aM
0- Igi
Predictors of Endoscopy in Minority Women Jennifer Christie, MD; Charlene Hooper; William H. Redd, PhD; Gary Winkel, PhD; Katherine DuHamel, PhD; Steven Itzkowitz, MA; and Lina Jandorf, MA New York, New York
Financial support: This research was funded by Grant #401CA86107-01 from the National Cancer Institute and supported by Grant No. RO1 CA104130-01. Background: Colorectal cancer (CRC) is the second leading cause of cancer related deaths in the United States. Underrepresented minorities suffer disproportionately from CRC largely because of disparities in CRC screening rates, particularly by endoscopic methods. This study evaluates the association between socioeconomic, medical and psychosocial factors and the use of endoscopy in low-income minority women. Methods: The participants were recruited from community health fairs, tenant association meetings, senior centers and local medical clinics. A survey instrument was administered to the minority women. Results: Eighty-one women age >50 were included in this analysis (44 African Amencans and 37 Hispanics). The two ethnic groups were demographically similar. The factors associated with having had endoscopy were language spoken (English versus Spanish), physician recommendation, cancer cons and decisional balance (difference between cancer cons and cancer pros). When endoscopy was modeled as a function of decisional balance and language spoken, only decisional balance was a significant predictor of endoscopy. Conclusions: Physician recommendation and decisional balance have a tremendous influence on whether minorty women undergo endoscopy. These data suggest that if physicians increase their communication with patients regarding the benefits of screening and address patients concerns, adherence with endoscopic CRC screening can be improved in minority women.
Key words: endoscopy a screening a minority * colon cancer U women © 2005. From the Division of Gastroenterology, Mount Sinai School of Medicine. Send correspondence and reprint requests for J Natl Med Assoc. 2005;97:1361-1368 to: Jennifer Christie, MD, Division of Gastroenterology, Mount Sinai School of Medicine, 1 Gustave Levy Place, Box 1069, New York, NY 10029; phone: (212) 241-3109; fox: (212) 426-5099; e-mail:
[email protected]
JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION
INTRODUCTION Colorectal cancer (CRC) is the second leading cause of cancer related deaths in the United States.' Race and ethnicity are significant determinants of cancer incidence, mortality and survival, with minorities disproportionately experiencing an increased burden of disease as compared with whites. African Americans have a 28% increased mortality rate for colon cancer and 44% increased mortality rate for rectal cancer compared with whites. When CRC is detected and treated at an early localized stage, the five-year survival is 90%.2 The survival rate drops substantially to 65% and 9% when the cancer spreads to regional and distant metastatic sites, respectively.2 While Hispanics experience lower incidence and mortality rates than whites, they are still more likely to present with advanced stage CRC at diagnosis.3 Data provided by the National Cancer Data Base (NCDB) from 1995 demonstrated that nearly 60% of whites presented with early stage rectal adenocarcinoma versus 54% for Hispanics and 51% for African Americans. Disappointingly, of the 147,000 new cases of CRC diagnosed in 2004, only 37% have been detected in the early stages.2 One reason for the disparities in CRC incidence and mortality is that rates for CRC screening among African Americans and Hispanics are significantly lower than the national norms identified by the Centers for Disease Control and Prevention (CDC). As of 2000, the fecal occult blood testing (FOBT) and lower endoscopy rates in African Americans were 21.6% and 35%, respectively. The screening rates for Hispanics are the lowest of all ethnic groups, with 31.2% having ever received an endoscopy.3-5 African Americans and Hispanics lag behind whites, who report a 39.2% use of endoscopy. There are several hypotheses, such as differences in socioeconomic and insurance status, to explain the disparities in CRC screening rates. However, a recent study of Medicare beneficiaries showed that African Americans were significantly less likely to VOL. 97, NO. 1 0, OCTOBER 2005 1361
PREDICTORS OF ENDOSCOPY IN MINORITY WOMEN
utilize CRC procedures for screening purposes.6 Moreover, even when controlled for age, gender, income and access to care, African Americans have been shown to be less likely to have had colonoscopy or sigmoidoscopy compared with whites.7 Therefore, socioeconomic status alone does not explain all of the disparities in CRC screening use, particularly by endoscopic methods. It is crucial, therefore, that we analyze how other factors may contribute to the disparities in CRC screening in order to devise strategies to eliminate the disparities. In the past, three major categories of factors have been associated with cancer screening in the community. These include socioeconomic, medical and psychosocial factors. Socioeconomic factors, such as age, race, income, education, insurance coverage, language and marital status, are by far the most widely investigated. Previous studies have associated age 18 who lived, worked or sought healthcare in East Harlem were considered eligible for the study. The participants were recruited from community health fairs, tenant association meetings, senior centers and local medical clinics (Settlement Health, Boriken Neighborhood Health Center and Metropolitan Hospital). Informed consent for participation in the study was obtained, and the survey was conducted by trained health educators and research interviewers between the months of July and December 2000. A total of 383 people (0.355% of the men and women in the East Harlem community) were approached, and 248 (65%) agreed to participate in the survey. Minority subjects were defined as being African-American or Hispanic in this study. African Americans and Hispanics comprised 96% of those surveyed. The purpose of this analysis was to evaluate female screening practices with regard to mammography for breast cancer, Pap tests for cervical cancer and endoscopy for colon cancer screening. CRC screening begins at age 50 for average-risk individuals. Therefore, women age 50 participated in the study (44 African Americans and 37 Hispanics).
Interview The instrument for the larger study was an IRBapproved survey designed to assess the socioeconomic demographics of the community, knowledge of and participation in cancer screening, personal and family medical history of cancer, and the presence of physician recommendation of each screening test. In addition, specific questions pertaining to attitudes and knowledge toward breast, cervical, colon and prostate cancer screening were addressed.
For this substudy of women, questions pertaining to JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION
prostate cancer were excluded. Using Likert-style questions, the survey assessed potential psychosocial barriers to screening, such as pros and cons, cancer worry, acculturation, medical mistrust, fatalism and temporal orientation. After obtaining informed consent, the participants were administered the survey either face-to-face or via telephone by an ethnically and linguistically similar interviewer. The participants were given a phone card or supermarket coupon for completing the survey.
Measures We analyzed how participants' socioeconomic and medical characteristics may affect use of endoscopy. In addition, we analyzed how psychosocial factors affect endoscopy rates in the population studied. Endoscopy in the analyses refers to either flexible sigmoidoscopy or colonoscopy because both are accepted methods of performing CRC screening in average-risk individuals age >50 (as discussed below). Socioeconomic Factors. We assessed whether any of the following factors had an impact on use of endoscopy: age (50-65 or >65), language of interview (English versus Spanish), race/ethnicity (African-American versus Hispanic), household income (less than or greater than $10,000 per year), marital status (married or living with partner versus not married or living with partner), level of education (less than or greater than high school), and insurance status (federal versus commercial versus none). Medical History Factors. These items addressed past screening for CRC and patient medical history as it pertains to endoscopy as well as the use of mammography and Pap tests for breast and cervical cancer screening, respectively. Multiple questions regarding personal and family cancer history, care of a family member or spouse with cancer, access to a primary care physician and whether their primary care doctor had ever recommended endoscopy were included (yes/no). Psychosocial Factors. Cancer pros and cons: This is a 23-item scale adapted by Manne et al. to determine how an individual's attitudes about the advantages (pros) and disadvantages (cons) of colon cancer screening affects their screening decisions'8 (alpha pros=0.56, alpha cons=0.766). * Cancer Worry: This is a four-item scale adapted from Lerman et al. that assessed the degree to which people worried about being diagnosed with cancer and how much distress it caused them30 (alpha=0.86). * Acculturation: This 10-item questionnaire assessed how assimilated one is in mainstream society. A modified version of the Snowden and VOL. 97, NO. 10, OCTOBER 2005 1363
PREDICTORS OF ENDOSCOPY IN MINORITY WOMEN
*
*
*
*
Hines acculturation model was used.3' African Americans and Hispanics were asked similar questions regarding music choices, neighborhood and personal relationships with others (alpha= 0.70 for African Americans and alpha=0.74 for Hispanics). Medical Mistrust: This 12-item survey assessed the degree to which individuals believed that healthcare providers treat people of their racial/ethnic group unequally2' (alpha=0.59). Fatalism: Fatalism was assessed with the Powe Fatalism Inventory. This 15-item inventory assesses cancer fatalism. It has been used previously to examine African-American fatalism with respect to cancer22 (alpha=0.75). Temporal Orientation: The 26-item Jones Temporal Orientation scale was used to assess whether participants were more focused on past, present or future events24 (alpha past=0.826, alpha present=0.529, alpha future=0.718). Decisional Balance: This is part of the transtheoretical model for conceptualizing behavioral change. Decisional balance is determined by cal-
culating the difference between the cancer pros and cons score. Decisional balance is proposed to be associated with an individual moving from one stage to another in the continuum of behavioral change.32
Statistical Analysis The SPSS and SAS statistical package were used to analyze the data. Descriptive analysis was used to evaluate the demographic, medical and psychosocial factors in African Americans and Hispanics. A univariate analysis was performed by using Student's t test and %2 to determine which factors were associated with ever having had sigmoidoscopy or colonoscopy. Based on the univariate analyses and the known literature, variables were selected to be included in the multiple regression model. SAS software was used to perform logistic regression analysis, in which endoscopy use was modeled as a function of the socioeconomic, medical and psychosocial factors to determine the predictors of minority women ever having had endoscopy.
Table 2. Socioeconomic factors and endoscopy rates No Endoscopy 42 (51%)
Significance Level
39 (49%) 9 (23%) 30 (77%)
21 (50%) 21 (50%)
0.012*
.65 Ethnicity African-American Hispanic
28 (72%) 11 (28%)
16 (38%) 26 (62%)
0.002**
Language of Interview English Spanish
32 (82%) 7 (10%)
23 (55%) 19 (45%)
0.009**
Education < High school * High school
13 (33%) 26 (66%)
23 (55%) 19 (45%)
0.052
$1 0,000
22 (61%) 14 (39%)
25 (68%) 12 (32%)
0.565
Marital Status Married or living with partner Not married or living with partner
6 (15%) 33 (85%)
7 (17%) 34 (83%)
0.875
27 (71%) 9 (24%) 2 (5%)
32 (84%) 3 (8%) 3 (8%)
0.163
Variable Total Age 50-64
Endoscopy
Income
Insurance Federal
Commercial None
*p
