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      Cancer Screening Test Use — United States, 2013

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          Abstract

          Regular breast, cervical, and colorectal cancer (CRC) screening with timely and appropriate follow-up and treatment reduces deaths from these cancers. Healthy People 2020 targets for cancer screening test use have been established, based on the most recent U.S. Preventive Services Task Force (USPSTF) guidelines (1). National Health Interview Survey (NHIS) data are used to monitor progress toward the targets. CDC used the 2013 NHIS, the most recent data available, to examine breast, cervical, and CRC screening use. Although some demographic subgroups attained targets, screening use overall was below the targets with no improvements from 2010 to 2013 in breast, cervical, or CRC screening use. Cervical cancer screening declined from 2010 to 2013. Increased efforts are needed to achieve targets and reduce screening disparities. NHIS is an annual survey of a nationally representative sample of the civilian, noninstitutionalized U.S. population. The Sample Adult file was used, for which one adult was selected randomly from each family to provide information, and the Person and Imputed Income files. The 2013 sample adult response rate was 61.2%. Data from the 2013 NHIS survey (2) were used to examine recent breast, cervical, and CRC screening, defined according to USPSTF recommendations: mammography within 2 years among women aged 50–74 years, Papanicolaou (Pap) test within 3 years among women aged 21–65 years without hysterectomy, and either fecal occult blood test (FOBT) within 1 year, sigmoidoscopy within 5 years and FOBT within 3 years, or colonoscopy within 10 years among respondents aged 50–75 years, respectively.* The overall proportions of persons screened were presented as crude percentages and age standardized to the 2000 U.S. standard population. Screening use was compared by sociodemographic and access factors. Insurance includes public or private health care coverage, but excludes Indian Health Service coverage or single service plans (i.e., that pay for only one type of service). Healthy People 2020 baseline estimates are based on 2008 NHIS data (the most recent data available in 2010 when the targets were set) (1). NHIS data from 2000, 2003, 2005, 2008, 2010, and 2013 were used to evaluate changes in screening percentages over time (2). Pearson Wald F tests were used to test for any differences across years. All statistics were weighted. Relative standard errors for all 2013 estimates were <30%. In 2013, after adjusting for age, 72.6% of women aged 50–74 years reported recent mammography (Table 1), below the Healthy People 2020 target of 81.1% (2008 baseline 73.7%) (1). Mammography use was lower among women aged 50–64 compared with 65–74 years, and lower among Hispanics compared with non-Hispanics. Use increased with increasing education and income. College graduates and those with income >400% of the federal poverty threshold met the target. Mammography use was lowest among those lacking insurance (38.5%) or a usual source of care (29.7%). Publicly insured women also were less likely to report screening than privately insured women. Mammography use was stable during 2000–2013 (p = 0.10) (Figure). Overall, 80.7% of women aged 21–65 years reported a recent Pap test (age-adjusted), below the Healthy People 2020 target of 93.0% (2008 baseline 84.5%) (1). Pap test use was lower for Asians, Hispanics, women aged 51–65 years, and foreign-born women. Uninsured and publicly insured women also were less likely than privately insured women to report screening. Use increased with increasing education and income. Use was lowest among women without a usual source of care (62.1%) or insurance (62.0%). Pap test use declined significantly by 5.5 percentage points from 2000 to 2013 (p<0.001) (Figure). Overall, after adjusting for age, 58.2% of respondents aged 50–75 years reported recent CRC tests (Table 2), below the Healthy People 2020 target of 70.5% (2008 baseline 52.1%) (1). CRC test use was lower among Asians and all Hispanic subgroups except Puerto Ricans compared with white and non-Hispanic respondents respectively. Use was lower among respondents aged 50–64 years (52.8%) compared with 65–75 years (69.4%) and increased with increasing education and income. Use was slightly lower among men than women (p = 0.047) and lower among foreign-born than U.S.-born respondents. Screening was particularly low among those without a usual source of care (17.8%) or insurance (23.5%). Publicly insured respondents also were less likely to report screening than privately insured respondents. Overall CRC test use increased significantly by 24.6 percentage points from 2000 to 2013 (p<0.001) (Figure). Use increased in every year assessed during 2000–2010, but not in 2013. This was true for men and women. Discussion Progress toward meeting Healthy People 2020 cancer screening targets was not observed in 2013 compared with 2010. Mammography use remained essentially stable, Pap test use declined, and CRC test use was essentially unchanged. Some subgroups attained or neared 2020 targets. The proportion of women in the highest education and income groups who were screened for breast cancer exceeded the target; the percentage of privately insured women screened was near the target value. The proportion of persons aged 65–75 years who were screened for CRC also was near the target value. Those furthest below targets were generally those without insurance or a usual source of care. For these groups, screening use was 42–53 percentage points below breast and CRC screening targets, and approximately 30 percentage points below the cervical cancer screening target. Reported screening for all three cancers was similar between whites and blacks and lower for Hispanics, with variation among racial and ethnic subgroups. Those without insurance or usual sources of care have experienced persistent large screening disparities (3–8). Findings from the 2000 NHIS survey identified these groups as among those least likely to be up-to-date with and experiencing the greatest disparities in breast, cervical, and CRC screening (7). Based on 1987 and 1992 NHIS data, Pap test use among women aged ≥25 years was similar to these 2013 findings for those lacking a usual source of care or insurance (58% versus 62% and 65% versus 62%, respectively) (7). Moreover, although CRC test use increased from 2000 to 2008 for the uninsured aged 50–64 years and those without a usual source of care, use was low (16%–20%) and 35–40 percentage points lower than other groups (9). These 2013 data also show low screening use in these groups with disparities of similar magnitude. Only general comparisons across studies are possible because screening estimates might vary because of differences in samples, survey questions, screening definitions and recommendations over time. This trend analysis used consistent sample and screening definitions. There are financial and nonfinancial barriers to receiving preventive services. The Affordable Care Act helps reduce financial barriers both by increasing access to insurance and by eliminating cost-sharing for breast, cervical, and CRC screening (among other preventive services) for many insured persons (10).† The National Breast and Cervical Cancer Early Detection Program§ and the Colorectal Cancer Control Program¶ reduce barriers by providing free or low-cost screening and linkages to diagnostic services for uninsured and underinsured low-income adults. The Colorectal Cancer Control Program also promotes screening through use of evidence-based interventions and health care system changes. Efforts are needed to understand why screening percentages are not increasing, and, for Pap tests, are decreasing. In 2012, screening every 5 years with a combination of Pap and human papillomavirus (HPV) tests also was included as a screening option for some women aged 30–65 years. It is unknown whether screening intervals might have been lengthened for some women after the 2012 updated recommendation, and if so, whether this might have contributed to decreased screening use as measured in the 2013 findings. Information about HPV testing was not available. No changes in USPSTF recommendations for breast or CRC screening were made during 2010–2013. For CRC, USPSTF guidelines were updated in 2002 and 2008, and NHIS questions about endoscopy were modified in 2010. To what extent this might have contributed to changes in screening use prior to 2010 is uncertain. The National Colorectal Cancer Roundtable set a goal of 80% screened by 2018.** More than a 20 percentage-point improvement is needed to meet this goal. Colonoscopy is more commonly used than other recommended CRC screening options (6). Promotion of all recommended CRC testing options, including less invasive methods like home FOBT might increase use, particularly because the test completed (presumably reflecting patient preferences) varies among subgroups (6). For this report, screening histories were examined only for persons in age groups recommended for routine screening. However, nearly one fourth of persons aged 51–65 years and 30% of those aged 65–75 years reported no recent cervical cancer and CRC screening, respectively, thus some might reach upper age limits for routine screening without adequate prior screening. Although USPSTF does not recommend routine screening for cervical cancer among average-risk women aged >65 years or for CRC among adults aged 76–85 years,†† screening might be indicated for some adults in these older groups who were not screened adequately when they were in a younger age group for which routine screening was recommended. The findings in this report are subject to at least seven limitations. First, NHIS data are self-reported and not verified by medical records. Second, the response rate was 61%, and nonresponse bias is possible despite adjustments for nonresponse. Third, although age-adjusted percentages for screening are presented that are consistent with Healthy People 2020 targets overall, percentages for subgroups are not age-adjusted. Fourth, Pap test data for 2003 were excluded because hysterectomy status was unknown. Fifth, screening guidelines and NHIS screening questions have changed over time. Sixth, confidence intervals were wide for some subgroups, indicating estimate imprecision. Finally, diagnostic tests rather than screening tests might have been reported by some respondents, possibly leading to overestimates of screening. Increased efforts are needed to reach Healthy People 2020 cancer screening targets and reduce disparities. More intensive or focused efforts might be required to overcome persistent barriers among specific population subgroups. Making available all recommended CRC screening options might increase alignment of tests with individual needs and preferences, and facilitate screening completion. Evidence-based interventions can increase screening use. Information about recommended interventions is available for communities and health systems from The Community Guide.§§ Cancer Control PLANET¶¶ provides resources for designing and implementing evidence-based programs. Such resources can help communities identify and implement effective interventions appropriate for their needs to increase use of these important services. What is already known on this topic? Screening is effective for detecting breast, cervical, and colorectal cancers early when the cancers can be more easily treated and deaths averted. Healthy People 2020 established targets for breast, cervical, and colorectal cancer screening in the United States. Disparities in screening use related to several demographic and health care access factors have been observed. What is added by this report? The most recent data on screening use (from 2013) show no progress toward meeting Healthy People 2020 targets for cancer screening. Mammography use in women aged 50–74 years was 72.6% (target 81.1%), Pap test use in women aged 21–65 years was 80.7% (target 93.0%), and CRC screening in persons aged 50–75 years was 58.2% (target 70.5%). Compared with 2000, mammography use was unchanged, Pap test use was lower and CRC screening was higher, although unchanged since 2010. Persons without a usual source of care or insurance generally were furthest below Healthy People 2020 targets. What are the implications for public health practice? Progress toward Healthy People 2020 targets requires efforts to increase breast, cervical and colorectal cancer screening use overall. Evidence-based interventions, such as client and provider reminders and others, can increase screening use.

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          Progress in cancer screening practices in the United States: results from the 2000 National Health Interview Survey.

          Understanding differences in cancer screening among population groups in 2000 and successes or failures in reducing disparities over time among groups is important for planning a public health strategy to reduce or eliminate health disparities, a major goal of Healthy People 2010 national cancer screening objectives. In 2000, the new cancer control module added to the National Health Interview Survey (NHIS) collected more detailed information on cancer screening compared with previous surveys. Data from the 2000 NHIS and earlier surveys were analyzed to discern patterns and trends in cancer screening practices, including Pap tests, mammography, prostate specific antigen (PSA) screening, and colorectal screening. The data are reported for population subgroups that were defined by a number of demographic and socioeconomic characteristics. Women who were least likely to have had a mammogram within the last 2 years were those with no usual source of health care (61%), women with no health insurance (67%), and women who immigrated to the United States within the last 10 years (61%). Results for Pap tests within the last 3 years were similar. Among both men and women, those least likely to have had a fecal occult blood test or endoscopy within the recommended screening interval had no usual source of care (14% for men and 18% for women), no health insurance (20% for men and 18% for women), or were recent immigrants (20% for men and 18% for women). An analysis of changes in test use since the 1987 survey indicates that the disparities are widening among groups with no usual source of care. No striking improvements have been observed for the groups with greatest need. Although screening use for most groups has increased since 1987, major disparities remain. Some groups, notably individuals with no usual source of care and the uninsured are falling further behind; and, according to the 2000 data, recent immigrants also experience a significant gap in screening utilization. More attention is needed to overcome screening barriers for these groups if the population benefits of cancer screening are to be achieved. Published 2003 by the American Cancer Society.DOI 10.1002/cncr.11208
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            Trends in colorectal cancer test use among vulnerable populations in the United States.

            Evaluating trends in colorectal cancer (CRC) screening use is critical for understanding screening implementation, and whether population groups targeted for screening are receiving it, consistent with guidelines. This study examines recent national trends in CRC test use, including among vulnerable populations. We used the 2000, 2003, 2005, and 2008 National Health Interview Survey to examine national trends in CRC screening use overall and for fecal occult blood test (FOBT), sigmoidoscopy, and colonoscopy. We also assessed trends by race/ethnicity, educational attainment, income, time in the United States, and access to health care. During 2000 to 2008, significant declines in FOBT and sigmoidoscopy use and significant increases in colonoscopy use and in the percentages of adults up-to-date with CRC screening occurred overall and for most population subgroups. Subgroups with consistently lower rates of colonoscopy use and being up-to-date included Hispanics; people with minimal education, low income, or no health insurance; recent immigrants; and those with no usual source of care or physician visits in the past year. Among up-to-date adults, there were few subgroup differences in the type of test by which they were up-to-date (i.e., FOBT, sigmoidoscopy, or colonoscopy). Although use of CRC screening and colonoscopy increased among U.S. adults, including those from vulnerable populations, 45% of adults aged 50 to 75-or nearly 35 million people-were not up-to-date with screening in 2008. Continued monitoring of CRC screening rates among population subgroups with consistently low utilization is imperative. Improvement in CRC screening rates among all population groups in the United States is still needed. ©2011 AACR.
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              Cancer screening - United States, 2010.

              (2012)
              Each year, approximately 350,000 persons are diagnosed with breast, cervical, or colorectal cancer in the United States, and nearly 100,000 die from these diseases. The U.S. Preventive Services Task Force (USPSTF) recommends screening tests for each of these cancers to reduce morbidity and mortality. Healthy People 2020 sets national objectives for use of the recommended cancer screening tests and identifies the National Health Interview Survey (NHIS) as the means to measure progress. Data from the 2010 NHIS were analyzed to assess use of the recommended tests by age, race, ethnicity, education, length of U.S. residence, and source and financing of health care to identify groups not receiving the full benefits of screening and to target specific interventions to increase screening rates. Overall, the breast cancer screening rate was 72.4% (below the Healthy People 2020 target of 81.1%), cervical cancer screening was 83.0% (below the target of 93.0%), and colorectal cancer screening was 58.6% (below the target of 70.5%). Screening rates for all three cancer screening tests were significantly lower among Asians than among whites and blacks. Hispanics were less likely to be screened for cervical and colorectal cancer. Higher screening rates were positively associated with education, availability and use of health care, and length of U.S. residence. Continued monitoring of screening rates helps to assess progress toward meeting Healthy People 2020 targets and to develop strategies to reach those targets.
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                Author and article information

                Journal
                MMWR Morb Mortal Wkly Rep
                MMWR Morb. Mortal. Wkly. Rep
                MMWR
                MMWR. Morbidity and Mortality Weekly Report
                U.S. Centers for Disease Control
                0149-2195
                1545-861X
                8 May 2015
                8 May 2015
                : 64
                : 17
                : 464-468
                Affiliations
                [1 ]Division of Cancer Prevention and Control, National Center for Chronic Disease Prevention and Health Promotion, CDC
                [2 ]Division of Cancer Control and Population Sciences, National Cancer Institute
                Author notes
                Corresponding author: Susan Sabatino, ssabatino@ 123456cdc.gov , 770-488-4227
                Article
                464-468
                4584551
                25950253
                14f67ff0-1f64-42b9-a9fa-e12102aaaa6e
                Copyright @ 2015

                All material in the MMWR Series is in the public domain and may be used and reprinted without permission; citation as to source, however, is appreciated.

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