0
Original Investigation |

Determinants of Racial/Ethnic Colorectal Cancer Screening Disparities FREE

Anthony F. Jerant, MD; Joshua J. Fenton, MD, MPH; Peter Franks, MD
[+] Author Affiliations

Author Affiliations: Department of Family and Community Medicine (Drs Jerant, Fenton, and Franks) and Center for Healthcare Policy and Research (Dr Franks), University of California Davis School of Medicine, Sacramento.


Arch Intern Med. 2008;168(12):1317-1324. doi:10.1001/archinte.168.12.1317.
Text Size: A A A
Published online

Background  The contributions of demographic, socioeconomic, access, language, and nativity factors to racial/ethnic colorectal cancer (CRC) screening disparities are uncertain.

Methods  Using linked data from 22 973 respondents to the 2001-2005 Medical Expenditure Panel Survey and the 2000-2004 National Health Interview Survey, we modeled disparities in CRC screening (fecal occult blood testing [FOBT], endoscopy, and combined FOBT and endoscopy) between non-Hispanic whites and Asians, blacks, and Hispanics, sequentially adjusting for demographics, socioeconomic status, clinical and access variables, and race/ethnicity–related variables (language spoken at home and nativity).

Results  With demographic adjustment, minorities reported less CRC screening (all measures) than non-Hispanic whites. Disparities were largest for combined screening in Asians (adjusted odds ratio [AOR], 0.40; 95% confidence interval [CI], 0.32-0.49) and Hispanics (AOR, 0.43; 95% CI, 0.39-0.48) and for endoscopic screening in Asians (AOR, 0.41; 95% CI, 0.33-0.50) and Hispanics (AOR, 0.43; 95% CI, 0.38-0.48). With full adjustment, all Hispanic/non-Hispanic white disparities and black/non-Hispanic white FOBT disparities were eliminated, whereas Asian/non-Hispanic white disparities remained significant (FOBT: AOR, 0.72 [95% CI, 0.52-1.00]; endoscopic screening: AOR, 0.63 [95% CI, 0.49-0.81]; and combined screening: AOR, 0.66 [95% CI, 0.52-0.84]).

Conclusions  Determinants of racial/ethnic CRC screening disparities vary among minority groups, suggesting the need for different interventions to mitigate those disparities. Whereas socioeconomic, access, and language barriers seem to drive the CRC screening disparities experienced by blacks and Hispanics, additional factors may exacerbate the disparities experienced by Asians.

Figures in this Article

Colorectal cancer (CRC) screening uptake is suboptimal, lagging behind other evidence-based cancer screening tests.1,2 In the 2004 Behavioral Risk Factor Surveillance System, only 57% of adults 50 years or older overall reported up-to-date CRC screening status.1 Marked disparities in CRC screening also seem to exist nationally between non-Hispanic whites and other racial/ethnic groups in the United States.312 For example, an analysis of pooled 1987-2003 National Health Interview Survey (NHIS) data found that up-to-date CRC screening was reported by 47% of white men and 44% of white women but in only 30.4% of Hispanic men and 31% of Hispanic women, in 43% of black men and 38% of black women, and in 29% of men and 32% of women of other ethnicity (including Asian).6 Such disparities in screening may contribute to the higher CRC incidence13,14 and mortality1416 rates observed in racial/ethnic minorities relative to non-Hispanic whites.

Previous studies have suggested several explanations for minority/non-Hispanic white screening disparities, including relatively lower socioeconomic status,5,812,1723 reduced access to care,5,8,10,11,17,18,2023 and language or acculturation barriers.4,20,22,23 However, previous studies812,1725 often excluded 1 or more of the 3 largest US racial/ethnic minority groups (Asians, blacks, and Hispanics), making comparisons of the importance of the various factors that affect CRC screening behavior across racial/ethnic groups difficult. Many studies were also confined to individuals in a single geographic region2125 or did not adjust for 1 or more known correlates of cancer screening behavior.4,5,812,18,19,2224

To address these limitations in the literature, we examined the correlates of CRC screening among all 4 major US racial/ethnic categories (non-Hispanic white, Asian, black, and Hispanic individuals) using linked data from the 2001-2005 Medical Expenditure Panel Survey (MEPS) and the 2000-2004 NHIS. By combining 5 panels of MEPS data, we derived a large enough nationally representative sample (>22 000 individuals) to compare CRC screening up-to-date rates among major US racial/ethnic subgroups. We constructed 4 models, adjusting progressively for age, sex, panel, and region of the United States (basic demographics [model 1]), additionally for socioeconomic status (model 2), additionally for access to care and self-rated health (model 3), and, finally, additionally for race/ethnicity–related factors (language spoken at home and nativity [model 4]).

SOURCES OF DATA

The primary source of data was the 2001-2005 MEPS,26 a nationally representative survey of health care use and costs in the US civilian, noninstitutionalized population conducted by the Agency for Healthcare Research and Quality. It uses an overlapping panel design and oversamples Hispanics and blacks. Data are collected for individuals during a 2-year period via a baseline interview and 5 follow-up interviews. The MEPS Household Component collects information on language spoken at home, country of origin, sociodemographic information, usual source of care, and health insurance coverage. The MEPS Household Component sample is drawn from a subsample of households included in the previous year's NHIS, an annual in-person household survey conducted by the National Center for Health Statistics.27 The NHIS collects information on several variables not included in MEPS that we expected might affect racial/ethnic CRC screening disparities: years of residence in the United States, citizenship status, and birth status (continental United States or elsewhere). Thus, we linked data for these variables in the 2000-2004 NHIS to the MEPS data. The MEPS point-in-time response rates for the 5 panels of public use data that we used were as follows: 2000, 70.5%; 2001, 71.4%; 2002, 69.2%; 2003, 68.9%; 2004, 68.2%; and 2005, 66.5%.

MEASURES
Race, Ethnicity, and Country of Origin

The MEPS respondents self-identify their racial category (white, black, Asian, Hawaiian native or other Pacific Islander, American Indian or Alaskan native, or multiple races) and ethnicity (Hispanic or non-Hispanic). Responses to race and ethnicity questions are crossed to derive combined race/ethnicity categories (eg, non-Hispanic white). The analyses in this article focus on adults 50 years or older classified in the MEPS as non-Hispanic white, Asian, black, or Hispanic.

CRC Screening

The MEPS respondents were asked whether they had ever undergone fecal occult blood testing (FOBT) or “flexible sigmoidoscopy or colonoscopy” (endoscopic screening, a single item) and, if so, the interval (in the past year; 2, 3, or 5 years ago; or >5 years ago). In these analyses, respondents were considered to be up-to-date for screening if they reported FOBT in the previous 2 years (based on randomized controlled trial data28) or endoscopic testing at any time (because there are no evidenced-based intervals for these tests).2

Sociodemographic Factors

The sociodemographic variables examined in the analyses were age (categorized as 50-54, 55-59, 60-64, 65-74, and ≥75 years), sex, rurality (living in a metropolitan statistical area [MSA] or not), household annual income level (<100%, 100%-124%, 125%-199%, 200%-399%, or ≥400% of the federal poverty level), educational attainment (less than high school, some high school, high school graduate, some college, or college graduate), geographic region (Northeast, Midwest, South, or West), and panel year.

Health Care Factors

The access-to-care variables examined were insurance status (private, public, or uninsured) and having a usual source of health care (yes or no). Self-rated health was assessed using a 5-point Likert scale response to the question, “In general, would you say your health was excellent, very good, good, fair, or poor?”

Language and Nativity

Respondents noted whether the language spoken at home was English or another language.

The NHIS respondents indicated whether they were born in the continental United States. Additional analyses explored length of time in the United States and citizenship, but the results are not reported herein because of significant proportions of missing data. Furthermore, analyses of nonmissing cases revealed that citizenship and length of time in the United States made no significant contribution beyond language and nativity.

DATA ANALYSIS

Data were analyzed using Stata version 10.0 (Stata Corp, College Station, Texas), adjusting for the complex survey design of the MEPS. Analyses incorporated the longitudinal strata and primary sampling units and were weighted to yield appropriate standard errors and estimates representative of the US civilian, noninstitutionalized adult population.

We constructed 3 sets of analyses with 4 sequential logistic regression models to determine the relationship between CRC screening and race/ethnicity (non-Hispanic white, Asian, black, and Hispanic) using CRC screening as the dependent variable in all the models. The 3 sets of analyses in each sequential logistic regression model examined up-to-date rates for the 2 studied CRC screening modalities combined (endoscopy and FOBT), for endoscopy alone, and for FOBT alone. The first model in each set (model 1) examined the relationship between CRC screening and race/ethnicity, adjusting only for basic demographics (age, sex, MSA residence, and region of the United States) and survey year. Model 2 adjusted additionally for socioeconomic status (annual income and educational level). Model 3 then included adjustment for access to care (insurance status and availability of a usual source of care) and self-rated health, and model 4 included race/ethnicity–related factors (language spoken at home and nativity). We also examined interactions between racial/ethnic group and the other covariates, but none were statistically significant, and they are not reported herein. Because adjusted odds ratios can be misleading when the prevalence of the outcome is greater than 10%, we also report adjusted percentages of persons screened by ethnic group.29

Complete data were available for 95.3% of 22 973 eligible participants. Incomplete data were more common in minorities, for whom complete response rates varied from 90.3% for blacks to 93.0% for Hispanics (Table 1). The unadjusted combined (FOBT and endoscopy) CRC screening rate was 54.1% and was significantly lower in minorities, especially Asians and Hispanics. The same general pattern was observed for FOBT and endoscopic screening considered separately. Colorectal cancer screening for both studied modalities combined and for endoscopic screening alone increased throughout the study, whereas for FOBT it declined (data not shown). Women were less likely than men to report being screened for CRC by means of FOBT or endoscopy.

Table Graphic Jump LocationTable 1. Distribution of Participant Characteristics by Racial/Ethnic Group

Table 1 provides the distribution of the variables examined by racial/ethnic group. Compared with non-Hispanic whites, Hispanics were less likely to be 75 years or older, had less education, had a lower annual income, had less private insurance, were less likely to have a usual source of care, had poorer self-rated health, were less likely to speak English at home, were less likely to be born in the United States, and were more likely to reside in MSAs. Patterns were similar for other minority groups, with some notable differences: compared with non-Hispanic whites, blacks were as likely to speak English at home and to be born in the continental United States, whereas Asians were less likely to be women and had more persons with less than 9 years and greater than 16 years of education.

Adjusted odds ratios for the logistic regression models are given in Table 2 (both CRC screening modalities combined), Table 3 (endoscopic screening), and Table 4 (FOBT). After adjustment for age, sex, MSA residence, region, and year, compared with non-Hispanic whites, all minorities, and especially Asians and Hispanics, were significantly less likely to report up-to-date CRC screening (model 1 in Tables 2-4). This disparity was more marked for endoscopic screening and was absent for blacks and FOBT. Although the disparity was most marked for Asians in model 1, the difference between Hispanics and Asians was not statistically significant in this model (results not shown).

Table Graphic Jump LocationTable 2. Relationship Between Racial/Ethnic Group and Combined Colorectal Cancer Screening With Progressive Adjustment
Table Graphic Jump LocationTable 3. Relationship Between Racial/Ethnic Group and Endoscopic Colorectal Cancer Screening With Progressive Adjustment
Table Graphic Jump LocationTable 4. Relationship Between Racial/Ethnic Group and FOBT Colorectal Cancer Screening With Progressive Adjustment

With additional socioeconomic adjustment, the disparities in CRC screening were attenuated for Hispanics and blacks (and, for blacks, eliminated for FOBT) relative to non-Hispanic whites, but there was little change in Asian/non-Hispanic white disparities (model 2 in Tables 2-4). The gradient in screening was steepest for educational level, with the most educated group (≥16 years of schooling) having adjusted odds ratios of greater than 2.00 relative to the least educated group (<9 years of schooling).

Adjustment for access and self-rated health further attenuated Hispanic/non-Hispanic white screening disparities but had little effect on Asian/non-Hispanic white disparities (model 3 in Tables 2-4). For FOBT, blacks were more likely to report being up-to-date than were non-Hispanic whites. Apart from their effects on Hispanic/non-Hispanic white disparities, addition of the access and self-rated health variables had little effect on the CRC screening odds ratios for the other minority groups. Those with worse self-rated health, availability of some insurance, and a usual source of care were more likely to report screening.

Finally, with the inclusion of language and nativity, Hispanic/non-Hispanic white disparities were attenuated such that they were no longer statistically significant, whereas Asian/non-Hispanic white disparities were attenuated but remained significant (model 4 in Tables 2-4). Speaking English at home and being born in the continental United States were associated with greater CRC screening. Analyses that included language and nativity separately suggested that language, rather than nativity, was the main driver of the attenuation in disparities in model 4 (data not shown but available on request from the authors).

The Figure illustrates how the odds ratios for race/ethnicity, adjusted for demographics only (model 1) and for demographics, socioeconomic status, access to care, self-rated health, language spoken at home, and nativity (model 4), translate into adjusted proportions of racial/ethnic groups screened. It underscores that Asian/non-Hispanic white CRC screening disparities remained clinically and statistically significant for all 3 study screening outcomes after full adjustment (model 4) (Figure). In contrast, after full adjustment, black/non-Hispanic disparities in CRC screening persisted only for FOBT (favoring blacks) and endoscopy (favoring non-Hispanic whites), whereas Hispanic/non-Hispanic white disparities were eliminated for all 3 screening outcomes.

Place holder to copy figure label and caption
Figure.

Adjusted proportions of participants reporting up-to-date colorectal cancer screening by race/ethnicity, adjusted for age, sex, metropolitan statistical area residence, and region (A) plus educational level, annual income, insurance status, availability of usual source of care, self-rated health, language spoken at home, and nativity (B). FOBT indicates fecal occult blood testing. Error bars represent SD.

Graphic Jump Location

The present analyses overcome some of the limitations of previous studies, including the exclusion of 1 or more large minority groups,812,1725 the use of nonnational samples,2125 and the lack of adjustment for key correlates of cancer screening behavior,4,5,812,18,19,2224 and demonstrate the differing contributions of demographics, socioeconomic factors, access and self-rated health, language, and nativity to CRC screening disparities that affect Asian, black, and Hispanic individuals in the United States.

We verified that statistically significant disparities in CRC screening exist for each of these racial/ethnic minority groups relative to non-Hispanic whites. The initial analyses, adjusted only for basic demographics, revealed that disparities in combined CRC screening (FOBT and endoscopy) are more marked for Hispanic and, especially, Asian individuals than for blacks, relative to non-Hispanic whites. A variety of previous national studies48,10,11,20 have suggested a substantial Hispanic/non-Hispanic white CRC screening disparity, but few studies4,5,22 have explored an Asian/non-Hispanic white disparity. The present findings call attention to a marked Asian/non-Hispanic white CRC screening disparity and suggest that federal public health and research initiatives aimed at increasing screening uptake in Asians should be implemented to complement those targeted to blacks and Hispanics.30

We further found that after sequential adjustment for an array of key correlates of CRC screening behavior—basic demographics, socioeconomic variables, access and self-rated health, and language spoken at home and nativity—black/non-Hispanic white and Hispanic/non-Hispanic white disparities in combined CRC screening were eliminated. Beyond socioeconomic factors, which disproportionately affect minorities, these findings suggest the effect of access and, for Hispanics, language-appropriate care on CRC screening uptake. In contrast, after full adjustment in these models, Asian/non-Hispanic white disparities in combined CRC screening remained statistically significant. Although this study design does not permit firm conclusions regarding the reason for this finding, the implication is that unmeasured cultural factors may contribute to the Asian/non-Hispanic white disparity in CRC screening. Less acculturated Asian individuals in the United States may have core health beliefs and values that differ from those in the “Western” health model, leading them to decline FOBT or endoscopy offered in the absence of worrisome symptoms.31 They may also be less likely to be offered CRC screening. Thus, culturally targeted interventions (focused on physicians and patients) might help address the Asian/non-Hispanic white CRC screening disparity. In contrast, enhancing access to health care might help mitigate black/non-Hispanic white disparities, whereas maximizing access to and linguistically appropriate provision of health care and information might help mitigate Hispanic/non-Hispanic white disparities.

The minority/non-Hispanic white disparities we observed were more pronounced for endoscopy than for FOBT. This finding suggests a current racial/ethnic technology diffusion gap32,33 and the potential for widening minority/non-Hispanic white CRC screening disparities across time because the primary driver of the recent secular increase in CRC screening in the United States has been the greater use of colonoscopy (with a concomitant decline in FOBT screening).1 Increasing access to and insurance coverage of colonoscopy in minority groups could narrow this gap but may be difficult to achieve given that access to colonoscopy is suboptimal even in non-Hispanic whites.34 It may be more feasible to increase uptake of FOBT in minorities, a much less expensive and more accessible test than colonoscopy34 and, to our knowledge, the only screening modality shown in randomized controlled trials to reduce CRC mortality rates.28 Quantitative FOBT holds particular promise for reducing ethnic/minority disparities because the positive cutoff point can be adjusted to match the risk of CRC in the targeted population.35,36

Finally, we found lower CRC screening rates for women than for men across all ethnic/minority groups, screening modalities, and analytic models. Although the reasons for this finding are unclear, specific efforts to engage women of all ethnicities and races in CRC screening seem to be justified.

This study has some limitations. First, FOBT and endoscopy are self-reported by MEPS respondents. Previous research37,38 suggests the potential for overreporting of screening by minorities, probably because of a social desirability effect. This may have contributed to the apparent black/non-Hispanic white FOBT disparity favoring blacks. To the degree that such overreporting of CRC screening may have occurred in minorities in this sample, these findings may underestimate minority/non-Hispanic white disparities in screening. It is also not possible to distinguish in the MEPS whether self-reported colonoscopy was for screening or diagnosis. Thus, the apparent minority/non-Hispanic white technology diffusion gap we observed could be because of less access to screening endoscopy for minorities, less access to follow-up endoscopy (eg, after abnormal FOBT results), or a combination. Regardless, such a technology diffusion gap may contribute, along with the overall CRC screening disparities presented herein, to the increased CRC incidence13,14 and mortality13,14 rates for minorities relative to non-Hispanic whites that are observed in some studies.

An additional limitation is that the MEPS data set we used in these analyses includes only a simple dichotomized language variable (English or another language spoken at home). Yet, many US Hispanic and Asian adults are fluently bilingual and might speak English and another language, depending on the context. For example, some Hispanic individuals may regularly speak Spanish when conversing with parents or spouses but may speak English with their children. Because the MEPS and the NHIS do not include questions to ascertain multilingualism, whether and how it might affect these findings are unknown. However, we did find that the dichotomous language variable is significantly associated with CRC screening. Finally, we used 3 large, composite, racial/ethnic groupings in the analyses to allow adequate power to explore minority/non-Hispanic white disparities in CRC screening. However, each of the categories encompasses various national origin and immigration cohorts, among whom significant differences in CRC screening may exist.23,39

In conclusion, disparities in CRC screening exist for each of the 3 largest racial/ethnic minority groups (Asians, blacks, and Hispanics) relative to non-Hispanic whites in the United States. The disparities seem to be most marked for Asians, a group that has previously attracted little investigation. Furthermore, the underlying determinants of racial/ethnic disparities in CRC screening seem to differ in each minority group, in turn implying the need for different strategies to mitigate the CRC screening disparities. Finally, there is evidence that current racial/ethnic CRC screening disparities are larger for endoscopic screening than for FOBT, suggesting a technology diffusion gap that could contribute to widening disparities across time,32,33 and for women relative to men. Each of these findings begins to provide needed direction to those seeking to develop and implement interventions to eliminate racial/ethnic CRC screening disparities in the United States.

Correspondence: Anthony F. Jerant, MD, Department of Family and Community Medicine, University of California Davis School of Medicine, 4860 Y St, Ste 2300, Sacramento, CA 95817 (afjerant@ucdavis.edu).

Accepted for Publication: January 13, 2008.

Author Contributions: Dr Jerant had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analyses. Study concept and design: Jerant, Fenton, and Franks. Acquisition of data: Franks. Analysis and interpretation of data: Jerant, Fenton, and Franks. Drafting of the manuscript: Jerant and Franks. Critical revision of the manuscript for important intellectual content: Jerant, Fenton, and Franks. Statistical analysis: Franks. Administrative, technical, and material support: Franks. Study supervision: Jerant and Franks.

Financial Disclosure: None reported.

Centers for Disease Control and Prevention (CDC), Increased use of colorectal cancer tests: United States, 2002 and 2004. MMWR Morb Mortal Wkly Rep 2006;55 (11) 308- 311
PubMed
US Preventive Services Task Force, Screening for colorectal cancer: recommendations and rationale. Ann Intern Med 2002;137 (2) 129- 131
PubMed
Cooper  GSKoroukian  SM Racial disparities in the use of and indications for colorectal procedures in Medicare beneficiaries. Cancer 2004;100 (2) 418- 424
PubMed
Goel  MSWee  CCMcCarthy  EPDavis  RBNgo-Metzger  QPhillips  RS Racial and ethnic disparities in cancer screening: the importance of foreign birth as a barrier to care. J Gen Intern Med 2003;18 (12) 1028- 1035
PubMed
Ioannou  GNChapko  MKDominitz  JA Predictors of colorectal cancer screening participation in the United States. Am J Gastroenterol 2003;98 (9) 2082- 2091
PubMed
Meissner  HIBreen  NKlabunde  CNVernon  SW Patterns of colorectal cancer screening uptake among men and women in the United States. Cancer Epidemiol Biomarkers Prev 2006;15 (2) 389- 394
PubMed
James  TMGreiner  KAEllerbeck  EFFeng  CAhluwalia  JS Disparities in colorectal cancer screening: a guideline-based analysis of adherence. Ethn Dis 2006;16 (1) 228- 233
PubMed
Pollack  LABlackman  DKWilson  KMSeeff  LCNadel  MR Colorectal cancer test use among Hispanic and non-Hispanic US populations. Prev Chronic Dis 2006;3 (2) A50http://www.cdc.gov/pcd/issues/2006/apr/05_0120.htm. Accessed October 9, 2007
PubMed
O'Malley  ASForrest  CBFeng  SMandelblatt  J Disparities despite coverage: gaps in colorectal cancer screening among Medicare beneficiaries. Arch Intern Med 2005;165 (18) 2129- 2135
PubMed
Seeff  LCNadel  MRKlabunde  CN  et al.  Patterns and predictors of colorectal cancer test use in the adult U.S. population. Cancer 2004;100 (10) 2093- 2103
PubMed
Wee  CCMcCarthy  EPPhillips  RS Factors associated with colon cancer screening: the role of patient factors and physician counseling. Prev Med 2005;41 (1) 23- 29
PubMed
Ananthakrishnan  ANSchellhase  KGSparapani  RALaud  PWNeuner  JM Disparities in colon cancer screening in the Medicare population. Arch Intern Med 2007;167 (3) 258- 264
PubMed
Cress  RDMorris  CEllison  GLGoodman  MT Secular changes in colorectal cancer incidence by subsite, stage at diagnosis, and race/ethnicity, 1992-2001. Cancer 2006;107 (5) ((suppl)) 1142- 1152
PubMed
Irby  KAnderson  WFHenson  DEDevesa  SS Emerging and widening colorectal carcinoma disparities between Blacks and Whites in the United States (1975-2002). Cancer Epidemiol Biomarkers Prev 2006;15 (4) 792- 797
PubMed
Chien  CMorimoto  LMTom  JLi  CI Differences in colorectal carcinoma stage and survival by race and ethnicity. Cancer 2005;104 (3) 629- 639
PubMed
Ries  LAWingo  PAMiller  DS  et al.  The annual report to the nation on the status of cancer, 1973-1997, with a special section on colorectal cancer. Cancer 2000;88 (10) 2398- 2424
PubMed
Coughlin  SSBerkowitz  ZHawkins  NATangka  F Breast and colorectal cancer screening and sources of cancer information among older women in the United States: results from the 2003 Health Information National Trends Survey. Prev Chronic Dis 2007;4 (3) A57http://www.cdc.gov/pcd/issues/2007/jul/06_0104.htm. Accessed October 9, 2007
PubMed
Rao  RSGraubard  BIBreen  NGastwirth  JL Understanding the factors underlying disparities in cancer screening rates using the Peters-Belson approach: results from the 1998 National Health Interview Survey. Med Care 2004;42 (8) 789- 800
PubMed
Shih  YCZhao  LElting  LS Does Medicare coverage of colonoscopy reduce racial/ethnic disparities in cancer screening among the elderly? Health Aff (Millwood) 2006;25 (4) 1153- 1162
PubMed
Shah  MZhu  KPotter  J Hispanic acculturation and utilization of colorectal cancer screening in the United States. Cancer Detect Prev 2006;30 (3) 306- 312
PubMed
Thompson  BCoronado  GNeuhouser  MChen  L Colorectal carcinoma screening among Hispanics and non-Hispanic whites in a rural setting. Cancer 2005;103 (12) 2491- 2498
PubMed
Wong  STGildengorin  GNguyen  TMock  J Disparities in colorectal cancer screening rates among Asian Americans and non-Latino whites. Cancer 2005;104 (12) ((suppl)) 2940- 2947
PubMed
Kandula  NRWen  MJacobs  EALauderdale  DS Low rates of colorectal, cervical, and breast cancer screening in Asian Americans compared with non-Hispanic whites: cultural influences or access to care? Cancer 2006;107 (1) 184- 192
PubMed
Yepes-Rios  MReimann  JOTalavera  ACRuiz de Esparza  ATalavera  GA Colorectal cancer screening among Mexican Americans at a community clinic. Am J Prev Med 2006;30 (3) 204- 210
PubMed
Greiner  KABorn  WNollen  NAhluwalia  JS Knowledge and perceptions of colorectal cancer screening among urban African Americans. J Gen Intern Med 2005;20 (11) 977- 983
PubMed
Agency for Healthcare Research and Quality, Medical Expenditure Panel Survey. http://www.meps.ahrq.gov/mepsweb/about_meps/survey_back.jsp. Accessed August 18, 2007
National Center for Health Statistics, National Health Interview Survey (NHIS). http://www.cdc.gov/nchs/nhis.htm. Accessed August 18, 2007
Mandel  JSBond  JHChurch  TR  et al.  Reducing mortality from colorectal cancer by screening for fecal occult blood. N Engl J Med 1993;328 (19) 1365- 1371
PubMed
Graubard  BIKorn  EL Predictive margins with survey data. Biometrics 1999;55 (2) 652- 659
PubMed
Coughlin  SSCostanza  MEFernandez  ME  et al.  CDC-funded intervention research aimed at promoting colorectal cancer screening in communities. Cancer 2006;107 (5) ((suppl)) 1196- 1204
PubMed
Choe  JHTu  SPLim  JMBurke  NJAcorda  ETaylor  VM “Heat in their intestine”: colorectal cancer prevention beliefs among older Chinese Americans. Ethn Dis 2006;16 (1) 248- 254
PubMed
Victora  CGVaughan  JPBarros  FCSilva  ACTomasi  E Explaining trends in inequities: evidence from Brazilian child health studies. Lancet 2000;356 (9235) 1093- 1098
PubMed
Goldman  DPLakdawalla  DN A theory of health disparities and medical technology: contributions to economic analysis and policy. http://www.bepress.com/bejeap/contributions/vol4/iss1/art8. Accessed October 9, 2007
Fisher  JAFikry  CTroxel  AB Cutting cost and increasing access to colorectal cancer screening: another approach to following the guidelines. Cancer Epidemiol Biomarkers Prev 2006;15 (1) 108- 113
PubMed
Imperiale  TF Quantitative immunochemical fecal occult blood tests: is it time to go back to the future? Ann Intern Med 2007;146 (4) 309- 311
PubMed
Levi  ZRozen  PHazazi  R  et al.  A quantitative immunochemical fecal occult blood test for colorectal neoplasia. Ann Intern Med 2007;146 (4) 244- 255
PubMed
Fiscella  KHolt  KMeldrum  SFranks  P Disparities in preventive procedures: comparisons of self-report and Medicare claims data. BMC Health Serv Res 2006;6122
PubMed
Holt  KFranks  PMeldrum  SFiscella  K Mammography self-report and mammography claims: racial, ethnic, and socioeconomic discrepancies among elderly women. Med Care 2006;44 (6) 513- 518
PubMed
Gorin  SSHeck  JE Cancer screening among Latino subgroups in the United States. Prev Med 2005;40 (5) 515- 526
PubMed

Figures

Place holder to copy figure label and caption
Figure.

Adjusted proportions of participants reporting up-to-date colorectal cancer screening by race/ethnicity, adjusted for age, sex, metropolitan statistical area residence, and region (A) plus educational level, annual income, insurance status, availability of usual source of care, self-rated health, language spoken at home, and nativity (B). FOBT indicates fecal occult blood testing. Error bars represent SD.

Graphic Jump Location

Tables

Table Graphic Jump LocationTable 1. Distribution of Participant Characteristics by Racial/Ethnic Group
Table Graphic Jump LocationTable 2. Relationship Between Racial/Ethnic Group and Combined Colorectal Cancer Screening With Progressive Adjustment
Table Graphic Jump LocationTable 3. Relationship Between Racial/Ethnic Group and Endoscopic Colorectal Cancer Screening With Progressive Adjustment
Table Graphic Jump LocationTable 4. Relationship Between Racial/Ethnic Group and FOBT Colorectal Cancer Screening With Progressive Adjustment

References

Centers for Disease Control and Prevention (CDC), Increased use of colorectal cancer tests: United States, 2002 and 2004. MMWR Morb Mortal Wkly Rep 2006;55 (11) 308- 311
PubMed
US Preventive Services Task Force, Screening for colorectal cancer: recommendations and rationale. Ann Intern Med 2002;137 (2) 129- 131
PubMed
Cooper  GSKoroukian  SM Racial disparities in the use of and indications for colorectal procedures in Medicare beneficiaries. Cancer 2004;100 (2) 418- 424
PubMed
Goel  MSWee  CCMcCarthy  EPDavis  RBNgo-Metzger  QPhillips  RS Racial and ethnic disparities in cancer screening: the importance of foreign birth as a barrier to care. J Gen Intern Med 2003;18 (12) 1028- 1035
PubMed
Ioannou  GNChapko  MKDominitz  JA Predictors of colorectal cancer screening participation in the United States. Am J Gastroenterol 2003;98 (9) 2082- 2091
PubMed
Meissner  HIBreen  NKlabunde  CNVernon  SW Patterns of colorectal cancer screening uptake among men and women in the United States. Cancer Epidemiol Biomarkers Prev 2006;15 (2) 389- 394
PubMed
James  TMGreiner  KAEllerbeck  EFFeng  CAhluwalia  JS Disparities in colorectal cancer screening: a guideline-based analysis of adherence. Ethn Dis 2006;16 (1) 228- 233
PubMed
Pollack  LABlackman  DKWilson  KMSeeff  LCNadel  MR Colorectal cancer test use among Hispanic and non-Hispanic US populations. Prev Chronic Dis 2006;3 (2) A50http://www.cdc.gov/pcd/issues/2006/apr/05_0120.htm. Accessed October 9, 2007
PubMed
O'Malley  ASForrest  CBFeng  SMandelblatt  J Disparities despite coverage: gaps in colorectal cancer screening among Medicare beneficiaries. Arch Intern Med 2005;165 (18) 2129- 2135
PubMed
Seeff  LCNadel  MRKlabunde  CN  et al.  Patterns and predictors of colorectal cancer test use in the adult U.S. population. Cancer 2004;100 (10) 2093- 2103
PubMed
Wee  CCMcCarthy  EPPhillips  RS Factors associated with colon cancer screening: the role of patient factors and physician counseling. Prev Med 2005;41 (1) 23- 29
PubMed
Ananthakrishnan  ANSchellhase  KGSparapani  RALaud  PWNeuner  JM Disparities in colon cancer screening in the Medicare population. Arch Intern Med 2007;167 (3) 258- 264
PubMed
Cress  RDMorris  CEllison  GLGoodman  MT Secular changes in colorectal cancer incidence by subsite, stage at diagnosis, and race/ethnicity, 1992-2001. Cancer 2006;107 (5) ((suppl)) 1142- 1152
PubMed
Irby  KAnderson  WFHenson  DEDevesa  SS Emerging and widening colorectal carcinoma disparities between Blacks and Whites in the United States (1975-2002). Cancer Epidemiol Biomarkers Prev 2006;15 (4) 792- 797
PubMed
Chien  CMorimoto  LMTom  JLi  CI Differences in colorectal carcinoma stage and survival by race and ethnicity. Cancer 2005;104 (3) 629- 639
PubMed
Ries  LAWingo  PAMiller  DS  et al.  The annual report to the nation on the status of cancer, 1973-1997, with a special section on colorectal cancer. Cancer 2000;88 (10) 2398- 2424
PubMed
Coughlin  SSBerkowitz  ZHawkins  NATangka  F Breast and colorectal cancer screening and sources of cancer information among older women in the United States: results from the 2003 Health Information National Trends Survey. Prev Chronic Dis 2007;4 (3) A57http://www.cdc.gov/pcd/issues/2007/jul/06_0104.htm. Accessed October 9, 2007
PubMed
Rao  RSGraubard  BIBreen  NGastwirth  JL Understanding the factors underlying disparities in cancer screening rates using the Peters-Belson approach: results from the 1998 National Health Interview Survey. Med Care 2004;42 (8) 789- 800
PubMed
Shih  YCZhao  LElting  LS Does Medicare coverage of colonoscopy reduce racial/ethnic disparities in cancer screening among the elderly? Health Aff (Millwood) 2006;25 (4) 1153- 1162
PubMed
Shah  MZhu  KPotter  J Hispanic acculturation and utilization of colorectal cancer screening in the United States. Cancer Detect Prev 2006;30 (3) 306- 312
PubMed
Thompson  BCoronado  GNeuhouser  MChen  L Colorectal carcinoma screening among Hispanics and non-Hispanic whites in a rural setting. Cancer 2005;103 (12) 2491- 2498
PubMed
Wong  STGildengorin  GNguyen  TMock  J Disparities in colorectal cancer screening rates among Asian Americans and non-Latino whites. Cancer 2005;104 (12) ((suppl)) 2940- 2947
PubMed
Kandula  NRWen  MJacobs  EALauderdale  DS Low rates of colorectal, cervical, and breast cancer screening in Asian Americans compared with non-Hispanic whites: cultural influences or access to care? Cancer 2006;107 (1) 184- 192
PubMed
Yepes-Rios  MReimann  JOTalavera  ACRuiz de Esparza  ATalavera  GA Colorectal cancer screening among Mexican Americans at a community clinic. Am J Prev Med 2006;30 (3) 204- 210
PubMed
Greiner  KABorn  WNollen  NAhluwalia  JS Knowledge and perceptions of colorectal cancer screening among urban African Americans. J Gen Intern Med 2005;20 (11) 977- 983
PubMed
Agency for Healthcare Research and Quality, Medical Expenditure Panel Survey. http://www.meps.ahrq.gov/mepsweb/about_meps/survey_back.jsp. Accessed August 18, 2007
National Center for Health Statistics, National Health Interview Survey (NHIS). http://www.cdc.gov/nchs/nhis.htm. Accessed August 18, 2007
Mandel  JSBond  JHChurch  TR  et al.  Reducing mortality from colorectal cancer by screening for fecal occult blood. N Engl J Med 1993;328 (19) 1365- 1371
PubMed
Graubard  BIKorn  EL Predictive margins with survey data. Biometrics 1999;55 (2) 652- 659
PubMed
Coughlin  SSCostanza  MEFernandez  ME  et al.  CDC-funded intervention research aimed at promoting colorectal cancer screening in communities. Cancer 2006;107 (5) ((suppl)) 1196- 1204
PubMed
Choe  JHTu  SPLim  JMBurke  NJAcorda  ETaylor  VM “Heat in their intestine”: colorectal cancer prevention beliefs among older Chinese Americans. Ethn Dis 2006;16 (1) 248- 254
PubMed
Victora  CGVaughan  JPBarros  FCSilva  ACTomasi  E Explaining trends in inequities: evidence from Brazilian child health studies. Lancet 2000;356 (9235) 1093- 1098
PubMed
Goldman  DPLakdawalla  DN A theory of health disparities and medical technology: contributions to economic analysis and policy. http://www.bepress.com/bejeap/contributions/vol4/iss1/art8. Accessed October 9, 2007
Fisher  JAFikry  CTroxel  AB Cutting cost and increasing access to colorectal cancer screening: another approach to following the guidelines. Cancer Epidemiol Biomarkers Prev 2006;15 (1) 108- 113
PubMed
Imperiale  TF Quantitative immunochemical fecal occult blood tests: is it time to go back to the future? Ann Intern Med 2007;146 (4) 309- 311
PubMed
Levi  ZRozen  PHazazi  R  et al.  A quantitative immunochemical fecal occult blood test for colorectal neoplasia. Ann Intern Med 2007;146 (4) 244- 255
PubMed
Fiscella  KHolt  KMeldrum  SFranks  P Disparities in preventive procedures: comparisons of self-report and Medicare claims data. BMC Health Serv Res 2006;6122
PubMed
Holt  KFranks  PMeldrum  SFiscella  K Mammography self-report and mammography claims: racial, ethnic, and socioeconomic discrepancies among elderly women. Med Care 2006;44 (6) 513- 518
PubMed
Gorin  SSHeck  JE Cancer screening among Latino subgroups in the United States. Prev Med 2005;40 (5) 515- 526
PubMed

Correspondence

CME
Meets CME requirements for:
Browse CME for all U.S. States
Accreditation Information
The American Medical Association is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians. The AMA designates this journal-based CME activity for a maximum of 1 AMA PRA Category 1 CreditTM per course. Physicians should claim only the credit commensurate with the extent of their participation in the activity. Physicians who complete the CME course and score at least 80% correct on the quiz are eligible for AMA PRA Category 1 CreditTM.
Note: You must get at least of the answers correct to pass this quiz.
You have not filled in all the answers to complete this quiz
The following questions were not answered:
Sorry, you have unsuccessfully completed this CME quiz with a score of
The following questions were not answered correctly:
Commitment to Change (optional):
Indicate what change(s) you will implement in your practice, if any, based on this CME course.
Your quiz results:
The filled radio buttons indicate your responses. The preferred responses are highlighted
For CME Course: A Proposed Model for Initial Assessment and Management of Acute Heart Failure Syndromes
Indicate what changes(s) you will implement in your practice, if any, based on this CME course.
NOTE:
Citing articles are presented as examples only. In non-demo SCM6 implementation, integration with CrossRef’s "Cited By" API will populate this tab (http://www.crossref.org/citedby.html).
Submit a Comment

Multimedia

Some tools below are only available to our subscribers or users with an online account.

Web of Science® Times Cited: 64

Related Content

Customize your page view by dragging & repositioning the boxes below.

Articles Related By Topic
Related Topics
PubMed Articles
JAMAevidence.com

Users' Guides to the Medical Literature
Clinical Resolution

Users' Guides to the Medical Literature
Clinical Scenario