Objective: The purpose of this report is to examine (a) gender-specific correlates of colorectal cancer test use using recent national data from 2003 and (b) patterns of colorectal cancer screening by gender and test modality over time.

Methods: We analyze data from the 1987, 1992, 1998, 2000, and 2003 National Health Interview Surveys. Our sample consists of men and women ≥50 years never diagnosed with colorectal cancer and who reported a recent fecal occult blood test and/or endoscopy.

Results: In 2003, both men and women reported higher rates of colonoscopy (32.2% and 29.8%, respectively) than use of FOBT (16.1% and 15.3%, respectively) or sigmoidoscopy (7.6% and 5.9%, respectively). Men reported higher use of endoscopy than women if they had a usual source of health care, had talked to a general doctor, and had two to five visits to the doctor in the past year. Men and women 65 years and older had higher rates of any recommended colorectal cancer test (55.8% and 48.5%, respectively) than persons 50 to 64 years (males, 41.0%; females, 31.4%). Use of colorectal cancer tests also was higher among both genders if they were not Hispanic, had higher educational attainment, were former smokers, had health insurance or a usual source of care, or if they talked to a general doctor. Recent use of colorectal cancer tests has increased since 2000 for both women and men largely due to increased use of colonoscopy.

Conclusions: Colorectal cancer testing is increasing for both men and women, although the prevalence of testing remains higher in men. Our data support previous findings documenting socioeconomic disparities in colorectal cancer test use. Access barriers to screening could be particularly difficult to overcome if colonoscopy becomes the preferred colorectal cancer screening modality. (Cancer Epidemiol Biomarkers Prev 2006;15(2):389–94)

Despite expert consensus and national guidelines (1) endorsing colorectal cancer screening as an effective strategy for reducing colorectal cancer incidence and mortality, uptake of screening has remained relatively low. In 2000, less than half (42%) of U.S. age-eligible adults reported receiving any of the recommended colorectal cancer screening tests (2). This relatively low rate of use has left many wondering why we have not witnessed the same steep increase in colorectal cancer screening that was observed with mammography after evidence-based recommendations for breast cancer screening were published. All the elements were in place by 2000 for the takeoff. The U.S. Preventive Services Task Force first published guidelines recommending colorectal cancer screening in 1996 (3). Two years later, colorectal screening became a covered Medicare benefit (http://healthservices.cancer.gov/seermedicare/considerations/testing.html). In 2000, most health plans in the United States covered at least one of the recommended colorectal cancer screening modalities (4). Nevertheless, rates of colorectal cancer screening remain low.

Correlates of colorectal cancer test use are similar to those observed for mammography and Papanicolaou tests and include race; ethnicity; age; education; income; and having health insurance coverage, a usual source of health care, a recent physician visit, use of other cancer screening tests, and a recommendation from a physician for screening (2, 5, 6). However, other characteristics of colorectal cancer screening distinguish it from breast and cervical screening, including a range of test modalities from which patients and physicians can choose [fecal occult blood testing (FOBT), sigmoidoscopy, colonoscopy, and double-contrast barium enema], patient responsibility in preparing for or completing the test, and the fact that this preventive service is recommended for both men and women.

Differences in colorectal cancer test use by gender have been documented. In general, studies have shown that men are more likely than women to be tested for colorectal cancer (7, 8) and that patterns of use by gender differ by test modality. For example, Seeff et al. (2) reported greater use of FOBT by women compared with men in 2000, but found that men had endoscopy more often than women. That colorectal cancer test use is higher in men than women is surprising because, in general, men tend to have lower use of medical services than women (9). One also would expect that high rates of breast and cervical cancer screening (5) would translate into greater opportunities for women to learn about and receive recommendations for colorectal cancer screening. Having seen a physician in the past year is strongly associated with colorectal cancer test use and increases with increasing numbers of physician visits (2). Furthermore, men have more colonic adenomas than do women (10) and there is a belief that colorectal cancer is a man's disease. This belief, coupled with years of publicity focusing women's attention on breast rather than colon cancer, may have contributed to the slower uptake of colorectal cancer screening among women compared with men (11, 12).

Trends in colorectal cancer test use to date suggest that patterns of use by gender and test modality may be changing. The purpose of this report is to examine (a) gender-specific correlates of colorectal cancer test use using recent national data from 2003 and (b) patterns of colorectal cancer screening by gender and test modality over time. We report national trends for colorectal cancer test use for any purpose and for screening.

We analyze data from the 1987, 1992, 1998, 2000, and 2003 National Health Interview Surveys (NHIS). The NHIS is the leading source of health information on the civilian, noninstitutionalized population in the United States (13). It is an in-person household survey that collects demographic and health information on an annual basis. The NHIS survey design oversamples Hispanics and African Americans to improve the precision of estimates for those populations (14, 15).

The NHIS includes questions on the use of FOBT and colorectal endoscopy, but the questions evolved over time to accommodate new technologies and research. The 2000 NHIS was the first time that questions specifically distinguished home from office FOBT and that questions distinguished among endoscopic tests (sigmoidoscopy, colonoscopy, and proctoscopy). Test descriptions were read to all eligible respondents for the first time in the 2003 NHIS.

Our sample consists of men and women age ≥50 years, reflecting the recommended starting age for colorectal cancer screening among persons at average risk. Because patterns in colorectal cancer test use over time were similar when stratified by age (50-64 and 65+), we display trends for both age groups combined. We report recent test use at intervals in compliance with published guidelines (1). Respondents who said that they had the test for follow-up or for a specific problem were classified as not having a recent test for screening purposes.

Table 1 shows recent use of home FOBT, sigmoidoscopy, colonoscopy, and any recommended colorectal cancer test for men and women by selected sociodemographic variables. In 2003, both men and women reported higher rates of recent colonoscopy use (32.2% and 29.8%, respectively) than use of FOBT or sigmoidoscopy. There were no significant differences in the prevalence of FOBT by gender. Uptake of endoscopic tests was fairly comparable between men and women, with a few exceptions. Men with a usual source of health care, who had seen or talked to a general doctor, and who had two to five visits to the doctor in the past year reported higher use of sigmoidoscopy and colonoscopy than their female counterparts. Recent use of sigmoidoscopy was significantly greater for men overall (7.6% for men versus 5.9% for women) and for non-Hispanic men (7.8% for men versus 6.1% for women). Men ages 65 years and older reported greater use of colonoscopy than women the same age (39.5% versus 33.7%). Having any recent colorectal cancer tests was significantly different for men and women overall (46.5% versus 43.1%) and by non-Hispanic ethnicity, age 65 years or older, married, public health insurance coverage, having a usual source of health care, seen or talked to a general doctor, and having two to five physician visits in the past year.

Table 1.

Colorectal cancer testing trends by gender

Home FOBT within past year
Sigmoidoscopy within 5 y
Colonoscopy within 10 y
Any recommended test
Males
Females
Males
Females
Males
Females
Males
Females
n% (95% CI)n% (95% CI)n% (95% CI)n% (95% CI)n% (95% CI)n% (95% CI)n% (95% CI)n% (95% CI)
Totals 4,692 16.1 (14.8-17.5) 6,856 15.3 (14.3-16.5) 4,622 7.6 (6.7-8.5) 6,773 5.9 (5.2-6.6) 4,618 32.2 (30.6-33.8) 6,760 29.8 (28.4-31.2) 4,592 46.5 (44.9-48.2) 6,710 43.1 (41.6-44.6)
Race
White 4,026 16.2 (14.8-17.7) 5,795 15.3 (14.1-16.5) 3,983 7.6 (6.7-8.6) 5,719 6.1 (5.4-7.0) 3,980 33.1 (31.4-34.8) 5,711 30.6 (29.1-32.1) 3,954 47.5 (45.8-49.3) 5,674 44.1 (42.5-45.8)
Black 530 18.1 (14.2-22.8) 881 15.1 (12.8-17.7) 506 7.6 (5.1-11.3) 881 4.1 (2.9-5.8) 505 27.3 (22.6-32.5) 876 25.7 (22.8-28.9) 505 42.8 (37.2-48.5) 865 37.5 (34.2-40.9)
Other 136 8.7 (4.6-15.8) 180 17.6 (10.8-27.2) 133 5.6 (2.6-11.4) 173 3.7 (1.6-8.6) 133 21.1 (14.4-29.8) 173 18.2 (12.8-25.3) 133 28.9 (21.3-37.9) 171 32.1 (23.9-41.4)
Hispanic or Latino
Yes 514 12.3 (8.4-17.7) 777 10.1 (7.7-13.2) 504 4.0 (2.3-6.9) 760 3.1 (1.9-4.9) 503 21.1 (16.9-26.1) 759 22.3 (19.1-25.9) 497 30.4 (25.3-36.0) 758 31.4 (27.7-35.2)
No 4,178 16.4 (15.1-17.8) 6,079 15.7 (14.6-17.0) 4,118 7.8 (6.9-8.8) 6,013 6.1 (5.4-6.9) 4,115 33.0 (31.3-34.7) 6,001 30.3 (28.9-31.8) 4,095 47.7 (46.0-49.5) 5,952 44.0 (42.4-45.6)
Age (y)
50-64 2,793 14.2 (12.6-15.9) 3,582 13.6 (12.3-15.0) 2,772 7.0 (6.0-8.2) 3,555 5.4 (4.5-6.4) 2,770 27.8 (25.8-29.9) 3,551 26.7 (24.9-28.5) 2,754 41.0 (38.8-43.2) 3,536 39.0 (37.1-41.0)
≥65 1,899 19.3 (17.2-21.5) 3,274 17.6 (16.1-19.3) 1,850 8.5 (7.2-10.1) 3,218 6.5 (5.6-7.6) 1,848 39.5 (37.1-41.9) 3,209 33.7 (31.8-35.8) 1,838 55.8 (53.2-58.3) 3,174 48.5 (46.3-50.7)
Education
<High school 1,011 12.2 (10.0-15.0) 1,625 11.4 (9.7-13.5) 968 3.5 (2.4-5.1) 1,583 2.6 (1.8-3.8) 965 21.2 (18.3-24.4) 1,579 24.9 (22.3-27.7) 964 31.8 (28.5-35.4) 1,571 34.2 (31.3-37.2)
High school graduate 1,320 15.4 (13.2-17.9) 2,221 14.5 (12.8-16.5) 1,299 5.0 (3.8-6.5) 2,199 5.3 (4.2-6.6) 1,294 33.8 (30.8-36.8) 2,197 28.9 (26.7-31.2) 1,291 45.2 (42.1-48.3) 2,169 42.0 (39.6-44.4)
Some college 1,078 16.6 (14.3-19.2) 1,712 17.0 (14.8-19.4) 1,072 8.0 (6.5-10.0) 1,704 6.9 (5.5-8.6) 1,074 33.7 (30.7-36.9) 1,701 31.2 (28.6-33.9) 1,065 49.1 (45.6-52.5) 1,696 45.4 (42.6-48.2)
College graduate 1,238 19.2 (16.6-22.1) 1,220 19.3 (16.8-22.0) 1,235 12.3 (10.3-14.6) 1,211 9.0 (7.1-11.3) 1,237 36.7 (33.6-39.9) 1,208 35.5 (32.5-38.6) 1,229 55.5 (52.3-58.7) 1,205 52.6 (49.3-55.8)
Annual household income*
<$20,000 1,117 13.9 (11.5-16.6) 2,491 12.2 (10.7-13.9) 1,084 3.3 (2.3-4.9) 2,441 4.0 (3.1-5.0) 1,081 27.0 (24.1-30.3) 2,433 25.8 (23.8-27.9) 1,077 38.6 (35.5-41.9) 2,410 36.6 (34.4-38.8)$20,000-34,999 1,094 14.3 (11.9-17.0) 1,613 15.0 (13.1-17.2) 1,073 5.6 (3.9-8.0) 1,591 5.6 (4.2-7.3) 1,071 32.0 (28.4-35.9) 1,588 30.5 (27.6-33.7) 1,066 43.8 (40.2-47.5) 1,579 42.8 (39.3-46.3)
$35,000-54,999 933 17.7 (14.9-20.9) 1,144 16.8 (14.2-19.8) 925 7.5 (5.7-9.7) 1,143 5.9 (4.4-7.8) 926 33.2 (29.7-36.8) 1,143 31.7 (28.4-35.2) 917 47.8 (44.2-51.6) 1,132 46.5 (42.9-50.1)$55,000-74,999 544 15.6 (12.0-19.9) 593 14.4 (11.2-18.3) 539 8.1 (5.6-11.7) 588 7.4 (5.3-10.3) 539 34.0 (29.3-38.9) 586 31.1 (25.8-37.1) 537 48.1 (43.1-53.1) 587 44.7 (39.4-50.2)
≥$75,000 1,004 18.1 (15.1-21.4) 1,015 19.0 (16.3-22.0) 1,001 11.6 (9.4-14.3) 1,010 7.8 (6.1-10.0) 1,000 34.0 (30.6-37.7) 1,010 31.6 (27.8-35.6) 994 52.1 (48.3-55.9) 1,003 48.2 (44.0-52.3) Marital status Married 2,784 17.2 (15.7-18.9) 2,699 16.3 (14.8-18.0) 2,757 8.1 (7.0-9.3) 2,693 6.6 (5.6-7.8) 2,757 34.8 (32.8-36.9) 2,691 30.2 (28.3-32.1) 2,744 49.7 (47.6-51.7) 2,676 44.5 (42.4-46.7) Unmarried 1,892 13.1 (11.3-15.1) 4,131 14.1 (12.9-15.5) 1,849 6.1 (4.9-7.4) 4,050 4.9 (4.2-5.7) 1,845 24.9 (22.6-27.3) 4,039 29.4 (27.8-31.0) 1,832 37.8 (35.2-40.6) 4,007 41.4 (39.7-43.2) Health coverage None 396 4.1 (2.3-6.9) 535 5.3 (3.5-7.8) 385 1.6 (0.7-3.6) 527 1.6 (0.7-3.4) 383 13.4 (9.5-18.6) 528 10.9 (8.2-14.4) 383 17.2 (13.1-22.4) 525 16.6 (13.3-20.5) Public 811 17.9 (15.0-21.2) 1,642 14.2 (12.1-16.5) 800 5.8 (3.9-8.5) 1,601 4.1 (3.1-5.5) 799 30.0 (26.6-33.5) 1,594 25.4 (22.8-28.3) 786 45.1 (41.0-49.3) 1,577 37.6 (34.6-40.8) Private 3,475 16.9 (15.4-18.5) 4,662 16.7 (15.4-18.1) 3,428 8.4 (7.4-9.6) 4,627 6.8 (5.9-7.7) 3,427 34.3 (32.4-36.3) 4,620 32.8 (31.2-34.5) 3,414 49.5 (47.6-51.5) 4,590 47.3 (45.5-49.1) Usual source of care Yes 4,233 17.3 (15.9-18.7) 6,451 15.9 (14.7-17.0) 4,176 8.1 (7.2-9.1) 6,376 6.1 (5.4-6.9) 4,173 34.1 (32.5-35.9) 6,364 30.9 (29.5-32.3) 4,148 49.5 (47.8-51.3) 6,314 44.7 (43.2-46.3) No (ER included) 454 2.9 (1.5-5.5) 401 6.7 (4.1-10.6) 442 1.5 (0.6-3.3) 393 2.4 (1.1-5.0) 441 10.1 (7.3-13.9) 392 10.1 (7.3-13.9) 439 12.5 (9.4-16.5) 392 15.5 (11.8-20.3) Seen or talked to a general doctor (men and women) Yes 3,584 19.1 (17.5-20.7) 5,611 16.8 (15.6-18.0) 3,527 8.3 (7.4-9.4) 5,544 6.3 (5.5-7.2) 3,523 36.6 (34.7-38.5) 5,532 32.9 (31.4-34.4) 3,505 53.0 (51.0-55.0) 5,489 47.2 (45.6-48.8) No 1,108 5.8 (4.5-7.5) 1,240 8.7 (7.0-10.9) 1,094 4.9 (3.6-6.7) 1,225 4.0 (3.0-5.4) 1,094 17.0 (14.6-19.8) 1,224 15.4 (13.2-17.8) 1,087 24.2 (21.4-27.2) 1,217 24.2 (21.3-27.3) No. physician visits in past year None 728 2.8 (1.5-5.2) 599 2.4 (1.4-4.0) 719 3.7 (2.4-5.8) 594 1.6 (0.8-3.2) 719 11.2 (8.6-14.3) 594 7.4 (5.3-10.2) 714 16.4 (13.2-20.2) 591 10.0 (7.7-13.0) One 624 12.1 (9.5-15.4) 731 10.6 (8.5-13.1) 612 5.7 (3.9-8.1) 726 4.4 (3.1-6.1) 613 22.0 (18.6-25.8) 724 18.5 (15.4-22.0) 610 32.0 (28.1-36.2) 720 30.0 (26.4-33.8) 2-5 1,928 18.1 (16.0-20.3) 2,833 16.5 (15.0-18.3) 1,892 8.9 (7.5-10.4) 2,790 6.0 (4.9-7.3) 1,891 37.1 (34.5-39.7) 2,787 29.1 (27.2-31.2) 1,892 53.1 (50.5-55.8) 2,770 43.7 (41.7-45.7) ≥6 1,378 21.3 (18.8-24.1) 2,639 18.4 (16.6-20.3) 1,365 8.5 (6.9-10.4) 2,611 7.1 (6.0-8.4) 1,361 40.1 (37.4-42.9) 2,603 39.0 (36.9-41.2) 1,343 58.5 (55.5-61.5) 2,579 54.0 (51.5-56.4) Mammogram within past 2 y Yes NA 4,797 19.6 (18.2-21.1) NA 4,739 7.3 (6.4-8.3) NA 4,736 35.8 (34.2-37.4) NA 4,714 52.4 (50.7-54.1) No NA 1,984 4.4 (3.4-5.6) NA 1,964 2.2 (1.5-3.1) NA 1,957 14.2 (12.5-16.1) NA 1,937 18.8 (16.9-20.9) Papanicolaou smear within past 3 y Yes NA 4,683 18.4 (17.0-19.8) NA 4,633 6.9 (6.0-7.8) NA 4,629 33.7 (32.0-35.3) NA 4,607 49.2 (47.5-50.9) No NA 2,048 8.4 (7.1-10.0) NA 2,019 3.5 (2.5-4.8) NA 2,013 20.3 (18.3-22.5) NA 1,995 28.3 (25.9-30.8) PSA within past year Yes 1,912 26.5 (24.1-29.0) NA 1,883 11.8 (10.2-13.7) NA 1,885 45.4 (42.9-48.0) NA 1,885 66.7 (64.2-69.2) NA No 2,630 8.0 (6.9-9.4) NA 2,595 4.3 (3.6-5.3) NA 2,590 21.8 (20.0-23.7) NA 2,572 30.6 (28.6-32.7) NA Smoking status Never 1,761 14.2 (12.2-16.5) 4,037 15.1 (13.7-16.6) 1,735 7.8 (6.4-9.5) 3,991 6.2 (5.4-7.2) 1,732 29.1 (26.6-31.8) 3,980 27.9 (26.3-29.6) 1,719 43.7 (41.0-46.4) 3,950 41.5 (39.8-43.2) Former 1,990 18.6 (16.7-20.7) 1,787 18.6 (16.5-21.0) 1,964 8.2 (7.0-9.6) 1,766 6.7 (5.4-8.3) 1,963 39.4 (36.8-42.1) 1,763 37.2 (34.5-40.1) 1,952 53.9 (51.4-56.4) 1,754 52.4 (49.4-55.4) Current 923 14.3 (11.9-17.2) 1,003 10.4 (8.2-13.1) 905 5.6 (4.1-7.5) 991 3.0 (2.0-4.4) 905 21.7 (18.8-24.9) 992 23.7 (20.8-27.0) 904 35.3 (31.8-39.0) 982 33.0 (29.5-36.6) Home FOBT within past year Sigmoidoscopy within 5 y Colonoscopy within 10 y Any recommended test Males Females Males Females Males Females Males Females n% (95% CI)n% (95% CI)n% (95% CI)n% (95% CI)n% (95% CI)n% (95% CI)n% (95% CI)n% (95% CI) Totals 4,692 16.1 (14.8-17.5) 6,856 15.3 (14.3-16.5) 4,622 7.6 (6.7-8.5) 6,773 5.9 (5.2-6.6) 4,618 32.2 (30.6-33.8) 6,760 29.8 (28.4-31.2) 4,592 46.5 (44.9-48.2) 6,710 43.1 (41.6-44.6) Race White 4,026 16.2 (14.8-17.7) 5,795 15.3 (14.1-16.5) 3,983 7.6 (6.7-8.6) 5,719 6.1 (5.4-7.0) 3,980 33.1 (31.4-34.8) 5,711 30.6 (29.1-32.1) 3,954 47.5 (45.8-49.3) 5,674 44.1 (42.5-45.8) Black 530 18.1 (14.2-22.8) 881 15.1 (12.8-17.7) 506 7.6 (5.1-11.3) 881 4.1 (2.9-5.8) 505 27.3 (22.6-32.5) 876 25.7 (22.8-28.9) 505 42.8 (37.2-48.5) 865 37.5 (34.2-40.9) Other 136 8.7 (4.6-15.8) 180 17.6 (10.8-27.2) 133 5.6 (2.6-11.4) 173 3.7 (1.6-8.6) 133 21.1 (14.4-29.8) 173 18.2 (12.8-25.3) 133 28.9 (21.3-37.9) 171 32.1 (23.9-41.4) Hispanic or Latino Yes 514 12.3 (8.4-17.7) 777 10.1 (7.7-13.2) 504 4.0 (2.3-6.9) 760 3.1 (1.9-4.9) 503 21.1 (16.9-26.1) 759 22.3 (19.1-25.9) 497 30.4 (25.3-36.0) 758 31.4 (27.7-35.2) No 4,178 16.4 (15.1-17.8) 6,079 15.7 (14.6-17.0) 4,118 7.8 (6.9-8.8) 6,013 6.1 (5.4-6.9) 4,115 33.0 (31.3-34.7) 6,001 30.3 (28.9-31.8) 4,095 47.7 (46.0-49.5) 5,952 44.0 (42.4-45.6) Age (y) 50-64 2,793 14.2 (12.6-15.9) 3,582 13.6 (12.3-15.0) 2,772 7.0 (6.0-8.2) 3,555 5.4 (4.5-6.4) 2,770 27.8 (25.8-29.9) 3,551 26.7 (24.9-28.5) 2,754 41.0 (38.8-43.2) 3,536 39.0 (37.1-41.0) ≥65 1,899 19.3 (17.2-21.5) 3,274 17.6 (16.1-19.3) 1,850 8.5 (7.2-10.1) 3,218 6.5 (5.6-7.6) 1,848 39.5 (37.1-41.9) 3,209 33.7 (31.8-35.8) 1,838 55.8 (53.2-58.3) 3,174 48.5 (46.3-50.7) Education <High school 1,011 12.2 (10.0-15.0) 1,625 11.4 (9.7-13.5) 968 3.5 (2.4-5.1) 1,583 2.6 (1.8-3.8) 965 21.2 (18.3-24.4) 1,579 24.9 (22.3-27.7) 964 31.8 (28.5-35.4) 1,571 34.2 (31.3-37.2) High school graduate 1,320 15.4 (13.2-17.9) 2,221 14.5 (12.8-16.5) 1,299 5.0 (3.8-6.5) 2,199 5.3 (4.2-6.6) 1,294 33.8 (30.8-36.8) 2,197 28.9 (26.7-31.2) 1,291 45.2 (42.1-48.3) 2,169 42.0 (39.6-44.4) Some college 1,078 16.6 (14.3-19.2) 1,712 17.0 (14.8-19.4) 1,072 8.0 (6.5-10.0) 1,704 6.9 (5.5-8.6) 1,074 33.7 (30.7-36.9) 1,701 31.2 (28.6-33.9) 1,065 49.1 (45.6-52.5) 1,696 45.4 (42.6-48.2) College graduate 1,238 19.2 (16.6-22.1) 1,220 19.3 (16.8-22.0) 1,235 12.3 (10.3-14.6) 1,211 9.0 (7.1-11.3) 1,237 36.7 (33.6-39.9) 1,208 35.5 (32.5-38.6) 1,229 55.5 (52.3-58.7) 1,205 52.6 (49.3-55.8) Annual household income* <$20,000 1,117 13.9 (11.5-16.6) 2,491 12.2 (10.7-13.9) 1,084 3.3 (2.3-4.9) 2,441 4.0 (3.1-5.0) 1,081 27.0 (24.1-30.3) 2,433 25.8 (23.8-27.9) 1,077 38.6 (35.5-41.9) 2,410 36.6 (34.4-38.8)
$20,000-34,999 1,094 14.3 (11.9-17.0) 1,613 15.0 (13.1-17.2) 1,073 5.6 (3.9-8.0) 1,591 5.6 (4.2-7.3) 1,071 32.0 (28.4-35.9) 1,588 30.5 (27.6-33.7) 1,066 43.8 (40.2-47.5) 1,579 42.8 (39.3-46.3)$35,000-54,999 933 17.7 (14.9-20.9) 1,144 16.8 (14.2-19.8) 925 7.5 (5.7-9.7) 1,143 5.9 (4.4-7.8) 926 33.2 (29.7-36.8) 1,143 31.7 (28.4-35.2) 917 47.8 (44.2-51.6) 1,132 46.5 (42.9-50.1)
$55,000-74,999 544 15.6 (12.0-19.9) 593 14.4 (11.2-18.3) 539 8.1 (5.6-11.7) 588 7.4 (5.3-10.3) 539 34.0 (29.3-38.9) 586 31.1 (25.8-37.1) 537 48.1 (43.1-53.1) 587 44.7 (39.4-50.2) ≥$75,000 1,004 18.1 (15.1-21.4) 1,015 19.0 (16.3-22.0) 1,001 11.6 (9.4-14.3) 1,010 7.8 (6.1-10.0) 1,000 34.0 (30.6-37.7) 1,010 31.6 (27.8-35.6) 994 52.1 (48.3-55.9) 1,003 48.2 (44.0-52.3)
Marital status
Married 2,784 17.2 (15.7-18.9) 2,699 16.3 (14.8-18.0) 2,757 8.1 (7.0-9.3) 2,693 6.6 (5.6-7.8) 2,757 34.8 (32.8-36.9) 2,691 30.2 (28.3-32.1) 2,744 49.7 (47.6-51.7) 2,676 44.5 (42.4-46.7)
Unmarried 1,892 13.1 (11.3-15.1) 4,131 14.1 (12.9-15.5) 1,849 6.1 (4.9-7.4) 4,050 4.9 (4.2-5.7) 1,845 24.9 (22.6-27.3) 4,039 29.4 (27.8-31.0) 1,832 37.8 (35.2-40.6) 4,007 41.4 (39.7-43.2)
Health coverage
None 396 4.1 (2.3-6.9) 535 5.3 (3.5-7.8) 385 1.6 (0.7-3.6) 527 1.6 (0.7-3.4) 383 13.4 (9.5-18.6) 528 10.9 (8.2-14.4) 383 17.2 (13.1-22.4) 525 16.6 (13.3-20.5)
Public 811 17.9 (15.0-21.2) 1,642 14.2 (12.1-16.5) 800 5.8 (3.9-8.5) 1,601 4.1 (3.1-5.5) 799 30.0 (26.6-33.5) 1,594 25.4 (22.8-28.3) 786 45.1 (41.0-49.3) 1,577 37.6 (34.6-40.8)
Private 3,475 16.9 (15.4-18.5) 4,662 16.7 (15.4-18.1) 3,428 8.4 (7.4-9.6) 4,627 6.8 (5.9-7.7) 3,427 34.3 (32.4-36.3) 4,620 32.8 (31.2-34.5) 3,414 49.5 (47.6-51.5) 4,590 47.3 (45.5-49.1)
Usual source of care
Yes 4,233 17.3 (15.9-18.7) 6,451 15.9 (14.7-17.0) 4,176 8.1 (7.2-9.1) 6,376 6.1 (5.4-6.9) 4,173 34.1 (32.5-35.9) 6,364 30.9 (29.5-32.3) 4,148 49.5 (47.8-51.3) 6,314 44.7 (43.2-46.3)
No (ER included) 454 2.9 (1.5-5.5) 401 6.7 (4.1-10.6) 442 1.5 (0.6-3.3) 393 2.4 (1.1-5.0) 441 10.1 (7.3-13.9) 392 10.1 (7.3-13.9) 439 12.5 (9.4-16.5) 392 15.5 (11.8-20.3)
Seen or talked to a general doctor (men and women)
Yes 3,584 19.1 (17.5-20.7) 5,611 16.8 (15.6-18.0) 3,527 8.3 (7.4-9.4) 5,544 6.3 (5.5-7.2) 3,523 36.6 (34.7-38.5) 5,532 32.9 (31.4-34.4) 3,505 53.0 (51.0-55.0) 5,489 47.2 (45.6-48.8)
No 1,108 5.8 (4.5-7.5) 1,240 8.7 (7.0-10.9) 1,094 4.9 (3.6-6.7) 1,225 4.0 (3.0-5.4) 1,094 17.0 (14.6-19.8) 1,224 15.4 (13.2-17.8) 1,087 24.2 (21.4-27.2) 1,217 24.2 (21.3-27.3)
No. physician visits in past year
None 728 2.8 (1.5-5.2) 599 2.4 (1.4-4.0) 719 3.7 (2.4-5.8) 594 1.6 (0.8-3.2) 719 11.2 (8.6-14.3) 594 7.4 (5.3-10.2) 714 16.4 (13.2-20.2) 591 10.0 (7.7-13.0)
One 624 12.1 (9.5-15.4) 731 10.6 (8.5-13.1) 612 5.7 (3.9-8.1) 726 4.4 (3.1-6.1) 613 22.0 (18.6-25.8) 724 18.5 (15.4-22.0) 610 32.0 (28.1-36.2) 720 30.0 (26.4-33.8)
2-5 1,928 18.1 (16.0-20.3) 2,833 16.5 (15.0-18.3) 1,892 8.9 (7.5-10.4) 2,790 6.0 (4.9-7.3) 1,891 37.1 (34.5-39.7) 2,787 29.1 (27.2-31.2) 1,892 53.1 (50.5-55.8) 2,770 43.7 (41.7-45.7)
≥6 1,378 21.3 (18.8-24.1) 2,639 18.4 (16.6-20.3) 1,365 8.5 (6.9-10.4) 2,611 7.1 (6.0-8.4) 1,361 40.1 (37.4-42.9) 2,603 39.0 (36.9-41.2) 1,343 58.5 (55.5-61.5) 2,579 54.0 (51.5-56.4)
Mammogram within past 2 y
Yes NA 4,797 19.6 (18.2-21.1) NA 4,739 7.3 (6.4-8.3) NA 4,736 35.8 (34.2-37.4) NA 4,714 52.4 (50.7-54.1)
No NA 1,984 4.4 (3.4-5.6) NA 1,964 2.2 (1.5-3.1) NA 1,957 14.2 (12.5-16.1) NA 1,937 18.8 (16.9-20.9)
Papanicolaou smear within past 3 y
Yes NA 4,683 18.4 (17.0-19.8) NA 4,633 6.9 (6.0-7.8) NA 4,629 33.7 (32.0-35.3) NA 4,607 49.2 (47.5-50.9)
No NA 2,048 8.4 (7.1-10.0) NA 2,019 3.5 (2.5-4.8) NA 2,013 20.3 (18.3-22.5) NA 1,995 28.3 (25.9-30.8)
PSA within past year
Yes 1,912 26.5 (24.1-29.0) NA 1,883 11.8 (10.2-13.7) NA 1,885 45.4 (42.9-48.0) NA 1,885 66.7 (64.2-69.2) NA
No 2,630 8.0 (6.9-9.4) NA 2,595 4.3 (3.6-5.3) NA 2,590 21.8 (20.0-23.7) NA 2,572 30.6 (28.6-32.7) NA
Smoking status
Never 1,761 14.2 (12.2-16.5) 4,037 15.1 (13.7-16.6) 1,735 7.8 (6.4-9.5) 3,991 6.2 (5.4-7.2) 1,732 29.1 (26.6-31.8) 3,980 27.9 (26.3-29.6) 1,719 43.7 (41.0-46.4) 3,950 41.5 (39.8-43.2)
Former 1,990 18.6 (16.7-20.7) 1,787 18.6 (16.5-21.0) 1,964 8.2 (7.0-9.6) 1,766 6.7 (5.4-8.3) 1,963 39.4 (36.8-42.1) 1,763 37.2 (34.5-40.1) 1,952 53.9 (51.4-56.4) 1,754 52.4 (49.4-55.4)
Current 923 14.3 (11.9-17.2) 1,003 10.4 (8.2-13.1) 905 5.6 (4.1-7.5) 991 3.0 (2.0-4.4) 905 21.7 (18.8-24.9) 992 23.7 (20.8-27.0) 904 35.3 (31.8-39.0) 982 33.0 (29.5-36.6)

NOTE: Data are from NHIS 2003: counts, weighted percentages, and 95% confidence intervals. Respondents are men and women ages 50 years and older who have never been diagnosed with colorectal cancer. n denotes the actual number of valid NHIS 2003 respondents and % denotes the weighted percentage of respondents with a recent test. Subjects who received a proctoscopy in the past 5 years are excluded from analysis. Values in boldface indicate a significant difference between males and females.

Abbreviations: 95% CI, 95% confidence interval; ER, emergency room; NA, not applicable.

*

Missing Incomes are imputed via The National Center for Health Statistics NHIS 2003 Imputed Family Income Files.

Men and women 65 years and older had higher rates of any recommended colorectal cancer test than persons 50 to 64 years of age. Use of colorectal cancer tests also was higher among men and women if they were not Hispanic or Latino, had higher educational attainment, were former smokers, had health insurance coverage, a usual source of care, or if they talked to a general doctor (Table 1). For example, 53% of men and 47% of women who saw or talked to a general doctor reported having any recommended colorectal cancer test compared with men and women who did not see or talk to a general doctor (only 24% of men and women in the latter group reported any recommended test). Likewise, women who reported recent mammography or Papanicolaou testing had higher rates of colorectal cancer test use than women who did not report having these other screening tests, as did men who reported having a recent prostate-specific antigen test. Former smokers of both genders (men, 53.9%; women, 52.4%) were more likely to report having any recommended colorectal cancer test than never (men, 43.7%; women, 41.5%) or current smokers (men, 35.3%; women, 33%). Colorectal cancer test use also increased for men and women as the number of visits to the doctor in the past year increased.

Figure 1 displays trends in recent use of colorectal cancer tests from 1987 to 2003 for women and men. The broken lines between 1998 and 2000 represent changes in the survey questions that were redesigned to more accurately distinguish between recommended screening tests. As can be seen, colorectal cancer testing rates have increased since 2000 for both women and men, and this increase is largely driven by a steep increase in colonoscopy use. Recent use of sigmoidoscopy has declined since 2000. Likewise, rates of home FOBT use among women (not shown in figure) declined from 17.5% in 2000 to 15.4% in 2003. Among men, rates of home FOBT in the past year were similar in 2000 and 2003 (16.6% and 16.3%, respectively).

Figure 1.

Recent use of colorectal cancer tests: 1987, 1992, 1998, 2000, and 2003. Percentages are standardized to the 2000 projected U.S. population by 5-year age groups. The relevant survey questions were redesigned after 1998; broken lines represent these changes. *, 1998 and before includes home or office FOBT, and colonoscopy, protoscopy, and sigmoidoscopy because we cannot adequately distinguish between tests during these years. Post 1998 includes home FOBT and sigmoidoscopy and colonoscopy. Source: NHIS.

Figure 1.

Recent use of colorectal cancer tests: 1987, 1992, 1998, 2000, and 2003. Percentages are standardized to the 2000 projected U.S. population by 5-year age groups. The relevant survey questions were redesigned after 1998; broken lines represent these changes. *, 1998 and before includes home or office FOBT, and colonoscopy, protoscopy, and sigmoidoscopy because we cannot adequately distinguish between tests during these years. Post 1998 includes home FOBT and sigmoidoscopy and colonoscopy. Source: NHIS.

Close modal

We also examined trends in the proportion of colorectal cancer test use that could be attributed to uptake of tests for screening purposes. Figure 2 displays colorectal cancer test use for any reason as well as for screening specifically. By 2003, for men and women, almost all (e.g., 90%) home FOBT was done for screening purposes. Not surprisingly, a smaller percentage of all recent endoscopies were done specifically for screening, although the proportion of endoscopies being done for screening purposes seems to be rising in both men and women. In 1998, 68% of men and 54% of women reported that their recent endoscopy was for screening purposes. By 2000, the proportion of endoscopies done for screening rose to 74% in men and 68% in women.

Figure 2.

Recent colorectal cancer test use for any reason and for screening purposes. Respondents are age 50+ years. All percentages are standardized to the 2000 projected U.S. population by 5-year age groups. FOBT includes tests within the past year. Recent endoscopy includes tests within the past 5 years (also includes colonoscopies in the past 10 years for 2000 and 2003). Source: NHIS.

Figure 2.

Recent colorectal cancer test use for any reason and for screening purposes. Respondents are age 50+ years. All percentages are standardized to the 2000 projected U.S. population by 5-year age groups. FOBT includes tests within the past year. Recent endoscopy includes tests within the past 5 years (also includes colonoscopies in the past 10 years for 2000 and 2003). Source: NHIS.

Close modal

Our analysis of NHIS data suggests that 2000 may be the beginning of an increase in colorectal cancer screening similar to the increase in mammography observed between 1987 and 1992. Increases in test use are similar for men and women, although higher rates of sigmoidoscopy and colonoscopy in men who report having a usual source of health care, having seen or talked to a general doctor, and who report two to five doctor visits in the past year might suggest differential referral or acceptance of these tests by gender.

With the exception of age, correlates of colorectal cancer tests are similar to those for use of Papanicolaou tests and mammograms.

Increased use of colonoscopy is driving the increase in colorectal cancer testing. The extension of Medicare coverage for screening colonoscopy to average-risk beneficiaries in 2000 has likely contributed to this increase and is supported by our data. Test use rates among men and women ages 65 years and older are significantly higher than for those ages 50 to 64 years. Uptake of colonoscopy has also been influenced by media attention, professional endorsement of colonoscopy, and reimbursement. Katie Couric's televised colonoscopy on the Today Show in March 2000 was associated with a temporal increase in use of that test (16). The American College of Gastroenterology recommendation in 2000 of colonoscopy as the preferred colorectal cancer screening test for average-risk patients (17) and the greater profitability of colonoscopy compared with sigmoidoscopy also are probable contributors to the surge in colonoscopy. The current average Medicare reimbursement for both facility and professional fees is over thrice higher for screening colonoscopy than for screening sigmoidoscopy.3

3

G.M. Brooks, Center for Medicaid and Medicare Services, personal communication, July 21, 2005.

Low-profit margins make it difficult for most primary care physicians to incorporate sigmoidoscopy in practice (18) and many consequently refer their patients for colorectal endoscopy (19).

The menu of colorectal cancer screening tests allows for flexibility, but can render decisions about recommending or choosing a particular test difficult. Each test has tradeoffs in terms of efficacy, complications, discomfort, frequency, time, and cost. Which test is best is a matter of personal preference that should be considered when recommendations for screening are made (20). It is not possible for us to assess with these data whether the increasing trend in colonoscopy use and the concurrent decline in sigmoidoscopy and FOBT reflect patient or provider preferences.

Our study is limited by the fact that NHIS data are cross-sectional and limited to self-report of selected individual correlates of colorectal test use. Self-reports of screening could lead to overestimates of adherence (21). We are unable to explore the influence of other potentially important correlates of screening, such as provider characteristics and practices, patient-provider communication, health plan policies regarding colorectal cancer tests, and geographic capacity for screening. Furthermore, the redesign of relevant survey questions to ask about endoscopic tests separately after 1998 may exaggerate the rate at which sigmoidoscopy declined and colonoscopy rose since 1998. Nevertheless, the recent national data do indicate that prevalence of colorectal cancer test use is higher than in previous years and that recent colonoscopy accounts for most of colorectal test use.

That the increase in colorectal cancer test use is almost exclusively driven by colonoscopy has implications for public health practice in the United States. Colonoscopy is an expensive, invasive, relatively time-consuming test that currently must be done by a physician. Even assuming that capacity exists to perform screening colonoscopy for every age-eligible person at recommended frequency (18, 22), promotion of colonoscopy as the “preferred” colorectal cancer screening test may widen socioeconomic disparities. Our data support previous findings that there are disparities in the use of screening by educational attainment, household income, health insurance coverage, and having a usual source of health care (2, 23). These barriers to screening could be particularly difficult to overcome if colonoscopy becomes the preferred colorectal cancer screening modality. Clinicians, health advocates, and policy-makers alike need to carefully consider the messages that are communicated to the public about colorectal cancer test options. Reliance on colonoscopy alone may be insufficient for high participation in colorectal cancer screening at a population level, which will be required to effectively reduce morbidity and mortality from colorectal cancer.

Grant support: National Cancer Institute grants CA 76330 and CA 97263 (S.W. Vernon).

The costs of publication of this article were defrayed in part by the payment of page charges. This article must therefore be hereby marked advertisement in accordance with 18 U.S.C. Section 1734 solely to indicate this fact.

We thank Tim McNeel and William Waldron of Information Management Services, Silverspring, MD for expert programming.

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