Has
the
Use
of
Cervical,
Breast,
and
Colorectal
Cancer
Screening
Increased
in
the
United
States?
Laurie
M.
Anderson,
PhD,
MPH,
and
Daniel
S.
May,
PhD
Introdtion
The
benefits
of
screening
for
selected
cancers
are
known
from
clinical
trials,
case-control
studies,
and,
in
the
case
of
the
Papanicolaou
(Pap)
test,
historical
data.
Screening
mammography
and
clini-
cal
breast
examination
can
reduce
breast
cancer
mortality-3;
use
of
the
Pap
test
can
reduce
mortality
from
invasive
cervical
cancer4;
and
procedures
for
the
early
detection
of
colorectal
cancer,
such
as
fecal
occult
blood
testing,
proctoscopy,
and
digital
rectal
examination,
may
also
reduce
mortality.5'6
However,
reducing
mortality
through
cancer
screening
can
be
fully
realized
only
if
the
screening
tests
are
acceptable
to
the
population
and
are
repeated
at
appropriate
intervals
to
de-
tect
disease
at
an
early
stage.7
This
report
describes
the
use
of
cervical,
breast,
and
colorectal
cancer
screening
modalities
within
the
US
popu-
lation
in
1987
and
1992
as
reported
in
the
National
Health
Interview
Survey,
Cancer
Control
Supplement.8'9
The
purpose
is
to
assess
trends
in
the
use
of
these
tests,
especially
among
sociodemographic
sub-
groups.
Methods
The
National
Health
Interview
Sur-
vey,
Cancer
Control
Supplement,
con-
tains
data
obtained
through
interviews
with
a
sample
of
the
civilian,
noninstitu-
tionalized
US
population
aged
18
or
older
using
a
multistage
sample
design.8'9
The
number
of
persons
interviewed
for
the
1987
survey
was
22
043
and
for
the
1992
survey,
12
035.
The
1992
sample
was
smaller
because
budgetary
constraints
prompted
discontinuation
of
the
cancer
supplement
interviews
after
the
28th
week
of
that
year.9
The
1987
and
1992
surveys
ascer-
tained
cancer
screening
knowledge
and
practices
as
follows:
Women
aged
18
and
older
were
asked
about
their
use
of
the
Pap
test;
women
aged
40
and
older,
about
their
use
of
mammography
and
clinical
breast
examination;
and
men
and
women
aged
40
and
older,
about
their
use
of
proctoscopic
examination,
digital
rectal
examination,
and
fecal
occult
blood
test-
ing.
For
each
of
the
six
cancer
screening
tests,
the
number
of
persons
in
the
appropriate
sex-age
group
who
had
ever
had
the
test
done
and
the
time
since
their
last
test
were
determined.
Screening
tests
were
distinguished
from
diagnostic
tests
by
asking
respondents
whose
most
recent
test
was
within
3
years
of
the
interview
the
reason
for
their
last
test.
In
1987,
respon-
dents
were
asked
if
their
last
test
was
done
because
of
a
health
problem.
For
pur-
poses
of
this
analysis,
it
was
assumed
that
those
who
answered
no
received
the
test
for
screening
purposes.
In
1992,
the
respondents
were
asked
the
main
reason
they
had
had
the
test
and
were
given
multiple-choice
answers.
Screening
exams
were
determined
from
responses
that
the
test
was
part
of
a
routine
physical
exam,
was
a
screening
test,
or
was
a
baseline
test
(asked
for
mammography
only).
Clinically
recommended
screening
intervals
and
age
guidelines
vary
for
the
six
tests
discussed
in
this
report;
for
simplicity
of
presentation,
however,
1-
and
3-year
intervals
are
presented
for
the
screening
modalities
reported
by
persons
aged
50
and
older
and,
for
the
Pap
test,
by
those
aged
18
and
older.
To
take
into
account
the
design
of
the
complex,
multistage
sample,
SUDAAN
(Survey
Data
Analysis)
soft-
ware
was
used
to
calculate
the
population
estimates,
their
standard
errors,
and
the
standard
errors
of
differences
between
pairs
of
estimates.10
Laurie
M.
Anderson
is
with
the
Office
of
Surveillance
and
Analysis
and
Daniel
S.
May
is
with
the
Division
of
Cancer
Prevention
and
Control
at
the
National
Center
for
Chronic
Disease
Prevention
and
Health
Promotion,
Centers
for
Disease
Control
and
Prevention,
Atlanta,
Ga.
Requests
for
reprints
should
be
sent
to
Laurie
M.
Anderson,
Mailstop
K-30,
Centers
for
Disease
Control
and
Prevention,
1600
Clifton
Rd
NE,
Atlanta,
GA
30333.
This
paper
was
accepted
on
January
20,
1995.
June
1995,
Vol.
85,
No.
6
Public
Health
Briefs
Results
In
1992,
35%
of
women
aged
50
and
older,
or
twice
the
proportion
reported
in
1987,
reported
having
had
a
screening
mammogram
within
the
past
year
(Table
1).
A
doubling
was
also
observed
in
screening
reported
within
the
previous
3
years.
Recent
Pap
smear
screening
re-
ported
by
women
aged
18
and
older
remained
basically
the
same
in
1987
and
1992.
Among
the
colorectal
cancer
screen-
ing
modalities,
the
proportion
of
the
population
screened
in
the
past
year
increased
by
less
than
5%
between
1987
and
1992
for
each
of
the
three
tests
reported.
One
third
of
the
1992
survey
respondents
aged
50
and
older
had
never
heard
of
proctoscopic
screening
for
colo-
rectal
cancer,
a
proportion
also
observed
in
1987.
Screening
Trends
among
Sociodemographic
Subgroups
Reported
cancer
screening
within
the
past
3
years
increased
significantly
between
1987
and
1992
for
five
of
the
six
test
modalities
in
most
sociodemographic
subgroups
(Table
2).
Exceptions
are
noted
below.
Breast
cancer
screening.
Mammogra-
phy
screening
increased
among
all
age
groups.
Women
over
age
75
continue
to
report
less
screening
than
women
aged
50
to
74;
however,
the
greatest
percentage
gain
between
the
reporting
periods
([1992-
1987]
*
1987)
was
in
the
oldest
age
group.
The
difference
in
reported
mam-
mography
screening
between
Black
and
White
women
disappeared
by
1992.
On
the
other
hand,
reported
screening
among
Hispanic
women
remained
below
that
of
non-Hispanics.
Higher
levels
of
education
were
associated
with
a
greater
likelihood
of
reported
mammography.
A
striking
gap
was
also
evident
between
women
living
above
and
those
living
below
the
poverty
level.
Women
in
rural
areas
continued
to
report
less
breast
cancer
screening
than
did
women
residing
in
urban
areas.
Cervical
cancer
screening.
Women
in
older
age
groups
reported
considerably
lower
use
of
the
Pap
test
than
did
younger
women
(Table
3).
Hispanic
women
re-
ported
less
Pap
testing
than
did
non-
Hispanic
women,
although
the
difference
decreased
considerably
between
1987
and
1992.
Women
with
more
than
a
high
school
education,
women
living
above
the
poverty
level,
and
women
residing
in
urban
areas
continued
to
report
more
cervical
cancer
screening
than
did
their
counterparts.
Overall,
no
significant
changes
in
Pap
testing
in
the
demographic
subgroups
were
observed
from
1987
to
1992
except
for
a
decrease
among
women
with
12
years
of
education.
Colorectal
cancer
screening.
More
men
than
women
reported
having
had
a
screen-
ing
proctoscopic
examination
in
the
past
3
years
(Table
2).
Such
examinations
in-
creased
more
among
older
persons
whereas
digital
rectal
examination
de-
creased
with
age;
however,
no
age
trend
was
observed
for
fecal
occult
blood
test-
ing.
Use
of
all
three
colorectal
screening
modalities
was
lower
among
Hispanics
than
among
non-Hispanics
and
was
higher
among
those
with
more
years
of
educa-
tion.
Persons
living
above
the
poverty
level
reported
more
screening
than
those
living
below.
A
similar
relationship
was
found
for
urban
and
rural
residents.
Discussion
Between
1987
and
1992,
use
of
mammography
showed
large
gains,
par-
ticularly
among
Black
women;
however,
much
of
the
increase
was
already
evident
by
1990.11
In
addition,
breast
cancer
screening
increased
among
groups-
specifically,
lower
income,
less
educated,
and
rural
women-that
historically
have
had
limited
access
to
preventive
health
services.
Despite
this
progress,
several
public
health
challenges
remain.
Pap
testing
at
regular
intervals
should
continue
to
be
emphasized.
Clearly,
colorectal
cancer
screening
tests
are
not
used
as
often
as
are
other
cancer
screening
modalities.
This
finding,
unlike
that
for
the
Pap
test
and
mammogram,
may
be
owing
to
less
consen-
sus
among
providers
about
the
benefits
of
recommending
these
procedures
to
their
patients.
Further
demonstration
of
and
education
about
the
efficacy
of
colorectal
cancer
screening
modalities
may
be
re-
quired.
Most
striking
are
the
continued
dis-
parities
in
the
use
of
cancer
screening
tests
in
the
United
States
between
those
living
above
and
those
living
below
the
poverty
level,
between
the
more
educated
and
the
less
educated,
and
between
those
living
in
urban
areas
and
those
living
in
rural
areas.
O
American
Journal
of
Public
Health
841
TABLE
1-Survey
Population
according
to
Screening
Status,
Year,
and
Weighted
Population
Estimates'
of
Persons
Aged
50
Years
or
Older
(18
or
Older
for
Pap
Smear)
Heard
of Test,
%
Never
Most
Recently
Screened
Heard
Never
in
the
Past,
%
of
Test,
Had
Ever
Had
Test
and
Year
Sample
%
Test
Test
3
Years
1
Year
Mammography
1987
5
052
17.2
46.0
36.9
22.6
16.5
1992
2
709
10.4
22.5
67.1
48.8
35.3
Clinical
breast
examination
1987
5052
10.1
11.1
78.8
56.2
41.6
1992
2
709
...
b
12.4
87.6
61.1
46.0
Pap
smear
1987
12
868
3.9
7.1
89.0
64.6
48.6
1992
6
981
...
b
8.7
91.3
65.4
49.3
Proctoscopy
1987
8
240
34.1
39.7
26.2
6.4
3.3
1992
4
428
32.1
34.8
33.1
9.4
4.7
Digital
rectal
examination
1987
8
240
21.0
18.5
60.5
30.7
21.3
1992
4
428
17.7
20.1
62.2
35.7
25.8
Fecal
occult
blood
test
1987
8
240
17.0
41.6
41.4
21.7
14.9
1992
4
428
16.7
34.9
48.4
26.3
17.3
aStandard
errors
of
the estimates
ranged
from
0.2
to
1.1.
bRespondents
were
not
asked
if
they
had
heard
of
clinical
breast
examination
or
Pap
smear
in
1992.
Those
responding
that
they
had
never
had
the
exam
are
in
the
"Heard
of
but
Never
Had"
column.
June
1995,
Vol.
85,
No.
6
Public
Health
Briefs
TABLE
2-Reported
Use
of
Breast
and
Colorectal
Cancer
Detection
Tests
for
Screening
In
the
Past
3
Years
among
People'
Aged
50
and
Older,
by
Sociodemographic
Group,
1987
and
1992
Fecal
Clinical
Digital
Occult
Mammog-
Breast
Proctos-
Rectal
Blood
raphy
Examination
copy
Examination
Test
Sex
Female
1987
22.6
56.2
5.6
32.0
22.8
1992
48.8*
61.1
*
7.3*
35.5*
26.9*
Male
1987
7.3
29.1
20.3
1992
12.1*
36.0* 25.4*
Age,
y
50-64
1987
26.0
62.2
5.7
31.0
21.1
1992
54.5*
66.0
8.5*
37.6*
25.5*
65-74
1987
21.9
52.2
8.0
32.7 24.7
1992
48.8*
61.5*
10.0
36.9*
28.1
75+
1987
15.2
46.3
5.7
26.3
18.4
1992
35.0*
48.8
1
1.0*
28.9
25.6*
Race
Black
1987
19.0
52.1
4.0
23.5
15.8
1992
50.4*
64.2*
10.3*
31.0* 22.4*
White
1987
23.2
57.0
6.7
31.9
22.4
1992
48.8*
61.1*
9.4*
36.5*
26.6*
Ethnicity
Hispanic
1987
17.7
51.7
2.2
21.2
12.4
1992
44.7*
58.6
8.1*
22.7
16.9
Non-Hispanic
1987
22.9
56.4
6.6
31.2
22.1
1992
48.9*
61.2*
9.5*
36.3*
26.7*
Education,
y
<
12
1987
14.8
46.1
3.5
22.8
14.7
1992
35.5*
53.8*
6.6*
24.9
19.3*
12
1987
25.4
60.7
6.4
32.7
22.7
1992
52.0*
61.6
8.6*
35.2
25.3
>
12
1987
31.0
65.6
10.6
39.8
30.8
1992
61.2*
70.1
13.7*
48.2*
35.2*
Poverty
levelb
Above
1987
24.8
59.6
7.0
33.0
23.7
1992
53.7*
64.3*
10.3*
38.6*
28.8*
Below
1987
10.8
38.4
2.3
16.4
9.7
1992
27.0*
49.1*
5.3*
21.6
14.9*
Unknown
1987
18.0
47.6
4.2
23.6
14.7
1992
36.0*
51.5
6.1
25.9
17.2
Residence
Rural
1987
16.5
48.2
5.2
25.7
16.8
1992
43.6*
58.0*
8.5*
30.6*
19.8
Urban
1987
24.8
59.0
6.8
32.4
23.4
1992
50.5*
62.2*
9.7*
37.4*
28.4*
Note.
Data
come
from
the
National
Health
Interview
Survey,
Cancer
Control
Supplements,
1987
and
1992.
aMammography
and
clinical
breast
examination
percentages
are
based
on
female
respondents
only.
bPoverty
status
calculations
are
based
on
family
income,
family
size,
and
number
of
children
younger
than
18
years.
Subjects
in
the
"Unknown"
category
did
not
state
their
income.
*Significantly
different
between
1987
and
1992
(P
<
.05).
References
1.
Shapiro
S,
Venet
W,
Strax
P,
Roeser
R.
Selection,
followup,
and
analysis
in
the
Health
Insurance
Plan
Study:
a
random-
ized
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breast
cancer
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Natl
Cancer
Inst
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1985;67:56-74.
2.
Tabar
L,
Fagerberg
CJG,
Gad
A,
et
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Reduction
in
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from
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with
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Lancet.
1985;1:829-832.
842
American
Journal
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Public
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Verbeek
ALM,
Hendricks
JHCL,
Holland
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International
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Research
on
Cancer,
Working
Group
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Evaluation
of
Cervical
Cancer
Screening
Programs.
TABLE
3-Reported
Use
of
Pap
Test
In
the
Past
3
Years
among
Women
Aged
18
and
Older,
by
Sociodemographic
Group,
1987
and
1992
%1987
%1992
Age,
y
18-39
72.2
71.8
40-49
68.5
70.6
50-64
60.5
63.2
65-74
50.6
54.0
75+
35.8
35.8
Race
Black
67.5
71.6
White
64.6
64.9
Ethnicity
Hispanic
57.1
62.6
Non-Hispanic
65.2
65.6
Education,
y
<
12
47.2
48.7
12
66.6
63.7*
>
12
74.0
76.0
Poverty
level
Above
67.4
68.2
Below
52.4
57.3
Unknown
52.2
52.0
Residence
Rural
61.6
59.6
Urban
65.5
67.0
Note.
Data
come
from
the
National
Health
Interview
Survey,
Cancer
Control
Supple-
ments,
1987
and
1992.
*Signiflcantly
different
between
1987
and
1992
(P
<
.05).
Screening
for
squamous
cervical
cancer:
duration
of
low
risk
after
negative
results
of
cervical
cytology
and
its
implication
for
screening
policies.
BrMed
J.
1986;293:659-
664.
5.
DeCosse
JJ,
Tsioulias
GJ,
Jacobson
JS.
Colorectal
cancer:
detection,
treatment,
and
rehabilitation.
CA.
1994;44:27-42.
6.
Mandel
JS,
Bond
JH,
Church
TR,
et
al.
Reducing
mortality
from
colorectal
cancer
by
screening
for
fecal
occult
blood.
NEnglJ
Med.
1993;328:1365-1371.
7.
Morrison
AS.
Screening
in
Chronic
Disease.
New
York,
NY:
Oxford
University
Press;
1985.
8.
1987National
Health
Interview
Survey
Can-
cer
Control
Public
Use
Record.
Hyattsville,
Md:
National
Center
for
Health
Statistics;
1989.
9.
1992
National
Health
Interview
Survey
Can-
cer
Control
Public
Use
Record.
Hyattsville,
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