Longitudinal Adherence With Fecal Occult Blood Test Screening in Community Practice

PURPOSE Although screening with fecal occult blood testing (FOBT) reduces colorectal cancer (CRC) mortality, its effectiveness may diminish if patients do not adhere with repeated screenings. Among patients who had previously engaged in FOBT screening, we assessed subsequent adherence with FOBT screening.METHODS We assessed longitudinal adherence with biennial FOBT screening (every other year) within a cohort of patients enrolled in an integrated Washington State health plan. Among 11,110 patients who participated in FOBT screening during a 2-year baseline period (2000–2001), we ascertained CRC screening use during a subsequent 2-year observation period (2002–2003). We used multinomial logistic regression to identify patient characteristics associated with higher incidence of repeat CRC screening (with or without FOBT) relative to patients who received no CRC screening.RESULTS Despite prior participation in FOBT screening, less than one-half of patients (44.4%; 95% CI, 42.9%–45.8%) completed FOBT screening during the 2-year observation period. Although 8.8% of patients (95% CI, 8.0%–9.7%) received other CRC tests without FOBT during the observation period, nearly one-half, 46.8% (95% CI, 45.3%–48.4%), received no CRC screening. After adjustment for other patient characteristics, receipt of a preventive health examination was strongly associated with FOBT adherence relative to no CRC screening (adjusted relative rate ratio = 11.16; 95% CI, 9.61–12.96).CONCLUSIONS Longitudinal adherence with FOBT screening was low in this insured population, potentially compromising its effectiveness in population CRC mortality reduction. Interventions to promote adherence may be necessary to achieve high effectiveness in population-based FOBT screening programs.     

Are we doing enough to screen for colorectal cancer? Findings from the 1999 Behavioral Risk Factor Surveillance System

OBJECTIVES: To estimate current rates of use of fecal occult blood testing (FOBT) and sigmoidoscopy or colonoscopy; to determine whether test use varies by demographic factors; and to compare 1999 rates of use with 1997 rates. STUDY DESIGN: The Behavioral Risk Factor Surveillance System is an ongoing, state-based random-digit-dialed telephone survey of the US population that collects various health behavior information, including the use of colorectal cancer (CRC) screening tests. POPULATION: In 1999, 63,555 persons 50 years of age or older responded to questions regarding FOBT and sigmoidoscopy or colonoscopy. OUTCOMES MEASURED: The proportion of survey respondents reporting having had FOBT and sigmoidoscopy/colonoscopy at any time; and the proportion reporting having had FOBT and sigmoidoscopy/colonoscopy within recommended time intervals. Data were recorded for the years 1997 and 1999, and analyzed according to various demographic factors. RESULTS: In 1999, 40.3% of respondents reported having had an FOBT at some time, and 43.8% reported having had a sigmoidoscopy or colonoscopy. Regarding recent test use, 20.6% of respondents reported having had an FOBT within the year, and 33.6% reported having had a sigmoidoscopy or colonoscopy within the past 5 years. Some demographic variation was noted. In 1997, 19.6% reported having had an FOBT within the year, and 30.3% reported having had a sigmoidoscopy or proctoscopy within the past 5 years. CONCLUSIONS: Use of CRC screening tests increased only slightly from 1997 to 1999. Usage remains low, despite consensus that screening for CRC reduces mortality from the disease. Efforts to promote awareness of, and screening for, CRC must intensify.     

Factors associated with colorectal cancer screening among Chinese-Americans

OBJECTIVE: To investigate factors associated with receipt of colorectal cancer (CRC) screening among urban senior Chinese-Americans. METHODS: Two hundred three men and women from three senior centers completed a questionnaire that included sections on demographics, fecal occult blood testing (FOBT) and sigmoidoscopy use, and potential barriers to screening. RESULTS: Receipt of a FOBT within the prior 12 months (37.9% of sample) was associated with fewer years of US residency, lower level of worries or fears of test results, and higher level of perceived susceptibility to CRC. Receipt of a flexible sigmoidoscopy within the past 5 years (22.2% of sample) was associated with higher levels of education, lower levels of worries or fears of test results, and higher level of perceived susceptibility of CRC. CONCLUSIONS: Intervention programs may target these areas to facilitate CRC screening in Chinese-Americans so that national goals can be met for all Americans.     

Measuring Patient Preferences for Colorectal Cancer Screening Using a Choice-Format Survey

OBJECTIVE: Colorectal cancer (CRC) screening uptake remains poor. Until we understand patient motivation and preferences for undertaking screening, it is unlikely the uptake will be optimal. Our objective is to examine patient preferences for CRC screening modalities and uptake rates using utility-based methods. METHODS: The preference survey was mailed to a random sample of Canadian subjects aged 40 to 60 years from a primary care network. A fractional factorial experimental design maximized D-efficiency and included four blocks with 12 choice tasks in a conditional two-step design, two-alternative discrete choice format with five screening attributes (process, pain, preparation, sensitivity, and specificity). Bivariate probit regression analysis was used to estimate patient preferences for attributes, choice probabilities for alternative modalities and expected rates of uptake. RESULTS: Five hundred forty-seven of 1047 surveys were returned. Almost 30% of respondents preferred no screening. The most preferred test attribute levels were noninvasive process (e.g., CT), no preparation, no pain, 100% specificity, and 90% sensitivity. Accuracy-related attributes were more important than test process-related attributes. Virtual colonoscopy was the most preferred, followed by colonoscopy, barium enema, sigmoidoscopy, and fecal DNA testing, based on simulated choice probability estimates. Fecal occult blood testing (FOBT) was least preferred. Adjusted screening uptake rate estimates showed the greatest impact (42% increase) would be achieved if all CRC screening modalities were available rather than FOBT alone. CONCLUSIONS: Our findings emphasize the important role of patient preferences for no screening and in selecting alternative CRC screening modalities. CRC screening implementation in Canada should consider patient preferences to optimize uptake.     

Manipulating perceptions of colorectal cancer threat: implications for screening intentions and behaviors

Affecting peoples' perceptions of the health threat of colorectal cancer (CRC), that is, the probability of the cancer's occurrence multiplied by the severity of the outcomes, has not been experimentally manipulated as a means to increase CRC screening intentions and behaviors. As an exploratory pilot study to inform a larger randomized trial on CRC screening, we used a four-group pre-post longitudinal design to test whether providing information about: 1) colorectal cancer risks (no/yes) and, 2) the severity of treatment and illness consequences (no/yes) affected CRC screening intentions (i.e., fecal occult blood test/sigmoidoscopy) and behaviors at a six-month follow-up. The sample consisted of 119 men and women aged 50 and older who were off schedule for having a fecal occult blood test (FOBT). Although perceptions of CRC risks were not affected by the experimental manipulations, perceived severity increased screening intentions for FOBT and lowered felt ambivalence towards FOBT. At the six-month follow-up, 31% participants had a FOBT. Participants who received severity information were significantly more likely to report having had a FOBT. These results suggest that: 1) more attention needs to be given to developing strategies to affect perception of CRC risk, and 2) increasing the perceived severity of CRC is an important construct to increase FOBT screening.     

Manipulating Perceptions of Colorectal Cancer Threat: Implications for Screening Intentions and Behaviors

Affecting peoples' perceptions of the health threat of colorectal cancer (CRC), that is, the probability of the cancer's occurrence multiplied by the severity of the outcomes, has not been experimentally manipulated as a means to increase CRC screening intentions and behaviors. As an exploratory pilot study to inform a larger randomized trial on CRC screening, we used a four-group pre-post longitudinal design to test whether providing information about: 1) colorectal cancer risks (no/yes) and, 2) the severity of treatment and illness consequences (no/yes) affected CRC screening intentions (i.e., fecal occult blood test/sigmoidoscopy) and behaviors at a six-month follow-up. The sample consisted of 119 men and women aged 50 and older who were off schedule for having a fecal occult blood test (FOBT). Although perceptions of CRC risks were not affected by the experimental manipulations, perceived severity increased screening intentions for FOBT and lowered felt ambivalence towards FOBT. At the six-month follow-up, 31% participants had a FOBT. Participants who received severity information were significantly more likely to report having had a FOBT. These results suggest that: 1) more attention needs to be given to developing strategies to affect perception of CRC risk, and 2) increasing the perceived severity of CRC is an important construct to increase FOBT screening.     

Predictors of fecal occult blood test (FOBT) completion among low-income adults

BACKGROUND: Fecal occult blood testing (FOBT) can reduce colorectal cancer (CRC) mortality. Unfortunately, CRC screening is underutilized. Sociocultural mediators of FOBT adherence have not been extensively studied in lower income, minority populations. This study prospectively studied FOBT return in a low-income, multiethnic population. METHODS: Participants (N = 298), aged > or =40 years, were surveyed and given FOBT kits with instructions. Those not returning kits within 30 days received a reminder telephone call. Bivariate and multivariate analyses assessed predictors of FOBT card return at 90 days. RESULTS: Participants (median age = 48) were predominately African American (69%), without private insurance (88%), and of low income. The largest group of participants preferred FOBT alone (46%), followed by whatever my doctor recommends (19%), endoscopy + annual FOBT (16%), endoscopy alone (14%), and no screening (5%). In multivariate analyses, FOBT return was predicted by age (OR = 1.05) and lack of reported FOBT barriers (OR = 3.81). Among those > or =50 and not up-to-date with screening, FOBT return was predicted by cancer fatalism (OR = 0.83). FOBT barriers were associated with age (OR = 0.96), less than high school education (OR = 2.05), and less physician trust (OR = 2.12). Endoscopy barriers were associated with age (OR = 0.93), less physician trust (OR = 1.95), and female gender (OR = 3.45). CONCLUSIONS: Younger individuals and those with less education, less trust in health care providers, and more fatalistic beliefs are at risk for CRC screening non-adherence. Strategies addressing common misconceptions should improve CRC screening rates in low-income, multiethnic populations.     

Guaiac versus immunochemical tests: faecal occult blood test screening for colorectal cancer in a rural community

OBJECTIVE: To describe patient participation and clinical performance in a colorectal cancer (CRC) screening program utilising faecal occult blood test (FOBT). METHODS: A community-based intervention was conducted in a small, rural community in north Queensland, 2000/01. One of two FOBT kits--guaiac (Hemoccult-II) or immunochemical (!nform)--was assigned by general practice and mailed to participants (3,358 patients aged 50-74 years listed with the local practices). RESULTS: Overall participation in FOBT screening was 36.3%. Participation was higher with the immunochemical kit than the guaiac kit (OR=1.9, 95% CI 1.6-2.2). Women were more likely to comply with testing than men (OR=1.4, 95% CI 1.2-1.7), and people in their 60s were less likely to participate than those 70-74 years (OR=0.8, 95% CI 0.6-0.9). The positivity rate was higher for the immunochemical (9.5%) than the guaiac (3.9%) test (chi2=9.2, p=0.002), with positive predictive values for cancer or adenoma of advanced pathology of 37.8% (95% CI 28.1-48.6) for !nform and 40.0% (95% CI 16.8-68.7) for Hemoccult-II. Colonoscopy follow-up was 94.8% with a medical complication rate of 2-3%. CONCLUSIONS: An immunochemical FOBT enhanced participation. Higher positivity rates for this kit did not translate into higher false-positive rates, and both test types resulted in a high yield of neoplasia. IMPLICATIONS: In addition to type of FOBT, the ultimate success of a population-based screening program for CRC using FOBT will depend on appropriate education of health professionals and the public as well as significant investment in medical infrastructure for colonoscopy follow-up.     

Barriers to colorectal cancer screening in rural primary care

BACKGROUND: Residents of rural communities may face unique barriers to obtaining colorectal cancer (CRC) screening, including reduced access to services. This study assessed the impact of patient, physician, and practice characteristics on rural primary care patient receipt of CRC screening. METHODS: We surveyed patients (N = 801) over 50 years of age and primary care physicians (N = 36) in rural practices. Medical students administered surveys to assess patient demographics, self-reported CRC screening, practice features, local availability of endoscopy, and physician screening test preferences. We used multivariable logistic regression analyses to investigate associations between independent variables, and (1) patient CRC screening status and (2) adequacy of CRC discussions between physicians and patients. RESULTS: Fifty-seven percent of patients reported being up-to-date with colorectal cancer screening and most in this group had received FOBT and endoscopy. A minority of patients (39%) reported adequate time to discuss CRC screening, and this was positively associated with being up-to-date with CRC screening in a multivariable analysis. Endoscopy was available in 58% of the practices and 44% of the practices had local gastroenterologists available on at least a monthly basis. The availability of endoscopic procedures and gastroenterological services were not associated with CRC screening or with use of endoscopy as a screening method. CONCLUSIONS: CRC screening among rural primary care patients is related to adequacy of physician CRC screening discussions but not access to endoscopic procedures. Efforts to improve CRC screening should focus on improving physician-patient discussions of CRC.     

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.     

Colorectal Cancer Screening Pilot Program for Underserved Women in Cumberland County,Maine

Over 800 Maine residents will be diagnosed with colorectal cancer (CRC) this year, and nearly 300 will die from the disease. While CRC screening can reduce these rates, it is only among insured populations that screening rates exceed 50%. This project aimed to reduce barriers to, and increase rates of CRC screening among underinsured and uninsured women, ages 50 years and over, residing in Cumberland County, Maine. The existing network of the Maine Breast and Cervical Health Program (MBCHP) was used to reach the target population. A packet containing (1) an offer for no-cost fecal occult blood test (FOBT) screening and CRC-related educational materials, and (2) a stamped, addressed postcard specifying the woman’s interest in these resources, was mailed to 300 MBCHP enrollees residing in Cumberland County. Women requesting screening were contacted by phone to further determine eligibility. Ninety-three women (31%) requested FOBT kits and 29 of these women requested educational materials. Ten women were ineligible for screening because of previous colonoscopy. Fifty-two completed FOBT kits (63%) were returned; all were negative. An additional 42 (14%) women requested educational materials only. To reduce the burden of CRC in Maine and nationally, disparate populations must be reached with efficient and effective screening services. Established networks are proven means for reaching uninsured and underinsured individuals with education, screening services, and necessary follow-up care. This project serves as a model for the future development of similar programs statewide and nationally.     

Colorectal cancer screening behavior in women attending screening mammography: Longitudinal trends and predictors

PURPOSE: Nationally representative surveys demonstrate that the adherence to screening mammography guidelines are associated with increased prevalence of colorectal cancer (CRC) screening; however, the incidence of CRC screening in the screening mammography population is unknown. Our purpose was to describe non-fecal occult blood test (FOBT) CRC screening utilization by women prior to and subsequent to screening mammography at a large academic medical center. MATERIALS AND METHODS: Using the institutional administrative data base, 17,790 women aged 50 and older who underwent screening mammography between 1998 and 2002 were retrospectively identified. We determined that women were current with non-FOBT CRC screening at the time of mammography if they had undergone flexible sigmoidoscopy or double-contrast barium enema in the 5 years or colonoscopy since 1995, the earliest for which data are available. We excluded FOBT as a form of CRC screening because the administrative data base did not adequately capture episodes of FOBT. Women who were not current were considered eligible for non-FOBT CRC screening. We then assessed the number of women who underwent flexible sigmoidoscopy, barium enema, or colonoscopy within 12 months following mammography. Age, insurance status, Breast Imaging Reporting and Data System classification, recommendations after screening mammography and year of mammography were examined as potential predictors of non-FOBT CRC screening completion. RESULTS: At the time of mammography, 13.3% women were current with non-FOBT CRC screening. Of women eligible for non-FOBT CRC screening at the time of mammography, 1.1% completed non-FOBT CRC screening within 12 months after mammography. The rate of non-FOBT CRC screening completion increased over time. After multivariate analysis, being insured by a commercial managed care organization or by Medicaid remained significant predictors of non-FOBT CRC screening. CONCLUSION: The prevalence of non-FOBT CRC screening is low in the population of women undergoing screening mammography, with an incidence of 1.0%. Future studies should examine whether delivering CRC screening interventions at a screening mammography visit increase adherence to non-FOBT CRC screening.     

Colorectal cancer screening participation by older women

OBJECTIVE: Although recent screening guidelines recommend annual fecal occult blood testing (FOBT) for adults aged > or = 50, a number of studies report that these tests are underused. Systematic efforts to increase awareness of colorectal cancer (CRC) and to promote screening participation are needed to meet national objectives for CRC control. METHODS: This study examined CRC-screening practices and evaluated factors related to recent participation in screening by FOBT in a sample of women aged 50 to 80 who were surveyed about their use of clinical preventive services at Group Health Cooperative, a managed care organization in western Washington State. RESULTS: Of the 931 women eligible for analysis, 75% reported ever having been screened by FOBT and 48% reported having been screened within 2 years before the survey. Participation in screening did not vary by demographic characteristics or by perceived or actual risk of CRC. Women with a positive attitudes toward CRC screening had sevenfold greater odds of recent screening by FOBT (odds ratio=7.1; 95% confidence interval, 4.4 to 11.6). Only 58% of study women reported that their physicians encouraged CRC screening, but this factor was strongly related to participation (odds ratio=12.7; 95% confidence interval, 6.6 to 24.4). CONCLUSIONS: We identified several areas in which understanding of CRC risk may be low. As a whole, these findings suggest that effective strategies to control CRC may include efforts to improve knowledge of risk and prevention, but must also appeal directly to primary care physicians to identify and address their barriers to screening recommendations.     

Applying a stage model of behavior change to colon cancer screening

BACKGROUND: There has been limited use of stages of change models in characterizing colorectal cancer (CRC) screening. We assess the applicability of the Precaution Adoption Model (PAPM) by determining the distribution of stages of adoption and by elucidating differences among stages. METHODS: The study is based on 1394 responses (69%) to a survey mailed in 2002 to patients in a primary care population. Survey measures included: self-reported CRC screening, sociodemographic characteristics, health system characteristics, attitudes and beliefs about CRC screening, perceived vulnerability to CRC, and worry about CRC. The main outcome was PAPM stage of adoption of CRC screening based on the ACS preferred guidelines: colonoscopy every 10 years alone or the combination annual FOBT plus sigmoidoscopy every 5 years. RESULTS: 57% were up-to-date with at least one test; 36% were up-to-date with the ACS preferred guidelines; provider recommendation, positive family history of CRC, and positive decisional balance score were significantly associated with higher compared to lower PAPM stages. CONCLUSIONS: The combination of PAPM stage assignment and other factors provides useful information for designing tailored interventions. There are special challenges in developing and interpreting PAPM stage assignments when a guideline offers multiple pathways to adherence and recommends a combination of two tests as a preferred option.     

Home-administered fecal occult blood test for colorectal cancer screening among worksites in Taiwan

BACKGROUND: This study assessed the perceived acceptance, difficulty level, and screening efficacy of home-administered fecal occult blood test (FOBT) among a Chinese population. METHODS: Participants (age 40 and above) were recruited at various worksites in Taiwan during the summer of 2002. A single group pretest and posttest design was used. RESULTS: The 1-month follow up rate was 81% (304/375). Screening result return rate (76%) and FOBT completion rate (74%) using the home-administered kit (HAK) were both high. Intention towards FOBT in the coming year significantly increased after the intervention (P<0.001). At pretest, participants demonstrated higher perceived acceptance and screening completion efficacy of FOBT using home-administered kit (HAK) than the traditional method (P<0.001). At posttest, the perceived difficulty of FOBT using HAK was significantly lower than the traditional stool-collecting method (P<0.001). While the acceptance of HAK remained high both before and after the intervention, the acceptance and screening efficacy towards traditional FOBT decreased significantly (P<0.001). CONCLUSIONS: This study showed the great potential of using home-administered FOBT to promote colorectal cancer (CRC) screening among a Chinese population. Future intervention using innovative screening strategies will need to consider the participant's stage of adoption and cultural beliefs related to screening and preventive behaviors.     

PIC4 Cost-Effectiveness of Piperacillin-Tazobactam Versus Ceftazidime in Patients with Febrile Neutropenia

Several models of colorectal cancer (CRC) screening cost-effectiveness have been published. Most of them are based on US costs of parameters/tests used.
OBJECTIVE: The purpose of this analysis was to provide a model to compare several screening programs using cost data related on Italian reimbursement system, both for ambulatorial and for hospital services.
METHODS: Four screening programs were assessed in comparison with nonscreening: annual fecal occult blood test alone (FOBT), flexible sigmoidoscopy every five years (FS), FOBT and FS combined, and one-time colonoscopy (CO). The analysis was carried out by considering a 10-year screening period. Effectiveness data were derived from recent literature; cost-effectiveness was defined as "cost per cancer prevented" (CCP) and "cost per cancer death prevented" (CCDP). Computer analysis was performed using algebraic formula. Data robustness was tested with sensitivity analysis of main variables: patient compliance, cost of cancer care, and cost of CO complication. Maximization analysis was carried out on a risk population (selected screening).
RESULTS: CO had the greatest impact on CRC mortality, followed by FS+FOBT, FS, and FOBT. CO also resulted in the most cost-effective program, both for CCP and for CCDP, followed by FOBT+FS, FS, and FOBT for all the compliance levels considered. Sensitivity analysis reinforced these results. Maximization analysis amplified both efficacy and cost-effectiveness of CO as a test for selected screening.
CONCLUSION: This model, even with the limitation linked to cost assumption problems, seems to be useful for authorities that will organize general population CRC screening programs.     

Evidence-based consumer choice: a case study in colorectal cancer screening

OBJECTIVES: To elicit community preferences for colorectal cancer (CRC) screening by faecal occult blood test (FOBT) using discrete choice modeling (DCM). To provide policymakers with information that would assist them in designing the future national screening program. METHODS: 301 participants in central Sydney, aged 50 to 70 years, at 'average' risk of CRC, participated in a face-to-face discrete choice study interview in which screening profiles were posed to derive estimates for preferences for CRC FOBT screening. RESULTS: Three characteristics were varied in our screening profiles, namely: benefit (CRC deaths prevented); potential harm (false positive induced colonoscopy); and notification policy (of test result). Ninety-four respondents (32%) did not trade off CRC deaths prevented for any reduction in harms. Twelve per cent always chose no screening. The remaining 56% traded benefits and harms. These latter respondents (n = 164) were willing to accept 853 (false positive induced) colonoscopies for one CRC death prevented. CONCLUSIONS: While survival was all that mattered for just over one-third of the sample and 12% would choose no screening, the remaining individuals were prepared to trade CRC deaths prevented against other characteristics. CRC screening will not receive unqualified community support, irrespective of harms. IMPLICATIONS: In any future national CRC screening program, consideration of these insights about community assessment of benefits, harms, costs and other characteristics of CRC screening is warranted.     

Colorectal cancer test use--Maryland, 2002-2006

During 2000-2004, Maryland had the thirteenth highest mortality rate for colorectal cancer (CRC) among the 50 states and the District of Columbia. The American Cancer Society (ACS), the U.S. Preventive Services Task Force, and other organizations recommend that adults begin 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. For those at average risk, ACS recommends screening with 1) a fecal occult blood test (FOBT) or fecal immunochemical test (FIT) every year, 2) flexible sigmoidoscopy every 5 years, 3) an annual FOBT or FIT combined with flexible sigmoidoscopy every 5 years, 4) double-contrast barium enema (DCBE) every 5 years, or 5) colonoscopy every 10 years. 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 goals described in Maryland's Comprehensive Cancer Control Plan (MCCCP). As milestones toward these goals, Maryland set the following targets for 2008 for persons aged > or =50 years: 1) decrease the percentage of Maryland residents who have never been screened for CRC to < or =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 > or =73% (from a 2002 baseline of 63.8%); and 3) increase the percentage of residents who have been screened with either colonoscopy in the past 10 years, or FOBT in the past year plus flexible sigmoidoscopy in the past 5 years, to > or =57% (from a baseline of 46.5% in 2002). This report describes trends in CRC test use based on results from MCS surveys completed in 2002, 2004, and 2006. The results indicated a significant decline (6.1 percentage points) in the percentage of Maryland residents aged > or =50 years who had never been tested for CRC, a 5.4 percentage-point increase in prevalence of up-to-date testing by any method, and a 13.9 percentage-point increase in prevalence of either colonoscopy in the past 10 years or FOBT in the past year plus flexible sigmoidoscopy in the past 5 years. However, Maryland residents who were neither white nor black (i.e., persons of other races) had a significantly lower prevalence of ever having a CRC test, as did persons without health insurance or those without a recent checkup. Although overall increases in CRC testing reflect substantial progress in Maryland, additional measures are needed to increase CRC testing among racial minority groups and the medically underserved.