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Influence of Family History and Preventive Health Behaviors on Colorectal Cancer Screening in African Americans Kathleen A. Griffith, PhD, CRNP1 Deborah B. McGuire, PhD, RN2 Renee Royak-Schaler, PhD, Med3 Keith O. Plowden, PhD, RN4 Eileen K. Steinberger, MD, MS5

BACKGROUND. African Americans (AAs) have low rates of colorectal cancer (CRC) screening. To the authors’ knowledge, factors that influence their participation, especially individuals with a family history of CRC (‘‘family history’’), are not well understood. METHODS. A secondary analysis of the 2002 Maryland Cancer Survey data examined predictors of risk-appropriate, timely CRC screening (‘‘screening’’) in

The Johns Hopkins University School of Nursing, Baltimore, Maryland.

AAs with a family history and in individuals without a family history. Predic-

2

prostate-specific antigen (PSA) screening, body mass index, activity, fruit/vege-

1

Department of Organizational Systems and Adult Health, University of Maryland at Baltimore, School of Nursing, Baltimore, Maryland.

tors that were evaluated included age, sex, family history, mammogram or table consumption, alcohol, smoking, perceived risk of cancer, education, employment, insurance, access to a healthcare provider, and healthcare pro-

3

vider recommendation of fecal occult blood test (FOBT) and/or sigmoidoscopy/colonoscopy.

4

tion for FOBT (odds ratio [OR] of 11.90; 95% confidence interval [95% CI], 6.84–

Department of Epidemiology and Preventive Medicine, University of Maryland at Baltimore, School of Nursing, Baltimore, Maryland. Department of Family and Community Health, University of Maryland at Baltimore, School of Nursing, Baltimore, Maryland. 5

Department of Epidemiology and Preventive Medicine, University of Maryland, Baltimore, School of Medicine, Baltimore, Maryland.

RESULTS. In individuals without a family history of CRC (N 5 492), recommenda20.71) and sigmoidoscopy/colonscopy (OR of 7.06; 95% CI, 4.11–12.14), moderate/vigorous activity (OR of 1.74; 95% CI, 1.06–2.28), and PSA screening history (OR of 2.68; 95% CI, 1.01–7.81) were found to be predictive of screening. In individuals with a family history (N 5 88), recommendation for sigmoidoscopy/ colonscopy (OR of 24.3; 95%, CI 5.30–111.34) and vigorous activity (OR of 5.21; 95% CI, 1.09–24.88) were found to be predictive of screening. However, family history did not predict screening when the analysis was controlled for age, education, and insurance. AAs who had a family history were less likely to screen compared with their white counterparts (N 5 293) and compared with AAs who

The Maryland Cancer Survey was supported by the Maryland Cigarette Restitution Fund. We thank Karen Soeken, PhD, for her methodological and statistical expertise; Louise Jenkins, PhD, RN, for her conceptual and methodological guidance; and Carmella S. Groves, MS, and Dianne M. Dwyer, MD, at the Center for Cancer Surveillance and Control, Maryland Department of Health and Mental Hygiene, for their support with the 2002 Maryland Cancer Survey data. Address for reprints: Kathleen A. Griffith, PhD, CRNP, the Johns Hopkins University School of Nursing, 525 North Wolfe Street, Suite 306, Baltimore, MD 21205; Fax: (410) 614-1446; E-mail: [email protected] Received November 27, 2007; revision received February 22, 2008; accepted March 14, 2008.

ª 2008 American Cancer Society

were at average risk for CRC (P < .05).

CONCLUSIONS. Regardless of family history, healthcare provider recommendation and activity level were important predictors of screening. Lower screening rates were observed in AAs who had a family history compared with individuals who did not. The authors believe that, for AAs who have a family history, further examination of barriers and facilitators to CRC screening within the cultural context is warranted. Cancer 2008;113:276–85.
2008 American Cancer Society.

KEYWORDS: mass screening, African Americans, colorectal neoplasms, disparity.

C

olorectal cancer (CRC) is the third most commonly detected cancer and the second leading cause of cancer-related death in the U.S.1 Despite the approximately 5% annual reduction in CRCrelated mortality between 1993 and 2001, which mainly was attributed to improvements in treatment,2 African Americans have a 20% higher incidence of CRC and a 40% higher disease-related mortality

DOI 10.1002/cncr.23550 Published online 9 June 2008 in Wiley InterScience (www.interscience.wiley.com).

CRC Screening in African Americans/Griffith et al.

compared with whites.3 This difference is attributable at least in part to differences in screening practices.3–7 Adherence to national screening guidelines for CRC could result in as much as an 80% reduction in mortality of the disease8 and, with approximately 153,760 new cases diagnosed in the U.S. in 2007,9 the potential impact of risk-appropriate screening is large. CRC screening rates have increased slightly during the last decade,2 but they remain low in all racial groups,10,11 and especially in African Americans.5,12 The literature suggests that several factors influence CRC screening. A family history of CRC often is associated with increased rates of screening in whites compared with the rates among those who do not have a family history of the disease.13–16 The impact of a family history of CRC on screening practices has been reported in a small sample of African-American individuals ages 40 years to 49 years (n 5 31), revealing that their completion of endoscopy (9.3%) was significantly lower than that in their white counterparts (27.9%; P < .03).2 A racial difference was not noted between those same groups for fecal occult blood testing (FOBT). That study suggested that a racial disparity may affect screening practices not only in those at average risk of the disease but also in individuals at increased risk by virtue of a positive family history of CRC. Provider recommendation of screening tests is associated strongly with CRC screening adherence both in African Americans and whites.17–20 Additional factors that reportedly are influential in CRC screening among African Americans include being a woman,21 being older,12,22 having an increased perceived risk of cancer,17,23 having been screened for other cancers,18,24 having a high school degree or higher education,18 exercising,25 and having health insurance.12,26 The American Cancer Society recommends that individuals at average risk begin screening for CRC at age 50 years and at age 40 years if they are at increased risk for the disease because of a family history.27 Few studies have examined completion rates of risk-appropriate CRC screening in a manner consistent with these recommendations.18 By not separating individuals who have received riskappropriate CRC screening within the recommended timeframe from those who have not, conclusions regarding adherence to screening may be of limited value. The current study was undertaken to address the gap in the literature related to riskappropriate, timely screening completion in African Americans and the role of a family history of CRC and other predictors of CRC screening suggested by the literature.

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MATERIALS AND METHODS Data Collection and Measures Data from the 2002 Maryland Cancer Survey (MCS),28 a cross-sectional survey of 5040 Maryland residents, were abstracted into a data file for this analysis using SPSS-PC version 12.0. The MCS questionnaire was developed with validated questions from national and state surveys, such as the Behavioral Risk Factor and Surveillance Survey, the National Health Interview Survey, the National Health and Nutrition Examination Survey, and the Maryland Department of Health and Mental Hygiene Oral Health Survey. In addition, several new questions were developed for the 2002 MCS. The 2002 MCS was conducted as a population-based, randomdigit dial, computer-assisted telephone interview (CATI) survey using list-assisted, disproportionate stratified sampling. Respondents for the MCS were limited to individuals ages
40 years who resided in a private household in the state of Maryland. Individuals who were not eligible for the survey included those who did not speak English or were unable to communicate because of a physical or mental impairment and those living in group homes or institutions. Maryland was divided into 2 geographic strata: urban (consisting of Baltimore City and the 7 counties in the Metropolitan Baltimore-Washington, DC area) and rural (consisting of the remaining counties in western and southern Maryland, and the eastern shore of Maryland). A survey and research firm (REDA International, Inc.) conducted the interviews for the survey using CATI technology. To reach a final disposition, REDA staff made up to 9 calling attempts. If it was determined that there was only 1 individual aged
40 years living in the household, then that adult was interviewed. If
2 individuals aged
40 years lived at that residence, then 1 was chosen at random for the interview. By using an anonymous questionnaire, interviewers asked questions about demographics, cancer screening behaviors, health risk factors, and access to healthcare.28 Each interview took 20 minutes on average. The secondary analysis study reported here was approved by the Institutional Review Boards at the University of Maryland.

Statistical Analysis African-American representation within the total sample of the MCS was 981 (20%). The inclusion criteria for this study were 1) age
50 years for individuals without a family history of CRC, or 2) age
40 years for individuals with a family history of CRC, and 3) complete data on survey items that were

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required to compute the dependent variable, which was risk-appropriate, timely completion of CRC screening. These criteria were applied to both whites and African Americans. After the application of inclusion criteria, 40l individuals were ineligible for the current analysis, because they were too young (N 5 355), or they had missing data on variables that were required to compute the dependent variable (N 5 43), or they did not complete the item on family history of CRC (N 5 3). Of the 580 individuals who were eligible, 88 reported a family history (
1 first degree relative with CRC) and were designated as being at increased risk for the disease. Variables from the MCS dataset were selected based on published reports of cancer screening predictors in the general population and specifically in African Americans. These variables included age, sex, body mass index, risk perception, fruit/vegetable intake, activity level, alcohol intake, smoking, insurance status, and self-reported history of screening for either breast cancer or prostate cancer, education, employment, healthcare access, and provider recommendation for screening (either FOBT within the last year or ever having a recommendation for endoscopy). Items from the MCS that had to be completed to compute the dependent variable, risk-appropriate, timely CRC screening, included name(s) of screening test(s), timeframe for completion of test(s), and reason(s) for undergoing test(s). Allowable reasons for undergoing these tests included part of a routine physical examination/screening and because of a family history of CRC. For individuals without a family history of cancer, risk-appropriate, timely CRC screening was defined as completion of either an FOBT within 1 year, sigmoidoscopy within the last 5 years, or colonoscopy within the last 10 years. In individuals with a family history of CRC, risk-appropriate, timely CRC screening was defined as having completed a colonoscopy within the last 10 years. These definitions were established in accordance with national recommendations that were updated in 2002 for individuals at average risk and increased risk for the disease.29 Fecal immunochemical tests were not included in the survey response options, because they were not part of average-risk screening recommendations until 2003.30 Identical inclusion criteria were applied to whites with a family history of CRC. Descriptive statistics were compiled to profile the African-American individuals; then, comparisons were made between individuals with and without a family history of CRC for each variable. Completion of risk-appropriate screening also was compared between African Americans with and without a family history of CRC and between African Americans

and whites in the MCS who had positive a family history of CRC. Qualification of individual variables for multivariate models to examine predictors of risk-appropriate, timely screening was determined using P < .20 as a cutoff value in bivariate logistic regression analysis. Three multivariate models—the first consisting of individuals with a family history of CRC, a second consisting of individuals without a family history of CRC, and a third consisting of the entire sample—were constructed to evaluate the independent influence of predictors on risk-appropriate, timely CRC screening. After specification of the main model for the group without a family history of CRC, interaction terms were added to this model based on correlations between the variables (F > .30) and the plausibility of each correlation. The intent of this procedure was to identify any moderating effect of one variable on the other. Then, a model containing interaction terms was compared with the main model. Interaction terms were not constructed for the group with a family history because the sample size was small, and the power was not sufficient to allow for additional variables beyond those that qualified in the bivariate analysis. The third model was constructed primarily to evaluate the role of a family history of CRC in the completion of riskappropriate, timely CRC screening and to identify any interactions between the family history variable and selected demographics. The demographic control variables that were included in this model—age, education, and health insurance status—were chosen because of their common use in multivariate modeling. Mediation, that is, the extent to which a variable accounts for the relation between the predictor and the outcome of risk-appropriate, timely screening, was considered in all multivariate models using the 3 standard criteria: 1) significant relation between the suspected mediator variable and the outcome, 2) significant relation between the suspected mediator and predictor variable, and 3) loss or reduction in significant relation between the predictor variable and the outcome variable when the suspected mediator was added to the model.31 The significance value for multivariate models was set at P < .05.

RESULTS Characteristics of the Study Sample In the sample that was eligible for the analysis of African Americans (N 5 580), individuals predominantly were women (65%) ages 50 years to 65 years. Nearly half had some college education or higher (48%) and were either employed (46.7%) or retired

CRC Screening in African Americans/Griffith et al.

(41.3%). The majority had health insurance (88.8%; data not shown). When individuals with and without a family history were compared, there was a significant difference between the groups (P < .05) on several variables, including age and cancer risk perception (see Table 1). The minimum age allowed for inclusion in the study differed between groups— age 40 years for those in the family history group and age 50 years for the group without a family history of CRC—and most likely accounted for the significant difference on this variable. African Americans and whites with a family history were compared on demographic variables, including age, sex, education, employment, and health insurance status. Significant differences included health insurance (94.2% of whites vs 87.5% of African Americans reported having complete health insurance during the previous 12 months; P 5 .044) and age (53% of whites vs 37.5% of African Americans were aged >65; P 5 .001). No other differences on demographics were noted (data not shown). Increased health insurance coverage may have been related to older age among whites. Reported CRC screening rates that were not based on risk between African Americans with and without a family history of CRC did not differ significantly for either endoscopy procedures (58.0% and 49.8%, respectively; P 5 .07) or FOBT (48.9% and 42.7%, respectively; P 5 .18; data not shown). The completion rate for risk-appropriate, timely CRC screening was 39.8% for African Americans with a family history of CRC and 53.4% for African Americans without a family history of CRC (P < .05). Among white respondents in the 2002 MCS with a family history of CRC (n 5 293), 65.5% completed risk-appropriate, timely CRC screening; but only 39.8% (n 5 35) of African Americans with a family history of CRC reported having received such screening (P < .05) (Table 2).

Individuals Without a Family History of CRC (n 5 492) Age, sex, activity level, daily servings of fruits and vegetables, history of prostate-specific antigen (PSA) screening in men, cigarette use, employment, insurance, having a primary healthcare provider, and recommendation of either endoscopy or FOBT were evaluated in the multivariate model after qualification in univariate analysis (see Table 3). In multivariate analysis, however, only PSA screening history, activity level, and provider recommendation were predictive of risk-appropriate, timely screening. Men with a history of PSA screening were 2.68 times more likely (95% confidence interval [95% CI], 1.01–7.81 times more likely) to have had risk-appropriate,

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TABLE 1 Sample Characteristics by Family History No family history of CRC (N 5 492) Characteristic

No.

Sex Men 177 Age, y* 40–49 50–64 329
65 163 Mammogram history (women) Yes 308 PSA history (men) Yes 124 BMI, kg/m2 24.9 121 25–34.9 172
35 168 Activity level Minimally active 196 Moderately active 166 Very active 103 Daily fruits and vegetables 2 131 3–4 189
5 158 Cigarette use Current smoker 91 Alcohol use Moderate to heavy drinker 85 Concern about cancer* Very concerned 229 Perceived amount of cancer in family* High 43 Perceived risk of cancer* High 76 Highest level of education
Family history of CRC (N 5 88)

%

No.

%

35

22

25

67 33

29 42 22

33 42 25

96.2

63

95.5

72.1

14

63.6

24.6 35 34.2

22 24 37

25 27.3 42

39.8 33.7 20.9

40 26 18

45.5 29.5 20.5

26.6 38.4 32.1

29 27 31

33 30.7 35.2

18.5

17

19.3

17.3

16

16

45.9

55

62.5

8.7

38

43.2

15.4

35

39.8

20.9 30.1 22 26

15 23 26 22

17 26.1 29.5 25

46.7 41.3

46 28

52.3 31.8

88.8

77

87.5

53.5

50

56.8

40.9

38

43.2

90.3

82

93.2

CRC indicates colorectal cancer; PSA, prostate-specific antigen; BMI, body mass index; FOBT, fecal occult blood test. * P <.05, indicating a significant difference between groups for this variable.

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TABLE 2 Timely Screening for Colorectal Cancer by Family History and Race African Americans

Caucasians

Timely CRC screening

No family history of CRC (N 5 492), %

Family history of CRC (N 5 88), %

Family history of CRC (N 5 293), %

Yes

53.4*

39.8*,y

65.5y

CRC indicates colorectal cancer. * P < .05, indicating a significant difference between groups for this variable. y P < .05, indicating a significant difference between groups for this variable.

TABLE 3 Risk-appropriate, Timely Completion of Colorectal Cancer Screening in Individuals Without a Family History of Colorectal Cancer Adjusted, N 5 454y

Unadjusted, N 5 492* Characteristic Sex Age, y 50–54 (Reference)
65 PSA screening history Yes No (reference) Smoking Nonsmoker Smoker (reference) Daily fruits/vegetables Education Activity level Minimal (reference) Moderate/vigorous Employment Employed Unemployed (reference) Homemaker/student Retired Insurance coverage Insured Insured—coverage lapse in last 12 mo Not insured (reference) Primary healthcare provider 1 >1 No provider (reference) FOBT recommended within last 12 mo Yes No (reference) Recommended endoscopy within last 12 mo Yes No (reference)

OR (95% CI)

P

OR (95% CI)

.09 <.005 1.00 1.33 (0.71–2.49)

.37 <.001

3.04 (1.51–6.11) 1.00

.44 .51 1.00 1.26 (0.65–2.45) .047 2.68 (1.01–7.81) 1.00

<.05 1.63 (1.03–2.57) 1.00

.91 1.03 (0.52–2.02) 1.00

.07 .15 <.02 1.00 1.59 (1.09–2.29) 2.61 (1.29–5.25) 1.00 1.98 (0.56–7.04) 3.41 (1.68–6.92) 3.54 (1.60–8.30) 1.52 (0.42–5.52) 1.00 3.64 (1.50–8.30) 4.42 (1.64–11.90) 1.00

P

.74 .21 .026 1.00 1.74 (1.06–2.28)

<.01 <.01 .29 <.001 <.001 <.001 .53 <.01 <.002 <.005

2.46 (0.87–6.95) 2.41 (0.45–12.76) 2.65 (0.87–8.10) 1.55 (0.56–4.28) 1.02 (0.16–6.32) 1.00 2.34 (0.73–7.41) 2.21 (0.55–8.91) 1.00

<.001 10.96 (6.98–17.20) 1.00

.34 .09 .30 .09 .63 .40 .98 .35 .15 .26 .000

11.90 (6.84–20.71) 1.00 <.001

6.32 (4.26–9.39) 1.00

OR indicates odds ratio; 95% CI, 95% confidence interval; PSA, prostate-specific antigen; FOBT, fecal occult blood test. * Unadjusted OR from bivariate logistic regression analysis. y Adjusted OR from multivariate logistic regression analysis.

.000 7.06 (4.11–12.14) 1.00

CRC Screening in African Americans/Griffith et al.

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TABLE 4 Timely Completion of Colorectal Cancer Screening in Individuals With a Family History of Colorectal Cancer Adjusted, N 5 86y

Unadjusted, N 5 88* Characteristic Activity level Minimal (reference) Moderate Vigorous Education
P

OR (95% CI)

OR (95% CI)

.14 1.00 0.90 (0.32–2.49) 2.93 (0.91–8.83) 1.00 0.53 (0.13–2.13) 0.79 (0.21–2.95) 2.62 (0.68–10.12) 20.74 (5.58–77.09) 1.00

.76 .07 .08 .37 .73 .16 <.001

P .08

1.00 0.86 (0.23–3.19) 5.21 (1.09–24.88) 1.00 0.74 (0.12–4.47) 0.46 (0.09–2.47) 1.80 (0.25–9.40)

.82 .04 .33 .74 .37 .48 .000

24.30 (5.30–111.34) 1.00

OR indicates odds ratio; 95% CI, 95% confidence interval. * Unadjusted OR from bivariate logistic regression analysis. y Adjusted OR from multivariate logistic regression analysis.

timely CRC screening than men without a PSA screening history. Those who participated in moderate or more vigorous exercise, which we defined as at least moderate activity 3 times weekly, were 1.74 times more likely (95%CI, 1.06–2.28 times more likely) to have completed risk-appropriate, timely screening than those who reported minimal or no activity. Individuals who received a provider recommendation for either sigmoidoscopy/colonoscopy or FOBT were 11.90 times more likely (95%CI, 6.84– 20.71 times more likely) and 7.06 times more likely (95%CI, 4.11–12.14 times more likely) to have had risk-appropriate, timely screening than those who had not received recommendations, respectively. Next, the presence of an interaction effect was investigated in the model of individuals without a family history. An interaction effect exists when the effect of an independent variable on a dependent variable depends on the value of another variable, called the moderator variable.31 Interaction terms were constructed for age and employment, age and activity level, age and insurance coverage, primary healthcare provider and insurance, primary healthcare provider and recommendation for FOBT, and primary healthcare provider and recommendation for sigmoidoscopy/colonoscopy. These terms were added to the model; and, because no significant interactions were identified, they were not included in the final model.

Individuals With a Family History of CRC (n 5 88) Three variables qualified for the multivariate models based on the same criteria that were used in the group without a family history. These variables

included activity level, highest education level, and ever receiving a recommendation for screening endoscopy from a health professional. In multivariate analysis, however, provider recommendation of endoscopy and activity level were identified as the only significant predictors of risk-appropriate, timely CRC screening. Individuals who received a recommendation were >24 times more likely (95% CI, 5.30–111.34 times more likely) to complete risk-appropriate, timely CRC screening without a recommendation, and individuals who participated in vigorous activity were 5.21 times more likely (95% CI, 1.09–24.88) to have completed risk-appropriate screening than those who reported minimal or no activity level (Table 4).

Family History of CRC and Risk-appropriate, Timely Screening In bivariate analysis, individuals without a family history were 1.74 times more likely (95% CI, 1.10–2.76) to report risk-appropriate screening. However, when family history was evaluated using simultaneous logistic regression and was controlled for age, highest education level, and insurance coverage, family history was no longer a significant predictor of riskappropriate, timely screening (Table 5). Age was identified as a mediator, which meant that it accounted for the relation between family history and risk-appropriate CRC screening in the model. The mediating effect of age was apparent because 1) its significant relation with both a family history of CRC and risk-appropriate, timely CRC screening in bivariate logistic regression was significant (data not

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TABLE 5 Age as a Mediator of Family History of Colorectal Cancer in Predicting Timely Colorectal Cancer Screening Unadjusted, N 5 580 Characteristic Family history of CRC Yes (reference) No Age, y 40–44 45–49 50–54 (Reference) 55–59 60–64 65–69 70–74
75 Education Insurance coverage Insured Insured—coverage lapse within last 12 mo Not insured (reference)

Adjusted, N 5 573 P

OR (95% CI)

OR (95% CI)

<.02 1.00 1.74 (1.10–2.76) 0.35 (0.98–1.30) 0.56 (0.17–1.88) 1.00 2.29 (1.39–3.75) 1.61 (0.96–2.69) 2.27 (1.24–3.9) 2.42 (1.30–4.51) 1.28 (0.71–2.31)

2.86 (1.50–5.46) 1.20 (0.38–3.88) 1.00

P .54

1.00 1.19 (0.76–2.10) <.01 .11 .35 <.001 .07 <.005 <.005 .41 .09 <.005 <.005 .74

0..42 (0.10–1.73) 0.58 (0.16–2.14) 1.00 2.28 (1.37–3.79) 1.78 (1.04,3.05) 2.15 (1.18–3.90) 2.58 (1.34–4.94) 1.45 (0.77–2.72)

2.59 (1.33–5.03) 1.34 (0.91–1.96) 1.00

.004 .72 .23 .02 .05 .029 .017 .101 .06 .010 .005 .65

OR indicates odds ratio; 95% CI, 95% confidence interval; CRC, colorectal cancer.

shown); 2) age persistently was significant in both the bivariate and multivariate models (P < .05); and 3) when age was entered into the model, family history was not significant. Except for the group aged
75 years, age predicted risk-appropriate, timely CRC screening in the multivariate model when family history was controlled, and family history was not predictive. Insurance, although it was significant, did not mediate family history in the adjusted model. No covariates were identified as moderators in the model.

DISCUSSION In the current study, we evaluated variables from the 2002 MCS that may motivate risk-appropriate, timely CRC screening in an African-American population. To our knowledge, a family history of CRC as a predictor of risk-appropriate, timely CRC screening has been evaluated only during the fifth decade of life in African Americans.12 Our investigation in the current study of a family history of CRC as a risk factor for risk-appropriate, timely CRC screening in individuals aged
40 years revealed several noteworthy findings. Although, in bivariate analysis, a family history of CRC in African Americans predicted lower riskappropriate screening rates compared with the rates observed in African Americans without a family history, it was not associated independently with riskappropriate, timely CRC screening. Our analysis

determined that age mediated that relation, especially advancing age, with individuals in the groups ages 65 to 69 years and 70 to 74 years more likely to be screened than individuals in the reference group ages 50 to 54 years. This finding suggests that the combination of age >65 years and eligibility for Medicare is a powerful predictor of risk-appropriate screening. Recent work suggests that African Americans at high risk for hereditary nonpolyposis CRC and familial adenomatous polyposis have significantly lower rates of knowledge about family history.32 It is possible that this difference extends to those at more moderate increased risk of CRC. It also is plausible that screening rates for some of the reported studies with whites did not reflect risk-appropriate screening, which is colonoscopy alone, in individuals with a family history of the disease. Several other influences, such as low health literacy and knowledge deficits related to screening tests, may account in part for the finding that a family history of CRC did not influence risk-appropriate screening rates. Further exploration of likely influences could result in the development of behavioral interventions, such as the introduction of literacy level-targeted educational materials, to improve risk-appropriate, timely screening. Although in the current study perception of cancer risk and cancer concern were found to be greater in African Americans who had a family history of CRC compared with African Americans who did not have a family history of CRC, risk-appropriate, timely

CRC Screening in African Americans/Griffith et al.

screening was significantly lower in those who had a family history of the disease. The association between a family history of CRC and increased perceived risk of the disease has been reported previously.33 Findings in the current study suggest that risk perception is not associated with risk-appropriate, timely CRC screening in those with a family history of the disease. The reasons why such perceptions of increased risk of CRC in family members did not translate into timely CRC screening are difficult to explain in the context of the current study and suggest that other unknown or unmeasured factors may play a role is screening decisions. Similar findings were reported, however, in white family members of patients with CRC whose perception of CRC risk was not influential in screening completion.34 Inverse correlates of screening in that study included feeling healthy and having concern about discomfort during the screening procedure. Further exploration of the role of perceived risk of cancer as well as fatalism in low screening rates for African Americans with a family history of CRC is essential to better define the importance of this influence in affecting risk-appropriate, timely CRC screening behaviors in African Americans. This exploration should be done, however, in a prospective study in which a reasonable possibility of making a causal correlation between fatalism and perceived risk can be evaluated and speculation can be avoided. Provider recommendation for CRC screening was a significant predictor of risk-appropriate, timely screening, for both those with and those without a family history of CRC. This finding also was documented by several other studies, which emphasized the importance of communicating and explaining the benefits of cancer screening to individuals.22,35 Although recommendation to screen for CRC has been documented as a correlate of screening behavior in African Americans with an average risk of CRC,17,19 no reported study to our knowledge has either addressed or supported this correlation in those with a family history of CRC. Our findings address this gap and support the potential importance of risk-appropriate CRC screening recommendations from healthcare providers for African Americans with a family history of CRC, who have rates that are 1.5 times lower than the rates among their white counterparts. Clinicians who work with African-American patients in a variety of settings have the ability to influence the use of cancer screening tests. One study of African-American women with a family history of breast cancer demonstrated that those who reported having discussions with providers regarding both their family history and their elevated risk were

283

significantly more likely to report timely mammography screening (with the past 2 years) than those who discussed only 1 or neither of these topics.36 Similarly, discussions concerning colonoscopy participation for African Americans with a family history of CRC that emphasized the benefits of risk-appropriate screening and offered counseling about test results could promote timely CRC screening. This process can be facilitated by disseminating evidencebased guidelines to clinicians for discussing family history and risk-based screening with FOBT or endoscopy, the benefits of screening and early detection, and delivering CRC test results. Our findings suggest using such an approach for increasing the rates of risk-appropriate, timely CRC screening for African Americans both with and without a family history of CRC. Activity level was predictive of timely screening in individuals both with and without a family history of CRC in this study. Several studies have demonstrated that regular exercise increases awareness and completion of CRC screening. Shapiro and colleagues25 reported that, compared with individuals who did not exercise, the odds ratio of CRC screening in regular exercisers was 50% higher. In addition, an analysis of cross-sectional data from a large group of individuals aged
50 years revealed significantly decreased use of screening sigmoidoscopy in individuals who did not exercise at all compared with regular exercisers.13 In the current study, it is possible that individuals who were active physically were active for the health benefit and, thus, were cognizant of the importance of screening for CRC. Future investigation into the link between physical activity and CRC screening practices will elucidate this correlation further and set the stage for interventions that increase adherence by cultivating healthy lifestyle choices. PSA screening was associated with risk-appropriate, timely CRC screening for men without a family history of CRC in this study. Other investigators also identified an association between screening for other types of cancer and screening for CRC. Canadian researchers reported that a recent history of PSA in men and a recent history of a Papanicolaou test and mammography in women was the strongest predictors of FOBT for individuals at average risk of CRC.37 Similarly, white men who were current with PSA screening recommendations were 7 times more likely to be current with CRC screening than men without current PSA screening.14 In 100 low-income African Americans aged >50 years, previous screening for CRC was identified as the only predictor of recent screening behavior (P < .01).24 Similar to physical ac-

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CANCER

July 15, 2008 / Volume 113 / Number 2

tivity, participation in behaviors that reflect a healthy lifestyle indicate an interest in self-care. Interventions that concomitantly address several preventive behaviors, such as a program that combines exercise and diet instruction along with cancer screening information, likely will increase participation in all activities, including screening for cancer. The current study had several limitations. Our analyses, as with all secondary data sources, were limited to the data available. Individuals who were deleted because of incomplete data on the variables required to calculate the dependent variable, riskappropriate CRC screening, may have biased the analysis toward those who could recall details related to screening history, including tests and recommendations. Such a deletion could have eliminated those with poor memory, such as individuals with medical problems. The data consisted of individuals from Maryland only; thus, the results cannot be generalized to the larger U.S. African-American population. The health insurance coverage rate of 88.6% among study participants was somewhat higher than the overall 81.5% rate for African-American Marylanders,38 limiting the generalizability of our results to African-American Marylanders until similar findings from subsequent studies are demonstrated. Finally, individuals classified as having a family history were those who reported having
1 first-degree relative(s) affected with CRC. Collection of data regarding the age at which relatives were diagnosed was not done; therefore, it is possible that some individuals who were classified as being at increased risk for CRC were done so unnecessarily. This study suggests that African Americans would benefit from a primary care approach that evaluates their risk factors for CRC and provides corresponding recommendations for appropriate screening tests. This recommendation is based upon lower rates of risk appropriate screening completion identified in this study for African Americans at increased risk compared to those at average risk and compared to whites at increased risk. It is also based on other cancer studies that have documented increases in cancer screening associated with physician discussions of risk, family history, and screening frequency for individuals with and without a family history of cancer.36,39 Therefore, assessing CRC screening history and making risk-based recommendations for appropriate screening are especially important for all African Americans beginning at age 50 years and at a younger age for those who have a family history of CRC. The results from this study provide a strong argument for exploring the barriers related to screen-

ing in African Americans, especially those who are have family members with CRC. Such exploration should begin with qualitative data collection in which common themes related to experiences with and beliefs regarding CRC screening can be ascertained. This approach should help generate hypotheses that can be tested in subsequent work and ultimately will result in culturally tailored interventions designed to increase screening rates. Such studies could lead to improved early detection and a subsequent reduction in CRC among African Americans.

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