Colorectal cancer screening behavior in women attending screening mammography: Longitudinal trends and predictors

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C NINGLONGITUDINAL TRENDS AND PREDICTORSsorMees 15CoPuRuth 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,caVA Center for Practice Management and Outcomes Research, Ann Arbor, MichiganbDepartment of Radiology, University of Michigan, Ann Arbor, MichigancDepartment of Internal Medicine, University of Michigan, Ann Arbor, MichigandDepartment of Health Management and Policy, University of Michigan, Ann Arbor, MichiganReceived November 8, 2004; received in revised form January 1, 2005; accepted June 3, 2005Purpose. 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.Introductionhe American Cancer Society estimated that thereOLORECTAL CANCER SCREEATTENDING SCREENIWomens Health IssuTaninCorrespondence 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). Previous1049-3867/05 $-See front matter.doi:10.1016/j.whi.2005.06.001stuingosCRcresig(33al.talyeal.rep(TfoudeWcodetriredcocowetivity(BresFOor&strgueitvioingsigforarewhbatheovShprHegoFOadmoSesudeyecamaCRstescralmscrpadrthiscr(CcadamosoCRremscrte20cacaagcausCaevimcespayecoetrsivspratauforwoadnocoal.coofreca pno(H20esttiothephvidR. 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 betweenmoidoscopy 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 screeninger 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 overallknpsintCRtowoaredeanwoMMPaW50maernusbarapofprPrCaginavingweshanexreavicuaanadvalimtypingtioaftadcesRAdahoWthezaSyintantemacvieAsWscrweforyecoor19CRphsigyeACweprbesinbeadstrciathecainsG0ancobilforcocodiaofusmoscrex12debaIdePobeBIanR. 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, we needestimate the rate of CRC screening compliance inmen undergoing screening mammography whoeligible for CRC screening. In this paper, wescribe non-FOBT CRC screening utilization prior tod subsequent to screening mammography formen attending breast cancer screening at a largeidwestern academic medical center.ethodstient population and data collectione retrospectively identified 17,790 women betweenand 75 years of age who participated in screeningmmography(CPT code 76092) at a large Midwest-academic medical center between 1998 and 2002ing the radiology information system (RIS) datase.Screening mammography is defined as mammog-hy performed in women who do not have a historybreast cancer, a palpable mass, or an active breastoblem. This age cohort was chosen as both the U.S.eventive Services Task Force and the Americanncer Society (ACS) recommend CRC screening be-ning at age 50 for asymptomatic individuals oferage risk who do not have risk factors predispos-to or a family history of CRC (Bolen, 1997; Ke-nter & Brevinge, 1996). Further, there are no dataowing that screening beyond 80 years is efficaciousd randomized controlled trials suggest that lifepectancy of at least 5 years may be required tolize the benefits of screening (U.S. Preventive Ser-es Task Force, 2002). Because we specifically eval-ted double-contrast barium enema, colonoscopy,d sigmoidoscopy as methods of CRC screeningherence, where the minimum recommended inter-l between screenings is 5 years, we chose an upperit of 75 years for our population.For each subject, we recorded their health insurancee, mammogram result (based on the Breast Imag-Reporting and Data System [BIRADS] classifica-n system) and the radiologists recommendationer screening mammography using the institutionalministrative data bases.Mammography quality assurance (QA) data, ac-sed through the RIS, was used to determine BI-DS classification and mammographers recommen-tion for screening mammography follow-up. Dataused within the institutions Health System Dataarehouse were used to determine insurance status attime of screening mammography and CRC utili-tion after screening mammography. The Healthstem Data Warehouse is an information systemegrating data from the Health Systems hospitald professional and clinical and financial data sys-s. The HSDW includes data from the hospital costcounting system and the professional billing system.The study was approved by the Institutional Re-w Board.certaining eligibility for colorectal cancer screeningomen who were not current with non-FOBT CRCeening at the time of screening mammographyre considered eligible for CRC screening. To screenCRC, the ACS recommends that individuals 50ars and older undergo FOBT annually, sigmoidos-py or double-contrast barium enema every 5 years,colonoscopy every 10 years (Kewenter & Brevinge,96). We considered women current with non-FOBTC screening at the time of screening mammogra-y if they had any of the following tests: 1) flexiblemoidoscopy or barium enema within the last 5ars; or 2) any previous colonoscopy. Although theS recommends colonoscopy every 10 years, were not able to determine colonoscopy utilizationior to 1995. Therefore, we considered the subject tocurrent with CRC screening if she had colonoscopyce 1995.We excluded FOBT as a method of CRC screeningcause of limitations in identifying this test throughministrative data bases. Institutional QA demon-ated that FOBT is usually performed in the clini-ns office and although the results are recorded inpatients medical chart, they are not consistentlyptured by administrative data bases.CRC screening utilization was determined using thetitutions administrative data base using CPT codes104 (screening flexible sigmoidoscopy) and G0121d G0105 (screening colonoscopy). Because the Gdes are a recent addition to the list of approved CPTling codes we also used existing procedure codesflexible sigmoidoscopy (45.24 or 45330), double-ntrast barium enema (76092 or 74280), or colonos-py (45378) in combination with V76.41 and V76.51gnostic codes (screening for malignant neoplasmsthe rectum or colon). These diagnostic codes wereed to differentiate between receiving flexible sig-idoscopy, barium enema, and colonoscopy foreening rather than for diagnostic evaluation of anisting medical condition.Completion of CRC screening in eligible women inmonths following screening mammography wastermined using the institutions administrative datase, as described.ntifying predictors of colorectal cancer screeningtential predictors of non-FOBT CRC screeninghavior included age, type of health insurance,RADS classification of the mammogram result,d recommendations after screening mammogra-phstrexmoBapopo(AthmaonfercoincofStaThtiofolrizTymeMclaormadascrorowtesmoforThwhvatorwalogORaningwavaincanoftheFOstaCosetQuEamapeprsoinswopemoatpathuTable 1. Characteristics of women 5075 years old receivingscrChNAg56Yea11222HeCCMMBIRNINRecRRMeFCDCR*FepR. C. Carlos et al. / Womens Health Issues 15 (2005) 249257252y (Table 1). Previous investigators have demon-ated that patients who undergo mammographyperience anxiety from a positive screening mam-graphy necessitating further evaluation (Lowe,landa, Del Mar, & Hawes, 1999). Even if the initialsitive mammogram is determined to be a falsesitive, residual distress and anxiety can existro, de Koning, Absetz, & Schreck, 1999). Al-ough there is no direct evidence that false-positivemmography results in enhanced CRC adherence,e may infer that this elevated concern may trans-to CRC adherence behavior from Aro et al.,eening mammography between 1998 and 2002Current WithCRCScreening*Not CurrentWith CRCScreening*aracteristic N (%) (N)2370 15420e*(y)059 1276 (53.8) 9186 (59.6)069 769 (32.4) 4389 (28.5)70 325 (13.7) 1845 (12.0)r of screeningmammography998 420 (17.7) 2923 (19.0)999 507 (21.4) 3072 (19.9)000 380 (16.0) 2498 (16.2)001 464 (19.6) 3151 (20.4)002 599 (25.3) 3776 (24.5)alth insurance typeommercial, nonmanagedcare381 (16.1) 4048 (26.3)ommercial, managedcare1202 (50.7) 7037 (45.6)edicare 738 (31.1) 4103 (26.6)edicaid 49 (2.1) 232 (1.5)ADS classification ofmammography resultsormal or benignfindings2330 (98.3) 15232 (98.8)ndeterminate or probablymalignant findings32 (1.4) 151 (1.0)ot specified 8 (0.3) 37 (0.2)ommendation for follow-upoutine screeningmammography in 12months2238 (94.4) 14470 (93.8)ecommend additionalimaging/tissuesampling/clinicalconsultation132 (5.6) 950 (6.2)thod of CRC screening*lexible sigmoidoscopy 1741 (75.5) olonoscopy 432 (18.9) ouble-contrast bariumenema132 (5.6) C, colorectal occult blood testing was not assessed. .05.upled with data from Fendrick et al., indicatingreased CRC adherence in women with a historybreast cancer (Fendrick, unpublished data).tistical analysise studys primary outcome was the rate of comple-n of non-FOBT CRC screening in the 12 monthslowing screening mammography. Age was catego-ed into three age groups: 5059, 6069, and of health insurance was categorized into com-rcial nonmanaged care, commercial managed care,edicare, or Medicaid. We dichotomized the BIRADSssification of mammographic findings into normalbenign findings and indeterminate or probablylignant findings. We also dichotomized recommen-tions after screening mammography into routineeening mammography recommended in 12 monthsno further screening mammography recommendeding to age, and requiring additional comparison,ting, or consultation. The year of screening mam-graphy was treated as a categorical variable.Each potential predictor variable was first screenedits relationship with cancer screening adherence.e univariate analysis was evaluated using 2 testen the predictors were dichotomous or categoricalriables and using Students t-test when the predic-s were continuous variables. Multivariate analysiss subsequently performed, using a constructedistic regression model to determine the adjusteds of each of the predictor variables. Multivariatealysis was conducted and the presence of confound-and effect modification was assessed using for-rd selection. Given the few number of predictorriables examined and the size of the population, weluded all predictor variables in the multivariatealysis. A nonparametric test for trend, an extensionthe Wilcoxon rank-sum test, was used to determinepresence of a significant temporal trend in non-BT CRC screening behavior (Cuzick, 1985). Alltistical analyses were done using Stata 7.0 (Statarp., College Park, TX). Statistical significance wasat .05.ality assurance of data collectionch woman may have participated in screeningmmography from one to five times during theriod of evaluation. To reduce bias attributable toeferences of women who underwent multiple epi-des of annual screening mammography at the sametitution, we conducted a subanalysis on uniquemen undergoing screening mammography in theriod of evaluation, where the last screening mam-gram represented the index mammogram.Many women who obtain screening mammographythe academic medical center reported on in thisper receive their routine clinical care elsewhere;s all non-FOBT CRC screening procedures may notbeencaidetheplatheroendaReCuThmaOfwiingcu50.01nocacuticCoSuwhtimaftmoblewiratyetimcococothocomamascr19nocaPrAfcia.00acothelikincQuInunwetimtheCRinthecocarapwomapr(14timinFOpaprinc.03Figscrdarsigtionofscrof eofR. C. Carlos et al. / Womens Health Issues 15 (2005) 249257 253captured within its administrative data base. Tosure that the administrative data base adequatelyptured all instances of non-FOBT CRC screening, wentified the subset of women who were enrolled inacademic medical centers large managed caren at the time of screening mammography, underassumption that these women would receive theirutine clinical care within the institution, and allcounters would be captured by the administrativeta bases.sultsrrent with colon cancer screeningere were 17,790 women who underwent screeningmmography between 1998 and 2002 (see Table 1).these 17,790 women, 2,370 (13.3%) were currentth non-FOBT CRC screening at the time of screen-mammography. A smaller proportion of womenrrent with non-FOBT CRC screening were aged59 compared to women who were not current (p). A greater proportion of women current withn-FOBT CRC screening had commercial managedre insurance compared to women who were notrrent (p .01). No other differences in characteris-s between the two groups were demonstrated.mpletion of colon cancer screening in eligible womenbsequent analysis was limited to the 15,420 womeno were eligible of non-FOBT CRC screening at thee of screening mammography. Length of follow-uper screening mammography ranged from 072nths (median 30 months). Only 175 (1.1%) of eligi-women completed non-FOBT CRC screeningthin 12 months of screening mammography. Thee of non-FOBT CRC screening completion in thear after screening mammography increased overe (Figure 1), the trend toward increasing CRCmpletion was statistically significant (p .05). Wempared the characteristics of eligible women whompleted non-FOBT CRC screening compared tose who did not (Table 2). More women whompleted non-FOBT CRC screening had commercialnaged care insurance or Medicaid (p .01). Thejority of women who completed non-FOBT CRCeening received mammography screening after98 compared to women who did not completen-FOBT CRC screening (p .01). No other signifi-nt differences in characteristics were identified.edictors of colon cancer screening completionter multivariate analysis (Table 3), having commer-l managed care insurance (adjusted OR 2.22, p 1) or Medicaid(adjusted OR 2.93, p .01) remainedsignificant predictor of non-FOBT CRC screeningmpletion within 1 year after mammography. Fur-r, compared to 1998, the first year of our study, theelihood of completion of non-FOBT CRC screeningreased over time (p .01).ality assurance of data collectionthe subanalysis of the 8,132 unique women whoderwent screening mammography, 1,241 (15.0%)re current with non-FOBT CRC screening at thee of the index mammogram, compared to 13.3% inoverall population. The average yearly non-FOBTC screening completion rate was 1.1%, the same asthe overall population. After multivariate analysis,significant predictors of non-FOBT CRC screeningmpletion included having commercial managedre insurance and the year of screening mammog-hy(see Table 3). If bias toward preferences ofmen who more frequently participated in screeningmmography influenced non-FOBT CRC screeningevalence and incidence, the effect is slight.In the subanalysis of 5,773 institutional insurees, 824.3%) were current with non-FOBT CRC screening ate of screening mammography compared to 13.3%the overall population. The average yearly non-BT CRC screening completion rate was 1.4%, com-red to 1.1% in the overall population. Significantedictors of non-FOBT CRC screening completionluded having managed care (adjusted OR 4.40, p ) and the year of screening mammography.ure 1. Colorectal (CRC) utilization in women undergoingeening mammography. CRC utilization is reflected in the calen-year of mammography utilization. There is a statisticallynificant trend toward increasing rates of CRC screening comple-over time.(p .05). Prevalence of CRC screening is the percentwomen who were current with CRC screening at the time ofeening mammography. Incidence of CRC screening is the percentligible women who completed CRC screening within 12 monthsscreening mammography.DiInmamaFOprFOmaCRnoingFOtheWcoingcacoissguefftioKuonwhunralDecoClnebysenforanhigphBu19poustarmoenvicorscrcascrscrmeingingtowiofrentemphwotimthadasphaalsatiTable 2. Characteristics of eligible women who completedcolmaChNuAg56HeCCMMYea11222BIRNIRecRRMeFCDCR*FepR. C. Carlos et al. / Womens Health Issues 15 (2005) 249257254scussionthe current study, we demonstrated, at the time ofmmography, a baseline prevalence of approxi-tely 13% of women who were current with non-BT CRC screening. The current study extends theevious analyses by evaluating the incidence of non-BT CRC screening completion after screeningmmography. Of the more than 85% eligible forC screening, the average rate of completion ofn-FOBT CRC screening was 1% in the year follow-screening mammography. Further, although non-BT CRC screening completion increased over time,maximum rate of completion did not exceed 2%.orectal cancer screening one year after screeningmmography compared to noncompletersaracteristicCompleted CRCScreening, N(%)Did Not CompleteCRC Screening,N(%)mber 175 15245e (y)059 112 (64.0) 9074 (59.5)069 52 (29.7) 4337 (28.4)70 11 (6.3) 1834 (12.0)alth insurance typeommercial, nonmanagedcare28 (16.0) 4020 (26.4)ommercial, managedcare109 (62.3) 6928 (45.4)edicare 38 (21.7) 4070 (26.7)edicaid 5 (2.9) 227 (1.5)r of screeningmammography998 13 (7.4) 2910 (19.1)999 41 (23.4) 3031 (19.9)000 28 (16.0) 2470 (16.2)001 39 (22.3) 3112 (20.4)002 54 (30.9) 3722 (24.4)ADS classification ofmammography resultsormal or benignfindings174 (99.4) 15054 (98.7)ndeterminate or probablymalignant findings1 (0.6) 191 (1.3)ommendation for follow-upoutine screeningmammography in 12months165 (94.3 14333 (94.8)ecommend additionalimaging/tissuesampling/clinicalconsultation10 (5.7 912 (1.3)thod of CRC screening*lexible sigmoidoscopy 79 (45.1) olonoscopy 26 (14.9) ouble contrast bariumenema70 (40.0) C, colorectal occult blood testing was not assessed. .05e speculate that the relative improvement in CRCmpletion rate over time may be an effect of increas-practitioner and public attention on colorectalncer screening in 2000. In 1999, Medicare beganvering CRC screening services. In 2000, the ACSued its first set of comprehensive cancer screeningidelines in nearly 20 years (ACS, 1980), the cost-ectiveness of CRC screening in the general popula-n was demonstrated (Frazier, Colditz, Fuchs, &ntz, 2000) and a screening colonoscopy was shownnational television. In particular, the latter event, inich a national correspondent on The Today Showderwent a colonoscopy has been linked to a tempo-increase in CRC screening rates (Cram et al., 2003).spite the improvement, the rate of CRC screeningmpletion in this population remains quite low.early, there is room for improvement. Given thear universal acceptance of screening mammographywomen, the mammography appointment repre-ts a potential teachable moment (Carlos, 2004)educating women about the risk of colon cancerd benefits of CRC screening.There are psychosocial factors that account for ah level of compliance with screening mammogra-y (Aro et al., 2000; Lauver, Henriques, Settersten, &mann, 2003; Zapka, Harris, Stoddard, & Costanza,91). Understanding these psychosocial factors cantentially increase compliance with CRC screening,ing the mammography suite as a delivery setting forgeted education. We posit that the screening mam-graphy encounter can be used as a gateway tocourage women to partake in CRC screening ser-es, regardless of the type of CRC screening methodwhich clinical service will be providing CRCeening. Within the mammography encounter, wen potentially close the loop between intention toeen when the woman is made aware of CRCeening need and actually scheduling an appoint-nt with her clinician to receive a referral for screen-(Carlos & Fendrick, 2005).Previous analyses of cancer screening behavior us-the BRFSS data have demonstrated that adherencebreast and cervical cancer screening is associatedth CRC screening adherence; however, the directionthe association could not be determined. The cur-t study addresses this limitation by evaluating theporal association between screening mammogra-y and CRC screening.Our study has several limitations. The prevalence ofmen who were current with CRC screening at thee of screening mammography is significantly lessn has been reported from analyses of the BRFSSta. Our institutional data collection relied on retro-ective analysis of administrative data, which mayve underestimated the true prevalence. Others haveo noted the limitations of claims data in the evalu-on of cancer screening and cancer detection (Fini-soZhBaCRendeacrecCRsinCRofWingofqudarepandeculosinvFOscrofpr36pamaadouTable 3. Correlates of completing CRC screening within 1 year after screening mammography in eligible womenVaAg56HeCMMYea11222BIRNRecR llow-uMu gressiopre tion wpre ctor vaORp*Th thus, tR. C. Carlos et al. / Womens Health Issues 15 (2005) 249257 255n, Wellins, Wennberg, & Lucas, 1999; Freeman,ang, Freeman, & Goodwin, 2000; Nattinger, Laud,jorunaite, Sparapani, & Freeman, 2004).In addition, we adopted a stringent definition ofC screening using only double-contrast bariumema, flexible sigmoidoscopy, or colonoscopy totermine adherence. Although FOBT remains ancessible and recommended form of CRC screening,ent work supports a more stringent definition ofC screening as up to one third of physicians usegle-sample in-office testing as the sole means ofC screening (Nadel et al., 2005), an ineffective formCRC screening (Collins, Lieberman, Durbin, &eiss, 2005). We likely underestimated CRC screen-adherence because we excluded FOBT as a meansCRC screening; compliance with FOBT was inade-ately captured in the institutional administrativeta base. Our estimate of CRC utilization, therefore,resents the lower bound of institutional compli-ce with CRC screening.In a previous analysis of the BRFSS 2001 data, wemonstrated that 22% of respondents who wererrent with CRC screening had received FOBT (Car-, Fendrick, Patterson & Bernstein, 2005). Otherestigators have demonstrated 5% incidence ofBT in the 6 months following identification of CRCeening need. Even assuming that similar utilizationFOBT was achieved in our current population, theevalence of CRC screening would be approximately% with an incidence of 6%, markedly lower com-riablee(y)05906970alth insurance typeommercial managed careedicareedicaidr of screening mammography998999000001002ADS classification of mammography resultsormal or definitely benign findingsommendation for follow-upoutine screening mammography in 12 months or no additional forecommended due to ageltivariate analysis was performed using a constructed logistic redictor variables. The presence of confounding and effect modificadictor variables examined and the size of the population, all predi, odds ratio; CI, confidence interval. .05.ere were no women on Medicaid who completed CRC screening;red to screening mammography rates. There re-ins a tremendous opportunity to improve CRCherence.Some women may have received their clinical caretside our institution, leading to underestimation ofcompletion rate of CRC screening. Therefore, wenducted a subanalysis of women whose primaryalth insurance was the institutions own healthurance plan. Among these women, although thee of CRC completion was statistically greater thanninstitutional insurees, the absolute rate of CRCeening completion remained extremely low (1.4%).rthermore, the significant predictors of CRC screen-completion were the same as in the larger popu-ion.Previous work has demonstrated that CRC screen-was influenced by demographic factors such asome, education or race/ethnicity (Shapiro et al.,01; Carlos, Fendrick, Patterson & Bernstein, 2005).ese data are not routinely collected as part of thenical encounter and are unavailable for analysis.We were unable to determine colonoscopy utiliza-n prior to 1995. Therefore, we considered the sub-t to be current with CRC screening if she had everd colonoscopy. This minor limitation may haveowed underestimation of prevalence of CRC screen-. The study was conducted at one large academicter in the Midwest and may not generalize to othermen.Adjusted OR (95% CI)in All CasesAdjusted OR (95% CI)in Unique Cases 1.33 (0.951.86) 1.36 (0.832.21)1.12 (0.592.15) 0.93 (0.432.00)2.22 (1.463.38) 3.36 (1.597.10)1.03 (0.561.89) 3.27 (1.367.89)2.93 (1.117.72) *2.99 (1.605.60) 1.85 (0.516.74)2.43 (1.264.71) 1.73 (0.397.78)2.68 (1.435.04) 5.30 (1.5917.6)3.06 (1.665.64) 3.56 (1.1011.5)2.23 (0.3016.7) 0.98 (0.137.35)p 1.11 (0.572.16) 2.18 (0.786.07)n model to determine the adjusted odds ratios of each of theas assessed using forward selection. Given the few number ofriables (above) were included in the multivariate analysis.his variable was excluded in the multivariate analysis.thecoheinsratnoscrFuinglatinginc20ThclitiojechaallingcenwoImAlcarapratscrtiftherapingbelowimtiovieasAlrecradwi&scrphjusutiinginbehigoftioscrcocoopadteaaimalrscrscramtioincthephAcThCAReAmAmArArBolBroCaCaCaCaCoCraCuFinFraFreHaHaHeR. C. Carlos et al. / Womens Health Issues 15 (2005) 249257256plicationsthough nationally representative survey data indi-te that women who adhere to screening mammog-hy are more likely to adhere to CRC screening, thee of CRC screening after women undergoingeening mammography is quite low. We have iden-ied at least two predictors of CRC screening, namelytype of insurance and year of screening mammog-hy. These factors are not readily modifiable. Find-s suggest that although CRC screening appears toimproving with time, they still remain relatively. Therefore, other interventions are necessary toprove CRC screening in this population.Why should radiologists be interested in recogni-n of potential teachable moments in imaging? Somew radiologists participation in CRC screening onlyproviders of the double-contrast barium enema.though the barium enema is currently the onlyommended radiologic imaging test, the role ofiologists in CRC screening will continue to expandth the maturation of virtual colonography (BromerWeinberg, 2005; Rex, 2002).Furthermore, the use of existing imaging-basedeening programs, such as screening mammogra-y, represents a novel use of imaging technology, nott as a diagnostic tool, but as a means for improvinglization of other proven but underemployed screen-services. Recognition of such teachable momentsradiology extends the underlying value of imagingyond its contribution to clinical management, andhlights the potential of radiology services as meansimproving overall patient care. This shift in valua-n further improves the cost-effectiveness of theeening mammography program by taking into ac-unt the life savings that accrue from decreasinglon cancer mortality (Carlos, 2004).Mammography, a widely accepted test, can be anportunity for improving colon cancer screeningherence. Screening mammography may represent achable moment for behavior-related interventioned at reducing risk of colon cancer. Targeting thiseady compliant group can potentially increase CRCeening adherence to levels approximating that ofeening mammography. Future studies should ex-ine whether delivering CRC screening interven-ns at a screening mammography visit may yieldreased adherence to CRC screening, particularly invast majority of women who receive mammogra-y as part of their routine care.knowledgmente project is supported in part by the NIH/NCI 1 K07108664 01A1.ferenceserican Cancer Society (ACS). Guidelines for the cancer-relatedcheckup: recommendations and rationale. (1980). 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Review of Gastroen-terological Disorders, 2 (Suppl 1), S211.noll, R. A., Miller, S. M., Unger, M., McAleer, C., Halbherr, T., &Bradley, P. (2002). Characteristics of female smokers attending alung cancer screening program: A pilot study with implicationsfor program development. Lung Cancer, 37, 257265.S. Preventive Services Task Force. (2002). Screening for colorectalcancer, recommendations and rationale. Agency for Healthcare Re-search and Quality, 03-510A. Available:, L. C., Shapiro, J. A., & Nadel M. R. (2002). Are we doingenough to screen for colorectal cancer? Findings from the 1999Behavioral Risk Factor Surveillance System. Journal of FamilyPractice, 51, 761766.thor DescriptionsRuth C. Carlos is a MRI radiologist interested pri-rily in the use of diagnostic imaging test experi-ces as teachable moments for improving womensalth behavior.A. Mark Fendrick is a general internist who hasen extensively involved in assessment of emerginghnologies and more recently has focused on bene--based copayment as a means of improving healthhavior.Paul H. Abrahamse is a staff research scientist.Qian Dong is an MRI radiologist.Stephanie K. Patterson is a breast imaging radiolo-t interested in racial and ethnic disparities in breastncer detection and treatment.Steven J. Bernstein is a general internist focusingappropriateness of use of medical technologies,e roles doctors and patients play in decisionking, the effects of patient decision aids, andys to improve adherence with clinical guidelines.COLORECTAL CANCER SCREENING BEHAVIOR IN WOMEN ATTENDING SCREENING MAMMOGRAPHY: LONGITUDINAL TRENDS AND...IntroductionMethodsPatient population and data collectionAscertaining eligibility for colorectal cancer screeningIdentifying predictors of colorectal cancer screeningStatistical analysisQuality assurance of data collectionResultsCurrent with colon cancer screeningCompletion of colon cancer screening in eligible womenPredictors of colon cancer screening completionQuality assurance of data collectionDiscussionImplicationsAcknowledgmentReferencesAuthor Descriptions


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