LONGITUDINAL TRENDS AND PREDICTORS
CoPuRuth C. Carlos, MD, MSa,b, A. Mark Fendrick, MDc,d, Paul H. Abrahamse, MAc,Qian Dong, MDb, Stephanie K. Patterson, MDb, and Steven J. Bernstein, MD, MPHa,b,c
aVA Center for Practice Management and Outcomes Research, Ann Arbor, MichiganbDepartment of Radiology, University of Michigan, Ann Arbor, Michigan
cDepartment of Internal Medicine, University of Michigan, Ann Arbor, MichigandDepartment of Health Management and Policy, University of Michigan, Ann Arbor, Michigan
Received November 8, 2004; received in revised form January 1, 2005; accepted June 3, 2005
Purpose. Nationally representative surveys demonstrate that the adherence to screening mam-mography guidelines are associated with increased prevalence of colorectal cancer (CRC)screening; however, the incidence of CRC screening in the screening mammography populationis unknown. Our purpose was to describe non-fecal occult blood test (FOBT) CRC screeningutilization by women prior to and subsequent to screening mammography at a large academicmedical center.
Materials and methods. Using the institutional administrative data base, 17,790 women aged50 and older who underwent screening mammography between 1998 and 2002 were retro-spectively identified. We determined that women were current with non-FOBT CRC screen-ing at the time of mammography if they had undergone flexible sigmoidoscopy or double-contrast barium enema in the 5 years or colonoscopy since 1995, the earliest for which data areavailable. We excluded FOBT as a form of CRC screening because the administrative database did not adequately capture episodes of FOBT. Women who were not current wereconsidered eligible for non-FOBT CRC screening. We then assessed the number of womenwho underwent flexible sigmoidoscopy, barium enema, or colonoscopy within 12 monthsfollowing mammography. Age, insurance status, Breast Imaging Reporting and Data Systemclassification, recommendations after screening mammography and year of mammographywere examined as potential predictors of non-FOBT CRC screening completion.
Results. At the time of mammography, 13.3% women were current with non-FOBT CRCscreening. Of women eligible for non-FOBT CRC screening at the time of mammography,1.1% completed non-FOBT CRC screening within 12 months after mammography. The rate ofnon-FOBT CRC screening completion increased over time. After multivariate analysis, beinginsured by a commercial managed care organization or by Medicaid remained significantpredictors of non-FOBT CRC screening.
Conclusion. The prevalence of non-FOBT CRC screening is low in the population of womenundergoing screening mammography, with an incidence of 1.0%. Future studies shouldexamine whether delivering CRC screening interventions at a screening mammography visitincrease adherence to non-FOBT CRC screening.
he American Cancer Society estimated that thereOLORECTAL CANCER SCREEATTENDING SCREENI
Womens Health IssuTanin
Correspondence to: Ruth C. Carlos, MD, MS, Assistant Profes-, Department of Radiology, University of Michigan, 1500 E.dical Center Drive, Ann Arbor, MI 48109-0030.
pyright 2005 by the Jacobs Institute of Womens Health.blished by Elsevier Inc.NG BEHAVIOR IN WOMENMAMMOGRAPHY:
(2005) 249257were 74,700 new cases of colorectal cancer (CRC)d an estimated 28,800 deaths from CRC in women2003 (Cancer Facts and Figures, 2003). Previous
1049-3867/05 $-See front matter.doi:10.1016/j.whi.2005.06.001
R. C. Carlos et al. / Womens Health Issues 15 (2005) 249257250dies have illustrated the potential benefit of screen-using fecal occult blood testing (FOBT), sigmoid-
copy, and colonoscopy to decrease mortality fromC. An older, randomized trial demonstrated de-ased mortality rates from CRC in individuals as-ned to annual FOBT compared to no screening% decrease after 18 years of follow-up) (Mandel et, 1993). More recent trials have found 1518% mor-ity reductions from biennial screening after 810ars of follow-up (Hardcastle et al., 1996; Kronborg et, 1996). A small randomized trial of sigmoidoscopyorted relative risk reduction in mortality of 20%hiis-Evensen et al., 1999). Other case-control studiesnd that sigmoidoscopy screening reduced risk ofath by 59% (Selby, Friedman, Quesenberry, &eiss, 1992). No identified studies evaluated double-ntrast barium enema using decreased incidence orath from CRC as endpoints. There is no screeningal that has reported the ability of colonoscopy touce CRC incidence or mortality; however, a case-ntrol study found decreased mortality fromlonoscopy screening (odds ratio [OR] 0.43) (Ke-nter & Brevinge, 1996).Despite ample evidence demonstrating the effec-eness of screening in reducing colon cancer mortal-, the Behavioral Risk Factor Surveillance SurveyRFSS) performed in 1999 revealed that only 40% ofpondents stated that they had ever submitted aBT, and 44% had undergone either sigmoidoscopycolonoscopy (Bolen, Rhodes, Powell-Griner, Bland,Holtzman, 2000; Janes et al., 1999). Using moreingent criteria to assess adherence to publishedidelines revealed that only 34% of respondents hadher sigmoidoscopy or colonoscopy within the pre-us 5 years, and only 21% had FOBT in the preced-year. The BRFSS did not differentiate between
moidoscopy or colonoscopy use and did not assessdouble-contrast barium enema use. Further, thereno reliable estimates of the proportion of womeno were screened for CRC using double-contrastrium enema.The rate of CRC screening continues to lag behindrate of breast cancer and cervical cancer screening
er the past 5 years (Seeff, Shapiro, & Nadel, 2002;apiro, Seeff, & Nadel, 2001), even with increasedomotional initiatives and public attention. The-althy People 2010 nationwide health initiative has aal that 50% of adults 50 years and older undergo aBT within a 2-year period and that at least 50% ofults 50 years and older will have ever had a sig-idoscopy (U.S. Department of Health and Humanrvices, 2000).Cross-sectional analyses of the BRFSS, based onrveys of noninstitutionalized participants, havemonstrated that the vast majority of women 50ars and older participate in breast and cervicalncer screening (82% and 70%, respectively), with arked discrepancy in the rate of participation ofC screening (Carlos, Fendrick, Patterson & Bern-in, 2005). In addition, women who participated ineening mammography within the past year wereost three times likely to be current with CRCeening guidelines compared to women who did notrticipate in screening mammography (Carlos, Fen-ick, Patterson & Bernstein, 2005). However, even ins highly compliant group, the prevalence of CRCeening adherence remained much lower than 50%arlos, Fendrick, Patterson & Bernstein, 2005). Be-use these analyses were based on cross-sectionalta, it could not be determined if screening mam-graphy preceded CRC screening. Although an as-ciation was found between mammography andC screening adherence, the direction of the effectains unknown.
Given its near universal acceptance by women,eening mammography represents a potentialachable moment(i.e., unique opportunity) (Carlos,04) for educating patients about the risk of colonncer. Using the setting of screening for one type ofncer(such as screening mammography) to encour-e compliance with screening for another type ofncer(such as colorectal cancer) represents a novele of the diagnostic imaging experience (Carlos, 2004;rlos & Fendrick, 2004). Other investigators havealuated the use of diagnostic testing as a method toprove health behaviors, most notably in smokingsation. Hepper et al. (1980) demonstrated thattients were more likely to quit smoking within 23ars of the first spirometry test if the test is abnormal,mpared to patients with a normal first-time spirom-y test result. Women participating in comprehen-e lung cancer screening protocol that includediral computed tomography documented a 16% quite after the procedure (Schnoll et al., 2002). Thesethors further demonstrated that 59% of current ormer smokers queried about lung cancer screeninguld be interested in receiving smoking cessationvice with screening. In the same population, 52%ted that they would quit if the scan was positive,mpared to 19% if the scan was negative (Schnoll et, 2002).Many reasons exist as to why a woman may notmplete CRC screening. Inadequate understandingthe health benefits screening provides, no doctorommendation, poor insurance coverage, and evensychological dread of the procedures may or mayt all constitute factors that reduce CRC screeningarewood, 2002; Walsh, Posner, & Perez-Stable,02). Educational efforts have been shown to mod-ly improve FOBT compliance. Coupling educa-nal intervention with a teachable moment increaseseffect of the intervention. Screening mammogra-
y represents a potential teachable moment for pro-ing CRC education designed to improve overall
R. C. Carlos et al. / Womens Health Issues 15 (2005) 249257 251owledge of CRC screening and to address specificychosocial concerns, similar to smoking cessationerventions (McBride, Emmons, & Lipkus, 2003).Before we can study the effectiveness of promotingC screening at these teachable moments,