cancer mortality), 4 found a large effect (greater than 33% RRR), and 8 found a moderate effect (13% to 33% reduction). The authors found concerns about quality in all studies. There was insufficient evidence to determine whether the effectiveness of screening is decreasing over time.

Conclusions

Current observational evidence shows that breast cancer screening in actual populations of women ages 50 to 69 reduces breast cancer mortality; the magnitude of the effect is probably smaller than predicted in the randomized controlled trials. Because the magnitude may change (either increase or decrease) in the future, further ecologic studies are needed. The methodology and infrastructure for these studies should be improved.     

Comparing participation rates between immunochemical and guaiac faecal occult blood tests: a systematic review and meta-analysis

Background

Biennial screening with faecal occult blood tests (FOBts) has been found to reduce colorectal cancer mortality. Faecal immunochemical tests (FITs) are superior to guaiac faecal occult blood tests (G-FOBts) due to their improved sensitivity and specificity. However the effectiveness of a screening programme depends highly on participation rates. The aim of this study was to review studies comparing guaiac faecal occult blood tests and faecal immunochemical tests, in terms of participation rates.

Methods

We searched PubMed and the Cochrane Library (2000-September 2011) to identify randomised control trials comparing guaiac faecal occult blood test with faecal immunochemical test participation rates. One author screened the titles and abstracts, and performed data extraction which was then checked by the other authors. Risk of bias in the included studies was also assessed.

Results

Seven studies met the eligibility criteria and were entered into a meta-analysis. Participation rates were significantly higher for individuals offered faecal immunochemical tests compared to those offered a guaiac faecal occult blood test (RR 1.21; 95% CI 1.09-1.33). Potential factors that could have influenced participation were discussed.

Conclusions

Colorectal cancer screening programmes currently using guaiac faecal occult blood tests could improve participation rates by converting to faecal immunochemical tests. More research examining the acceptability of faecal immunochemical tests, from a patient perspective, is warranted.     

Overdiagnosis in breast cancer: design and methods of estimation in observational studies

Objectives

In recent years observational epidemiological studies have been used to estimate overdiagnosis in breast cancer screening. These estimates vary widely. In this paper we present some of the methodological issues which explain the large variability of the reported findings.

Methods

Different types of observational studies were identified according to study design, definition of the population, adjustment for breast cancer risk and adjustment for lead time.

Results

The majority of observational studies that have estimated breast cancer overdiagnosis have analyzed temporal trends or geographical differences in breast cancer incidence. Estimates of overdiagnosis in a dynamic population vary widely, from 4% to 52%. Only a few studies have used the cohort approach and they found estimates varying from 1% to 5%.

Conclusions

The cohort approach is preferable to the analysis of a dynamic population because it allows the follow-up of a group of women who have had the opportunity for screening and evaluates if there is sufficient follow-up after the last screen.     

Elective pregnancy termination in a large cohort of women with hyperemesis gravidarum

Background

This study was conducted to describe characteristics of women who terminated their pregnancies secondary to hyperemesis gravidarum (HG).

Study Design

Data were obtained from a survey provided on an HG Web site from 2003 to 2005.

Results

Of 808 women who completed the survey, 123 (15.2%) had at least one termination due to HG, and 49 (6.1%) had multiple terminations. Prominent reasons given for the terminations were inability to care for the family and self (66.7%), fear that they or their baby could die (51.2%), or that the baby would be abnormal (22.0%). These same women were three times as likely to state that their health care providers were uncaring or did not understand how sick they were [64/123 (52.0%) vs. 168/685 (24.5%), odds ratio 3.34 (95% CI 2.21-5.05), p<.001].

Conclusion

These data suggest that the physical and psychological burden of HG has been underestimated, and that further education within the medical community may be warranted.     

Primary Care Physicians and Disparities in Colorectal Cancer Screening in the Elderly

Objective

To examine whether having a primary care physician (PCP) is associated with reduced ethnic disparities for colorectal cancer (CRC) screening and whether clustering of minorities within PCPs contributes to the disparities.

Data Sources/Study Setting

Retrospective cohort study of Medicare beneficiaries age 66–75 in 2009 in Texas.

Study Design

The percentage of beneficiaries up to date in CRC screening in 2009 was stratified by race/ethnicity. Multilevel models were used to study the effect of having a PCP and PCP characteristics on the racial and ethnic disparities on CRC screening.

Data Collection/Extraction Methods

Medicare data from 2000 to 2009 were used to assess prior CRC screening.

Principal Findings

Odds of undergoing CRC screening were more than twice as high in patients with a PCP (OR = 2.05, 95 percent CI 2.03–2.07). After accounting for clustering and PCP characteristics, the black–white disparity in CRC screening rates almost disappears and the Hispanic–white disparity decreases substantially.

Conclusions

Ethnic disparities in CRC screening in the elderly are mostly explained by decreased access to PCPs and by clustering of minorities within PCPs less likely to screen any of their patients.     

Do social inequalities in cervical cancer screening persist among patients who use primary care? The Paris Prevention in General Practice survey

Objective

Social inequalities in cervical cancer screening may be related to either lack of access to care or inadequate delivery of preventive care by providers. We sought to characterize social inequalities among women consulting general practitioners with a wide range of social position indicators.

Methods

In 2005-06, 59 randomly recruited general practitioners from the Paris metropolitan area enrolled every woman aged 50-69 years seen during a two-week period. Cervical cancer screening status (overdue if the last cervical cancer screening had been more than 3 years earlier) was analyzed for 858 women in a logistic mixed model that considered: occupational class (in 5 levels, based on last occupation), education, income, characteristics related to family, housing, neighborhood, household wealth (social allocations, perceived financial difficulties in 4 levels, income tax), employment status, supplementary health insurance, and social network (4 levels).

Results

The rate of overdue patients did not vary between general practitioners (21%). social position indicators associated with overdue status (odds ratio between 2 adjacent decreasing social levels) were occupational class (1.20, 95% CI: 1.03-1.41), social network (1.52, 95% CI: 1.18-1.94), financial difficulties (1.42, 95% CI: 1.07-1.88), neighborhood safety (2.15, 95% CI: 1.10-4.20), and allocations (3.34, 95% CI: 1.12-9.96).

Conclusions

Even among women visiting general practitioners we observed marked social inequalities that persist above and beyond occupational class.     

Quality varies across clinical practice guidelines for mammography screening in women aged 40-49 years as assessed by AGREE and AMSTAR instruments

Objective

To assess the quality of clinical practice guidelines providing recommendations on the frequency of mammography screening in asymptomatic, average-risk women 40-49 years of age.

Study Design and Setting

We searched the National Guideline Clearinghouse and MEDLINE for guidelines published from 2005 to 2010. Five independent assessors rated the quality of each guideline and its underlying evidence review using the Appraisal of Guidelines for Research and Evaluation (AGREE) and Assessment of Multiple Systematic Reviews (AMSTAR) instruments, respectively.

Results

Eleven guidelines were appraised. Ten referenced an underlying evidence review; two referenced the same review. Three reviews were rated good, one was moderate, and five were rated poor quality. On overall assessment of the quality of the guidelines, two were strongly recommended, two were recommended with provisos, and seven were either not recommended or the assessors were unsure whether to recommend it. Most guidelines clearly presented their recommendations, but the rigor of development, applicability, and stakeholder involvement varied. Seven guidelines recommended mammography screening as part of a periodic health examination and four recommended individualized screening in the target population. The latter four guidelines were based on good-quality reviews and three were recommended by the assessors.

Conclusion

Guideline users need to be aware of the variability in quality and identify the high-quality guidelines that meet their needs.     

Impact of age-specific recommendation changes on organized breast screening programs

Background

Recent changes in recommendations for mammography screening for women in their forties could have an impact on organized screening programs, as these require clear definition of target and eligible populations.

Current status

Internationally, a majority of programs target women fifty and over, and so the recent USPSTF age recommendations for screening are quite consistent with this practice. However, there is a good deal of variability in the availability of population-based screening programs to women in their forties should they choose to participate.

Future impact

Several programs are reviewing recommendations regarding the eligibility of women in their forties; as guidelines indicate women in this age group should be eligible for screening, even if not targeted, there is discussion as to whether they should be allowed in programs so that they benefit from the same programmatic quality assurance afforded to the target population of women over 50. Clear communication of the evidentiary basis for the eligibility criteria and target populations is required, so that the public is aware that programs are designed to deliver maximal population impact, while minimizing population risk.     

The effect of patient gynecologic history on clinician contraceptive counseling

Background

Contraceptive providers have an important influence on women's selection of contraception. Previous studies suggest that clinicians inappropriately limit use of intrauterine contraception (IUC). This study investigated the influence of patients' gynecologic histories on recommendations for IUC and other methods of contraception.

Study Design

Videos of standardized patients varying by history of pelvic inflammatory disease (PID) and parity were shown to clinicians at meetings of national medical societies. Participants indicated their contraceptive recommendations for the patient and whether they would have concerns were the patient to use IUC.

Results

Five hundred twenty-four providers viewed one video of a standardized patient and completed the survey. Gynecologic history was significantly associated with recommendations for the contraceptive ring, contraceptive patch, and copper IUC. Many clinicians indicated that they had concerns about the use of IUC with respect to risks such as PID, infertility and ectopic pregnancy. Concerns about infertility and pain with use of IUC were related to gynecologic history.

Conclusions

Patient gynecologic characteristics affect recommendations for some reversible contraceptive methods. Clinicians continue to have concerns about IUC use despite evidence supporting its safety.     

Like mother, like daughter? Mother's history of cervical cancer screening and daughter's Human Papillomavirus vaccine uptake in Flanders (Belgium)

Objective

We investigated whether and to what extent the uptake of the Human Papillomavirus (HPV) vaccine by girls aged 12-18 was related to the cervical cancer screening history of age-appropriate older female household members (assumed to be their mothers) in Flanders (Belgium).

Methods

We studied administrative records on 127,854 female members of the National Alliance of Christian Mutualities, which is the largest health insurance fund in Flanders. Reimbursement data for HPV vaccination of girls for the period 2007-2009 were linked with reimbursement data for cervical cancer screening of their mothers in the three preceding years. A multilevel logit model was used to study associations between both preventive behaviors. In the model we controlled for both the girl's and the mother's age, the province of residence and the socio-economic background of the family.

Results

A clear association between a mother's history of participation in cervical cancer screening and her daughter's HPV vaccination initiation was found. The conditional odds of HPV vaccination initiation were more than 4 times higher for girls whose mother had one Pap test than for girls whose mother had none (odds ratio [OR] = 4.5; 95% confidence interval [CI] = 3.5-5.9). For girls whose mother had three or more Pap tests, the conditional odds were 16 times higher than for girls whose mother did not have any pap tests ([OR] = 16.0; 95% [CI] = 12.1-21.2). The effect of screening (having received 1 pap smear as compared to none) was larger for girls living in neighborhoods with the lowest median income ([OR] = 6.0, 95% [CI] = 3.6-10.1).

Conclusion

In a situation where both cervical cancer screening and HPV vaccination are opportunistic, we found evidence that these preventive behaviors cluster within families.     

A community-based randomized trial of a faith-placed intervention to reduce cervical cancer burden in Appalachia

Objective

Faith Moves Mountains assessed the effectiveness of a faith-placed lay health advisor (LHA) intervention to increase Papanicolaou (Pap) test use among middle-aged and older women in a region disproportionately affected by cervical cancer and low screening rates (regionally, only 68% screened in prior 3 years).

Method

This community-based RCT was conducted in four Appalachian Kentucky counties (December 2005-June 2008). Women aged 40-64 and overdue for screening were recruited from churches and individually randomized to treatment (n = 176) or wait-list control (n = 169). The intervention provided LHA home visits and newsletters addressing barriers to screening. Self-reported Pap test receipt was the primary outcome.

Results

Intention-to-treat analyses revealed that treatment group participants (17.6% screened) had over twice the odds of wait-list controls (11.2% screened) of reporting Pap test receipt post-intervention, OR = 2.56, 95% CI: 1.03-6.38, p = 0.04. Independent of group, recently screened participants (last Pap > 1 but < 5 years ago) had significantly higher odds of obtaining screening during the study than rarely or never screened participants (last Pap ≥ 5 years ago), OR = 2.50, 95% CI: 1.48-4.25, p = 0.001.

Conclusions

The intervention was associated with increased cervical cancer screening. The faith-placed LHA addressing barriers comprises a novel approach to reducing cervical cancer disparities among Appalachian women.     

How do we achieve informed choice for women considering breast screening?

Objective

In current medical literature, mammography and other cancer screening programs are subject to controversy because of debate about the magnitude and nature of the benefits and harms. This paper discusses the issues around informed choice for women considering breast screening.

Method

We discuss qualitative and quantitative studies of women’s attitudes to breast screening and informed choice.

Results

Women view breast screening as a way of avoiding potential regret, and reassurance from normal results is highly valued. Screening participants acknowledge anxiety about false positives but awareness regarding potential overdetection of indolent breast cancer is minimal, and research is needed to assess how better understanding of screening downsides may affect women’s views. In any case, weighing up screening advantages and disadvantages is sensitive to personal preferences.

Conclusions

Communicators have an ethical obligation to make balanced information available to women, which is flexible enough to respond to the level of detail and involvement desired by each individual. Many women want to know more and to participate more actively in screening decisions. Techniques have been developed to present balanced information and support individual decision making in ways that are accessible and empowering for the wider community. Evaluations of breast cancer screening must integrate clinical data with evidence on the perspectives of women themselves.     

Cancer mortality in poultry slaughtering/processing plant workers belonging to a union pension fund

Background

The role of zoonotic biological agents in human cancer occurrence has been little studied. Humans are commonly exposed to viruses that naturally infect and cause cancer in food animals such as poultry that constitute part of the biological environment. It is not known if these viruses cause cancer in humans.

Objective

To study cancer mortality in the largest cohort to date, of 20,132 workers in poultry slaughtering and processing plants, a group with the highest human exposures to these viruses.

Methods

Mortality in poultry workers was compared with that in the US general population through the estimation of standardized mortality ratios.

Results

Significantly increased risks were observed in the cohort as a whole or in subgroups, for several cancer sites, viz: cancers of the buccal cavity and pharynx; pancreas; trachea/bronchus/lung; brain; cervix; lymphoid leukemia; monocytic leukemia; and tumors of the hemopoietic and lymphatic systems. Elevated SMRs that were not statistically significant were observed for cancers of the liver, nasopharynx, myelofibrosis, and myeloma. New sites observed to be significantly in excess in this study were cancers of the cervix and penis.

Conclusion

This large study provides evidence that a human group with high exposure to poultry oncogenic viruses has increased risk of dying from several cancers. Other occupational carcinogenic exposures could be of importance in explaining some of the findings, such as fumes from wrapping machines. These findings may have implications for public health amongst persons in the general population who may also be exposed to these viruses. What is needed now are epidemiologic studies that can demonstrate whether the excess of specific cancers can be attributed to specific occupational exposures while adequately controlling for other potential occupational and non-occupational carcinogenic exposures.