Cancer screening burdens elderly patients

Elena Altemus is 89 and has dementia. She often forgets her children's names, and sometimes can't recall whether she lives in Maryland or Italy.
Yet Altemus, who entered a nursing home in November, was screened for breast cancer this summer. "If the screening is not too invasive, why not?" said her daughter, Dorothy Altemus. "I want her to have the best quality of life possible."

27 dec 2017--But a growing number of geriatricians, cancer specialists and health-system analysts say there are many reasons. Such testing in the nation's oldest patients is highly unlikely to detect lethal disease, hugely expensive and more likely to harm than help since any follow-up testing and treatment is often invasive.
And yet such screening is widespread in the United States, the result of medical culture, aggressive awareness campaigns and financial incentives to doctors.
By looking for cancer in people who are unlikely to benefit, "we find something that wasn't going to hurt the patient, and then we hurt the patient," said Dr. Sei Lee, an associate professor of geriatrics at the University of California-San Francisco.
Nearly 1 in 5 women with severe cognitive impairment—including older patients like Elena Altemus—are still get regular mammograms, according to the American Journal of Public Health—even though they're not recommended for people with a limited life expectancy. And 55 percent of older men with a high risk of death over the next decade still get PSA tests for prostate cancer, according to a 2014 study in JAMA Internal Medicine.
Among people in their 70s and 80s, cancer screenings often detect slow-growing tumors that are unlikely to cause problems in patients' lifetimes. Such patients often die of something else long before their cancers would ever have become a threat, said Dr. Deborah Korenstein, chief of general internal medicine at New York's Memorial Sloan Kettering Cancer Center. Prostate cancers, in particular, are often harmless.
Patients with dementia, for example, rarely live longer than a few years.
"It generally takes about 10 years to see benefit from cancer screening, at least in terms of a mortality benefit," Korenstein said.
Enthusiasm for cancer screenings runs high among patients and doctors, both of whom tend to overestimate the benefits but underappreciate the risks, medical research shows.
In some cases, women are being screened for tumors in organs they no longer have. In a study of women over 30, nearly two-thirds who had undergone a hysterectomy got at least one cervical cancer screening, including one-third who had been screened in the past year, according to a 2014 study in JAMA Internal Medicine.
Even some patients with terminal cancer continue to be screened for other malignancies.
Nine percent of women with advanced cancer—including tumors of the lung, colon or pancreas—received mammograms and 6 percent received cervical cancer screening, according to a 2010 study of Medicare recipients over age 65. Among men on Medicare with incurable cancer, 15 percent were screened for prostate cancer.
Although screenings can extend and improve lives for healthy, younger adults, they tend to inflict more harm than good in people who are old and frail, Korenstein said. Testing can lead to anxiety, invasive follow-up procedures and harsh treatments.
"In patients well into their 80s, with other chronic conditions, it's highly unlikely that they will receive any benefit from screening, and more likely that the harms will outweigh the benefits," said Dr. Cary Gross, a professor at the Yale School of Medicine.
By screening patients near the end of life, doctors often detect tumors that don't need to be found and treated. Researchers estimate that up to two-thirds of prostate cancers are overdiagnosed, as are a third of breast tumors.
"Overdiagnosis is serious," Gross said. "It's a tremendous harm that screening has imposed. ... It's something we're only beginning to reckon with."
A variety of medical specialties—from the American College of Surgeons to the Society of General Internal Medicine—have advised doctors against screening patients with limited time to live.. For example, the American Cancer Society recommends prostate and breast cancer screenings only in patients expected to live 10 years or more.
In November, a coalition of patient advocates, employers and others included prostate screenings in men over age 75 in its list of the top five "low-value" medical procedures. Dr. A. Mark Fendrick, co-director of the coalition, referred to the five procedures as "no-brainers," arguing that health plans should consider refusing to pay for them.
Prostate cancer screening in men over 75 cost Medicare at least $145 million a year, according to a 2014 study in the journal Cancer. Mammograms in this age group cost the federal health plan for seniors more than $410 million a year, according to a 2013 study in JAMA Internal Medicine.
And while cancer screenings generally aren't expensive—a mammogram averages about $100—they can begin a series of follow-up tests and treatments that add to the total cost of care.
Most spending on unnecessary medical care stems not from rare, big-ticket items, such as heart surgeries, but cheaper services that are performed much too often, according to an October study in Health Affairs.
Many older patients expect to continue getting screened, said Dr. Mara Schonberg, an associate professor at Harvard Medical School and Boston's Beth Israel Deaconess Medical Center.
"It's jarring for someone who's been told every year to get screened and then at age 75 you tell them to stop," she said.

What are the benefits and harms of cancer screening? Most guidelines don't tell you

Screening for cancer has many obvious benefits - you're preventing cancer or catching it early. But each screening tool also comes with potential harms or risks.
A new study finds most cancer screening guidelines do not clearly spell out the benefits and harms of the recommended actions.

24 feb 2016--Researchers from the University of Michigan Health System examined 55 professional guideline recommendations for cancer screening or prevention. They found 69 percent did not quantify and present benefits and harms in comparable terms.
"Almost all medical interventions have tradeoffs between different types of benefits and harms," says Tanner J. Caverly, M.D., MPH, clinical lecturer of internal medicine at the University of Michigan Medical School and a research investigator at the VA Ann Arbor Healthcare System Center for Clinical Management Research.
"Patients rely on doctors to base screening recommendations on sound judgment as to whether, in their individual context, the benefits outweigh the harms. For this judgment, doctors need a clear understanding, in quantitative and comparable terms, about the degree of potential benefit and the degree of potential harm."
The study, published in the Journal of the National Cancer Institute, looked at guidelines such as mammography screening for breast cancer, PSA testing for prostate cancer, colonoscopy for colon cancer, HPV vaccination for cervical cancer and other screening tests. Guidelines were from agencies such as the U.S. Preventive Services Task Force, the American Cancer Society and the National Comprehensive Cancer Network.
The researchers found that 31 percent of guidelines recommending screening presented absolute effects for both benefits and harms. Meanwhile, 55 percent presented the tradeoffs unevenly, explaining the benefit but not the harm or presenting the numbers in different ways.
For example, some studies used relative risk reduction, often a larger number, to show benefit - people who were screened were twice as likely to survive. But they used absolute risk, often a much smaller number, to demonstrate harm - 1 percent of people screened had a false diagnosis.
"By unevenly presenting the statistics, guidelines can unintentionally give a false picture of the benefits and harms. The relative risk of "twice as likely" sounds significant, but in terms of absolute risk it might represent a very small difference," said senior author Angela Fagerlin, Ph.D., professor and chair at the University of Utah's Department of Population Health Sciences and a research scientist at the Salt Lake City VA.
The researchers suggest that guidelines should quantify and present all important benefit and harm information in a well-designed table or graphic, so that they can be easily compared.
"Improving how guidelines present the benefits and harms would help doctors better understand the trade-offs and facilitate informed discussions with patients. It would also help us to build better decision support tools for physicians," says Caverly, who is also a member of the U-M Institute for Healthcare Policy and Innovation.

More information: Journal of the National Cancer Institute, published online Feb. 24, 2016, DOI: 10.1093/jnci/djv436


Provided by University of Michigan Health System

Editorial calls for comprehensive approach to cancer screening

May 9, 2012– An editorial by Marcus Plescia, MD, MPH, director of the Division of Cancer Prevention and Control at the Centers for Disease Control and Prevention (CDC), calls for a more organized and comprehensive approach to increase cancer screening participation among those who are insured or are likely to become insured through the Patient Protection and Affordable Care Act. The editorial, which appears in the American Cancer Society journal, CA: A Cancer Journal for Clinicians, says public health has a responsibility to lead a national approach to cancer control that is comprehensive, strategic, and organized, and that a system to improve cancer screening could act as a model for other clinical preventive services.

11 may 2012--Despite efforts to increase screening for breast and cervical cancers, rates have not improved in almost a decade. Meanwhile, screening rates for colorectal cancer are unacceptably low. Lack of insurance has traditionally been the main factor preventing adults from obtaining cancer screening. And while the Patient Protection and Affordable Care Act will help address this, access to health insurance and medical care are not the only factors that limit participation in cancer screening. Many people who currently have health insurance and regular access to medical care are not being screened.
Dr. Plescia says the infrastructure to promote and ensure cancer screening in the United States must be expanded to achieve desired screening goals. Efforts could include the development of centralized data systems for cancer screening, which could be used to develop more organized, systematic approaches.
While most patients are offered screening tests when they visit a medical provider for unrelated reasons, evidence-based interventions, including reminders to clients and providers to ensure that individuals are screened on time, have been shown to increase cancer screening rates. Screening registries have been found to improve the follow-up of patients with positive screening tests. But widespread implementation of these approaches has been challenging in a fragmented health care system. In a recent study of primary care physicians' practices, only 40% reported that they had a system in place to remind patients to come in for breast or cervical cancer screenings.
"In an era of health care reform, public health has opportunities to ensure that participation in cancer screening is widespread and equitable," concludes the editorial. "Given the magnitude of cancer morbidity and mortality… public health has a responsibility to lead a national approach to cancer control that is comprehensive, strategic, and organized."
More information: Plescia M., Richardson L.C., and Joseph D. New roles for public health in cancer screening [published online ahead of print May 9, 2012]. CA Cancer J Clin. 2012. doi: 10.3322/caac.21147
Provided by American Cancer Society

Despite guidelines, elderly receiving too many cancer screenings

14 dec2011-- Despite guidelines from a major medical group recommending limited – or no – screenings for four types of cancer for people in their 60s, 70s, and 80s, a UConn researcher has found that more than half of elderly adults continue to receive the screenings.

Keith Bellizzi, an assistant professor in the Department of Human Development and Family Studies in the College of Liberal Arts and Sciences, says that despite the U.S. Preventive Services Task Force guidelines against routine screening for breast, colorectal, cervical, and prostate cancer at the age of 75 years (65 for cervical cancer), more than 50 percent of physicians continue to recommend the tests. High rates continue for people in their 80s.

Bellizzi found that elderly Hispanics and African Americans were screened less often than Caucasians, differences accounted for by lower educational attainment in these two groups compared to Caucasians.

The USPSTF guidelines recommend against routine cervical cancer screenings in women older than 65; ending routine screening for mammography and colorectal cancer in adults 75 or older; and against screening for prostate cancer in men 75 and older. Other agencies and organizations also recommend fewer screenings for the elderly.

“These findings reinforce the need to examine factors that physicians consider in deciding to screen their patients, and underscores the critical role for health care providers to make informed screening decisions for their patients,” says Bellizzi.

The study will be published later this month in the Archives of Internal Medicine, a publication of the American Medical Association. Joining Bellizzi in the work was Erica Breslau and Allison Burness of the National Cancer Institute.

Bellizzi analyzed data from the CDC’s National Health Interview Survey, an annual in-person nationwide survey used to track health trends in American citizens, to estimate the prevalence of cancer screening among older adults in different racial groups. The study population of 49,575 individuals included 1,697 who were 75 to 79 years of age and 2,376 who were 80 years of age and older.

“In the United States, the number of adults 65 years or older, currently estimated at 36.8 million, is expected to double by the year 2030. Providing high-quality care to this growing population while attempting to contain costs will pose a significant challenge,” Bellizzi says. “While a great deal is known about cancer screening behaviors and trends in young and middle-aged adults, less is known about screening behaviors in older adults from different racial backgrounds.”

Historically, older adults have been excluded from cancer screening trials, so screening efficacy data on this population is limited, Bellizzi says. Research also is needed to determine the value of continued screening in elderly Americans, and whether the benefits – potentially longer lives – outweigh the negatives: complications from tests, false positives putting unneeded stress on the patient and their families, treatment of clinically unimportant cancers, distress, and anxiety.

“Older adults are becoming increasingly heterogeneous with respect to health status because of earlier lifestyle behaviors and health trajectories,” Bellizzi says. “As such it is quite likely that continued screening for certain segments of the older adult population is warranted.

“At the same time, there are segments of the older adult population with limited life expectancy, poor health status, and concomitant health conditions that would likely not benefit from screening. The challenge is how do we make this determination,” he says.

Done properly, he adds, “we would improve the quality of care in the older population, while containing health care costs.”

Provided by University of Connecticut

Too many cancer screening options confuse patients, lead them to avoid screenings altogether

06 jan 2011-- Adhering to cancer screening recommendations is one of the best things people can do to reduce their risk of dying from cancer. But research at Virginia Commonwealth University Massey Cancer Center suggests that when patients are presented more than one colorectal cancer screening option, there is a greater chance of confusion and, therefore, a greater chance of neglecting screening recommendations.

The study, published in the journal Cancer Epidemiology, Biomarkers & Prevention, included data from more than 3,350 patients and provides the first empirical evidence linking multiple screening options with patient confusion, and patient confusion with screening adherence. Of the patients surveyed, the researchers found that 56 percent had discussed two or more colorectal cancer screening options with their physicians. Those patients presented with multiple options were 1.6 times more likely to be confused than those presented with one screening method. They also were 1.8 times less likely to follow screening recommendations.

The research was led by Resa M. Jones, M.P.H., Ph.D., assistant professor of epidemiology and community health at VCU Massey Cancer Center, whose recent research has been focused on evaluating barriers to colorectal cancer screenings.

“We found that confusion about multiple colorectal cancer screening options may act as a barrier to screening. Recognizing and minimizing confusion about the various options through public health messages, patient-physician communication and interventions could lead to increased screening adherence,” says Jones. “These results also have potential implications for other health-related topics where multiple options or choices are given.”

Currently, there are several different ways to screen for colorectal cancer: fecal occult blood testing, flexible sigmoidoscopy, colonoscopy and barium enema. These methods vary by frequency, accuracy, preparations, discomfort and cost. Additionally, the American Cancer Society and the U.S. Multi-Society Task Force on Colorectal Cancer now recommend more screening options than the U.S. Preventive Services Task Force suggests. All of these factors could add to patient confusion.

The data for this study were obtained using a questionnaire mailed to patients 50 to 75 years old who visited their doctor at least once in the past two years. Most of the patients earned more than $20,000 per year and were insured. Jones plans to further explore socioeconomic factors contributing to patient confusion about colorectal cancer screening and hopes to conduct a randomized trial to increase screening adherence in underserved populations by addressing barriers.

“Colorectal cancer is the second leading cause of cancer death. Patients whose cancers are detected early face much better outcomes than those diagnosed in later stages,” says Jones. “It’s important that patients have choices, but we have to be sure those choices are understood so that they don’t overwhelm the patient and become barriers to proper screening and care.”

Provided by Virginia Commonwealth University

Guidelines for cancer screening differ by group

24 nov 2009--Several doctors groups and advocacy groups set guidelines for cancer screening, and they update that advice periodically as new information emerges. Sometimes they agree, sometimes they don't. Last year, a number of groups got together and issued consensus guidelines for colon cancer.

The U.S. Preventive Services Task Force, a government-appointed, independent panel of doctors and scientists, also makes recommendations looked to by doctors groups, insurers and policy makers.

The latest advice from the major medical groups for routine screening — primarily for people who don't have a family history of a particular cancer or other risk factors:

Breast cancer:

• American Cancer Society: Mammograms yearly beginning at age 40; breast exam by doctor at least every three years in 20s and 30s, annually after 40; breast self-exam an option.

• American College of Obstetricians and Gynecologists: Mammograms every 1-2 years for women in their 40s; annual mammograms age 50 and older; breast exam by a doctor annually from age 19; breast self-exam can be recommended.

• U.S. Preventive Services Task Force: Mammograms every two years for women ages 50 to 74, after 75 the risks and benefits unknown; recommends against self-exam; value of exams by doctors unknown.

Cervical cancer:

• Cancer Society: Start Pap tests about three years after first intercourse but no later than 21; annually or every 2-3 years for women over 30 who have three normal tests; stop at 70 after at least three negative tests and no abnormal tests in last 10 years; discontinue after a total hysterectomy.

• ACOG: Start Pap tests at age 21 and then every two years; 30 years and older, every three years after three normal tests; reasonable to stop at age 65 or 70; discontinue after hysterectomy.

• Task Force: Start Pap tests within three years of sexual activity or by age 21; at least every three years, stop after 65 if negative tests and no high risk; discontinue after hysterectomy.

Prostate cancer:

• Cancer Society: No routine testing recommended; doctors should discuss benefits and limitations, and offer screening — a physical exam and blood test for a substance called PSA — to men beginning at age 50, with at least a 10-year life expectancy.

• Task Force: No recommendation for or against screening for men under 75; men over 75 should not be screened.

• American Urological Association: Men 40 and older should be offered a baseline PSA test and exam.

Colon cancer:

• Cancer Society and other major groups: Start screening at 50 with one of these tests: colonoscopy every 10 years; a sigmoidoscopy of the lower colon every five years; CT colonography or "virtual colonoscopy" every five years; barium enema every five years, stool blood test annually; stool DNA test, no interval given.

• Task force: Screen from age 50 to 75 with one of three tests: colonoscopy every 10 years; a sigmoidoscopy every five years, combined with a stool blood test every three years; a stool blood test every year.

___

On the Net:

Task Force: http://www.ahrq.gov/CLINIC/uspstfix.htm

Cancer Society: http://tinyurl.com/screening-guidelines

Cancer screening rates among older Medicaid patients fall short of national objectives

14 oct 2008--Only about half of Medicaid recipients age 50 and older appear to receive recommended screening tests for colorectal, breast and cervical cancer, according to a report in the October 13 issue of Archives of Internal Medicine, one of the JAMA/Archives journals.
These three types of cancer are potentially curable when detected early, and eliminating disparities in screenings is part of the government's Healthy People 2010 plan, according to background information in the article. "State Medicaid agencies are in a unique position to monitor and improve the quality of care received by some of the nation's most vulnerable citizens," the authors write. "Medicaid is the largest provider of health insurance for minority populations in America. Medicaid recipients, by virtue of Medicaid eligibility criteria, frequently share other characteristics associated with health-related disparities: low income, old age, and/or chronic disability because of advanced disease, physical limitation, severe mental illness or developmental disability."
C. Annette DuBard, M.D., M.P.H., of the North Carolina Department of Health and Human Services, Raleigh, and the University of North Carolina at Chapel Hill Cecil G. Sheps Center for Health Services Research, and colleagues studied a representative sample of 1,951 North Carolina Medicaid recipients age 50 and older. Medical records were reviewed to determine whether physicians had recommended and patients had received cancer screening examinations.
"Documentation that colorectal, breast and cervical cancer screening was recommended by the primary care provider was found for only 52.7 percent, 60.4 percent and 51.5 percent of eligible patients, respectively," the authors write. "Documented rates of adequate screening were 28.2 percent for colorectal cancer, 31.7 percent for mammography within two years and 31.6 percent for Papanicolaou [cervical cancer] test within three years. When medical record and claims data were combined, approximately half of eligible patients had evidence of screening."
Despite Medicaid recipients' access to primary care and full coverage of cancer screening services, these rates are substantially lower than those in the general population, the authors note. "Lack of a screening recommendation by the physician, rather than patient refusal of recommended tests, accounted for most instances of screening delinquency," they conclude. "Efforts to increase cancer screening rates among Medicaid recipients must address patient, physician and organizational barriers to the routine identification and delivery of preventive services."
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(Arch Intern Med. 2008;168[18]:2014-2021. Available pre-embargo to the media at www.jamamedia.org.)

Early Test for Cancer Isn’t Always Best Course

By TARA PARKER-POPE
17 aug 2008--Sometimes what you don’t know might end up being better for you.
For years patients have been told that early cancer detection saves lives. Find the cancer before the symptoms appear, the thinking goes, and you’ve got a better chance of beating the disease.
So it might have seemed surprising last week when a panel of leading medical experts offered exactly the opposite advice. They urged doctors to stop screening older men for prostate cancer, which will kill an estimated 28,600 men in the United States this year.
Their advice offered a look at the potential downside of cancer screening and our seemingly endless quest to detect cancer early in otherwise healthy people. In this case, for men 75 and older, the United States Preventive Services Task Force concluded that screening for prostate cancer does more harm than good.
“We’ve done a great job in public health convincing people that cancer screening tests work,” said Peter B. Bach, a pulmonologist and epidemiologist at Memorial Sloan-Kettering Cancer Center in New York City. “We’re uncomfortable with the notion that some screening tests work and others don’t. That seems mystifying to people.”
But the reality is that while some cancer screening tests — like the Pap smear for cervical cancer or mammography for breast cancer — clearly save lives, the benefits of other screening tests are less clear.
Studies of lung cancer screening, for instance, have failed to prove that it prolongs life. A mass screening for neuroblastoma in Japanese infants was halted after it became clear that the effort wasn’t saving children and worse, led to risky treatments of tumors that weren’t life threatening.
The case seemed stronger for screening for prostate cancer. By some measures, death rates from the disease in the United States have plummeted since the introduction of the screening test for prostate specific antigen, which detects levels of a protein that can signal prostate cancer.
The data, in fact, are highly misleading. The introduction of screening can trigger big statistical fluctuations that can be difficult to interpret. But if you look at prostate cancer statistics in the 1970s, long before screening was introduced, death rates have dropped only slightly since then. The small decline seems largely because of improvements in treatment, many experts say, though others point to early detection as the reason.
Whether there really is a measurable benefit from PSA screening for younger men won’t be known for a few more years, after data from two major clinical trials studying the test are reported.
How can it be that finding prostate cancer early doesn’t help save lives? For starters, a large percentage of prostate cancers aren’t deadly. They are slow growing and unlikely to result in any symptoms before the end of a man’s natural life expectancy. By some estimates, as many as 44 percent of the men who are treated for prostate cancer as a result of PSA testing didn’t need to be. Had they been left alone, they would have died of something else and never known they had cancer.
“Screening tests don’t only pick up life-threatening cancers, they pick up tumors that look identical to traditional tumors, but they don’t have the same biologic behavior,” said Dr. Barry Kramer, associate director for disease prevention at the National Institutes of Health. “Some are so slow growing they never would have caused medical problems in the person’s natural life span.”
In the case of PSA testing, the Preventive Services Task Force, an expert panel that makes recommendations about preventive care for healthy people, said there was not enough evidence to recommend for or against screening of younger men, although they urged doctors to advise men of all the risks and benefits of screening. But they did conclude that 75 is the age at which the risks clearly begin to outweigh the benefits, and the disease, if detected, would most likely not have a meaningful effect on life expectancy.
Another problem with determining the value of screening is that it results in “lead time bias.” For instance, someone diagnosed with lung cancer at the age of 65 may die at 67 and be remembered as a two-year survivor. If the same man had been diagnosed at 57 through screening and died at the age of 67, he would be known as a 10-year survivor. That sounds a lot better, but the reality is that diagnosis and treatment didn’t prolong his life. He died at 67 either way.
“Even a harmful screening test could appear on the surface as a helpful test,” Dr. Kramer said. “Because you measure survival from the date of diagnosis, even if the person dies of the same cause on the same day they would have without screening, it looks like survival was longer.”
Any screening test can lead to false positives, followed by invasive and risky tests. Large numbers of people often end up being poked, prodded and tested only to discover they’re fine.
Biopsies to detect prostate cancer get mixed reviews. Some men find them to be a minor discomfort; others say they were left in debilitating pain. Once cancer is found, surgery, radiation or hormone therapy, or “watchful waiting,” may be advised.
Treatments for prostate cancer can cause significant harm, rendering men incontinent or impotent, or with other urethral, bowel or bladder problems. Hormone treatments can cause weight gain, hot flashes, loss of muscle tone and osteoporosis.
“It’s just a needle stick, but the cascade of events that follows are fairly serious,” Dr. Bach said. “I think the burden is on medicine to try and generate some evidence that the net benefits are there before drawing that tube of blood.”
The problem with prostate screening is that some men are very likely to have been saved by early detection. But how many have been hurt?
“I’m a little worried we may look back on the prostate cancer screening era, after we learn results of clinical trials, and see that we’ve harmed a lot of people without doing them good,” said Dr. David Ransohoff, a professor of medicine and cancer screening researcher at the University of North Carolina at Chapel Hill. “By being so aggressive with so many people, did we do the right thing? I don’t know that it’s going to turn out that way.”

Perceived Medical Discrimination May Discourage Cancer Screening

By Charles Bankhead
PALO ALTO, Calif., 07 aug 2008 -- Perceived discrimination in medical care translated into lower rates of screening for breast and colorectal cancer in minority patients, investigators here found.
Patients who perceived discrimination in the healthcare setting were up to 70% less likely to be screened, LaVera M. Crawley, M.D., of Stanford, and colleagues, reported in the August issue of Cancer Epidemiology Biomarkers and Prevention.
Overall, women were influenced more than men by the perception of discrimination.
However, the lowest screening rates were among men who had a usual source of care and sensed discrimination.
"These findings of a significant association between perceived racial or ethnic-based medical discrimination and cancer screening behaviors have serious implications for cancer health disparities," the authors concluded.
However, they cautioned that "we cannot know whether the reported events represented actual discriminatory acts or if perception of discrimination was accurate. Clearly, more research is needed to confirm these initial findings and to explain the gender differences as well as to explore important subgroup differences."
In a 2002 report on unequal treatment in American health care, the Institute of Medicine expressed concern that racial and ethnic discrimination may play a major role in health-care disparities.
Although difficult to measure directly, discrimination, either real or perceived, has been shown to affect health-seeking behaviors, such as preventive services, the authors said.
Most studies that have examined perceived discrimination and health outcomes have focused on generalized discrimination, rather than medical discrimination (related to the care received), they continued.
To examine the impact of perceived medical discrimination on cancer screening, the investigators reviewed data from the 2003 and 2005 California Health Interview Survey. Both surveys elicited information about minority respondents' perception of discrimination in the healthcare setting.
The study involved a total of 11,245 African-American, American Indian/Alaskan Native, Asian, and Latino adults, comprising 8,051 women ages 40 to 75 and 3,194 men ages 50 to 75.
More than half had at least some college education, about 85% had health insurance, and more than 90% reported a usual source of care.
The primary outcome measures were rates of screening for colorectal cancer in men and women ages 50 to 75 and rates of breast cancer screening in women ages 40 to 75.
The overall screening rate for colorectal cancer (endoscopy within the past five years and/or fecal occult blood testing within the past year) was 41.8% among women and 43.4% among men.
About 60% of the women reported having a mammogram within the past year.
The responses showed that 8.9% of women and 6.2% of men had perceived medical discrimination within the past five years.
As compared with respondents who reported no discrimination, women who perceived medical discrimination were 34% less likely to be screened for colorectal cancer (OR 0.66, 95% CI 0.64 to 0.69) and 48% less likely to be screened for breast cancer (OR 0.52, 95% CI 0.51 to 0.54).
Men who perceived discrimination were just as likely to be screened for colorectal cancer as those who reported no discrimination (OR 1.02, 95% CI 0.97 to 1.07).
However, men who perceived discrimination and reported having a usual source of care were 70% less likely to be screened (OR 0.30, 95% CI 0.28 to 0.32).
The findings suggest that "some persons may delay or avoid getting screened for cancers and that this delay may be associated with racial or ethnic-based experiences they encounter within the medical setting," the authors said.
The authors acknowledged that a cross-sectional survey precludes an examination of causality.
They also noted a potential for sample bias because of low response rates to the surveys (33.5% in 2003 and 26.9% in 2005).
The authors reported no disclosures.
Additional source: Cancer Epidemiology, Biomarkers & PreventionSource reference: Crawley LM, et al "Perceived medical discrimination and cancer screening behaviors of racial and ethnic minority adults" Cancer Epidemiol Biomarkers Prev 2008; 17: OF1-8.

Severely Obese Women More Likely to Skip Cancer Scans

Severely obese woman are more likely than other women to skip cancer screenings, even though being severely obese increases their risk of developing and dying of cancer.
U.S. researchers analyzed data from about 8,300 women, aged 40 to 74, who took part in the 2000 National Health Interview survey.
They found that severely obese women were up to 10 percent less likely than normal-weight women to be up-to-date on clinical breast exams, mammograms and Pap smears.
The study also found that severely obese women were 51 percent less likely to adhere to doctors' recommendations for mammography and 83 percent less likely to adhere to Pap recommendations. The study did find that doctors are equally likely to recommend mammography and Pap smears to obese and non-obese women.
The study is published in the June issue of the American Journal of Preventive Medicine. It was also presented at a meeting of the American Society of Preventive Oncology in March.
It's important to learn why severely obese women (those with a body-mass index of 40 or higher) are less likely to go for cancer screenings, said lead author Jeanne Ferrante, who practices in the family medicine department at the University of Medicine and Dentistry of New Jersey/New Jersey Medical School in Newark.
Ferrante plans to survey doctors to find out whether there are barriers that prevent severely obese women from being screened for cancer, such as a lack of proper equipment to examine severely obese patients.
She is also gathering information from patient focus groups, and has found that severely obese women feel embarrassed because of their weight.
"They don't like to be examined. They don't like to wear two gowns or have a scale inadequate to weigh them," Ferrante said in a prepared statement.

Periodic Health Examination May Facilitate Cancer Screening

March 28, 2007 — The periodic health examination (PHE) is an appropriate time for primary care clinicians to encourage cancer screening and was linked significantly with patient completion of breast and colorectal cancer screening and prostate-specific antigen (PSA) testing, according to the results of a retrospective cohort study reported in the March 26 issue of the Archives of Internal Medicine.
"Patients and physicians strongly endorse the importance of preventive or periodic health examinations (PHEs)," write Joshua J. Fenton, MD, MPH, from the University of California, Davis, in Sacramento, California, and colleagues. "However, the extent to which PHEs contribute to the delivery of cancer screening is uncertain."
The investigators determined the association between receipt of a PHE and cancer testing in a population-based cohort of 64,288 enrollees in a Washington State health plan who were aged 52 to 78 years and eligible for colorectal, breast, or prostate cancer screening in 2002-2003. Endpoints included completion of any colorectal cancer testing (fecal occult blood testing, sigmoidoscopy, colonoscopy, or barium enema), screening mammography, and PSA testing.
During the study period, 52.4% of the enrollees received a PHE. Receiving a PHE was significantly associated with completion of colorectal cancer testing, after adjustment for demographics, comorbidity, number of outpatient visits, and historical preventive service use before January 1, 2002 (incidence difference, 40.4% [95% confidence interval (CI), 39.4% - 41.3%]; relative incidence, 3.47 [95% CI, 3.34 - 3.59]).

Preventive Checkups Open Door to Cancer Screening

SACRAMENTO, Calif., March 26 -- Health-plan patients who take advantage of periodic routine physicals are more likely to be screened for colorectal cancer, and for breast or prostate cancer, found researchers here.
Of patients who received a prepaid health exam in 2002 to 2003, colon cancer screening was three times higher compared with patients who did not have a checkup, Joshua Fenton, M.D., of the University of California, Davis here, and colleagues reported in the March 26 issue of the Archives of Internal Medicine.
Breast cancer screening for women was slightly greater among the checkup patients, while PSA testing for eligible men was almost three times greater.
These findings emerged from a retrospective cohort study to determine the association between preventive checkups and cancer testing in a population-based sample of 64,288 enrollees in a Washington State health plan (Group Health Cooperative). Participants were 52 to 78 years old and eligible for colorectal, breast, or prostate cancer screening.
Tests included completion of any colorectal cancer testing (fecal occult blood testing, sigmoidoscopy, colonoscopy, or barium enema), screening mammography, and PSA testing.