Colorectal Cancer Screening History Research Articles

Effects of personalized colorectal cancer risk information on laypersons’ interest in colorectal cancer screening: The importance of individual differences

ObjectiveTo evaluate how personalized quantitative colorectal cancer (CRC) risk information affects laypersons’ interest in CRC screening, and to explore factors influencing these effects. MethodsAn online pre-post experiment was conducted in which a convenience sample (N=578) of laypersons, aged >50, were provided quantitative personalized estimates of lifetime CRC risk, calculated by the National Cancer Institute Colorectal Cancer Risk Assessment Tool (CCRAT). Self-reported interest in CRC screening was measured immediately before and after CCRAT use; sociodemographic characteristics and prior CRC screening history were also assessed. Multivariable analyses assessed participants’ change in interest in screening, and subgroup differences in this change. ResultsPersonalized CRC risk information had no overall effect on CRC screening interest, but significant subgroup differences were observed. Change in screening interest was greater among individuals with recent screening (p=.015), higher model-estimated cancer risk (p=.0002), and lower baseline interest (p<.0001), with individuals at highest baseline interest demonstrating negative (not neutral) change in interest. ConclusionEffects of quantitative personalized CRC risk information on laypersons’ interest in CRC screening differ among individuals depending on prior screening history, estimated cancer risk, and baseline screening interest. Practice implicationsPersonalized cancer risk information has personalized effects—increasing and decreasing screening interest in different individuals.

Comparative Effectiveness of Multifaceted Outreach to Initiate Colorectal Cancer Screening in Community Health Centers: A Randomized Controlled Trial.

Colorectal cancer (CRC) screening rates are low among vulnerable populations. Fecal immunochemical tests (FITs) are one screening modality with few barriers. Studies have shown that outreach can improve CRC screening, but little is known about its effectiveness among individuals with no CRC screening history. We sought to determine whether outreach increases FIT uptake among patients with no CRC screening history compared to usual care. This study was a patient-level randomized controlled trial, including 420 patients who had never completed CRC screening and were eligible for FIT; 66% were female, 62.1% were Latino, and 70.7% were uninsured. The main outcome measure was FIT completion within 6 months of the randomization date. We assessed FIT completion at different time points corresponding to receipt of outreach components. All analyses were re-run with 12-month data. Patients who received outreach were more likely to complete FIT than those in usual care (36.7% vs. 14.8%; p < 0.001). FIT completion was more common among patients with increased clinic visits. The difference in FIT completion between the outreach and usual care groups decreased over time. The intervention improved FIT uptake among patients with no CRC screening history. However, the intervention was less effective than in a previous trial targeting patients due for repeat screening. Additional research is needed to determine the best methods for improving CRC screening among this hard-to-reach group.

Development and validation of a risk score predicting risk of colorectal cancer.

Quantifying the risk of colorectal cancer for individuals is likely to be useful for health service provision. Our aim was to develop and externally validate a prediction model to predict 5-year colorectal cancer risk. We used proportional hazards regression to develop the model based on established personal and lifestyle colorectal cancer risk factors using data from 197,874 individuals from the 45 and Up Study, Australia. We subsequently validated the model using 24,233 participants from the Melbourne Collaborative Cohort Study (MCCS). A total of 1,103 and 224 cases of colorectal cancer were diagnosed in the development and validation sample, respectively. Our model, which includes age, sex, BMI, prevalent diabetes, ever having undergone colorectal cancer screening, smoking, and alcohol intake, exhibited a discriminatory accuracy of 0.73 [95% confidence interval (CI), 0.72-0.75] and 0.70 (95% CI, 0.66-0.73) using the development and validation sample, respectively. Calibration was good for both study samples. Stratified models according to colorectal cancer screening history, that additionally included family history, showed discriminatory accuracies of 0.75 (0.73-0.76) and 0.70 (0.67-0.72) for unscreened and screened individuals of the development sample, respectively. In the validation sample, discrimination was 0.68 (0.64-0.73) and 0.72 (0.67-0.76), respectively. Our model exhibited adequate predictive performance that was maintained in the external population. The model may be useful to design more powerful cancer prevention trials. In the group of unscreened individuals, the model may be useful as a preselection tool for population-based screening programs.

Barriers to Colorectal Cancer Screening Between Arab American and Southeast Asian Americans

Introduction: To define and compare the characteristics and barriers to colorectal cancer screening (CRCS) in 2 ethnic populations who did not receive CRCS in metropolitan Detroit, MI, area. Methods: After announcing the study in 4 community centers in Detroit metropolitan area, individuals identified themselves as Arab Americans (ArAs) and Southeast Asian Americans (SEAAs) completed the study survey. Information obtained were country of origin, age, health insurance status, length of time in the United States, education level, CRCS history, family history of colorectal cancer, access to a primary care physician (PCP), the ability of their PCP to communicate in their native language, and barriers to CRCS. The results were compared between both populations. Results: A total of 171 individuals participated in the study. There were 41 SEAAs, representing 24% of the study population and 130 ArAs (76%). A larger percent of the SEAAs did not have CRCS compared to ArAs (70.7% vs. 45.4%; p=0.005). Compared to unscreened SEAAs, unscreened ArAs are older and have been living for a longer duration in the United States (Table 1). They were also more likely to have received a high school degree or higher and more likely to earn $20,000 or more annually. Although both unscreened ArAs and SEAAs have PCPs, a higher proportion of ArAs have PCPs that can communicate in their native language (97.8% vs. 63.6%; p<0.001). ArAs were found to be less aware about CRCS and have a lower tolerability to screening tests compared to SEAAs (Table 2). In addition, more ArAs did not think that CRCS is necessary (52.5% vs. 20.7%; p=0.004). Other factors including embarrassment, language barriers, and scheduling issues were not significantly different between both groups. Overall, ArAs were more willing to undergo CRCS if the above barriers were eliminated (86.4% vs 31%; p<0.001).Table 1: Characteristics of Unscreened Arab Americans and Southeast Asian AmericansTable 2: Comparison of Barriers to CRCS Between Arab Americans and Southeast Asian AmericansConclusion: ArA are more likely to undergo CRCS if barriers are eliminated when compared to SEAA. This effect may be as a result of living in the United States for longer period of time and integration with the American culture. Although SEAAs are more likely to have high school education or more, they are less likely to undergo CRCS. Increasing medical provider participation and educational and outreach programs to minorities can be used to increase CRCS in both ArA and SEAA populations.

Agreement between self-reported and registered colorectal cancer screening: a meta-analysis.

This random-effects meta-analysis investigates the accuracy of self-reported colorectal cancer screening history as a function of screening mode (colonoscopy, flexible sigmoidoscopy, faecal occult blood testing - FOBT, double-contrast barium enema - DCBE) and survey mode (written, telephone, face-to-face). Summary estimates of sensitivity, specificity, positive predictive value (PPV) and area under the receiver operating characteristic curve (AUC) were calculated. Medical record data were used as reference. We included 23 studies comprising 11,592 subjects. Colonoscopy yielded higher AUC [0.948, 95% confidence interval (CI) = 0.918, 0.968] than flexible sigmoidoscopy (0.883, 95% CI = 0.849, 0.911) and FOBT (0.869, 95% CI = 0.833, 0.898). Colonoscopy showed the highest sensitivity (0.888, 95% CI = 0.835, 0.931), whereas specificity was comparable between screening modes (ranging from 0.802 for FOBT to 0.904 for DCBE). AUC was not significantly different between survey modes. Prevalence of screening history correlated positively with sensitivity and negatively with specificity, possibly because of errors in the medical records. In conclusion, the accuracy of self-reported cancer screening is generally moderate, and higher for colonoscopy than for sigmoidoscopy and FOBT.

Clinical case management and navigation for colonoscopy screening in an academic medical center

One of 5 nationally funded Centers for Disease Control and Prevention Colorectal Cancer (CRC) Screening Demonstration Programs, Project SCOPE, was conducted at an academic medical center and provided colonoscopy screening at no cost to underserved minority patients from local community health centers. Established barriers to CRC screening (eg, financial, language, transportation) among the target population were addressed through clinical coordination of care by key project staff. The use of a clinician with a patient navigator allowed for the performance of precolonoscopy "telephone visits" instead of office visits to the gastroenterologist in virtually all patients. The clinician elicited information relevant to making screening decisions (eg, past medical and surgical history, focused review of systems, medication/supplement use, CRC screening history). The patient navigator reduced barriers, including, but not limited to, scheduling, transportation, and physical navigation of the medical center on the day of colonoscopy. Preprogram preparation was vital in laying groundwork for the project, yet enhancements to the program were ongoing throughout the screening period. Detailed referral forms from primary care physicians, coupled with information obtained during telephone interviews, facilitated high colonoscopy completion rates and excellent patient satisfaction. Similarly valuable was the employment of a bilingual patient navigator, who provided practical and emotional patient support. Academic medical centers can be efficient models for providing CRC screening to disadvantaged populations. Coordination of care by a preventive medicine department, directing the recruitment, scheduling, prescreening education, and the evaluation and preparation of target populations had an overall positive effect on CRC screening with colonoscopy among patients from a community health center.

Screening Patterns in Patients with a Family History of Colorectal Cancer Often Do Not Adhere to National Guidelines

Currently, there are no data on adherence to guidelines for colorectal cancer (CRC) screening in patients with a family history. We conducted a retrospective study to assess if such patients were being appropriately screened according to American Gastroenterological Association (AGA) guidelines. Two independent reviewers performed a comprehensive medical record review of family and CRC screening history on 362 adults with a family history of CRC in a first-degree relative who had recently undergone screening colonoscopy. The endpoint was appropriate initiation of screening and endoscopist-recommended subsequent screening intervals, as compared to AGA guideline recommendations. Of 362 subjects, only 146 (40.3 %) were screened appropriately; 213 (58.9 %) had late initiation of screening (i.e., screening was started ≥5 years later than the age recommended by guidelines) and three (0.8 %) had premature initiation (i.e., screening was started ≥1 year too early). Of cases involving delayed screening initiation, 126 were not under primary care at the time when screening was supposed to have started, while most of the remaining received either no or incorrect screening recommendations from their primary care provider. Of 270 subjects with no neoplasia found on initial screening, 112 (41.5 %) had endoscopist-recommended subsequent screening intervals that were ≥2 years shorter than that recommended by guidelines. Results were similar if American Society of Gastrointestinal Endoscopy or American College of Gastroenterology guidelines were used. Patients with a family history often suffer from late initiation of screening and overly short endoscopist-recommended subsequent intervals for colonoscopy. Further education of patients and providers on screening recommendations may be helpful.

Colorectal cancer screening: what do women from diverse ethnic groups want?

Little is known about factors associated with willingness to undergo colorectal cancer (CRC) screening for personal or public health benefit among women from diverse race/ethnic groups. To evaluate factors associated with willingness to undergo CRC screening for personal and public health benefit among women from diverse race/ethnic groups. We interviewed women aged 50 to 80 from four racial/ethnic groups from primary care clinics in 2003-2005. We asked about demographics, CRC screening knowledge and history, perceived risk of colon cancer, and about the outcomes of intention to be screened for personal benefit and for public health benefit. Of the 492 women who completed the interview, 32 % were White, 16 % were African American, 21 % were Latina and 32 % were Asian. Up-to-date screening was reported by 77 % of women, with similar numbers obtaining fecal occult blood test (FOBT) within 2 years or colonoscopy within 10 years. The majority of women were "likely or very likely" to get FOBT or colonoscopy after learning the benefits and risks. Multivariate models showed that compared to Whites, fewer Asians would undergo colonoscopy (OR = 0.28; 95 % CI: 0.12, 0.63), while more Latinas would undergo colonoscopy (OR = 6.14; 95 % CI: 1.77, 21.34) and obtain regular CRC screening (OR = 4.47; 95 % CI: 1.66, 12.04). The majority would obtain CRC screening even if they would not personally benefit; those who perceived themselves to be at higher than average cancer risk were more likely to participate in CRC screening for public health benefit (OR = 2.32; 95 % CI: 1.32, 4.09). The majority of women are willing to undergo screening for personal benefit. Asians were less likely, and Latinas more likely, to accept colonoscopy. Most are also willing to undergo screening for public health benefit. Self-perceived risk of CRC was the most consistent predictor of willingness and intention to be screened for either personal or public health benefit.

Lessons learned from the Family Health Promotion Project

193 ISSN 1758-194X Colorect. Cancer (2012) 1(3), 193–195 10.2217/CRC.12.25 1Colorado School of Public Health, Department of Epidemiology & University of Colorado Cancer Center, 13001 E. 17th Place, Aurora, CO 80045, USA 2Denver VA Medical Center & University of Colorado School of Medicine, 1055 Clermont St., Denver, CO 80220, USA *Author for correspondence: dennis.ahnen@ucdenver.edu The Family Health Promotion Project (FHPP) is a prospective controlled trial designed to test the effectiveness of a telephone-based counseling intervention to promote colonoscopy screening in members of high-risk colorectal cancer (CRC) families. FHPP participants were recruited from two National Cancer Institute-funded registries: the Colon Family Registry (CFR) and the Cancer Genetics Network (CGN). Both of these are multisite registries that have enrolled individuals diagnosed with CRC (probands with CRC) and their family members [1,2]. The FHPP recruited subjects from eight CFR and four CGN sites across the USA. Prior to randomization, FHPP participants completed a baseline survey that included information about CRC screening history, knowledge of CRC screening guidelines, attitudes and beliefs regarding colonoscopy, perceived barriers to CRC screening and perceived risk of CRC. The intervention was delivered by trained counselors using the Computer Assisted Telephone Interviewing (CATI) unit of the Survey Shared Resource of the University of Colorado Cancer Center. The intervention itself was designed to promote colonoscopy screening as this is the recommended CRC screening option for members of high-risk families; it was well grounded in behavioral theory and used motivational interviewing methodology. The design and baseline survey results have recently been published [3]. During the course of the FHPP we learned important lessons both from the study design and from the initial survey results. First and foremost, we learned that these registries are a valuable resource for conducting prevention trials in high-risk populations, which are often difficult to identify on a population level. The CFR and CGN had enrolled a large number of probands with CRC and their close relatives and had collected three-generation family histories. Having extensive family history data enabled us to easily identify individuals eligible for FHPP who were at increased risk for CRC due to an early “First and foremost, we learned that these registries are a valuable resource for conducting prevention trials in high-risk populations, which are often difficult to identify on a population level.” COMMENTARY

The many faeces of colorectal cancer screening embarrassment: Preliminary psychometric development and links to screening outcome

Although embarrassment may be among the most easily modified discrete emotional barriers to patients seeking health care or testing, work in the area of colorectal cancer (CRC) has been restricted by the absence of suitable instrumentation. The current report describes the development and validation of a self-report instrument assessing two specific aspects of CRC screening embarrassment and their links to screening outcomes. Convenience sampling was used to recruit 245 European American, African-American, and immigrant Caribbean community-dwelling men and women (aged 45-75 years) living in Brooklyn, New York. Participants completed the measure of CRC screening embarrassment, an array of convergent and divergent validity measures including dispositional embarrassment, general medical embarrassment, neuroticism, trait emotion, social desirability, previous treatment avoidance because of embarrassment, relevant health characteristics, and a brief CRC screening history. As expected, CRC screening embarrassment was not unidimensional and had two reliable and distinct components, one concentrated on faecal/rectal embarrassment and the other on embarrassment arising from unwanted intimacy during examinations. In addition to demonstrating patterns of convergent and divergent validity consistent with their separation, multivariate analyses indicated that faecal/rectal embarrassment (but not intimacy concerns) predicted CRC screening frequency. The current report extends current understanding by identifying the specific sources of embarrassment that may contribute to patients' avoidance of CRC screening. Directions for future study and implications for clinical practice and interventions are discussed.

The community uptake of an online CRC risk assessment and its utility to assess for a potential hereditary colon cancer syndrome

Purpose The identification of individuals with Hereditary Non Polyposis Colorectal Cancer (HNPCC) in the population is suboptimal. Causes include lack of physician recognition or failure to take an accurate family history. While colorectal cancer (CRC) in HNPCC is preventable by annual colonoscopy it is underutilized in part by lack of physician recommendation or poor understanding of personal risk of disease. We developed an online CRC risk assessment (http://www.clevelandclinic.org/score) incorporating family and personal history of adenomas and CRC which generated a pedigree, risk category and screening recommendations based on ACG guidelines. Modifiable lifestyle factors were also assessed and personalized recommendations were provided to minimize neoplasia due to those factors. We assessed the feasibility and online uptake of this tool and determined the proportion of high risk individuals who meet criteria suspicious for HNPCC. Methods The assessment included questions on demographics, use of previous CRC screening, and family and personal history of adenomas and CRC in 3 generations. Height, weight, age > or < 50, race, smoking exposure, physical activity, and dietary habits assessed. Risk categories included average, low, medium, and high.

Community Uptake of an Online CRC Risk Assessment

Purpose: Colorectal cancer (CRC) screening is underutilized. Major barriers include lack of physician recommendation or poor understanding of personal risk. We created an online CRC risk assessment incorporating family and personal history of adenomatous polyps and CRC which created a family tree, personalized risk score and screening recommendations based on ACG guidelines. Modifiable lifestyle factors were assessed and recommendations provided to minimize risk due to those factors (BMI, diet, smoking, physical activity). We sought to assess the feasibility and uptake of this tool. Methods: The risk assessment was created for CRC awareness month. Survey invited participants to complete questions on demographics, previous use of CRC screening, and family and personal history of polyps and CRC in 3 generations. Height weight, age > or < 50, race, quantified smoking exposure, physical activity, and dietary habits were assessed. Results: 3515 participants completed the risk assessment. 67% of participants were male, 81% white and 46% were under the age of 50. The mean BMI was 28.4. 53% reported eating < 3 servings of fruits and vegetables daily and 45% did not exercise at least 30 minutes 3-4 days per week. 61% of individuals reported never smoking and 28% were former smokers. 39% of individuals underwent previous screening with 89% of them reporting colonoscopy use. 11% of the population reported a history of adenomatous polyps and 1.3% reported CRC. The 405 indivdiduals who reported polyps/CRC had a higher BMI 29.6 vs. 28.1 (p= 0.013); age over 50 19% vs. 6% (p < 0.001); greater current packs of cigarettes (p = 0.024) and years of current smoking (p=0.032). Multivariable regression analysis (Table 1)confirmed that age, BMI and FDR with adenomatous polyps and cancer were associated with an increased OR for colorectal neoplasia. The risk score (Table 2), based upon the personal and family history provided revealed that 65% of the population was average risk, 11% low risk, 22% medium risk and 2% high risk. Self reported use of screening was associated in multivariable analysis to be associated with increased dietary intake of fruits/vegetables (3-5 vs. <3 servings daily 1.8 (1.4-2.3, p< 0.0001), FDR with CRC 2.2 (1.6-3.2, p<0.0001) and sibling with CRC 4.2 (2.3-7.7, p=0.0001). Conclusion: An online risk assessment tool is a feasible modality to provide consumer driven education regarding CRC risks and appropriate screening measures according to ACG guidelines. Whether the tool increases uptake of CRC screening is not known.Table: Factors associated with reported personal Hx CRC/polypsTable: Risk factors, risk score and screening recommendations

Systems of support to increase colorectal cancer screening and follow-up rates (SOS): Design, challenges, and baseline characteristics of trial participants

BackgroundScreening decreases colorectal cancer (CRC) morbidity and mortality, yet remains underutilized. Screening breakdowns arise from lack of uptake and failure to follow-up after a positive screening test. ObjectivesSystems of support to increase colorectal cancer screening and follow-up (SOS) is a randomized trial designed to increase: (1) CRC screening and (2) follow-up of positive screening tests. The Chronic Care Model and the Preventive Health Model inform study design. MethodsThe setting is a large nonprofit healthcare organization. In part-1 study, patients age 50–75 due for CRC screening are randomized to one of 4 study conditions. Arm 1 receives usual care. Arm 2 receives automated support (mailed information about screening choices and fecal occult blood tests (FOBT)). Arm 3 receives automated and assisted support (a medical assistant telephone call). Arm 4 receives automated, assisted, and care management support (a registered nurse provides behavioral activation and coordination of care). In part-2, study patients with a positive FOBT or adenomas on flexible sigmoidoscopy are randomized to receive either usual care or nurse care management. Primary outcomes are: 1) the proportion with CRC screening, 2) the proportion with a complete diagnostic evaluation after a positive screening test. ResultsWe sent recruitment letters to 15,414 patients and 4675 were randomized. Randomly assigned treatment groups were similar in age, sex, race, education, self-reported health, and CRC screening history. ConclusionsWe will determine the effectiveness and cost effectiveness of stepped increases in systems of support to increase CRC screening and follow-up after a positive screening test over 2years.

Provider Recommendations for Colorectal Cancer Screening in Elderly Veterans

Decisions regarding colorectal cancer (CRC) screening in the elderly depend on providers' assessment of likelihood of benefit partly based on patient comorbidity and past screening history. We aimed to describe providers' experiences and practice patterns regarding screening for CRC in elderly patients in the VA system. A survey was sent to VA primary care providers who had previously participated in the CanCORS-sponsored Share Thoughts on Care study and at a VA medical center. The surveys consisted of clinical vignettes that varied by patient age (75, 80, or 85 years), comorbidity, and past CRC screening history. Completed questionnaires were received from 183 of 351 providers (52%). Ninety-five percent of providers would recommend screening for a healthy 75 year old compared to 66% and 39% for a healthy 80 and 85 year old, respectively (p-values < 0.0001). Providers were more likely to recommend screening for a 75 year old with moderate CHF versus severe CHF [61% versus 15%, OR 9.0 (95% CI 5.8-14.0), p < 0.0001] and more likely to recommend screening for an 80 year old with prior colonoscopy within the preceding 10 years, versus 5 years [42% versus 23%, OR 2.6 (95% CI 1.9-3.5), p < 0.0001]. A substantial minority of respondents (range 15-21%) reported they would screen a 75 year old with an active malignancy, severe CHF, or severe COPD. Provider demographic characteristics were not significantly associated with the probability of a screening recommendation. VA providers incorporate patient age, comorbidity, and past CRC screening history into CRC screening recommendations for elderly veterans; however, substantial proportions of these recommendations are inappropriate.

Colorectal Cancer Screening in Patients with a Positive Family History: An Analysis of Screening Referral Patterns and Reasons for Non-Adherence to National Guidelines

Background: ASGE guidelines recommend the use of colonoscopic screening and initiation of colorectal cancer (CRC) screening at an earlier age for patients at elevated risk for CRC because of a positive family history. Currently, there are no data on referral patterns for screening in such high-risk patients. From anecdotal experience, we believe that many such patients are being referred by their primary care providers at an inappropriately late age. Our study had two objectives: (1) To assess if patients with a family history are being appropriately referred for screening; (2) To uncover possible reasons for non-adherence in those patients not in compliance with guidelines. Methods: We retrospectively reviewed the most recent 161 screening colonoscopies performed at Virginia Mason Clinic involving patients with a family history of CRC in a first-degree relative. For each patient, two independent reviewers abstracted detailed family and CRC screening history data from our comprehensive electronic medical records system. Based on the abstracted information, we determined whether each patient had been referred for screening in accordance with ASGE guidelines. For non-adherent patients, we then tried to find possible reasons that could explain non-adherence. Results: Out of 161 patients referred for screening, 103 (64%) had not been compliant with guidelines. Specifically, 92 (57%) had delayed initiation of screening (i.e. screening was started at an age much later than that recommended by the guidelines), 5 (3%) had premature initiation of screening, and 6 (4%) had screening with the wrong modality. Of cases involving delayed screening initiation, in 15 (16%) the patient was not under primary care at the time screening was supposed to have started, in 3 (3%) the patient refused screening despite recommendations by primary care, and in 26 (28%) the patient was older than the recommended age by the time CRC was discovered in their relatives (usually siblings). The remaining patients exhibited no discernible reason for delayed initiation of screening. Conclusions: Because our study included only patients with a family history of CRC referred for screening colonoscopy instead of all patients with a family history in the Virginia Mason system, the strikingly high proportion of patients with delayed initiation of screening implies inappropriate referral patterns from primary care, as opposed to unwillingness to undergo screening on the part of the patients. Although some cases demonstrate mitigating reasons for non-adherence to guidelines, our results strongly suggest inadequate knowledge of CRC screening guidelines in primary care providers.

Validation of a Colorectal Cancer Risk Prediction Model Among White Patients Age 50 Years and Older

Validation of an absolute risk prediction model for colorectal cancer (CRC) by using a large, population-based cohort. The National Institutes of Health (NIH) -American Association of Retired Persons (AARP) diet and health study, a prospective cohort study, was used to validate the model. Men and women age 50 to 71 years at baseline answered self-administered questionnaires that asked about demographic characteristics, diet, lifestyle, and medical histories. We compared expected numbers of CRC patient cases predicted by the model to the observed numbers of CRC patient cases identified in the NIH-AARP study overall and in subgroups defined by risk factor combinations. The discriminatory power was measured by the area under the receiver-operating characteristic curve (AUC). During an average of 6.9 years of follow-up, we identified 2,092 and 832 incident CRC patient cases in men and women, respectively. The overall expected/observed ratio was 0.99 (95% CI, 0.95 to 1.04) in men and 1.05 (95% CI, 0.98 to 1.11) in women. Agreement between the expected and the observed number of cases was good in most risk factor categories, except for in subgroups defined by CRC screening and polyp history. This discrepancy may be caused by differences in the question on screening and polyp history between two studies. The AUC was 0.61 (95% CI, 0.60 to 0.62) for men and 0.61 (95% CI, 0.59 to 0.62) for women, which was similar to other risk prediction models. The absolute risk model for CRC was well calibrated in a large prospective cohort study. This prediction model, which estimates an individual's risk of CRC given age and risk factors, may be a useful tool for physicians, researchers, and policy makers.

Racial differences in colorectal cancer screening practices and knowledge within a low-income population.

Although colorectal cancer (CRC) is the third leading cause of cancer death among US women and is particularly deadly among African Americans, CRC screening rates remain low. Within a low-income population of women, the authors examined racial differences in practices, knowledge, and barriers related to CRC screening. Face-to-face interviews were conducted with 941 women (white, n= 186; African American, n= 755) older than age 50 years who were living in subsidized housing communities in 11 cities in North and South Carolina. Women were asked questions about their CRC screening history and their knowledge and beliefs concerning CRC screening. Half (49%) of the women interviewed were within CRC screening guidelines, and this did not vary by race (P= .17). However, African American women were half as likely as white women to report having had a screening colonoscopy within the past 10 years (odds ratio [OR], 0.46; P< .001). Awareness of tests for CRC was low overall (39%) and was lower among African Americans than whites (OR, 0.44; P< .001). Compared with white women, African American women were less likely to report embarrassment as a barrier (OR, 0.59; P= .008) and more likely to report lack of insurance coverage (OR, 1.75; P= .098). Efforts must continue to increase women's knowledge of both CRC screening tests and colon cancer risk factors. Among these low-income women, routine encounters with the healthcare system may present opportunities to reduce deficits in CRC knowledge and to improve overall CRC screening rates.

Colorectal Cancer Screening among the Medically Underserved

Prevalence of physician recommendation and patient completion of colorectal cancer screening was investigated among Federally Qualified Health Centers (FQHC) serving low-income neighborhoods in Chicago. Medical records of 3,416 patients receiving primary care services at 1 of 31 FQHCs were randomly chosen for review. In all, 642 patients were identified by age and family history as eligible for colorectal cancer screening and included in this study. Patient demographic information and colorectal cancer screening history were collected. The physician screening recommendation rate was 9.2% (n=59); 7.0% (n=45) of patients were determined to have been appropriately screened for colorectal cancer, primarily by Fecal Occult Blood Test (94.1%, n=43). Among patients who received a recommendation from their physician, 76.2% had completed a screening test. Older patients were more likely than their younger counterparts to have received a recommendation from their physician (p<.05) and to have been screened (p<.01). Organizational interventions are needed to support physicians in medically underserved areas and to promote recommended screening practices.

Predictors of Pap smear screening in socioeconomically disadvantaged elderly women.

The objective for this study was to identify predictors for participation in Pap smear screening in a socioeconomically disadvantaged older population. A cross-sectional survey design was used to examine data from 238 southern women 50 years of age and older who were recruited from 24 randomly selected congregate meal sites of the Council on Aging. The 45-item questionnaire covered demographics, Pap smear screening history, and colorectal cancer screening history. Among this older, very low income population, women who had never had Pap smears (17.2%) were significantly more likely to have no phone or to be unable to use a phone (adjusted odds ratio (aOR) = 4.1; 95% confidence interval (CI) 1.6-10.6), to have annual incomes of less than $5,800 (aOR = 3.1; 95% CI 1.1-9.0), to be widowed (aOR = 2.8; 95% CI 1.1-7.3), to have no family history of cancer (aOR = 3.3, 95% CI 1.3-10.0), to report having never had a rectal examination (aOR = 5.4, 95% CI 1.8-16.0), and not to have participated in a free fecal occult blood testing program (aOR = 5.0, 95% CI 2.0-10.0). These data, unique in including very low income (< $10,000) and older women (65 and over), found that income and access to a phone were strongly correlated with cervical cancer screening participation. Women who lacked external incentives for screening (being widowed and not having a family history of cancer) were less likely to obtain screening. This study's finding that "not having a phone" was a strong predictor for nonparticipation in cervical cancer screening has implications for national telephone-derived estimates of cervical cancer screening.