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.