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JOURNAL OF WOMEN’S HEALTHVolume 16, Number 4, 2007© Mary Ann Liebert, Inc.DOI: 10.1089/jwh.2006.0108
Breast, Colorectal, and Skin Cancer Screening Practicesand Family History of Cancer in U.S. Women
MONA SHAH, M.P.H.,1 KANGMIN ZHU, M.D., Ph.D.,1RICHARD C. PALMER, Dr.P.H., M.P.H.,2 ISMAIL JATOI, M.D., Ph.D.,3
CRAIG SHRIVER, M.D.,4 and HONGYU WU, M.D.1
ABSTRACT
Background: Several national medical organizations recommend more intensive screening orscreening at an earlier age for individuals with a family history of breast, colorectal, or skincancer. This study examined whether women with a family history of cancer were more likelyto use breast, colorectal, or skin cancer screenings compared with those without such a fam-ily history.
Methods: The data for this study came from female respondents who participated in the2000 National Health Interview Survey. The age range of the study subjects and the defini-tions of cancer screening were determined based on the American Cancer Society recom-mendations on cancer screening.
Results: When compared with women without a family history of breast cancer, women witha family history were more likely to undergo a screening mammogram. Women who had a fam-ily history of colorectal cancer were twice as likely to use colorectal cancer screening than wo-men without a family history of colorectal cancer. The association of family history with col-orectal and breast cancer screening was stronger among the younger age group for which ascreening test is recommended if one has such a family history. The association between skincancer screening and family history of skin cancer was significant only in younger women.
Conclusions: Women with a family history of cancer were more likely to have colorectal,breast, and skin cancer screening examinations. This may be a result of more physicians’ rec-ommendations and higher personal motivation for getting cancer screening, suggesting thatthe efficacy of national guidelines has been increasing somewhat.
INTRODUCTION
IT IS ESTIMATED THAT 1 IN 4 DEATHS is due to can-cer, with the risk even greater among individ-
uals with a family history of cancer.1 There is
evidence that a history of colorectal cancer in afirst-degree relative (a parent or sibling) elevatesa person’s lifetime risk,2 and women with a family history of breast cancer are also at in-creased risk of the disease.3 Similarly, several
1United States Military Cancer Institute, Walter Reed Army Medical Center, Washington, DC.2Department of Preventive Medicine & Biometrics, Uniformed Services University, Bethesda, Maryland.3Department of Surgery, National Naval Medical Center, Bethesda, Maryland.4Clinical Breast Care Project, Department of Surgery, Walter Reed Army Medical Center, Washington, DC.The opinions and assertions contained in this paper represent the private views of the authors and should not be
construed as reflecting the official views of the U.S. Departments of the Army, Navy, or Defense or the U.S. Gov-ernment.
studies have shown that individuals with a fam-ily history of malignant melanoma have a higheroccurrence of the disease.4–6 Therefore, cancerscreening and early detection may be more im-portant for individuals who have a family historyof cancer.
Consequently, increased screening or earlierscreening of people with a family history of can-cer has been recommended by several nationalmedical organizations.1,7 The American CancerSociety (ACS) advises that for certain cancers,screening should begin at an earlier age for wo-men at increased risk, which includes those witha first-degree relative with cancer. The ACS rec-ommends that breast and colorectal cancerscreening begin 10 years earlier for women at in-creased risk for those cancers than for the generalpopulation.8 For skin cancer, the United StatesPreventive Services Task Force recommends thatpatients at high risk, such as those with familialmelanoma syndrome or those who have a first-degree relative with melanoma, be referred to adermatologist for monitoring and screening ex-aminations.7,9 For patients with a family historyof melanoma, the ACS recommends that regulartotal skin examination should be considered.9
Studies have found a greater likelihood of can-cer screening and stronger intentions for futurescreening among people with a positive familyhistory.10–14 This suggests that people with a fam-ily history of cancer are more aware of the rec-ommended guidelines and have better knowl-edge and more motivation to be screened.However, to the best of our knowledge, therehave been few large population-based studiesthat have examined whether women with a fam-ily history of cancer are more likely to be screenedfor breast, skin, and colorectal cancers early. Forthis study, we used the 2000 National Health In-terview Survey (NHIS) to assess whether there isa difference in breast, colorectal, and skin screen-ing behaviors among women with and without afamily history of cancer.
MATERIALS AND METHODS
Study subjects
The data for this study came from the NHISconducted by the Centers for Disease Control andPrevention’s (CDC) National Center for HealthStatistics (NCHS). The NHIS is one of the princi-
pal sources of health information for the civiliannoninstitutionalized population of the UnitedStates. It is a cross-sectional household interviewsurvey. The sampling plan follows a multistagearea probability design that permits the repre-sentative sampling of households. Black and Hispanic/Latino populations are oversampled toincrease the precision of estimates for those sub-groups. This study used data collected in 2000, inwhich a Cancer Control supplement was admin-istered to an adult sample that was randomly se-lected from adults living in the households par-ticipating in the NHIS.15
The Cancer Control module collected informa-tion on breast, colorectal, and skin screenings. Forthis study, we selected study subjects within theage ranges recommended for screening by theACS. For the general population, recommendedages were �50 years for colorectal cancer screen-ing and �40 years for breast and skin screening.For this analysis, we used an upper limit of 79years, as recall data might be less accurate forolder women and the effectiveness of cancerscreening tests has not been well established forwomen over the age of 80.16–18 For a secondanalysis, we included women aged 40–49 for col-orectal cancer screening and aged 30–39 for breastand skin cancer screening to assess whether thefamily history/cancer screening association wasstronger among younger women who might berecommended for a screening test only if theyhave a family history of cancer. Even though theACS has not recommended an earlier screeningage for those who have a family history of skincancer, we included women who were a decadeyounger (aged 30–39) than the recommendedACS screening population for skin cancer to re-main consistent with colorectal and breast cancerscreening.
Data collection
The Cancer Control module contained sectionscovering cancer screening, genetic testing, andfamily history. Data for colorectal, breast, andskin screenings were examined for each of thethree screening tests. Respondents were asked, insequence, about ever having any of these testsperformed, when the test was performed, and ifappropriate, the reason for testing. If the test wasundertaken to evaluate a clinical abnormality oras a follow-up of an earlier examination, it wasconsidered a diagnostic rather than a screening
CANCER SCREENING AND FAMILY HISTORY IN U.S. WOMEN 527
test. Respondents who underwent the specifictest for diagnostic purposes or who had alreadybeen diagnosed with the specific cancer were ex-cluded from each of the separate screening analy-ses.
Colorectal cancer screening use was assessedbased on the use of a home-based fecal occultblood test (FOBT) and the use of sigmoidoscopy,colonoscopy, or proctoscopy. Respondents wereasked whether they had ever undergone anFOBT, when the most recent examination oc-curred, and the reason for which the test was per-formed. Women who had a home FOBT withinthe past year were classified as appropriatelyscreened. We used only home FOBT because sci-entific evidence showed that office FOBT was notvery effective in detecting colorectal cancer.1,19
The design of the NHIS survey prevented us fromdistinguishing between colonoscopy and sigmoi-doscopy according to the ACS recommendations(once every 10 years for the former and onceevery 5 years for the latter). Thus, we defined en-doscopic screening as having any endoscopic testwithin the past 5 years.
Breast cancer screening use was defined basedon having a mammogram in the past year. Wo-men aged � 30 were asked whether they hadever had a mammogram; those who respondedpositively were then asked when they had theirmost recent examination.
Skin cancer screening was assessed based onwhether the respondent had ever had the skinchecked from head to toe for cancer by a physi-cian. Those who answered affirmatively werethen asked when their most recent skin exami-nation took place. Skin cancer screening in thisanalysis was defined as having a physician ad-ministered skin examination in the past year.
These time frames were determined based onthe most recently published ACS recommenda-tions on the frequency of cancer screening.2 Foreach of the screening tests, we excluded womenfrom the analysis who had a medical history ofthat particular cancer.
Family history of cancer was our predictorvariable. Subjects were asked if any first-degreeblood relative had ever been diagnosed with can-cer. If yes, survey participants were asked whatkind of cancer the family member was diagnosedwith. Demographic data collected included age,race, ethnicity, education, marital status, familyincome, and ratio of family income to povertythreshold.
Statistical analysis
Women who were missing information aboutscreening were excluded from the analysis. Weexcluded 638 women from the breast cancerscreening analysis, 431 from the colorectal can-cer screening analysis, and 472 from the skin cancer screening analysis. Among the youngerwomen, we omitted 224 women from the breastcancer screening analysis, 228 from the colorectalcancer screening analysis, and 184 from the skincancer screening analysis.
We first computed descriptive statistics to de-scribe the sample. Multivariate logistic regressionwas then conducted. Demographic variableswere retained in all multivariate models becauseof their possible effects on study results. Poten-tial confounders were selected if they were re-lated to family history of cancer and the specificcancer screening. The selected variables differeddepending on the screening tests under analysis.
For each cancer screening method, we assessedwhether family history of the designated cancerthat was screened for could increase screening forthe cancer. Because women may be more con-cerned about cancer occurrence as a result of anycancers in their family members and are, there-fore, motivated to seek cancer screening, we alsoanalyzed the use of cancer screening in terms offamily history of any cancer. An association maybe stronger for family history of the designatedcancer because of its more direct effects.
All statistics were calculated using SUDAAN20
and SAS version 8.02.21 Percentages and standarderrors were calculated by incorporating the 2000NHIS sample weights and design information.
RESULTS
Table 1 shows demographic characteristics ofthe study subjects according to family history ofcancer. Women with a family history of breast orcolorectal cancer were slightly older than thosewithout such a family history. However, womenwith a family history of skin cancer were morelikely to be in a younger age group comparedwith those without a family history of skin can-cer. Women who had a history of breast, colo-rectal, or skin cancer were more likely to be non-Hispanic white. Whereas only 1.8% of womenwith a family history of skin cancer were non-Hispanic blacks, the corresponding percentage
SHAH ET AL.528
TA
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E1.
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Fam
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Fam
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Var
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Age
, yea
rs40
–49
3021
(36
.28%
)23
3 (2
5.92
%)
3052
(36
.20%
)26
8 (4
0.61
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50–5
921
83 (
26.2
1%)
239
(26.
59%
)21
04 (
43.0
3%)
143
(35.
57%
)22
33 (
26.4
9%)
186
(28.
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)60
–69
1572
(18
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)18
0 (2
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1454
(29
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6 (3
3.83
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1625
(19
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70–8
015
52 (
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247
(27.
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)13
32 (
27.2
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123
(30.
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20 (
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89 (
13.4
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Rac
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ity
His
pani
c11
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71 (
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624
(12.
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(6.
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)12
39 (
14.7
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21 (
3.18
%)
Non
-His
pani
c w
hite
5636
(67
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)69
8 (7
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3403
(69
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1 (8
2.34
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5504
(65
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)62
1 (9
4.09
%)
Non
-His
pani
c bl
ack
1289
(15
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5 (1
2.79
%)
738
(15.
09%
)39
(9.
70%
)14
34 (
17.0
1%)
12 (
1.82
%)
Non
-His
pani
c ot
her
235
(2.8
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15 (
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125
(2.5
6%)
6 (1
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3 (3
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Ed
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Les
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igh
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182
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49 (
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80 (
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1935
(22
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igh
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duc
atio
n26
48 (
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298
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59 (
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145
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34 (
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194
(29.
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3 ye
ars
of c
olle
ge20
93 (
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232
(25.
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00 (
22.4
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98 (
24.3
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2092
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Col
lege
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ree
thro
ugh
som
e16
45 (
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181
(20.
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)81
5 (1
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78 (
19.4
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1569
(18
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)19
5 (2
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post
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uate
wor
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wn
89 (
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100
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arit
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r liv
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445
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37 (
45.7
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177
(44.
03%
)42
07 (
49.9
1%)
384
(58.
18%
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idow
ed15
98 (
19.1
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218
(24.
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36 (
27.3
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124
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12 (
19.1
2%)
87 (
13.1
8%)
Div
orce
d o
r se
para
ted
1806
(21
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986
(20.
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)73
(18
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)18
25 (
21.6
5%)
137
(20.
76%
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ever
mar
ried
731
(8.7
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62 (
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304
(6.2
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28 (
6.97
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745
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51 (
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now
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27 (
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Fam
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com
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5317
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2883
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5297
(62
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�$2
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024
53 (
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236
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149
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44 (
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130
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558
(6.7
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311
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404
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589
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(11.
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(6.
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1.99
1264
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776
(15.
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)79
(19
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)13
17 (
15.6
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81 (
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7%)
2–2.
9998
8 (1
1.86
%)
122
(13.
57%
)54
2 (1
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%)
45 (
11.1
9%)
1004
(11
.91%
)85
(12
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)3–
3.99
734
(8.8
1%)
85 (
9.45
%)
400
(8.1
8%)
23 (
5.72
%)
719
(8.5
3%)
71 (
10.7
6%)
4–4.
9963
8 (7
.66%
)73
(8.
12%
)31
6 (6
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)28
(6.
97%
)63
7 (7
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)57
(8.
64%
)�
537
76 (
45.3
4%)
407
(45.
27%
)22
97 (
46.9
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185
(46.
02%
)37
83 (
44.8
8%)
320
(48.
48%
)
a Stu
dy
subj
ects
wit
h a
mis
sing
val
ue o
n an
y of
the
vari
able
s w
ere
excl
uded
.
was 17.0% among women without a family his-tory of the disease. Women with a family historyof skin cancer were more likely to have a familyincome of �$20,000 compared with women with-out a family history of skin cancer, whereas wo-men having a family history of breast cancer wereless likely to have a family income of �$20,000.However, the distribution in ratio of family incomewas similar between women with and without afamily history of breast, colorectal, or skin cancer.
Figure 1 depicts the screening prevalence byfamily history of the designated cancer that wasscreened for. Women with a family history ofbreast cancer were more likely to participate inbreast cancer screening compared with thosewithout such a family history. Women with afamily history of colorectal cancer and thosewith a family history of skin cancer were morelikely to participate in colorectal cancer and skincancer screening, respectively, compared withthose without a family history. The results weresimilar for the younger population, althoughfamily history of any cancer and skin cancerscreening was significant in the younger agegroup.
The odds ratio (OR) and 95% confidence inter-vals (95% CI) for women are presented in Table 2.When the analysis was adjusted for only sociode-mographic variables, we found that women who
had a family history of any cancer were more likelyto be screened for breast cancer than women with-out a family history of cancer (OR � 1.14, 95% CI1.03-1.25). The corresponding OR estimate was 1.50(95% CI 1.30-1.71) for colorectal cancer screening.Women with a family history of any cancer hadany increased OR estimate for skin cancer screen-ing, but the CI included the null (OR � 1.03, 95%CI 0.86-1.24). After adjusting for other potential fac-tors, the associations remained significant for col-orectal cancer screening, although the strength ofthe association decreased slightly compared towhen adjusting for only sociodemographic vari-ables. The association included the null for skin andbreast cancer screening.
The association was stronger when examiningthe relationship of screening and family historyfor the specific cancer. The analyses, controllingfor only sociodemographic variables, showedthat women with a family history of breast can-cer were also more likely to undergo a breast can-cer examination than women without a familyhistory (OR � 1.61, 95% CI 1.38-1.88). It was alsoshown that women who had a family history ofcolorectal cancer were more than twice as likelyto use colorectal cancer screening than womenwithout a family history of colorectal cancer(OR � 2.39, 95% CI 1.91-2.99). Finally, womenwith a family history of skin cancer were 1.32
SHAH ET AL.530
FIG. 1. Family history of cancer among women with and without a screening test, NHIS, 2000.
times more likely to undergo a skin care evalua-tion in the past year than women without a fam-ily history of the disease; however, the confidenceinterval included the null. Further adjustment forother potential confounders did not substantiallyalter the OR estimates (Table 2).
The ORs and 95% CIs for women in theyounger age group are shown in Table 3. Com-pared to the results in Table 2, the OR estimateswere higher for all three screening tests. After ad-justment for all potential confounders, the ORsfor family history of cancer that was screened forwere 2.70 (95% CI 1.71-4.24) for breast screening,2.25 (95% CI 1.42-3.55) for colorectal screening,and 2.10 (95% CI 1.35-3.27) for skin cancer screen-ing. The OR estimates also increased for familyhistory of any cancer, but the results were not asprominent.
DISCUSSION
We examined the use of breast, colorectal, andskin cancer screening among women who had at
least one first-degree relative with cancer andthose who did not. Our study demonstrated thatwomen with a family history of breast or colo-rectal cancer were more likely to have beenscreened for these cancers compared with womenwithout a family history of the cancer, and thisassociation was stronger for younger women. Forskin cancer screening, family history increasedscreening use only in younger women.
The identified associations may be a result ofthe combination of physician’s recommendationsand women’s risk perceptions and intentions ongetting screened. Health professionals or healtheducators may provide women information thatcancer risk may be elevated among individualswith a family history and, subsequently, recom-mend appropriate screening.22 It is well docu-mented that physicians are perceived as an im-portant source of information and, therefore, caninfluence an individual’s cancer screening be-havior.22–25
It is also likely that having a personal familyhistory of cancer increases one’s awareness of de-veloping cancer and subsequently motivates an
CANCER SCREENING AND FAMILY HISTORY IN U.S. WOMEN 531
TABLE 2. ODDS RATIOS (95% CONFIDENCE INTERVALS) OF CANCER SCREENING USE BY FAMILY HISTORY
OF ANY CANCER, BREAST, COLORECTAL, AND SKIN CANCER AMONG FEMALES, NHIS, 2000
Adjusted for Adjusted for allsociodemographic factorsa confounding factorsb
No Yes OR (95% CI) No Yes OR (95% CI)
Breast cancer screening (age 40–79)Family history of any cancer No 2092 2171 1.00 2092 2171 1.00
Yes 1893 2433 1.14 (1.03–1.25) 1891 2433 1.06 (0.96–1.18)Family history of breast cancer No 3672 313 1.00 3671 4025 1.00
Yes 4025 579 1.61 (1.38–1.88) 312 579 1.54 (1.30–1.82)Colorectal cancer screening (age 50–79)
Family history of any cancer No 1700 566 1.00 1687 566 1.00Yes 1707 888 1.50 (1.30–1.71) 1707 888 1.36 (1.17–1.58)
Family history of colorectal cancer No 3200 1261 1.00 3200 1261 1.00Yes 207 193 2.39 (1.91–2.99) 207 193 2.17 (1.73–2.72)
Skin cancer screening (age 40–79)Family history of any cancer No 4103 289 1.00 4103 289 1.00
Yes 3907 319 1.03 (0.86–1.24) 3907 319 1.02 (0.84–1.22)Family history of skin cancer No 7418 546 1.00 7418 546 1.00
Yes 592 62 1.32 (0.99–1.76) 592 62 1.27 (0.95–1.69)
aAdjusted for sociodemographic factors: age, marital status, family income, education, and ratio of family incometo poverty threshold.
bBreast cancer screening: Adjusted for sociodemographic variables plus insurance status, smoking status, alcoholconsumption, melanoma skin cancer, restless last 30 days, seen obstetrician/gynecologist last 12 months, discussedgenetic testing with MD, amount of cancer in family. Colorectal cancer screening: Adjusted for sociodemographicvariables plus insurance status, smoking status, alcohol consumption, family history of ovarian cancer, pain/achinglast 12 months, risk of getting cancer in the future, amount of cancer in family. Skin cancer screening: Adjusted forsociodemographic variables plus adjusted for insurance status, smoking status, alcohol consumption, work status,last week, past 12 months, heard of genetic testing for cancer risk.
individual to participate in screening. Intentionto be screened is one of the strongest and mostconsistent factors associated with future cancerscreening.26–28 Intention to screen because of fam-ily history of cancer may be a result of increasedknowledge and concern that an individual mayalso be diagnosed with cancer. In this study, wo-men with a family history may have a higher in-tention to screen, resulting in more use of cancerscreening.
These attributes would also explain whyyounger women were more likely to be screenedwhen they had a family history of cancer com-pared with their same-aged counterparts withouta family history of cancer. A stronger associationbetween family history and cancer screening sug-gests that the national guidelines based on fam-ily history of cancer have been somewhat fol-lowed. Because breast and colorectal screening isnot cost-effective among young women with av-erage risk of cancer,29,30 routine screening is notrecommend by ACS for younger women in thegeneral population but is recommended only ifthey have an increased risk, such as a family his-
tory of the designated cancer(s). Therefore, it canbe imagined that the family history/cancer asso-ciation is stronger for younger women comparedwith their older counterparts, as older womenhave a recommendation to undergo screeningtests even when they do not have a family his-tory of cancer.
An association between skin cancer screeningand family history of skin cancer or any cancersuggests that the association is less specific tofamily history of the designated cancer for skincancer screening compared with colorectal orbreast cancer screening. Because more intensiveskin cancer screening is not indicated in ACSguidelines for individuals with a family historyof skin cancer, the identified association for wo-men with a family history of any cancer might bea result of the effect that women with a familyhistory of cancer (no matter if it may be geneti-cally related) are more likely to seek cancerscreening. Past studies have found that womenwho were aware of their risk and heightened sus-ceptibility were more likely to partake in pre-ventive health measures.31,32 Therefore, it is pos-
SHAH ET AL.532
TABLE 3. ODDS RATIOS (95% CONFIDENCE INTERVALS) OF CANCER SCREENING USE BY FAMILY HISTORY OF
ANY CANCER, COLORECTAL, PROSTATE, AND SKIN CANCER AMONG YOUNG FEMALES, NHIS, 2000
Adjusted for Adjusted for allsociodemographic factorsa confounding factorsb
No Yes OR (95% CI) No Yes OR (95% CI)
Breast cancer screening (age 30–39)Family history of any cancer No 2124 254 1.00 2103 254 1.00
Yes 803 142 1.55 (1.21–1.98) 799 142 1.34 (1.02–1.76)Family history of breast cancer No 2816 352 1.00 2791 352 1.00
Yes 111 44 3.42 (2.25–5.19) 111 44 2.70 (1.71–4.24)Colorectal cancer screening (age 40–49)
Family history of any cancer No 1581 117 1.00 1570 117 1.00Yes 1155 121 1.45 (1.08–1.95) 1151 121 1.15 (0.83–1.60)
Family history of colorectal cancer No 2605 208 1.00 2590 208 1.00Yes 131 30 2.80 (1.81–4.33) 131 30 2.25 (1.42–3.55)
Skin cancer screening (age 30–39)Family history of any cancer No 2373 90 1.00 2346 90 1.00
Yes 939 59 1.56 (1.10–2.22) 933 59 1.54 (1.09–2.19)Family history of skin cancer No 3130 128 1.00 3099 128 1.00
Yes 182 21 2.20 (1.42–3.41) 180 21 2.10 (1.35–3.27)
aAdjusted for sociodemographic factors: age, marital status, family income, education, and ratio of family incometo poverty threshold.
bBreast cancer screening: Adjusted for sociodemographic variables plus insurance status, smoking status, alcoholconsumption, melanoma skin cancer, restless last 30 days, seen obstetrician/gynecologist last 12 months, discussedgenetic testing with MD, amount of cancer in family. Colorectal cancer screening: Adjusted for sociodemographicvariables plus insurance status, smoking status, alcohol consumption, family history of ovarian cancer, pain/achinglast 12 months, risk of getting cancer in the future, amount of cancer in family. Skin cancer screening: Adjusted forsociodemographic variables plus adjusted for insurance status, smoking status, alcohol consumption, work status,last week, past 12 months, heard of genetic testing for cancer risk.
sible that having a personal family history of can-cer increases one’s perception of developing can-cer and subsequently motivates an individual toparticipate in screening. Younger women mighthave an increased awareness over their oldercounterparts that family history is a risk factor forcancer, which might explain why the increasedassociation was found only in the younger agegroup.
An additional concern raised by this study isthe low rates of breast cancer screening. Amongthose with a family history, about 65% had abreast cancer screening test in the past year, andthe rate was even lower among those without afamily history. The lower rate of compliance formammography in our study is probably due tothe narrow screening time frame. Other studiesreport mammogram use in the past 2 years,33–35
whereas we looked at breast cancer screening usein the past year.
Limitations of this study include the cross-sectional and self-report nature of the data used.The cross-sectional feature prevents us from as-certaining a temporal relation between familyhistory and screening use. However, it is morelikely that cancer in the family occurred beforescreening, as screening use was defined ac-cording to a limited time frame immediatelyprior to the interview (1 year for most screen-ing procedures) in this study. Prospective lon-gitudinal studies that examine screening use ofwomen with a family history of cancer wouldhelp clarify the true relationship between fam-ily history and screening use. Screening historyand family history of cancer were based on self-report and, therefore, might be prone to recallbias. If women with a family history were morelikely to recall or report their participation incancer screening, the association would be over-estimated. However, self-reported breast, col-orectal, and skin screening use has been foundto be reasonably accurate.36–39
In conclusion, despite the potential limita-tions, this study found increased breast and col-orectal cancer screening among women with afamily history of the cancer, which is consistentwith the ACS recommendations for earlier andincreased surveillance of women with a familyhistory of cancer. More efforts to promotescreening in these groups are needed becausecancer screening has the highest positive pre-dictive values in women with a family historyof cancer.
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E-mail: [email protected]
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