Increased Use of Colorectal Cancer Tests --- United States, 2002 and 2004

Colorectal cancer is the second leading cause of cancer-related death (after lung/bronchus cancer) in the United States (1). In 2002, a total of 139,534 adults in the United States had colorectal cancer diagnosed, and 56,603 died* (1). The U.S. Preventive Services Task Force and other national organizations recommend that adults aged >50 years be screened for colorectal cancer with one or more of the following tests: fecal occult blood testing (FOBT) every year, sigmoidoscopy or double-contrast barium enema every 5 years, or colonoscopy every 10 years (2--4). To estimate current rates of use of colorectal cancer screening tests and to evaluate changes in test use, CDC compared data from the 2002 and 2004 Behavioral Risk Factor Surveillance System (BRFSS) surveys (5). This report describes the results of that comparison, which indicated that the proportion of BRFSS respondents reporting use of FOBT and/or sigmoidoscopy or colonoscopy had increased overall from 2002 to 2004. Measures to increase awareness and encourage regular colorectal cancer screening must be continued to reduce mortality from colorectal cancer.

In 2004, a total of 49 states^† and the District of Columbia (DC) participated in BRFSS, a state-based, random-digit--dialed telephone survey of the noninstitutionalized, U.S. civilian population aged >18 years. Interviewers asked 146,794 participants aged >50 years whether they had ever had a blood stool test using a home test kit (i.e., FOBT), whether they had ever had a sigmoidoscopy or colonoscopy, and when the latest test had been performed. Respondents who refused to answer a question or did not know the answer to a question (approximately 3% overall) were excluded from analysis of the specific question. Aggregated percentages and 95% confidence intervals were calculated.

Results from the 2004 BRFSS survey were compared with results from 2002. Data were weighted to the sex, racial/ethnic, and age distribution of each state's adult population using intercensal estimates and were age-standardized to the 2000 U.S. standard population. The median state CASRO response rate for the entire survey was 52.7% (range: 32.2% in New Jersey to 66.6% in Nebraska). Survey questions and response options were identical for the two surveys. In both 2002 and 2004, respondents were asked if they had ever used a "special kit at home to determine whether the stool contains blood (FOBT)," whether they had ever had "a tube inserted into the rectum to view the colon for signs of cancer or other health problems (sigmoidoscopy or colonoscopy)," and when these tests were last performed. For this report, sigmoidoscopy and colonoscopy are described as "lower endoscopy." Percentages were estimated for persons aged >50 years who reported receiving an FOBT within 1 year preceding the survey and/or lower endoscopy within 10 years preceding the survey. Because BRFSS does not differentiate between sigmoidoscopy and colonoscopy, the surveillance period used was 10 years, the recommended interval for colonoscopy.

In 2004, 57.3% of adults aged >50 years reported having had an FOBT within 1 year preceding the survey and/or a lower endoscopy within 10 years preceding the survey (Table), compared with 54.4 % in 2002 (5). The proportion of persons aged >50 years who had received FOBT within 1 year preceding the survey declined to 18.7% in 2004 from 21.8% in 2002; however, the proportion who reported receiving lower endoscopy within the 10 years preceding the survey increased to 50.6% in 2004 from 45.2% in 2002.

By state, the proportion of respondents who reported having had an FOBT within 1 year preceding the survey and/or lower endoscopy within 10 years preceding the survey ranged from 47.9% in Mississippi to 68.2% in Minnesota (Table). Among states/areas that participated in both surveys, 14 states and DC determined that >60% of persons reported having had an FOBT within 1 year preceding the survey and/or a lower endoscopy within the 10 years preceding the survey, compared with seven states and DC in 2002 (Figure).

Reported by: LC Seeff, MD, J King, MPH, LA Pollack, MD, KN Williams, MA, Div of Cancer Prevention and Control, National Center for Chronic Disease Prevention and Health Promotion, CDC.

Editorial Note:

The findings in this report indicate that the number of states/areas where >60% of the population have been screened for colorectal cancer nearly doubled, from eight in 2002 to 15 in 2004. Although this increase in reported use of colorectal cancer tests is encouraging, use of tests for colorectal cancer continues to lag behind use of mammography and Papanicolau smear tests for breast cancer and cervical cancer, respectively (6). In 2002, the rate of death from colorectal cancer in the United States was 19.6 per 100,000 persons (1). Healthy People 2010 objective 3-5 calls for reducing the colorectal cancer death rate from a baseline of 21.2 per 100,000 in 1998 to 13.9 in 2010. To achieve this national health objective, further gains in colorectal cancer screening will be required.

The increases in screening in 2004 likely can be attributed to greater public awareness of its importance, resulting from activities by the medical and public health communities, including encouragement of regular screening, extensive research into screening§ (7), colorectal cancer awareness campaigns, Medicare adoption (since 2001) of coverage for all recommended colorectal cancer screening tests, adoption (in 2004) of a Health Plan Employer Data and Information Set (HEDIS) measure to encourage health plans to cover colorectal cancer screening tests (8), and establishment of screening programs in certain states (9,10).

The findings in this report are subject to at least four limitations. First, the results might overestimate actual colorectal cancer screening rates because 1) BRFSS does not determine the indication for the test (i.e., screening versus diagnostic use), and 2) assessment of use of lower endoscopy within 10 years included persons who had a sigmoidoscopy more than 5 years preceding the survey and, therefore, were not compliant with screening recommendations. Second, because the survey is administered by telephone, only persons with land-line telephones are represented in the analysis. Third, responses are self reports and not validated by medical record review. Finally, the survey response rate was low (52.7%).

To increase colorectal cancer screening, in August 2005, CDC awarded cooperative agreements to five sites¶ to establish colorectal cancer screening demonstration programs for low-income U.S. men and women aged >50 years who have inadequate or no health insurance coverage for colorectal cancer screening. Screening services in these programs are expected to begin by early April 2006. CDC also provides funding to 21 state programs to implement specific colorectal cancer prevention strategies through National Comprehensive Cancer Control Program (NCCCP) initiatives.** In addition, CDC recently funded the Cancer Research and Prevention Foundation to assist 14 states in the delivery of a 1-day colorectal cancer Dialogue for Action conference.†† These conferences are designed to encourage attendees to work with providers, health-care systems, and the public to address barriers to colorectal cancer screening in their states. CDC continues the Screen for Life: National Colorectal Cancer Action Campaign to promote colorectal cancer screening among all persons aged >50 years and encourage them to discuss screening options with their health-care providers.§§

An estimated 50%–60% of colorectal cancer deaths might be prevented if all persons aged >50 years were screened routinely (7); however, colorectal cancer screening test use has been slow to increase. Coordinated activities by CDC, state and local health departments, and the medical community to raise awareness about the burden of this disease, address barriers to screening, and promote use of screening tests should be sustained to reduce deaths from colorectal cancer.

Acknowledgment

This report is based, in part, on data contributed by state BRFSS coordinators.

References

1. US Cancer Statistics Working Group. United States cancer statistics: 1999--2002 incidence and mortality. Atlanta, GA: US Department of Health and Human Services, CDC, National Cancer Institute; 2005. Available at http://www.cdc.gov/cancer/npcr/uscs/index.htm.
2. US Preventive Services Task Force. Screening for colorectal cancer: recommendations and rationale. Rockville, MD: Agency for Healthcare Research and Quality; 2002. Available at http://www.ahrq.gov/clinic/3rduspstf/colorectal/colorr.htm.
3. Winawer S, Fletcher R, Rex D, et al. Colorectal cancer screening and surveillance: clinical guidelines and rationale. Update based on new evidence. Gastroenterology 2003;124:544--60.
4. Smith RA, von Eschenbach AC, Wender R, et al. American Cancer Society guidelines for the early detection of cancer: update of early detection guidelines for prostate, colorectal, and endometrial cancers. CA Cancer J Clin 2001;51:38--75.
5. CDC. Colorectal cancer test use among persons aged >50 years---United States, 2001. MMWR 2003;52:193--6.
6. Shenson D, Bolen J, Adams M, Seeff L, Blackman D. Are older adults up to date with cancer screening and vaccinations? Prev Chronic Dis 2005;2:A04.
7. Pignone M, Rich M, Teutsch SM, et al. Screening for colorectal cancer in adults at average risk: a summary of the evidence for the U.S. Preventive Services Task Force. Ann Intern Med 2002;137:132--41.
8. National Committee on Quality Assurance. The state of health care quality 2004. New measure: colorectal cancer screening. Washington, DC: National Committee on Quality Assurance; 2004. Available at http://www.ncqa.org/communications/sohc2004/colorectal_cancer.htm.
9. New York State Department of Health. Info for consumers: New York state cancer services. Albany, NY: New York State Department of Health; 2006. Available at http://www.health.state.ny.us/nysdoh/cancer/center/cancer_services.htm.
10. Palitz AM, Selby JV, Grossman S, et al. The Colon Cancer Prevention Program (CoCaP): rationale, implementation, and preliminary results. HMO Pract 1997;11:5--12.

* Includes incidence data for approximately 93% of the U.S. population and mortality data for the entire country.

^† BRFSS data for Hawaii were not available for 2004.

^§ Information available at http://www.cdc.gov/cancer/publications/publica-scientif-05.htm#colorectal and http://www.thecommunityguide.org/cancer/screening/default.htm.

^¶ The Research Foundation of SUNY at Stony Brook, New York (county-based: Suffolk County); Nebraska Department of Health and Human Services (statewide); Missouri Department of Health and Senior Services (city-based: St. Louis), Maryland Department of Health and Mental Hygiene (city-based: Baltimore); Seattle and King County, Washington (county-based: King, Clallam, and Jefferson counties).

** Available at http://www.cdc.gov/cancer/ncccp/index.htm.

^§§ Available at http://www.cdc.gov/colorectalcancer/what_cdc_is_doing/sfl.htm.

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Date last reviewed: 3/23/2006