Screening for breast cancer, cervical cancer, and colorectal cancer (CRC) reduces mortality from these cancers.* However, screening test receipt has been below national targets with disparities observed in certain populations (1,2). National Health Interview Survey (NHIS) data from 2018 were analyzed to estimate percentages of adults up to date with U.S. Preventive Services Task Force (USPSTF) screening recommendations. Screening test receipt remained below national Healthy People 2020 (HP2020) targets, although CRC test receipt neared the target. Disparities were evident, with particularly low test receipt among persons who were uninsured or did not have usual sources of care. Continued monitoring helps assess progress toward targets and could inform efforts to promote screening and reduce barriers for underserved populations.
Data from the 2018 NHIS, an annual survey of a nationally representative sample of the civilian, noninstitutionalized U.S. population,† were used to examine up-to-date breast, cervical, and colorectal cancer screening test receipt per USPSTF recommendations. Information about tests was collected from one randomly selected adult per family (final sample adult response rate was 53.1%) (3). Respondents were asked whether they had ever received each test and when they received their most recent test. Respondents with a personal history of the cancer in question were excluded from analysis for that cancer type. Percentages with Korn-Graubard confidence intervals (4) are presented overall and by sociodemographic and health care access factors. Percentages of respondents who were up to date with screening were also age-standardized to the 2000 U.S. standard population, consistent with HP2020 cancer screening measures. NHIS-imputed income files were used. NHIS data from 2005, 2008, 2010, 2013, 2015, and 2018 were used to examine differences across years in percentages of persons who were up to date with screening, according to USPSTF recommendations in effect for each year. For 2018, “up-to-date” status was defined as receipt of the following: mammography within 2 years among women aged 50–74 years for breast cancer screening; Pap test within 3 years for women aged 21–65 years or Pap test plus human papillomavirus (HPV) test (co-testing) within 5 years for women aged 30–65 years for cervical cancer screening (among women without hysterectomy); and home blood stool or fecal immunochemical test (FIT) within 1 year; colonoscopy within 10 years; computed tomography (CT) colonography, or sigmoidoscopy within 5 years; or FIT-DNA test within 3 years among adults aged 50–75 years for CRC screening.
In August 2018, USPSTF added HPV testing alone as a cervical cancer screening option for women aged 30–65 years§; however, because this analysis used data collected beginning January 2018 regarding screening in the preceding 3–5 years, this option was not included. Wald F tests were used to test for any differences across years (treated categorically) and groups. Sample adult weights and design variables were used to account for the complex sample design. Estimates not meeting National Center for Health Statistics data presentation standards for proportions were suppressed (4). All analyses were performed using SAS (version 9.4; SAS Institute) and SUDAAN (version 11.0.3; RTI International).
Among women aged 50–74 years, 72.4% were up to date with mammography (age-standardized 72.3%) (Table 1), which is below the HP2020 target (81.1%). Lower test receipt was associated with having lower educational attainment and income, not having a usual source of care, and being uninsured or having only public health insurance coverage. Approximately 30%–40% of women without a usual source of care or health insurance coverage were up to date. Although the percentage of women up to date with mammography has not varied substantially by year (Figure), the absolute number of women who received a mammogram has increased. The estimated number of women tested (numerator) was 4,097,142 in 2005 and 5,558,224 in 2018, reflecting growth in the population of women aged 50–74 years (denominator) age-eligible for testing.
TABLE 1. Percentage of U.S. women age-eligible for screening who were up to date with breast and cervical cancer screening, by sociodemographic and access-to-care factors — United States, 2018. Characteristic Breast cancer screening* Cervical cancer screening† No. %§ (95% CI) No. %§ (95% CI) Overall 5,311 72.4 (70.8–73.9) 7,732 82.9 (81.6–84.0) Age group, yrs ¶ 21–30 —** —** 1,717 75.8 (72.8–78.7) 31–40 —** —** 1,989 90.1 (88.5–91.6) 41–50 —** —** 1,590 87.9 (85.7–89.8) 51–65 —** —** 2,436 79.5 (77.4–81.5) 50–64 3,229 71.5 (69.6–73.4) —** —** 65–74 2,082 74.3 (71.7–76.7) —** —** P-value†† 0.076 <0.001 Race White 4,312 72.7 (71.0–74.3) 5,943 83.2 (81.9–84.5) Black 625 72.9 (67.8–77.6) 1,038 87.1 (84.0–89.7) AI/AN 52 —§§ 102 73.6 (57.8–86.0) Asian 210 70.5 (62.3–77.9) 460 75.8 (70.4–80.7) Multiple race 108 65.3 (52.0–77.1) 173 77.5 (68.5–84.9) P-value†† 0.588 0.002 Ethnicity ¶¶ Non-Hispanic 4,768 72.6 (71.0–74.2) 6,475 83.2 (81.9–84.5) Hispanic 543 70.7 (65.5–75.6) 1,257 81.4 (78.0–84.4) Puerto Rican 64 79.8 (67.9–88.8) 127 81.1 (72.0–88.3) Mexican/Mexican American 283 70.3 (62.9–77.1) 739 78.4 (73.5–82.7) Central/South American 101 73.0 (59.2–84.1) 217 86.9 (79.8–92.2) Other Hispanic 95 63.9 (51.3–75.2) 174 87.3 (80.1–92.7) P-value†† 0.471 0.283 Education Less than high school 597 63.0 (57.7–68.1) 686 72.1 (67.3–76.7) High school/GED 1,311 68.6 (65.5–71.5) 1,490 78.4 (75.5–81.2) Some college 1,686 71.6 (68.9–74.2) 2,344 82.3 (80.2–84.2) College degree 1,694 80.4 (78.1–82.7) 3,188 88.2 (86.5–89.8) P-value†† <0.001 <0.001 Federal poverty threshold, % ≤138 1,060 58.6 (54.5–62.6) 1,677 73.7 (70.4–76.8) >138–250 980 66.7 (62.6–70.6) 1,401 78.4 (75.3–81.4) >250–400 1,030 72.1 (68.5–75.5) 1,556 84.3 (81.8–86.5) >400 2,240 79.5 (77.3–81.6) 3,098 88.2 (86.7–89.7) P-value†† <0.001 <0.001 Duration of U.S. residence, yrs ¶ ≤10 51 —§§ 303 65.0 (58.3–71.3) >10 748 73.0 (68.4–77.2) 1,133 82.0 (78.9–84.8) Born in United States 4,502 72.7 (71.1–74.3) 6,273 84.3 (83.0–85.5) P-value†† 0.028 <0.001 Sexual orientation Gay or lesbian 63 —§§ 124 64.7 (52.9–75.4) Straight 5,118 72.6 (71.0–74.1) 7,288 83.4 (82.2–84.6) Bisexual 24 —§§ 171 79.0 (69.5–86.6) Other 23 —§§ 41 —§§ P-value†† 0.304 0.007 Usual source of care Yes 4,956 75.1 (73.6–76.6) 6,705 85.2 (84.0–86.4) No 354 32.0 (26.1–38.4) 1,025 67.7 (63.9–71.3) P-value†† <0.001 <0.001 Insurance¶, *** Private 3,305 77.2 (75.5–78.9) 5,302 86.4 (85.1–87.6) Military 167 78.2 (70.2–85.0) 217 91.9 (86.6–95.6) Public only 1,521 67.2 (64.2–70.2) 1,321 79.5 (76.4–82.4) Uninsured 304 39.5 (32.8–46.5) 865 65.0 (60.6–69.1) P-value†† <0.001 <0.001 FIGURE.Percentage of adults up to date* with screening for breast, cervical, and colorectal cancers, by cancer type, sex, and year — United States, 2005–2018
* Up to date with U.S. Preventive Services Task Force screening recommendations in effect for each year defined as breast cancer: mammography within 2 years among women aged 50–74 years (all survey years); cervical cancer 2015–2018: Pap test within 3 years among women aged 21–65 years without hysterectomy, or Pap test plus human papillomavirus (HPV) test (co-testing) within 5 years among women aged 30–65 years without hysterectomy; cervical cancer before 2015: Pap test within 3 years among women aged 21–65 years without hysterectomy; colorectal cancer (CRC) 2018: home blood stool test within 1 year, sigmoidoscopy or computed tomography (CT) colonography within 5 years, colonoscopy within 10 years, or fecal immunochemical test (FIT)–DNA test within 3 years among adults aged 50–75 years; CRC 2010–2015: home blood stool test within 1 year, colonoscopy within 10 years, or sigmoidoscopy within 5 years with home blood stool test within 3 years among adults aged 50–75 years; CRC 2005–2008: home blood stool test within 1 year, colonoscopy within 10 years, or sigmoidoscopy within 5 years among adults aged 50–75 years.
Among women aged 21–65 years, 82.9% were up to date with cervical cancer screening (age-standardized 83.4%) (Table 1), which is below the HP2020 target (93.0%). Lower test receipt was associated with younger and older age groups, Asian race, lower educational attainment and income, shorter U.S. residence, gay or lesbian sexual orientation, no usual source of care, and being uninsured or having only public insurance coverage. Cervical cancer test receipt varied from 2005 to 2018 (Figure), with declines from 85.3% in 2005 to 80.5% in 2013, followed by an increase (82.9% in 2018).
Among adults aged 50–75 years, 66.9% were up to date with CRC testing (age-standardized 66.7%) (Table 2), nearing the HP2020 target (70.5%). Lower test receipt was associated with age 50–64 years, American Indian/Alaska Native or Asian race, Hispanic ethnicity, lower educational attainment or income, non-U.S. birthplace, no usual source of care, and non-military health insurance coverage or no insurance. Approximately 30% of those without a usual source of care or health insurance were up to date. Test receipt increased since 2005 (46.6%) (Figure).
TABLE 2. Percentage of U.S. adults aged 50–75 years who were up to date with colorectal cancer screening* — United States, 2018. Characteristic Colorectal cancer screening No. %† (95% CI) Overall 10,595 66.9 (65.8–68.1) Age group, yrs § 50–64 6,294 61.8 (60.2–63.3) 65–75 4,301 76.9 (75.4–78.4) P-value¶ <0.001 Sex Men 4,846 67.4 (65.8–69.0) Women 5,749 66.5 (64.9–68.1) P-value¶ 0.437 Race White 8,630 67.9 (66.6–69.2) Black 1,197 65.3 (61.8–68.7) AI/AN 116 54.7 (42.7–66.3) Asian 432 58.1 (52.1–63.9) Multiple race 201 66.9 (58.2–74.7) P-value¶ 0.007 Ethnicity** Non-Hispanic 9,637 68.2 (67.0–69.4) Hispanic 958 57.6 (53.4–61.7) Puerto Rican 121 76.6 (67.2–84.4) Mexican/Mexican American 513 52.3 (46.6–58.0) Central/South American 173 57.7 (48.1–66.9) Other Hispanic 151 63.4 (55.2–71.1) P-value¶ <0.001 Education Less than high school 1,132 54.2 (50.6–57.8) High school/GED 2,704 63.5 (61.3–65.7) Some college 3,218 67.7 (65.7–69.7) College degree 3,499 73.5 (71.7–75.2) P-value¶ <0.001 Federal poverty threshold, % ≤138 1,881 56.9 (53.9–60.0) >138–250 1,924 59.7 (56.8–62.7) >250–400 2,053 66.3 (63.4–69.0) >400 4,737 72.7 (71.0–74.3) P-value¶ <0.001 Duration of U.S. residence¶ ≤10 yrs 81 32.8 (21.5–45.8) >10 yrs 1,384 58.6 (55.3–61.8) Born in U.S. 9,113 69.2 (68.0–70.4) P-value¶ <0.001 Sexual orientation Gay or lesbian 199 75.3 (67.2–82.3) Straight 10,140 66.9 (65.8–68.1) Bisexual 44 —†† Other 44 —†† P-value¶ 0.118 Usual source of care Yes 9,739 70.2 (69.0–71.3) No 856 29.4 (25.5–33.5) P-value§ <0.001 Insurance §,§§ Private 6,488 69.0 (67.5–70.4) Military 631 80.6 (76.7–84.1) Public only 2,812 68.2 (66.1–70.4) Uninsured 640 30.2 (25.5–35.1) P-value¶ <0.001 DiscussionIn 2018, receipt of screening tests for breast, cervical, and colorectal cancers was below national HP2020 targets. CRC test receipt increased after 2005 and neared the target in 2018, whereas breast and cervical cancer test receipt remained below targets with little change over this period. Test receipt varied across groups. As was also found in previous reports, testing for all three cancers decreased with decreasing educational attainment and income (1,2). Cervical cancer test receipt differed by sexual orientation, CRC test receipt varied by ethnicity, and both differed by age, race, and duration of U.S. residence. Information about lower test receipt in some groups might help inform targeted efforts to promote screening and reduce disparities. Lower test receipt in the youngest age groups for cervical cancer and CRC screening might, in part, reflect the transition of persons who previously did not meet screening criteria.
The lowest percentages of breast cancer and CRC screening test receipt were among respondents who lacked a usual source of care (32.0% and 29.4% for breast cancer and CRC screening, respectively) or health insurance coverage (39.5% and 30.2% for breast cancer and CRC screening, respectively); the largest disparities on the basis of these characteristics were for breast cancer and CRC screening. Most persons in these groups were not up to date with breast cancer or CRC tests. These large disparities have persisted for years (1,2,5,6). The number of persons without health insurance has declined in recent years (7). However, among those lacking insurance or a usual source of care, most were not up to date with USPSTF breast cancer and CRC screening recommendations. CDC’s National Breast and Cervical Cancer Early Detection Program provides low-income, uninsured, and underinsured women access to breast and cervical cancer screening and diagnostic services.¶ The Colorectal Cancer Control Program supports implementation of evidence-based interventions and supporting strategies in health systems to increase screening use.** Even among those with health insurance coverage, some groups might be farther below targets than others. For example, approximately 77%–78% of women with private or military insurance were up to date with USPSTF breast cancer screening recommendations, nearing the HP2020 target of 81.1%, compared with 67% of women with only public insurance. Of note, HP2020 determined targets based on population totals rather than specific groups.
The findings reported reflect receipt of tests within recommended screening intervals. They do not reflect test overuse, screening quality, or adequacy of follow-up. For example, positive results on CRC screening stool tests need follow-up colonoscopy to complete evaluation, and problems in CRC screening quality exist (8,9).
The findings in this report are subject to at least five limitations. First, data are self-reported and potentially subject to social desirability and recall bias. Second, survey questions about tests have changed over time. Third, the 2018 sample adult response rate was 53%, and nonresponse bias might exist despite survey weight adjustments; response rates for earlier years have been published (3). Fourth, because of limited sample sizes, estimates could not be generated for all groups. Finally, percentages might include tests performed for diagnostic purposes. NHIS data from 2018 include self-reported reasons for mammograms but not for cervical cancer tests or the CRC screening measure. Among women who received a mammogram within 2 years in the current analysis, 95% reported that it was part of a “routine exam.” A study of CRC tests (10) also suggested that a majority of respondents reported that tests were performed for screening. Consistent with HP2020 measures†† and previous reports (1,2,5,6,10), the current analysis included all tests because those receiving diagnostic tests might be considered screened in effect and therefore up to date with screening recommendations.
Continued monitoring can help assess whether national screening targets are achieved, and inform efforts that promote screening test receipt as recommended and reduce barriers for underserved populations to eliminate disparities. To promote screening for these three cancers, the Community Preventive Services Task Force recommends evidence-based interventions that increase client demand for, access to, and provider delivery of screening services.§§ The Task Force noted that evidence-based interventions can be selected and adapted to meet the needs of communities and specific populations and can be combined to address multiple barriers, potentially at multiple levels. Resources are available to help identify, implement, and evaluate evidence-based approaches through The Community Guide, Evidence-Based Cancer Control Programs¶¶ and Cancer Control P.L.A.N.E.T. (Plan, Link, Act, Network with Evidence-based Tools).***
Summary. What is already known about this topic?Receipt of screening for breast cancer, cervical cancer, and colorectal cancer (CRC) is below national targets. Large population disparities in screening receipt exist.
What is added by this report?In 2018, receipt of screening tests for breast and cervical cancers remained below Healthy People 2020 targets, with little change since 2005. CRC screening receipt increased in recent years and has neared the target (70.5%). Screening test receipt was low among persons without health insurance coverage or a usual source of care.
What are the implications for public health practice?Continued monitoring of screening rates can help assess whether national screening targets are achieved. Information about test receipt might help inform efforts that promote screening test use as recommended and reduce barriers for underserved populations to eliminate disparities.
All authors have completed and submitted the International Committee of Medical Journal Editors form for disclosure of potential conflicts of interest. No potential conflicts of interest were disclosed.
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