In all, women who get the recommended screenings for breast and cervical cancer are still far more likely than other women to have their colons examined through colonoscopy or other methods, the U-M team reports. But a large percentage of even these apparently health-conscious women fail to get screened for colon cancer, the No. 3 cause of cancer death in women after lung cancer and breast cancer.
In a presentation on May 15 at the annual meeting of the Society for General Internal Medicine, and in a recent talk at the American Roentgen Ray Society annual meeting, the U-M team reports findings from national and Michigan population samples that show a gap between adherence to different types of cancer screening.
In those presentations, and in a recent editorial in the American Journal of Managed Care, the researchers suggest that doctors use the occasion of one cancer screening to educate and motivate women to have another.
"Women have internalized the public health message that they should go for regular mammograms, and that they should have Pap smears, because that's what normal women do for themselves," says Ruth C. Carlos, M.D., M.S., the U-M Health System radiologist who led the research. "Now, they need to add colorectal screenings to the list – and we think that there's tremendous opportunity for physicians and health systems to use women's other screening appointments to increase their awareness."
Carlos is lead author on a presentation at the SGIM meeting, to be given by Steven Bernstein, M.D., that shows the gap between breast, cervix and colon cancer screening using data from the Centers for Disease Control and Prevention's 2001 Behavioral Risk Factors Surveillance Survey. It asked 52,478 women over the age of 50 what cancer checks they'd had, and compared their answers with American Cancer Society guidelines.
In all, only 46 percent had been checked for colon cancer as recommended, while nearly 70 percent were up-to-date with cervical cancer screening, and more than 82 percent had been getting their breasts checked like they should. Even among women who had had both mammograms and Pap smears regularly, only 51 percent had gotten their colons checked by colonoscopy or another test.
Still, women who had both mammograms and Pap smears as recommended were more than five times as likely to have had a colonoscopy or other colon cancer check as women who hadn't been getting breast or cervical tests. Even women who were up-to-date with either breast or cervical cancer screening, but not the other, were twice as likely to get a colon cancer screening as those who hadn't had either their breasts or cervix checked recently.
Women who had health insurance or a personal physician were more likely to have been screened for colon cancer, while women who described themselves as being in good health, and women who smoked, were less likely to go for colon screening.
The team found similar patterns when they looked at the records for all the women between the ages of 50 and 89 who had had mammograms at UMHS in 1998. Those results, presented at the ARRS meeting last week, showed that of 4,100 women, only 12 percent were current with their recommended colon cancer screening schedule at the time of their mammogram. Another three percent of the remainder went for a colon check sometime in the next few years.
"Screening mammogram is so accepted, we can use it as a teachable moment to educate women about colorectal cancer risk," says Carlos. "They've already accepted going in to see a doctor for a breast cancer check, and tolerating discomfort for the sake of their future health, so why don't we use that time as a means to reach out to women who might not be aware of their colon cancer risk and the fact that screening and early detection saves lives?"
Physicians, insurers and others need to think globally, and seek novel moments that can be used to educate patients so they don't fall through the cracks, she adds. For instance, radiologists can take time during mammography appointments to educate women about their colon cancer risk, and to suggest they ask their primary care doctors whether it's time for a colonoscopy or other colon test. ACS guidelines call for women (and men) over 50 who have no elevated risk factors to have a colonoscopy every 10 years, or a sigmoidoscopy every five years, or a test of their feces each year.
To increase women's adherence to colon cancer screening guidelines, Carlos and her colleagues say, doctors offices, insurance providers and health systems will have to make organizational changes. From reminder postcards to dedicated clerical staff to educational materials, they note that there are substantial opportunities to boost rates of screening. There's also an incentive: a major health care quality rating system, known as HEDIS, has recently added rates of colon cancer screening to its report cards for health providers.
The fact that most women go for mammograms and Pap smears year after year is great, but getting them in the door for their first colonoscopy may hold even more life-saving value, adds Mark Fendrick, M.D., M.S., Carlos's co-author on the AJMC editorial and a professor of internal medicine.
"Many women undergo repeated testing for one disease, and completely neglect screening tests for other treatable cancers," he says. "We need greater emphasis on, at minimum, initial testing for multiple conditions. That will maximize the benefits of screening."
Carlos is currently leading a clinical trial that randomizes women to receive education during their mammogram appointments about either colorectal cancer screening or diabetes screening. The researchers will review the women's records up to a year later to see if they get checked for colon cancer or spoke to their physicians about it.
If this approach works for colon cancer screening, it could also work for other tests that are under-utilized even though they're known to catch or prevent disease early, or allow for effective intervention, says Fendrick. From bone density scans to adult vaccines, he notes, "If we have a test that's at 80 percent adherence and another that's at 20, we should go to the 80 percent to encourage them to have that other test."