US women screen at low rates for both cervical and colorectal cancers than a single cancer: a cross-sectional population-based observational study

  1. Diane M Harper
  2. Melissa Plegue
  3. Masahito Jimbo
  4. Sherri Sheinfeld Gorin
  5. Ananda Sen

  • Curated by eLife

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    Evaluation Summary:

    The authors analyzed a national database to gain insights on deficits in cervical and colorectal cancer screening in the United States. Their work may provide a set of predictors to enhance health promotion messaging to women who are underscreened and thus eliminate disparities in cancer control.

    (This preprint has been reviewed by eLife. We include the public reviews from the reviewers here; the authors also receive private feedback with suggested changes to the manuscript. Reviewer #1 agreed to share their name with the authors.)

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Abstract

Using screen counts, women 50–64 years old have lower cancer screening rates for cervical and colorectal cancers (CRC) than all other age ranges. This paper aims to present woman-centric cervical cancer and CRC screenings to determine the predictor of being up-to-date for both.

Methods:

We used the Behavioral Risk Factor Surveillance System (BRFSS), an annual survey to guide health policy in the United States, to explore the up-to-date status of dual cervical cancer and CRC screening for women 50–64 years old. We categorized women into four mutually exclusive categories: up-to-date for dual-screening, each single screen, or neither screen. We used multinomial multivariate regression modeling to evaluate the predictors of each category.

Results:

Among women ages 50–64 years old, dual-screening was reported for 58.2% (57.1–59.4), cervical cancer screening alone (27.1% (26.0–28.2)), CRC screening alone (5.4% (4.9–5.9)), and neither screen (9.3% (8.7–9.9)). Age, race, education, income, and chronic health conditions were significantly associated with dual-screening compared to neither screen. Hispanic women compared to non-Hispanic White women were more likely to be up-to-date with cervical cancer screening than dual-screening (adjusted odds ratio [aOR] = 1.39 (1.10, 1.77) ). Compared to younger women, those 60–64 years are significantly more likely to be up-to-date with CRC screening than dual-screening (aOR = 1.75 (1.30, 2.35) ).

Conclusions:

Screening received by each woman shows a much lower rate of dual-screening than prior single cancer screening rates. Addressing dual-screening strategies rather than single cancer screening programs for women 50–64 years may increase both cancer screening rates.

Funding:

This work was supported by NIH through the Michigan Institute for Clinical and61 Health Research UL1TR002240 and by NCI through The University of Michigan Rogel Cancer62 Center P30CA046592 grants.

Article activity feed

  1. Version published to 10.7554/elife.76070 on eLife
  2. eLife

    Author Response

    Reviewer #1 (Public Review):

    The weakness of the paper is that the analysis is based on a self-report survey which may not be an accurate method of determining cancer screening rates due to recall.

    Claim data or medical records may provide a more reliable "gold standard" than self-reports

    We agree. Many data sources, including prospective collection, electronic health record downloads, survey sources, and payment-related databases, can tally screenings per patient. The first sentence of our limitations section states this.

    It is a cross-sectional self-report survey whose responses are not equivalent to validated medical records or claims data (St Clair 2017 (36)).

    We also provide evidence of the accuracy of self-report in the subsequent two sentences of the limitations section, which we addressed in the above comment (Anderson 2019).

    In general, surveys are critical for providing rich information about the individuals and for observations regarding population health and it could help to better understand some measures. However, it is necessary to discuss better that this kind of information may be biased.

    We agree with the reviewer. BRFSS has been extensively studied by the CDC, as seen in Anderson 2019, definitively showing that those who are screened DO accurately report this in a self-report survey. We have stated this in the limitations section of the discussion section.

    Those who do not screen will inaccurately report by about 50% that they did screen.

    For future analysis, it could be useful to perform an analysis where self-report data and claim report information serve as a source of information together, it means to perform an analysis to compare self-reported information with objectively recorded participation in colorectal and cervical cancer screening in the national screening programme in the United States. It will allow to verify whether self-reported ever uptake corresponds with recorded ever uptake among survey respondents

    We agree that comparing self-report to claims data would be interesting. We point out to the reviewer that both datasets are samplings of the whole population, not the entire population. Claims data is subject to significant miscoding errors in the clinic that make it not as reliable as would be desired. The US does not have a population registry as other countries do. Our BRFSS is the best we have, and it drives our health programs and expenditures for public health.

    Reviewer #3 (Public Review):

    Weaknesses:

    1. The CRC testing stated is not the 'routine' recommendations.

    Our statement: "CRC screening is defined as using a home kit for blood stool tests including fecal occult blood test (FOBT) or fecal immunochemical test (FIT) or office-based procedures including sigmoidoscopy or colonoscopy" accurately represents the current routine screening recommendations in the US.

    Also, since it is self-reported, a patient might have under-reported obtaining a Pap or HPV test when she only received a speculum exam

    We agree with you. We address this in the limitations section.

    1. Significant difference between those that were identified and those included in eligibility suggesting elements of selection bias and potential generalizability of respondents to the population

    Please see the supplemental figure where we enumerate the exclusion reasons.

    We appreciate the reviewer’s concern about the bias of non-responders. Because of this remark, we repeated our analyses, using propensity scoring of missing information to create missingness weights. Combining the survey weight with the missingness weights allowed re-calculations of all analyses. The new results are presented in Tables 1-4. The adjustment did not change the interpretation of any analysis, but slightly changed the aOR and 95% confidence limits. Our conclusions remain strong.

    1. Data does not take into account the payer mix and potential for health insurance limitations of access

    We appreciate the reviewer's concern. This distribution of data is not available in BRFSS. 90% of the BRFSS respondents reported some form of insurance without identifying private vs. public sources. Our past work shows that the largest stratifier is among those with no insurance vs. any other type (Harper DM, Plegue M, Harmes KM, Jimbo M, SheinfeldGorin S. Three large scale surveys highlight the complexity of cervical cancer under-screening among women 45-65years of age in the United States. Prev Med. 2020 Jan;130:105880. doi: 10.1016/j.ypmed.2019.105880. Epub 2019 Nov 1. PMID: 31678587; PMCID: PMC8088237.). In addition, after the ACA passed, there are no longer any copays for any cancer screening test for any person of any age in the US.

  3. eLife

    Evaluation Summary:

    The authors analyzed a national database to gain insights on deficits in cervical and colorectal cancer screening in the United States. Their work may provide a set of predictors to enhance health promotion messaging to women who are underscreened and thus eliminate disparities in cancer control.

    (This preprint has been reviewed by eLife. We include the public reviews from the reviewers here; the authors also receive private feedback with suggested changes to the manuscript. Reviewer #1 agreed to share their name with the authors.)

  4. eLife

    Reviewer #1 (Public Review):

    This work provides a different metric for cervical and colorectal cancers screening considering the screens each woman has received (self-reported). Using the traditional screen counts, it was reported that 50-64 years old women have lower screening rates for both cancers compared to all other age ranges. In this work, the authors use the Behavioural Risk Factor Surveillance System to evaluate the screening rates based on what woman has received more than was offered which allowed authors to enrich the understanding of possible predictors for being up-to-date for cervical and colorectal cancers screening. The findings of this work can help to understand better unscreened population and explore which predictors could be useful for promoting uptake of cervical and colorectal cancers screening. The analysis is done with a population sample which allows the results to be extrapolated to the United States.

    The weakness of the paper is that the analysis is based on a self-report survey which may not be an accurate method of determining cancer screening rates due to recall. Claim data or medical records may provide a more reliable "gold standard" than self-reports. In general surveys are critical for providing rich information about the individuals and for observations regarding population health and it could help to better understand some measures. However, it is necessary to discuss better that this kind of information may be biased.

    For future analysis, it could be useful to perform an analysis where self-report data and claim report information serve as a source of information together, it means to perform an analysis to compare self-reported information with objectively recorded participation in colorectal and cervical cancer screening in the national screening programme in the United States. It will allow to verify whether self-reported ever uptake corresponds with recorded ever uptake among survey respondents.

  5. eLife

    Reviewer #2 (Public Review):

    This manuscript focuses on assessing the percentage of women who are within guidelines for screening for two common cancers - cervical and colorectal cancer (CRC). This area of inquiry has not been examined in many studies and is an area that could lead to interventions to increase adherence. In addition to the importance of the topic, other strengths include the large sample size, the robustness of the data - BRFSS, 2018, the number of covariates available in the dataset, and the implications of estimating prevalence within a national survey.

    Weaknesses center around the use of jargon, e.g., women did not choose a screen - this is self-reported behavior; "screens"; inconsistencies - e.g., measures for cervical screening are not consistent (lines 138-141 vs 160-162); incomplete descriptions - e.g., was White Non-Hispanic White; and reporting of results - e.g., "cervical cancer screening was...: vs how it should read - 86% of women reported being UTD with cervical cancer screening...".

    The results are presented in descriptive, unadjusted multinomial regressions and multivariate multinomial logistic regression. There are a few problems with this section: 1) the presentation of the data is confusing given all the comparisons - some seem redundant; 2) why are unadjusted results included; and 3) data needs to be included in the text. The issue of correct language when referring to screening persists in this section.

    The conclusions in the Discussion are not all supported by the data. For example, if one looks at the data in the Figure, by test, women are 86% and 66% UTD for cervical and CRC screening compared to the HP 2030 goals of 84% and 74% respectively. One can't use the "dual" screening rate of 59% to compare to single screen that the HP 2030 goals were derived from. The first conclusion again is using different jargon - by-woman analysis. The second conclusion - age - is not well explained. The explanation about the physician level influencing decision also does not make sense given the data in this study. Patient level does not discuss options for CRC screening. The discussion of the COVID-19 pandemic is not relevant to the results of this analysis. There are several statements about the use of HPV self-test kits - these are not yet approved in the US, and other hypotheses stated are not supported based on data from this analysis. Lastly, the conclusions do not discuss what needs to be done to follow-up on this study.

    In summary, the idea the investigators are trying to examine is important but attention to details, methods, wording, and conclusions would improve this paper and present a more complete message.

  6. eLife

    Reviewer #3 (Public Review):

    Strengths:

    1. The behavioral risk factor surveillance system has a broad generalizable population
    2. Known sociodemographic risk factors factored into appropriate dual screening
    3. Data reiterated the need for new strategies for reach and access for cancer prevention, particularly for those living in poverty or with low health literacy
      Weaknesses:
    4. The CRC testing stated is not the 'routine' recommendations. Also, since it is self-reported, a patient might have under-reported obtaining a Pap or HPV test when she only received a speculum exam
    5. Significant difference between those that were identified and those included in eligibility suggesting elements of selection bias and potential generalizability of respondents to the population
    6. Data does not take into account the payer mix and potential for health insurance limitations of access
  7. Version published to 10.1101/2021.11.28.21266963v1 on medRxiv