How many eligible adults receive tests to screen for colorectal cancer?

Only about one-half (52%) of community-dwelling adults ages 50 and older had received at least one of three recommended tests for colorectal cancer as of 2003. Among the states in 2004, rates of blood stool testing ranged from 18 percent to 40 percent while rates of colorectal endoscopy ranged from 45 percent to 66 percent.

Percentage of Community-Dwelling Adults Ages 50 and Older Who Received a Test for Colectoral Cancer, 2000 and 2003

Why is this important?

• Colorectal cancer (cancer of the colon or rectum) is the second most frequent cause of cancer death, claiming 56,000 lives annually and reducing lifespan by 14 years on average (ACS 2005; Reis et al. 2005).
• Medical experts recommend regular screening for colorectal cancer among adults ages 50 and older to detect polyps or cancers at an earlier and more treatable stage (USPSTF 2002; Winawer et al. 2003).
• Colorectal cancer screening options include fecal occult blood test at home every year and/or sigmoidoscopy every five years, or total colon examination by colonoscopy every 10 years or by double-contrast barium enema every five years.

Findings

Among community-dwelling adults ages 50 and older in 2003:

• Two of 10 (22%) had performed a blood stool test at home in the past two years.
• Four of 10 (43%) had ever received a sigmoidoscopy or colonoscopy.
• Five of 10 (52%) had received any of the tests in the given intervals.

There was little change in the rate of screening from 2000 to 2003 (NCI 2005).

Among the states (including the District of Columbia) in 2004:

• The proportion who had performed a blood stool test in the past two years ranged from 18 percent in Alaska to 40 percent in North Carolina.
• The proportion who had ever received a sigmoidoscopy or colonoscopy ranged from about 45 percent in Louisiana to 66 percent in Minnesota (NCCD 2006).

Implications

Colorectal cancer screening remains widely underused. Common reasons that people cite for not receiving colorectal cancer screening include lack of awareness and lack of a physician recommendation (Seeff et al. 2004). Another quality concern is that many physicians report using office-based blood stool testing (not counted in rates shown in the chart), which is less accurate than home-based testing recommended by experts (Nadel et al. 2005).

Improvement Ideas and Resources

A meta-analysis of research studies found that "organizational changes that make identification and delivery of [preventive] services a routine part of patient care" were the most effective interventions for increasing adult preventive care. Education, reminders, and financial incentives also were generally effective (Stone et al. 2002). Some recently studied interventions that have been associated with increased colorectal cancer screening include:

• facilitating systems changes in physician office practices to support preventive service delivery (Wei et al. 2005);
• offering videotaped or nurse-led patient education on colorectal cancer screening (Pignone et al. 2000; Stokamer et al. 2005); and
• mailing blood stool tests to patients to be completed before scheduled primary care appointments (Goldberg et al. 2004).

Measure:

The denominator includes civilian, noninstitutionalized adults ages 50 and older. The numerator includes those in the denominator who reported receiving certain tests for colorectal cancer recommended by the Multisociety Task Force on Colorectal Cancer (Winawer et al. 2003) and the American Cancer Society (Smith et al. 2006): a blood stool test at home in the past two years, a sigmoidoscopy or colonoscopy ever, or either test in the specified time interval. These testing intervals are used for monitoring purposes but do not precisely correspond to expert recommendations. The survey did not ask about double-contrast barium enema. Changes in survey questions prevent direct comparisons to years prior to 2000. National rates were age-adjusted to the 2000 U.S. standard population.

Limitations:

Self-reported data are subject to potential recall bias. Testing intervals shown in the chart are used for quality monitoring purposes but do not precisely correspond to expert recommendations. The survey did not ask about testing by double-contrast barium enema. Changes in survey questions prevent direct comparisons with years prior to 2000.

Source:

National rates were compiled by the National Cancer Institute (NCI 2005) using data from the National Health Interview Survey, a nationally representative household survey of the civilian, noninstitutionalized population. State rates were compiled by the National Center for Chronic Disease Prevention and Health Promotion (NCCD 2006) using data from the Behavioral Risk Factor Surveillance System, a telephone survey that is representative of the civilian, noninstitutionalized adult population in each state.

References:

* Indicates source of data used in the chart(s).ACS (American Cancer Society). 2005. Cancer Facts and Figures. Atlanta, Ga.: American Cancer Society. Goldberg, D., G. D. Schiff, R. McNutt et al. 2004. Mailings Timed to Patients' Appointments: A Controlled Trial of Fecal Occult Blood Test Cards. American Journal of Preventive Medicine. 26 (5): 431–5. Nadel, M. R., J. A. Shapiro, C. N. Klabunde et al. 2005. A National Survey of Primary Care Physicians' Methods for Screening for Fecal Occult Blood. Annals of Internal Medicine 142 (2): 86–94. * NCCD (National Center for Chronic Disease Prevention and Health Promotion). 2006. Behavioral Risk Factor Surveillance System. Atlanta, Ga.: Centers for Disease Control and Prevention.* NCI (National Cancer Institute). 2005. Cancer Trends Progress Report: 2005 Update. Bethesda, Md.: National Institutes of Health. Pignone, M., R. Harris, and L. Kinsinger. 2000. Videotape-Based Decision Aid for Colon Cancer Screening. A Randomized, Controlled Trial. Annals of Internal Medicine 133 (10): 761–9. Reis, L., M. Eisner, C. Kosary et al. 2005. SEER Cancer Statistics Review, 1975–2002. Bethesda, Md.: National Cancer Institute.Seeff, L. C., M. R. Nadel, C. N. Klabunde et al. 2004. Patterns and Predictors of Colorectal Cancer Test Use in the Adult U.S. Population. Cancer 100 (10): 2093–103. Smith, R. A., V. Cokkinides, and H. J. Eyre. 2006. American Cancer Society Guidelines for the Early Detection of Cancer, 2006. CA: A Cancer Journal for Clinicians. 56 (1): 11–25. Stokamer, C. L., C. T. Tenner, J. Chaudhuri et al. 2005. Randomized Controlled Trial of the Impact of Intensive Patient Education on Compliance with Fecal Occult Blood Testing. Journal of General Internal Medicine 20 (3): 278–82. Stone, E. G., S. C. Morton, M. E. Hulscher et al. 2002. Interventions that Increase Use of Adult Immunization and Cancer Screening Services: A Meta-Analysis. Annals of Internal Medicine 136 (9): 641–51. USPSTF (U.S. Preventive Services Task Force). 2002. Screening for Colorectal Cancer: Recommendation and Rationale. Annals of Internal Medicine 137(2): 129–31. Wei, E. K., C. T. Ryan, A. J. Dietrich et al. 2005. Improving Colorectal Cancer Screening by Targeting Office Systems in Primary Care Practices: Disseminating Research Results into Clinical Practice. Archives of Internal Medicine 165 (6): 661–6. Winawer, S., R. Fletcher, D. Rex et al. 2003. Colorectal Cancer Screening and Surveillance: Clinical Guidelines and Rationale—Update Based on New Evidence. Gastroenterology 124 (2): 544–60.