148
Articles
Cancer Screening Practices Among Primary Care Physicians Serving Chinese Americans in San Francisco MARION M. LEE, PhD; FLORENCE LEE, MPH; SUSAN STEWART, PhD; STEPHEN McPHEE, MD San Francisco, California
Previous research has reported a lack of regular cancer screening among Chinese Americans. The overall objectives of this study were to use a mail survey of primary care physicians who served Chinese Americans in San Francisco to investigate: a) the attitudes, beliefs, and practices regarding breast, cervical, and colon cancer screening and b) factors influencing the use of these cancer screening tests. The sampling frame for our mail survey consisted of: a) primary care physicians affiliated with the Chinese Community Health Plan and b) primary care physicians with a Chinese surname listed in the Yellow Pages of the 1995 San Francisco Telephone Directory. A 5-minute, self-administered questionnaire was developed and mailed to 80 physicians, and 51 primary care physicians completed the survey. A majority reported performing regular clinical breast examinations (84%) and teaching their patients to do self-breast examinations (84%). However, the rate of performing Pap smears was only 61% and the rate of ordering annual mammograms for patients aged 50 and older was 63%. The rates of ordering annual fecal occult blood testing and sigmoidoscopy at regular intervals of three to five years among patients aged 50 and older were 69% and 20%, respectively. Barriers (patient-specific, provider-specific, and practice logistics) to using cancer screening tests were identified. The data presented in this study provide a basis for developing interventions to increase performance of regular cancer screening among primary care physicians serving Chinese Americans. Cancer screening rates may be improved by targeting the barriers to screening identified among these physicians. Strategies to help physicians overcome these barriers are discussed. (Lee MM, Lee F, Stewart S, McPhee S. Cancer screening practices among primary care physicians serving Chinese Americans in San Francisco. West J Med 1999; 170:148-155) Chinese Americans are a large and growing ethnic group in the United States. From 1980 to 1990, the Chinese population in the United States more than doubled to 1,645,472 people.t Data from the Surveillance Epidemiology and End Results (SEER) Program of the San Francisco Bay Area (1988-1992) showed that the five most common cancer sites among Chinese American men were lung, colorectal, prostate, liver, and oral cancer, and the five most common cancer sites among Chinese American women were breast, colorectal, lung, uterine, and ovarian cancer.2 Early detection of many of these cancers, when treatment is more likely to be successful, can dramatically improve survival rates. Regular use of screening tests can detect cancers of the breast, colon, rectum, and cervix at an early stage. However, few data are available on cancer screening practices among Chinese Americans. Underutilization of cancer
screening tests among Chinese Americans has been reported in a few previously published studies.3'5 The Centers for Disease Control and Prevention's (CDC) Behavioral Risk Factor Surveillance System (BRFSS) conducted a survey on Chinese in Oakland during 1989-1990 showing that among Chinese women aged 40 and older, 68% reported never having a mammogram and 75% reported never having had a clinical breast examination.4 In a recent telephone survey of Chinese women in San Francisco, California, the rates of having a mammogram (women aged 40 and older) and a Pap smear at regular intervals were 25% and 37%, respectively.5 The low screening rates may be explained not only by patient characteristics and patient barriers to screening, but also by physician practice patterns. Primary care physicians have the opportunity and ability to promote cancer screening practices among their
From the Department of Epidemiology and Biostatistics, University of California, San Francisco, California (Dr Lee and Ms Lee); Northern California Cancer Center, Union City, California (Dr Stewart); and Department of Medicine, University of California, San Francisco, California (Dr McPhee). Reprint requests to Dr Marion Lee, Box 0560, University of California, San Francisco, CA 94143-0560 (e-mail:
[email protected]).
WJM, March 1999-Vol 170, No. 3 WIM,
March
1999-Vol
170,
No.
in Chinese Cancer Screening in Chinese Americans-Lee Americans-Lee et et al al 149 149
3Cancer Screening
patients. Physicians increasingly function as gatekeepers to and coordinators of cancer prevention activities. Cancer screening tests such as mammography require a physician referral. The most often cited reason for not having a cancer screening test by patients, regardless of ethnicity, is that their physician has never recommended it.6'7 Physician endorsement of a cancer screening test can have a positive impact on patient motivation.8 Patients are more likely to have the screening test if they perceive that their physician strongly recommends the test.9 Since Chinese greatly respect authority, the advice of physicians about cancer screening tests could be very effective in this ethnic population. Despite the acceptance of a preventive philosophy among physicians and the establishment of cancer screening guidelines by national organizations,"1'6 many studies have documented a gap between recommended guidelines and physicians' screening practices.15-19 Barriers to the practice of cancer screening among primary care physicians have been investigated.'-26 These barriers include: a) lack of education, knowledge, and training (sigmoidoscopy, Pap smear); b) patient refusal (rectal exam, sigmoidoscopy, mammography, and Pap smear); c) patient discomfort or embarrassment (Pap smear, mammography and sigmoidoscopy); d) cost to patient (mammography and sigmoidoscopy); e) physician forgetfulness (clinical breast exam, mammography, fecal occult blood test); f) professional ambiguity and confusion of guidelines; and g) practice logistical difficulties, such as time constraints, availability of technology, personnel and office space. Those studies, however, did not specifically focus on physicians who serve predominantly Chinese American populations. To date, there are no reports in the literature that describe the prevalence of and barriers to prescribing cancer screening tests among physicians serving this ethnic population. Recognizing the importance of studying the factors influencing cancer screening practices among patients and among their physicians, we focused on two converging pathways-the medical care system of providers (primary care physicians) and the sociocultural system of consumers (Chinese American women) in San Francisco. We studied interacting factors that influence practices of providers who prescribe the cancer screening tests and the actions of consumers in using these tests. A total of 775 Chinese American women completed a telephone survey. Results of the consumer survey have been previously published.5 This paper describes the results of the physician mail survey. In the physician mail survey, we examined screening practices regarding breast, cervical, and colorectal cancer among primary care physicians who served in San Francisco's Chinese community. The survey objectives were to assess the physicians': a) demographic and acculturation characteristics; b) practice settings; c) attitudes, beliefs, and practices (ie, compliance with specific cancer screening guidelines and screening intervals); d) perceived barriers and benefits of screening; and e) use of
educational materials and follow-up/reminder systems relating to prescribing cancer-screening tests (clinical breast exam, mammogram, teaching breast self-exam, Pap smear, digital rectal exam, fecal occult stool test, and flexible sigmoidoscopy).
Methods The sampling frame for our physician survey consisted of two samples of physicians: a) all primary care physicians who were affiliated with the Chinese Community Health Plan (CCHP) and b) all primary care physicians with Chinese surnames who were listed in the 1995 Yellow Pages of the San Francisco telephone directory. To be eligible, physicians were required to: a) have predominantly Chinese patients in their current practice in San Francisco and b) specialize in obstetrics and gynecology, internal medicine, family practice, or general practice. A 5-minute, self-administered questionnaire was developed to address our objectives. An invitation letter explaining the aims of the study along with a copy of the questionnaire and a stamped return envelope were sent to each eligible physician. Physicians who had not returned questionnaires after two weeks received a telephone call emphasizing the importance of the study and requesting their cooperation. A total of three phone calls were made to nonresponding physicians. Questionnaire data were then assessed for completeness and summarized. We determined the percentages of survey question responses. Standard statistical tests including chi-square statistics and student t tests were performed when appropriate.
Results The survey was conducted during the spring of 1995. Of the 95 physicians (22 from the CCHP, 73 from the yellow pages), 80 physicians were found to be eligible, and 51 (68% from CCHP, 32% from yellow pages) completed the mail survey yielding a response rate of 62%. The demographic characteristics and practice setting of the physicians are shown in Table 1. Most of the study physicians (84%) were male with a mean age of 50.2 years. About half of them (55%) were born in the United States. The majority (76%), however, obtained their medical degree in the United States. Half (48%) were internists and a quarter (24%) were family practitioners. About three-quarters of the physicians (77%) had an individual private practice. Their average length of time practicing in San Francisco was 13 years. Over half (62%) of their patients were Chinese. Most of their patients (61%) had either Medicaid or Medicare insurance. A majority of physicians (79%) and their staff (82%) were able to speak the Chinese language to their patients. Table 2 shows breast and cervical cancer screening practices of primary care physicians. Although all physicians reported having ordered mammograms for their asymptomatic female patients, only 63% ordered annual mammograms for their patients aged 50 and older. Most
Cancer Screening in Chinese Americans-Lee et al
WJM, March 1999-Vol 170, No. 3
150 15
WIM,
A
170
Mach199-o --
l
No
. il
olrt. I .5
tra
3
acrSreicnCins
mrcn-e
ta
,
rt 'i.Ii ..
;i.|
*1'
ic
':
'i
.-.A Y -t rcs-v ll
;
mended by study physicians: Sixty-nine percent reported ordering this test annually for asymptomatic patients aged 50 and older. About half (51%) of the physicians did not order regular sigmoidoscopy for patients older than age 50. One quarter (23%) of the physicians reported referring their patients to other physicians for this procedure. Only 20% of physicians performed sigmoidoscopy for patients aged 50 and older at regular intervals of three to five years. About half of the physicians did not follow any guidelines for colorectal cancer screening (Table 3). The colorectal cancer screening guidelines of the American Cancer Society
i
(84%) reported performing regular clinical breast examinations, while only 61% performed Pap smears in their office. More than half of the physicians followed specific guidelines for breast (75%) and cervical (55%) cancer screening (Table 3). The breast and cervical cancer screening guidelines of the American Cancer Society were the most frequently cited guidelines followed by the physicians. For colorectal cancer screening (Table 4) fecal occult blood testing (FOBT) was most frequently recom-
LI'.
!i ............ 5
t. Cett;Gi LU?0 3
Qepnrtt
hYS i
K' -t
(7:.
?:.'i.. Ic, r N f,.r~
',M.
;.c';rtidv
F 5 A3* Ti3 R tl
vjo;
.
.1
-
'c)s\.\JI I
-:-. :I -,,.7
;' '..Ai;^.-;
t nlr,.i r.4tl 'i. r-7n;>
br Geast\tV.li? :(
j';f
1-$ II il jr
Ci1']1; 11
MIII'..
t.
-I
':
I;
51 Cancer Screening in Chinese Americans-Lee et al 1 5-1
WJM, March 1999-Vol 170, No. 3 70 -1
WIM. March 1999-Vol
No. 3--
TABLE 5.-Top Three Reasons for Not Prescribinq Caoncer Screening Tests Among Study Physicians (n 51) Mammogram
1. Cost to patient (30%°) 2. Patient concerned about pain or discomfort (28%)o 3. Patient is healthy, hias no physical symptoms, therefore, thinks tests unnecessary
Pap
(26%)
smear
Patient feels embarrassed, uncomfortable to have anvone exam her genitalia (29%1o) 2. Patient is healthv; has no phvsical symptoms, therefore thinks test unnecessaryv (29%o) 3. Patient dces not nave the timne, th nks test inconvenient (20°o) Fecal occult blood testing 1. Patient does not have the time, th nks test incon\enient (26%o) 1.
2.
Cost to patient
3.
Patient is healthyv test
(13%)
unnecessary
has no
physical symptorns therefore thinks
(90.,)
Sigmoidoscopy 1. Pat;ent concerned about pain or discomfort (58%0,) 2. Patient is healthy, has no physical symptoms, therefore thinks test unnecessary (330§3 3. Patient dces not nave the time, th nks test inconvenient (1 70%)
were the most frequently cited guidelines followed by the physicians. Table 5 shows the three most frequently cited reasons by physicians for not prescribing the screening tests. "Patient feels healthy, has no physical symptoms; therefore, they feel the screening test is unnecessary" was a common reason cited by the physicians for not doing a Pap smear, ordering a mammogram, a fecal occult blood test, or a sigmoidoscopy. The primary barrier reported for not ordering a mammogram, however, was cost to the patient, and patient discomfort was the primary barrier for not ordering a sigmoidoscopy test. "Patient embarrassment," and "inconvenience to patient" were cited as the primary reasons for not ordering a Pap smear
and fecal occult blood testing, respectively. The barriers reported by physicians for not performing clinical breast examinations were: a) inadequate training to perform clinical breast exam and b) feeling it was inappropriate to perform clinical breast examination when the patient came for other health problems.
TABLE
Cace
SrenicjinChnseAmrian-Le
t
l
The establishment of an effective reminder system improve cancer prevention services in a medical practice. Less than half of the study physicians, however, reported having a reminder system for clinical breast examination (38%), mammography (49%), digital rectal examination (35%), fecal occult blood test (41%), and sigmoidoscopy (21%). Table 6 shows the attitudes towards breast cancer screening among study physicians. Seventy-six percent disagreed [somewhat (31%) + strongly (45%)] that screening mammograms were not cost effective for women. Seventy-three percent agreed [somewhat (53%) + strongly (20%)] that there was a general consensus regarding guidelines on breast cancer screening, and, 66% indicated that women should be allowed to refer themselves for breast cancer screening. Table 7 presents the cancer screening practices by physician's age and specialty. Younger physicians performed more screening tests than older physicians. As expected, obstetrics/gynecology doctors performed more breast and cervical screening tests than other specialists. In particular, the differences in the percentage of physicians in each specialty performing Pap smears in asymptomatic women reached statistical significance. can
27
Discussion A majority of primary care physicians (84%) serving Chinese Americans in San Francisco reported performing regular clinical breast examinations and teaching breast self-examinations. The rate of performing Pap smears, however, was only 61%, and the rate of ordering annual mammograms for patients aged 50 and older was only 63%. The rates of ordering annual fecal occult blood testing and sigmoidoscopy at regular intervals of three to five years among patients aged 50 and older were 69% and 20%, respectively. This utilization rate is lower than published cancer screening guidelines and recommendations. 101 3 One explanation for this low utilization rate could be that the physicians have no preference for any specific cancer screening guideline. Although a majority of physicians (75%) reported following specific guidelines for breast screening, only about half reported following specific guidelines for cervical (55%) and colorectal (47%) cancer screening. The cancer screening guidelines issued by the American Cancer Society were most
6.--Attitudes Toward Breast Cancer Screening Amnong Study Physicians (r = 51 ~5s.4
3 (6%) .......... Screening rmammograms are not cost-effective for women ......... 1... 10 (20%) There is a general consensus regarding gLidelines on breast cancer screening . 1 7 (330'c) . I.W%omen should be allowxed to refer themselves for screenino ..1...........
8 (1E60o) 27 (53%;...) 1 7 (330.;
5m
,
D!.jcrw
:
Di:o,r2t
16 (31 %) 23 (45°o) 9 (18%;;) 5 (1 0%1) O1%) 12 (240%)5 (I
152
Cancer Screening in Chinese Americans-Lee et al
WJM, March 1999-Vol 170, No. 3 IM
152
MacI99Vl10
acrSreiqi
o
hns
mrcn-e
ta
ThABL 7. -Self-Reported Cancer Screening Practices by Physician Age and Specialty Age 35-49 Years t' 28
50-79 Years rn = 2'
.n.ternai .1,le-C-
rnmnq lis.3r4r'sfor w-vomer aqed 50 ... 21 (75%)
11(50%k/) 1 7(77) 1 1(50)
1 2 (50 ) 20 (83)
-
..
..]. ~
.-'ionr(lc m-
