Effect of an equal-access military health system on racial disparities in colorectal cancer screening : CRC Screening in a Military Health System

Individuals in the USA without private medical insurance are less likely to have access to medical care or participate in cancer screening programmes than those with private medical insurance. Smaller regional studies in the USA suggest that uninsured and Medicaid-insured individuals are more likely to present with advanced-stage cancer than privately insured patients; however, this finding has not been assessed using contemporary, national-level data. Furthermore, patients with cancer from ethnic minorities are more likely to be uninsured or Medicaid-insured than non-Hispanic white people. Separating the effects on stage of cancer at diagnosis associated with these two types of patient characteristics can be difficult. Patients with cancer in the USA, diagnosed between 1998 and 2004, were identified using the US National Cancer Database-a hospital-based registry that contains patient information from about 1430 facilities. Odds ratios and 95% CIs for the effect of insurance status (Medicaid, Medicare (65-99 years), Medicare (18-64 years), private, or uninsured) and ethnicity (white, Hispanic, black, or other) on disease stage at diagnosis for 12 cancer sites (breast [female], colorectal, kidney, lung, melanoma, non-Hodgkin lymphoma, ovary, pancreas, prostate, urinary bladder, uterus, and thyroid) were estimated, while controlling for patient characteristics. 3,742,407 patients were included in the analysis; patient characteristics were similar to those of the corresponding US population not included in the analysis. Uninsured and Medicaid-insured patients were significantly more likely to present with advanced-stage cancer compared with privately insured patients. This finding was most prominent for patients who had cancers that can potentially be detected early by screening or symptom assessment (eg, breast, colorectal, and lung cancer, as well as melanoma). For example, the odds ratios for advanced-stage disease (stage III or IV) at diagnosis for uninsured or Medicaid-insured patients with colorectal cancer were 2.0 (95% CI 1.9-2.1) and 1.6 (95% CI 1.5-1.7), respectively, compared with privately-insured patients. For advanced-stage melanoma, the odds ratios were 2.3 (2.1-2.5) for uninsured patients and 3.3 (3.0-3.6) for Medicaid-insured patients compared with privately insured patients. Black and Hispanic patients were noted to have an increased risk of advanced-stage disease (stage III or IV) at diagnosis, irrespective of insurance status, compared with White patients. In this US-based analysis, uninsured and Medicaid-insured patients, and those from ethnic minorities, had substantially increased risks of presenting with advanced-stage cancers at diagnosis. Although many factors other than insurance status also affect the quality of care received, adequate insurance is a crucial factor for receiving appropriate cancer screening and timely access to medical care.

Screening is effective in reducing the incidence and mortality of colorectal cancer. Rates of colorectal cancer test use continue to be low. The authors analyzed data from the National Health Interview Survey concerning the use of the home-administered fecal occult blood test (FOBT) and sigmoidoscopy/colonoscopy/proctoscopy to estimate current rates of colorectal cancer test use and to identify factors associated with the use or nonuse of tests. In 2000, 17.1% of respondents reported undergoing a home FOBT within the past year, 33.9% reported undergoing an endoscopy within the previous 10 years, and 42.5% reported undergoing either test within the recommended time intervals. The use of colorectal cancer tests varied by gender, race, ethnicity, age, education, income, health care coverage, and having a usual source of care. Having seen a physician within the past year had the strongest association with test use. Lack of awareness and lack of physician recommendation were the most commonly reported barriers to undergoing such tests. Less than half of the U.S. population age >/= 50 years underwent colorectal cancer tests within the recommended time intervals. Educational initiatives for patients and providers regarding the importance of colorectal cancer screening, efforts to reduce disparities in test use, and ensuring that all persons have access to routine primary care may help increase screening rates. Copyright 2004 American Cancer Society.

To critically evaluate recent studies that examined determinants of CRC screening behaviors among average-risk older adults (>or=50 years) in the United States. A PUBMED (1996-2006) search was conducted to identify recent articles that focused on predictors of CRC initiation and adherence to screening guidelines among average-risk older adults in the United States. Frequently reported predictors of CRC screening behaviors include older age, male gender, marriage, higher education, higher income, White race, non-Hispanic ethnicity, smoking history, presence of chronic diseases, family history of CRC, usual source of care, physician recommendation, utilization of other preventive health services, and health insurance coverage. Psychosocial predictors of CRC screening adherence are mostly constructs from the Health Belief Model, the most prominent of which are perceived barriers to CRC screening. Evidence suggests that CRC screening is a complex behavior with multiple influences including personal characteristics, health insurance coverage, and physician-patient communication. Health promotion activities should target both patients and physicians, while focusing on increasing awareness of and accessibility to CRC screening tests among average-risk older adults in the United States.