Decision making in prostate-specific antigen screening National Health Interview Survey, 2000.

BACKGROUND: The net benefits and harms of prostate cancer screening with the prostate-specific antigen (PSA) test are uncertain, and professional organizations recommend that physicians discuss these uncertainties with patients before initiating screening. Using a nationally representative sample of men reporting past PSA screening, we aimed to determine the extent to which screening was initiated by physicians and preceded by physician-patient discussions. METHODS: Cross-sectional analysis of data from the 2000 National Health Interview Survey; 2,676 men aged 40 and older underwent PSA screening and met study inclusion criteria. We analyzed the proportions of men for whom PSA screening was (1) was initiated by the physician versus the patient, and (2) preceded by discussions about the test's advantages and disadvantages. RESULTS: Overall, 74% (95% CI=71.8-76.0) of recipients reported that PSA screening was initiated by their physician, and the proportion increased with advancing age, declining health status, lack of family history of prostate cancer, presence of a usual source of medical care, and non-Hispanic ethnicity. Sixty-five percent (95% CI=63.1-67.1) of screening recipients reported prescreening discussions with their physicians. Discussions were more common with physician-initiated screening than with patient-initiated screening, and among patients reporting a usual source of medical care, non-blue-collar occupation, and black race. CONCLUSIONS: Among U.S. men receiving PSA screening, screening is usually initiated by physicians, frequently in men relatively less likely to benefit from it, and often without prior discussion of the test's advantages and disadvantages. Further examination of the PSA decision-making process among screened and unscreened men is warranted.

A national survey of primary care physicians' methods for screening for fecal occult blood.

BACKGROUND: Screening with the fecal occult blood test (FOBT) has been shown to reduce colorectal cancer incidence and mortality in randomized, controlled trials. Although the test is simple, implementation requires adherence to specific techniques of testing and follow-up of abnormal results. OBJECTIVE: To examine how FOBT and follow-up are conducted in community practice across the United States. DESIGN: Cross-sectional national surveys of primary care physicians and the public. SETTING: The Survey of Colorectal Cancer Screening Practices in Health Care Organizations and the 2000 National Health Interview Survey. PARTICIPANTS: 1147 primary care physicians who ordered or performed FOBT and 11 365 adults 50 years of age or older who responded to questions about FOBT use. MEASUREMENTS: Self-reported data on details of FOBT implementation and follow-up of positive results. RESULTS: Although screening guidelines recommend home tests, 32.5% (95% CI, 29.8% to 35.3%) of physicians used only the less accurate method of single-sample in-office testing; another 41.2% (CI, 38.3% to 44.0%) used both types of test. Follow-up of positive test results showed considerable nonadherence to guidelines, with 29.7% (CI, 27.1% to 32.4%) of physicians recommending repeating FOBT. Furthermore, sigmoidoscopy, rather than total colon examination, was commonly recommended to work up abnormal findings. Nearly one third of adults who reported having FOBT said they had only an in-office test, and nearly one third of those who reported abnormal FOBT results reported no follow-up diagnostic procedures. LIMITATIONS: The study was based on self-reports. Data from the National Health Interview Survey may underestimate the prevalence of in-office testing and inadequate follow-up. CONCLUSIONS: Mortality reductions demonstrated with FOBT in clinical trials may not be realized in community practice because of the common use of in-office tests and inappropriate follow-up of positive results. Education of providers and system-level interventions are needed to improve the quality of screening implementation.

Age, race, and repeated prostate-specific antigen (PSA) test use in the National Health Interview Survey.

BACKGROUND: Prostate cancer is the second leading cause of cancer death in American men. Prostate-specific antigen (PSA) test use was examined in US men aged > or = 40 years to clarify the relationship with age and race. METHODS: The National Health Interview Survey (2000) collected information about PSA test use in a representative sample of the US population. This study examined whether men reported having had three or more PSA tests within the past five years by age and race subgroups. RESULTS: Prostate-specific antigen (PSA) test use rates were lowest in men aged 40-49 and highest in men aged 65-79. Receipt of three or more PSA tests within the past five years varied by age and race. Use was higher for African-American men, compared with White men aged 40-49; similar for African-American and White men aged 50-64; higher for White than African-American men aged 65-79; and similar for African-American and White men aged > or = 80. CONCLUSION: The PSA test use patterns showed variation by age and race subgroups, and these patterns are better understood when examining both variables at the same time.

Awareness and use of the prostate-specific antigen test among African-American men.

Although African-American men have a greater burden of prostate cancer than whites and other racial and ethnic groups, few studies on the burden of prostate cancer have focused on African Americans specifically. We used a sample of African-American men (N = 736) who participated in the 2000 National Health Interview Survey to explore their awareness of the prostate-specific antigen (PSA) test. Among African-American men aged > or = 45 with no history of prostate cancer, 63% had heard of the PSA test and 48% had been tested. Bivariate analyses showed significant associations between sociodemographic, family composition, health status and perceived risk with having heard of the PSA test and having been tested. The multivariate model showed significant associations between having heard of the PSA test and age, level of education, living in an MSA, and having private or military health insurance. For ever being tested, the multivariate model showed significant associations for age, private or military health insurance, being in fair or poor health, and having a family history of prostate cancer. Some of the correlates, such as age, increased levels of education and being married, were consistent with previous studies, but other correlates, such as metropolitan statistical area, health status and perceived risk, differed from previous studies.

Breast and cervical cancer screening among Appalachian women.

Medical service shortages, rural residence, and socioeconomic and cultural factors may pose barriers to breast and cervical cancer screening among women living in the Appalachian region of the United States. This study determined the rates of breast and cervical cancer screening in Appalachia and identified factors associated with screening. Data from the Behavioral Risk Factor Surveillance System, 1996 to 1998, for the Appalachian region were analyzed to determine the percentage of women > or =40 years of age who had had a mammogram or clinical breast examination (CBE) within the past 2 years and the percentage of women > or =18 years of age who had had a Pap test within the past 3 years. Screening rates were compared with those for women living elsewhere in the United States. Screening rates were further assessed according to demographic, socioeconomic, and physical and behavioral health factors. Multiple logistic regression analyses were conducted to examine the predictors of screening. Overall, 14,520 Appalachian women > or =18 years of age reported on Pap tests; 13,223 women > or =40 years of age reported on mammogram screening, and 13,124 women reported on CBE screening. Among Appalachian women, 68.8% [95% confidence interval (CI), 67.8-69.9] had a mammogram, 75.1% (95% CI, 74.1-76.1) had a CBE in the past 2 years, and 82.4% (95% CI, 81.5-83.3) had a Pap test in the past 3 years. These rates were at most approximately 3% lower than those for women living elsewhere in the United States, but these differences were statistically significant. Older women and women with less education or income were screened less commonly. Women who had visited a doctor within the past year were more likely to have been screened. Additional interventions are needed to increase breast and cervical cancer screening rates for Appalachian women to meet the goals of Healthy People 2010, targeting in particular population groups found to have lower screening rates.

Sunburn prevalence among adults in the United States, 1999.

BACKGROUND: Exposure to high levels of sunlight, such as a sunburn, is a strong determinant of melanoma risk. METHODS: To describe statewide and U.S. estimates of sunburn prevalence in the United States and determine demographic and behavioral predictors of sunburn, we analyzed data from the 1999 Behavioral Risk Factor Surveillance System, a population-based telephone survey conducted in all 50 states, the District of Columbia, and Puerto Rico. RESULTS: Of 156,354 adults aged > or =18 years, 31.7% (95% confidence interval, 31.3%-32.1%) reported a sunburn in the past year; of adults aged 18 to 29 years, 57.5% reported such a sunburn. Reporting was highest among white, non-Hispanic males (44.1%), followed by white non-Hispanic females (35.3%), and lowest among black non-Hispanic males and females (5.1% and 5.3%, respectively). Statewide period prevalence of sunburn among whites was highest (>45%) in Wisconsin, Utah, Wyoming, Washington, DC, and Indiana, and lowest (<30%) in Puerto Rico, Arizona, Tennessee, Oklahoma, and New York. CONCLUSIONS: Nationwide and statewide skin cancer prevention efforts should target young adults. Periodic monitoring of sunburn is important in evaluating the effectiveness of those efforts.

Nonadherence to breast and cervical cancer screening: what are the linkages to chronic disease risk?

BACKGROUND: Several preventive practices that reduce chronic disease risk have been associated with breast and cervical cancer screening, including maintenance of normal weight and avoidance of cigarette smoking. A history of certain chronic illnesses such as diabetes and cardiovascular disease has also been related to cancer screening. Nevertheless, studies that have attempted to identify women who are less likely to have had a recent breast or cervical cancer screening test have infrequently examined the associations of breast and cervical cancer screening with multiple health factors that influence chronic disease risk. METHODS: To clarify relationships between cancer screening and health behaviors and other factors that influence chronic disease risk, we examined the self-reported breast and cervical cancer screening practices of women in the United States by using data from the 1999 Behavioral Risk Factor Surveillance System. The women were described according to their recent use of mammography and the Papanicolaou test, physician visits within the past year, health insurance coverage, and preventive practices that reduce chronic disease risk. RESULTS: Overall, 74.5% (95% CI, 73.9%-75.1%) of the women in this sample aged 40 years or older (n = 56,528) had received a mammogram within the past 2 years. The percentage of women who had been screened for breast cancer, however, varied widely by factors associated with reducing the risk of chronic disease (e.g., cholesterol check in the past 2 years, blood pressure check in the past 2 years, normal weight, avoidance of cigarette smoking) and having access to health care (e.g., health insurance coverage, recent physician visit). Similarly, 84.4% (95% CI, 83.9%-84.9%) of all women aged 18 years or older who had not undergone a hysterectomy (n = 69,113) had received a Papanicolaou test in the past 3 years, and factors associated with reduced chronic disease risk and health care access were related to having had a recent Papanicolaou test. CONCLUSION: The results of this study suggest that underscreened women who are at risk for breast and cervical cancer are likely to benefit from programs that identify and address coexisting prevention needs. The identification of coexisting prevention needs might assist in developing interventions that address multiple risks for chronic disease among women and might subsequently help improve the efficiency and effectiveness of prevention programs.

Breast and cervical cancer screening among Mississippi Delta women.

The purpose of the study was to determine breast and cervical cancer screening among women living in the Mississippi Delta region. Using data from the Behavioral Risk Factor Surveillance System for 1999--2000, we determined the prevalence of mammography (women 40 years and older, n = 6,028) and Pap testing (women 18 years and older, n = 6,502) within the past 2 or 3 years, respectively. We examined predictors of testing and compared results with those for women living elsewhere in the United States. Among Delta women, 69.4% (95% confidence interval [CI] 67.9% to 70.9%) had a mammogram and 85.5% (95% CI 84.3% to 86.6%) a Pap test. Mammography prevalence was lower among black and white Delta women than among black and white women elsewhere. Pap testingwas lower among older (65 years and older) Delta women or women who did not visit a doctor within the past year than among their counterparts elsewhere. Additional interventions are needed to meet the goals of Healthy People 2010 for all women.

Disparities in mammography use among US women aged 40-64 years, by race, ethnicity, income, and health insurance status, 1993 and 2005.

OBJECTIVE: To examine current disparities in mammography use, and changes in disparities over time by race, ethnicity, income, insurance, and combinations of these characteristics. RESEARCH DESIGN: Comparison of cross-sectional surveys of mammography use using the 1993 and 2005 National Health Interview Survey. SUBJECTS: Women aged 40-64 (1993, n = 4167; 2005, n = 7434). MEASURES: Mammogram within prior 2 years. RESULTS: In 2005, uninsured women reported the lowest mammography use (38.3%). Though screening increased 6.9 percentage points among low-income, uninsured women, the overall disparity between insured and uninsured women did not change significantly between 1993 and 2005. Screening seems to have declined among middle-income, uninsured women, increasing the gap compared with middle-income, insured women. The lower mammography use in 1993 among American Indian/Alaska Native compared with white women was not present in 2005; however, lower use among Asian compared with white women emerged in 2005. We found no differences between African American and white women. Hispanic women were less likely than non-Hispanic women to report screening in 2005 (58.1% vs. 69.0%). CONCLUSIONS: Although mammography use increased for some groups between 1993 and 2005, low-income, uninsured women continued to have the lowest screening rates in 2005 and the disparity for this group was not reduced. The gap in screening use for middle-income, uninsured women increased, resulting from possible declines in mammography even for uninsured women not in poverty. Asian women became less likely to receive screening in 2005. Continuing efforts are needed to eliminate disparities. Increased efforts are especially needed to address the large persistent disparity for uninsured women, including middle-income uninsured women.

Provider counseling about health behaviors among cancer survivors in the United States.

PURPOSE: To examine provider discussion or counseling of US cancer survivors about diet, exercise, and tobacco use. METHODS: We used 2000 National Health Interview Survey data to examine whether US cancer survivors reported that, within 1 year, a provider (1) discussed diet, (2) recommended they begin or continue exercise, or (3) asked about smoking. We included survivors more than 1 year beyond diagnosis (n = 1,600) and adults without cancer (AWCs; n = 24,636) who saw/talked to a provider within 1 year. We used generalized linear contrasts in bivariable analyses and logistic regression to calculate predicted marginals adjusted for age, sex, comorbidity, usual source of care, and number of provider visits in the prior year. RESULTS: Few survivors reported discussions or recommendations for all three health behaviors (10% of survivors v 9% of AWCs; P = .57). Although report was more likely than among AWCs, few survivors reported diet discussions (30% of survivors v 23% of AWCs; P < .0001) or exercise recommendations (26% of survivors v 23% of AWCs; P < .005), and a minority were asked about smoking (42% of survivors v 41% of AWCs; P = .41). After adjustment, survivors were less likely to report exercise recommendations than were AWCs (22% v 24%, respectively; P = .02). Colorectal cancer survivors were less likely than were AWCs of similar age range to report exercise recommendations (16% v 27%, respectively; P < .003) or smoking discussions (31% v 41%, respectively; P < .05). Cervical cancer survivors were more likely than AWCs of similar age range to discuss smoking (58% v 43%, respectively; P < .001). CONCLUSION: Findings from this nationally representative sample suggest that many providers may miss opportunities to counsel survivors about healthy behaviors, perhaps particularly colorectal cancer survivors.

Health insurance coverage and cost barriers to needed medical care among U.S. adult cancer survivors age<65 years.

BACKGROUND: The health insurance and cost barriers to care among cancer survivors age <65 years were examined. METHODS: Using the 1998 and 2000 National Health Interview Survey, survivors ages 18 to 64 years (n=1718) were compared with similarly aged adults without cancer (n=50,276) to examine health insurance and reported delayed/missed needed medical care within the previous year because of cost. Findings were initially adjusted for age, sex, race, and ethnicity, and further adjusted for employment, income, health status, marital status, and region. RESULTS: Before adjustment, survivors were less likely to be uninsured (12.4% vs. 18.0%) and more likely to have public insurance (11.2% vs. 6.2%). After initial adjustment, survivors were as likely to lack insurance, less likely to have private insurance, and more likely to have public insurance. After further adjusting, differences in being uninsured were found to be small, differences in having private insurance were eliminated, and differences in having public insurance were reduced. Survivors most likely to lack insurance were younger, female, African-American, or lower income. Survivors, particularly uninsured or publicly insured survivors, were more likely to delay/miss care because of cost. Overall, 20.9% of survivors, including 68% of uninsured survivors, reported delaying/missing needed care. CONCLUSIONS: Health insurance coverage among cancer survivors age<65 years appears to be comparable to that of adults of similar age, sex, race, and ethnicity, but survivors may more likely be publicly insured. Differences are attributable in part to employment, income, and health status, factors potentially influenced by cancer. Unmet medical care needs because of cost were common among survivors, particularly uninsured survivors.

Geographic variation in the incidence of colorectal cancer in the United States, 1998-2001.

BACKGROUND: This study examined the incidence rates and risk factors for colorectal cancer in 9 geographic divisions in the United States. METHODS: The colorectal cancer cases were diagnosed between 1998 and 2001 in 39 states and the District of Columbia (grouped into 9 geographic divisions in the United States). The association between colorectal cancer and geographic division was analyzed using the Poisson regression model controlling for demographics and ecologic measures of education, behavioral factors and colorectal cancer screening data extracted from the Behavioral Risk Factor Surveillance System. RESULTS: The age-adjusted incidence rates of colorectal cancer were highest in the Middle Atlantic division, followed by New England division, East and West North Central divisions, East South Central and South Atlantic divisions, West South Central and Pacific divisions, with the lowest rate observed in the Mountain division. Old age, male gender, black race, less than a twelfth-grade education, smoking, and no physical activity were significantly associated with higher incidence rates of colorectal cancer, whereas having sigmoidoscopy/colonoscopy in the past 5 years, fecal occult blood test in the past year, and obesity were associated with lower incidence rates of colorectal cancer. The relative ranking of incidence rates of colorectal cancer across divisions changed after adjusting for these factors. CONCLUSIONS: Significant geographic variation in colorectal cancer exists in the United States. Risk factors, including demographics, education, behavior, and screening use, can only partially explain the differences across geographic divisions.

Breast and cervical cancer screening practices among Hispanic women in the United States and Puerto Rico, 1998-1999.

BACKGROUND: Results from recent studies suggest that Hispanic women in the United States may underuse cancer screening tests and face important barriers to screening. METHODS: We examined the breast and cervical cancer screening practices of Hispanic women in 50 states, the District of Columbia, and Puerto Rico from 1998 through 1999 by using data from the Behavioral Risk Factor Surveillance System. RESULTS: About 68.2% (95% confidence interval [CI] = 66.3 to 70.1%) of 7,253 women in this sample aged 40 years or older had received a mammogram in the past 2 years. About 81.4% (95% CI = 80.3 to 82.5%) of 12,350 women aged 18 years or older who had not undergone a hysterectomy had received a Papanicolaou test in the past 3 years. Women with lower incomes and those with less education were less likely to be screened. Women who had seen a physician in the past year and those with health insurance coverage were much more likely to have been screened. For example, among those Hispanic women aged 40 years or older who had any health insurance coverage (n = 6,063), 72.7% (95% CI 70.7-74.6%) had had a mammogram in the past 2 years compared with only 54.8% (95% CI 48.7-61.0%) of women without health insurance coverage (n = 1,184). CONCLUSIONS: These results underscore the need for continued efforts to ensure that Hispanic women who are medically underserved have access to cancer screening services.

Breast and cervical carcinoma screening practices among women in rural and nonrural areas of the United States, 1998-1999.

BACKGROUND: Prior studies have suggested that women living in rural areas may be less likely than women living in urban areas to have had a recent mammogram and Papanicolau (Pap) test and that rural women may face substantial barriers to receiving preventive health care services. METHODS: The authors examined both breast and cervical carcinoma screening practices of women living in rural and nonrural areas of the United States from 1998 through 1999 using data from the Behavioral Risk Factor Surveillance System. The authors limited their analyses of screening mammography and clinical breast examination to women aged 40 years or older (n = 108,326). In addition, they limited their analyses of Pap testing to women aged 18 years or older who did not have a history of hysterectomy (n = 131,813). They divided the geographic areas of residence into rural areas and small towns, suburban areas and smaller metropolitan areas, and larger metropolitan areas. RESULTS: Approximately 66.7% (95% confidence interval [CI] = 65.8% to 67.6%) of women aged 40 years or older who resided in rural areas had received a mammogram in the past 2 years, compared with 75.4% of women living in larger metropolitan areas (95% CI = 74.9% to 75.9%). About 73.0% (95% CI = 72.2% to 73.9%) of women aged 40 years or older who resided in rural areas had received a clinical breast examination in the past 2 years, compared with 78.2% of women living in larger metropolitan areas (95% CI = 77.8% to 78.7%). About 81.3% (95% CI = 80.6% to 82.0%) of 131,813 rural women aged 18 years or older who had not undergone a hysterectomy had received a Pap test in the past 3 years, compared with 84.5% of women living in larger metropolitan areas (95% CI = 84.1% to 84.9%). The differences in screening across rural and nonrural areas persisted in multivariate analysis (P < 0.001). CONCLUSIONS: These results underscore the need for continued efforts to provide breast and cervical carcinoma screening to women living in rural areas of the United States.

Breast cancer screening practices among women in the United States, 2000.

Results from recent studies indicate that many women in the US undergo routine screening for breast cancer, but some groups of women are under-screened. In this study, we examined the breast cancer screening practices of white and black women in the United States, according to Hispanic ethnicity and other factors, using data from the 2000 National Health Interview Survey. Among women aged > or =40 years, 71.2% (95% confidence interval, CI: 70.0-72.4%) of the 8201 white women and 67.6% (95% CI: 64.5-70.6%) of the 1474 black women in this sample reported having a mammogram in the past two years. About 60.3% (95% CI: 56.7-70.3%) of 970 Hispanic women (including those who reported they were white or black) and 71.5% (95% CI: 70.3-72.7%) of 8705 non-Hispanic women reported having a mammogram in the past two years. About 74.8% (95% CI: 73.8-76.8%) of 8176 white women and 73.8% (95% CI: 71.1-76.6%) of 1471 black women aged > or =40 years had received a clinical breast examination in the past two years. About 60.1% (95% CI: 56.1-64.0%) of 969 Hispanic women (including those who reported they were white or black) and 75.6% (95% CI: 74.6-76.6%) of 8678 non-Hispanic women had received a clinical breast examination in the past two years. Women with lower incomes, those with less education, and recent immigrants were less likely to be screened. Women who had a usual source of health care and those with health insurance coverage were more likely to have been screened. These results underscore the need for continued efforts to ensure that uninsured women and those who are medically underserved have access to cancer screening services.

Breast and cervical cancer screening practices among Hispanic and non-Hispanic women residing near the United States-Mexico border, 1999-2000.

This study examined the breast and cervical cancer screening practices of Hispanic and non-Hispanic women (n = 3,568) in counties that approximate the US southern border region. According to the Health Resources Services Administration (HRSA), border counties are those in which any part of the county is within 100 kilometers (62.14 miles) of the border. The study used data from Behavioral Risk Factor Surveillance System (BRFSS) surveys of adults aged > or = 18 years conducted in 1999 and 2000. The study looked at recent use of mammography and the Papanicolaou (Pap) test. Hispanic women were less likely to have had a recent mammogram or Pap test as compared with non-Hispanic women in border counties, and as compared with Hispanic and non-Hispanic women in nonborder counties of Texas, New Mexico, Arizona, and California combined, and with other women in the United States. Results underscore the need for continued efforts to ensure that medically underserved women who live in the border region have access to cancer screening services.

Prostate-specific antigen test use reported in the 2000 National Health Interview Survey.

BACKGROUND: In 2000, the National Health Interview Survey (NHIS) collected information about prostate-specific antigen (PSA) test use in a representative sample of U.S. men. METHODS: This study examined PSA test use in subgroups defined by personal and social characteristics. RESULTS: Among men aged 50 and older with no history of prostate cancer, 56.8% reported ever having had a PSA test, 34.1% reported having had a screening PSA test during the previous year, and 30.0% reported having had three or more tests during the previous 5 years. Screening was greater among men aged 60-79 years, those with greater access to care, and those practicing other preventive behaviors. Among men in their 40s, use tended to be higher among African-American men. CONCLUSIONS: The prevalence and patterns of PSA screening suggest that PSA is used like other cancer screening tests among about a third of U.S. men. Because of the lack of scientific consensus on whether prostate cancer screening is beneficial, more information is needed on how knowledgeable both patients and practitioners are about the potential benefits and harms of screening and how prostate cancer screening decisions are made.