Understanding Those Who Do Understanding Those Who Do and Do Not Plan to Get and Do Not Plan to Get

Colorectal Cancer (CRC)Colorectal Cancer (CRC) ScreeningScreening

Costanza ME, White MJ, Stark JR, Stoddard Costanza ME, White MJ, Stark JR, Stoddard AM, Avrunin JS, Luckmann R, and Clemow LAM, Avrunin JS, Luckmann R, and Clemow L

University of Massachusetts Medical SchoolUniversity of Massachusetts Medical SchoolWorcester, MAWorcester, MA

Facts about CRCFacts about CRC

2nd leading cause of cancer-specific 2nd leading cause of cancer-specific deaths for men and women in the deaths for men and women in the U.S.U.S.

57,000 CRC deaths in 200357,000 CRC deaths in 2003

Facts about CRC ScreeningFacts about CRC Screening

CRC screening reduced mortality by CRC screening reduced mortality by >> 30%30%

< 50% of U.S. men and women over age < 50% of U.S. men and women over age 50 are current with screening guidelines50 are current with screening guidelines

CRC screening recommendations are CRC screening recommendations are more complex than those for other more complex than those for other cancers (e.g., breast, cervical) cancers (e.g., breast, cervical)

ACS Preferred CRC Screening ACS Preferred CRC Screening GuidelinesGuidelines

(Beginning at age 50 for those at average risk)(Beginning at age 50 for those at average risk)

Annual fecal occult blood test (FOBT) and Annual fecal occult blood test (FOBT) and sigmoidoscopy every 5 yearssigmoidoscopy every 5 years

Colonoscopy every 10 yearsColonoscopy every 10 years

Double-contrast barium enema every 5-10 Double-contrast barium enema every 5-10 yearsyears

Factors that Predict Adherence Factors that Predict Adherence to the Guidelinesto the Guidelines

Basic knowledge about CRC screeningBasic knowledge about CRC screening

Individual riskIndividual risk

Lack of barriers to screening (i.e. Lack of barriers to screening (i.e. embarrassment, fear of pain or abnormal embarrassment, fear of pain or abnormal results)results)

Intention to be screenedIntention to be screened – useful for – useful for tailoring interventionstailoring interventions

MethodsMethods

Baseline mailed survey for a RCT of telephone Baseline mailed survey for a RCT of telephone counseling to increase CRC screening counseling to increase CRC screening

Theoretical Framework – Weinstein’s Precaution Theoretical Framework – Weinstein’s Precaution Adoption Process Model (PAPM), a stage-based Adoption Process Model (PAPM), a stage-based model of health behaviormodel of health behavior

Study ParticipantsStudy Participants– 2,934 male & female patients from 37 primary 2,934 male & female patients from 37 primary

care practicescare practices– 50-75 years old50-75 years old– Had visited their PCP during the past 2 yearsHad visited their PCP during the past 2 years

MethodsMethods

Survey MeasuresSurvey Measures– CRC screening history and screening intentionCRC screening history and screening intention– PAPM stagePAPM stage– Pros and ConsPros and Cons– Perceived vulnerability and worryPerceived vulnerability and worry– Sociodemographic and other characteristicsSociodemographic and other characteristics

Data AnalysisData Analysis– Frequency distributions, cross classifications & logistic Frequency distributions, cross classifications & logistic

regression regression – Bivariate & multivariate associations – to develop a Bivariate & multivariate associations – to develop a

main effects modelmain effects model

Survey Response – 69%

Characteristics of Study Sample (n=1370)Characteristics of Study Sample (n=1370)

n (%)n (%)

AgeAge 50-6450-64

65-7565-75

1039 (75%)1039 (75%)

352 (25%)352 (25%)

GenderGender MaleMale

FemaleFemale

545 (40%)545 (40%)

818 (60%)818 (60%)

Race/EthnicityRace/Ethnicity White, non-HispanicWhite, non-Hispanic

Non-WhiteNon-White

1312 (94%)1312 (94%)

82 (6%)82 (6%)

Marital StatusMarital Status Married/PartnerMarried/Partner

Not Married/PartnerNot Married/Partner

1069 (77%)1069 (77%)

314 (23%)314 (23%)

Characteristics of Study Sample (n=1370)Characteristics of Study Sample (n=1370)

n (%)n (%)

Highest Highest Level of Level of EducationEducation

< High School Graduate< High School Graduate

High School Graduate/ Tech/ High School Graduate/ Tech/ Vocational SchoolVocational School

Some CollegeSome College

College GradCollege Grad

Post-College GradPost-College Grad

69 ( 5%)69 ( 5%)

333 (24%)333 (24%)

326 (24%)326 (24%)

297 (22%)297 (22%)

353 (26%)353 (26%)

Yearly Yearly incomeincome

<$25,000<$25,000

$25,000 - <$40,000$25,000 - <$40,000

$40,000 - <$65,000$40,000 - <$65,000

$65,000+$65,000+

208 (16%)208 (16%)

201 (16%)201 (16%)

268 (21%)268 (21%)

603 (47%)603 (47%)

Characteristics of Study Sample (n=1370)Characteristics of Study Sample (n=1370) n (%)n (%)

Historical Screening StatusHistorical Screening StatusMeets ACS preferred guidelinesMeets ACS preferred guidelines 499 (36%)499 (36%)

PAPM Stage of AdoptionPAPM Stage of Adoption

UnawareUnaware 94 (7%)94 (7%)

UnengagedUnengaged 220 (16%)220 (16%)

RelapsedRelapsed 51 (4%)51 (4%)

Decided NoDecided No 10 (1%)10 (1%)

UndecidedUndecided 142 (10%)142 (10%)

Decided YesDecided Yes 354 (26%)354 (26%)

Action/MaintenanceAction/Maintenance 499 (36%)499 (36%)

Characteristics of Study Sample (n=1370)Characteristics of Study Sample (n=1370)

n (%)n (%)

Provider RecommendationProvider Recommendation

Advised to have CRC screeningAdvised to have CRC screening 697 (51%)697 (51%)

Not advised to have CRC screening/don’t Not advised to have CRC screening/don’t knowknow

678 (49%)678 (49%)

Family HistoryFamily History

Blood relatives with CRCBlood relatives with CRC 153 (11%)153 (11%)

No blood relatives with CRC/don’t knowNo blood relatives with CRC/don’t know 1222 (89%)1222 (89%)

Factors Associated with Intention to Get Factors Associated with Intention to Get CRC ScreeningCRC Screening

Intention to Get CRC Screening by Age

05

1015202530354045

Un

aw

are

,U

ne

ng

ag

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or

Re

lap

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De

cid

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De

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ed

Ye

s

Act

ion

/M

ain

ten

an

cePAPM Stage

Pe

rce

nt

50-64 (1012)

65-75 (345)

p=<.0001

Factors Associated with Intention to Get Factors Associated with Intention to Get CRC ScreeningCRC Screening

Intention to Get CRC Screening by MD Recommendation

05

10152025303540

Un

aw

are

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ng

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or

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De

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ain

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PAPM Stage

Pe

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nt Advised CRC

screening (684)

Not Advised (659)

p=<.0001

Factors Associated with Intention to Get Factors Associated with Intention to Get CRC ScreeningCRC Screening

Intention to Get CRC Screening by Family History of CRC

010203040506070

Un

aw

are

,U

ne

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ag

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or

Re

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De

cid

ing

De

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Ye

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Act

ion

/M

ain

ten

an

ce

PAPM Stage

Pe

rce

nt Family History (153)

No family history/Don't know (1190)

p=<.0001

Factors Associated with Intention to Get Factors Associated with Intention to Get CRC ScreeningCRC Screening

Intention to Get CRC Screening by Pros and Cons

707580859095

100

Unaware,Unengaged or

Relapsed

Deciding Decided Yes Action/Maintenance

PAPM Stage

Pro

s an

d C

on

s S

core

p=<.0001

Factors Associated with Intention to Factors Associated with Intention to Get CRC ScreeningGet CRC Screening

(Mean)(Mean)

Unaware, Unaware, Unengaged Unengaged or Relapsedor Relapsed

DecidingDeciding Decided Decided YesYes

Action/ Action/ MaintenanceMaintenance

pp-Value-Value

Perceived Perceived VulnerabilityVulnerability

-0.3-0.3 -0.04-0.04 0.040.04 0.20.2 <0.0001<0.0001

Multivariable Logistic RegressionMultivariable Logistic Regression(Odds Ratio, overall (Odds Ratio, overall pp-Value)-Value)

Action/Maintenance/ Action/Maintenance/

Decided YesDecided Yes

vs.vs.

Undecided/Not Thinking Undecided/Not Thinking AboutAbout

UndecidedUndecided

vs.vs.

Not Thinking AboutNot Thinking About

AgeAge

50-64 vs. 65-7550-64 vs. 65-75 0.64 0.01 0.64 0.01

MD RecommendationMD Recommendation

Yes vs. No/DKYes vs. No/DK 1.93 <0.00011.93 <0.0001 1.74 0.021.74 0.02

Family HistoryFamily History

Yes vs. No/DKYes vs. No/DK 2.83 <0.00022.83 <0.0002

Pros & Cons of Pros & Cons of ScreeningScreening 1.13 <0.00011.13 <0.0001 1.05 <0.00011.05 <0.0001

DiscussionDiscussion

The study sample is highly educated and not The study sample is highly educated and not very diversevery diverse

Men and women are evenly distributed by Men and women are evenly distributed by stagestage

MD recommendation is powerful in motivating MD recommendation is powerful in motivating patients to actionpatients to action

DiscussionDiscussionIncreasing positive trends were seen in Increasing positive trends were seen in

– Perceived vulnerability: increases at Perceived vulnerability: increases at least 10-fold between each stage closer least 10-fold between each stage closer to actionto action

– Pros & Cons: score increases Pros & Cons: score increases significantly from unaware, unengaged significantly from unaware, unengaged or relapsed group to action/maintenance or relapsed group to action/maintenance indicating a growing positive perception indicating a growing positive perception of CRC screeningof CRC screening

DiscussionDiscussion

Implications for an intervention to Implications for an intervention to accelerate the adoption of CRC screeningaccelerate the adoption of CRC screening

– Those current with screening (36%) Those current with screening (36%) and those who intend to be screened and those who intend to be screened (26%) may require only a postcard (26%) may require only a postcard reminderreminder

– Those not intending to get screened Those not intending to get screened may benefit from an intervention tailored may benefit from an intervention tailored to PAPM stageto PAPM stage

DiscussionDiscussion

A tailored intervention could focus onA tailored intervention could focus on

– Increasing their knowledge about CRC Increasing their knowledge about CRC & CRC screening& CRC screening

– Addressing their barriers & cons to Addressing their barriers & cons to screening screening

– Encouraging them to get screened using Encouraging them to get screened using motivational interviewingmotivational interviewing

DiscussionDiscussion

Public Health ImplicationsPublic Health Implications

Those who are unaware, unengaged, Those who are unaware, unengaged, undecided or who have relapsed or undecided or who have relapsed or decided not to be screened represent a decided not to be screened represent a significant number of people between 50-significant number of people between 50-75 years of age in the U.S. population75 years of age in the U.S. population

Accelerating CRC screening adoption will Accelerating CRC screening adoption will reduce mortality & morbidity from this reduce mortality & morbidity from this diseasedisease