Colorectal cancer is the second leading cause of cancer-related death in the
United States (1). An estimated 135,400 new cases and 56,700 deaths from colorectal
cancer are expected during 2001 (1). Since the mid-1990s, national guidelines
have recommended that persons aged >50 years at average risk for colorectal
cancer should have screening tests regularly. To estimate rates for the use of
colorectal cancer screening tests and to evaluate trends in test use, CDC analyzed data from
the 1999 Behavioral Risk Factor Surveillance System (BRFSS) on the use of a
home administered fecal occult blood test (FOBT) and sigmoidoscopy/colonoscopy, and
then compared them with similar data from 1997. The findings in this report indicate
that the proportion of the U.S. population that has been screened remains low. In
1999, 44% of BRFSS respondents reported receiving FOBT and/or
sigmoidoscopy/colonoscopy within the recommended period compared with approximately
41% reporting FOBT and/or sigmoidoscopy/proctoscopy within the recommended period
1997 (2). Efforts to address barriers and to promote the use of colorectal
cancer screening should be intensified.
In 1999, the 50 states, District of Columbia, and Puerto Rico participated in
BRFSS, an ongoing, statebased, randomdigit--dialed telephone survey of the
civilian, noninstitutionalized population aged
>18 years. A total of 63,555 respondents
aged >50 years were asked whether they ever had FOBT using a home kit, whether
they ever had sigmoidoscopy or colonoscopy, and when the last test had been
performed. Responses coded as "don't know/not sure" or "refused" were excluded from
analyses (<2%). Aggregated and state-specific proportions, standard errors, 95%
confidence intervals, and p-values were calculated using SAS and SUDAAN.
Data in this analysis were weighted to the age, sex, and race/ethnicity
distribution of each state's adult population using intercensal estimates and were age
standardized to the 1999 BRFSS population. The median state response rate of 56.7%
(range: 38.4%--83.9%) was calculated using the cooperation rate formula (i.e., the number
of completed interviews divided by the number of potential respondents
[households with a resident aged >18 years]). The 1999 questions about the use of
sigmoidoscopy were modified from the 1997 questions. In 1997, respondents were asked
whether they had received sigmoidoscopy or proctoscopy. Proctoscopy is performed with
a shorter instrument than sigmoidoscope and is not recommended as a
colorectal cancer screening test. In 1999, "sigmoidoscopy/proctoscopy" was replaced
with "sigmoidoscopy/colonoscopy." Colonoscopy evaluates the entire colon and
is recommended once every 10 years in some guidelines
(3,4). For this report, "sigmoidoscopy/proctoscopy" and "sigmoidoscopy/colonoscopy" are referred to
as "sigmoidoscopy" unless otherwise specified.
In 1999, 40.3% (25,263 of approximately 63,000) of respondents reported
ever having FOBT, and 43.8% (26,388) of the respondents reported ever
having sigmoidoscopy. For tests received within the recommended period, 20.6%
(12,518) had FOBT within the year preceding the survey, 33.6% (19,535) had
sigmoidoscopy within the preceding 5 years (Table 1), and 44.0% (25,871) had either FOBT within
the year preceding the survey or sigmoidoscopy within the preceding 5 years (Figure 1).
In 1997, 19.6% (9832 of approximately 51,000) of the respondents had FOBT within
the year preceding the survey, and 30.3% (14,678) had sigmoidoscopy within
the preceding 5 years (Table 1). Although these rate changes in testing use
were statistically significant (p<0.05), actual increases were small. By state, the
proportion of respondents who had FOBT within the preceding year ranged from 8.2% (112
of 1366) in Puerto Rico to 36.4% (187 of 500) in the District of Columbia; the
proportion that had sigmoidoscopy/colonoscopy within the preceding 5 years ranged from
20.4% (275 of 1357) in Puerto Rico to 46.1% (410 of 981) in Delaware (Table 2).
Reported by the following state BRFSS coordinators: S Reese, MPH, Alabama; P
Owen, Alaska; B Bender, MBA, Arizona; G Potts, MBA, Arkansas; B Davis, PhD, California; M
Leff, MSPH, Colorado; M Adams, MPH, Connecticut; F Breukelman, Delaware; I Bullo, District
of Columbia; S Hoecherl, Florida; L Martin, MS, Georgia; F Reyes-Salvail, MS, Hawaii;
J Aydelotte, MA, Idaho; B Steiner, MS, Illinois; L Stemnock, Indiana; J Davila, Iowa; C
Hunt, Kansas; T Sparks, Kentucky; B Bates, MSPH, Louisiana; D Maines, Maine; A Weinstein,
MA, Maryland; D Brooks, MPH, Massachusetts; H McGee, MPH, Michigan; N Salem,
PhD, Minnesota; D Johnson, MS, Mississippi; J Jackson-Thompson, PhD, Missouri; P
Feigley, PhD, Montana; L Andelt, PhD, Nebraska; E DeJan, MPH, Nevada; L Powers, MA,
New Hampshire; G Boeselager, MS, New Jersey; W Honey, MPH, New Mexico; C Baker, New
York; Z Gizlice, PhD, North Carolina; L Shireley, MPH, North Dakota; P Pullen, Ohio; K Baker,
MPH, Oklahoma; K Pickle, MPH, Oregon; L Mann, Pennsylvania; Y Cintron, MPH, Puerto Rico;
Hesser, PhD, Rhode Island; M Wu, MD, South Carolina; M Gildemaster, South Dakota;
D Ridings, Tennessee; K Condon, MS, Texas; K Marti, Utah; C Roe, MS, Vermont; K
Carswell, MPH, Virginia; K Wynkoop Simmons, PhD, Washington; F King, West Virginia; K
Pearson, Wisconsin; M Futa, MA, Wyoming. Epidemiology and Health Svcs Research Br, Div
of Cancer Prevention and Control, National Center for Chronic Disease Prevention and
Health Promotion, CDC.
Since 1997, the proportion of the U.S. population that reported
having had FOBT and sigmoidoscopy has increased slightly but remains low. Various
factors may contribute to the continued underuse of these tests, including lack of
knowledge by the public and health-care providers of the effectiveness of screening and
low reimbursement rates for health-care providers who perform screening tests
The findings in this report are subject to at least four limitations. First, because
of the wording change in the BRFSS questionnaire from "sigmoidoscopy/proctoscopy"
in 1997 to "sigmoidoscopy/colonoscopy" in 1999, comparing endoscopic procedures
for these years must be interpreted with caution. Data on the use of colonoscopy
were collected only in 1999; however, some tests reported as
sigmoidoscopies/proctoscopies in 1997 probably were colonoscopies because some respondents
may have been unable to distinguish among the three tests. It is unknown whether
the reported increase from 1997 to 1999 represents a true increase in sigmoidoscopy
use or previously unmeasured rates of colonoscopy use. Second, because the survey
was administered over the telephone, only persons who own telephones were
represented in this analysis. Third, 43.3% of the eligible respondents were contacted but did
not complete the telephone interview or could not be reached for an interview.
Finally, responses were self-reported and were not validated through medical record review.
For persons aged >50 years at average risk for colorectal cancer,
recommended screening options include one or more of the following tests: annual
FOBT, sigmoidoscopy every 5 years, colonoscopy every 10 years, or double-contrast
barium enema every 5--10 years (3,4,7). Despite their efficacy in reducing incidence
and mortality from colorectal cancer (8), screening tests are underused. To draw
attention to this disease, the U.S. Congress designated March as "National Colorectal
Cancer Awareness Month." During March 2001, CDC and the Health Care
Financing Administration launched the third annual "Screen for Life: A National
Colorectal Cancer Action Campaign." Using print, television, and radio announcements
and brochures and fact sheets, the campaign was designed to raise awareness
of colorectal cancer and to encourage persons aged
>50 years to discuss screening with their health-care provider and select the appropriate test(s). CDC also produced
"A Call to Action: Prevention and Early Detection of Colorectal Cancer," a
slide presentation for health-care providers. All material is available on the
World-Wide Web, http://www.cdc.gov/cancer/screenforlife
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American Cancer Society, 2001 (publication no. 5008.01).
- CDC. Screening for colorectal cancer---United States, 1997. MMWR
- Winawer SJ, Fletcher RH, Miller L, et al. Colorectal cancer screening: clinical
guidelines and rationale. Gastroenterology 1997;112:594--642.
- Smith RA, von Eschenbach AC, Wender R, et al. American Cancer Society guidelines
for the early detection of cancer: update of early detection guidelines for
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- Peterson SK, Vernon SW. A review of patient and physician adherence to
colorectal cancer screening guidelines. Seminars in Colon and Rectal Surgery 2000;11:58--72.
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does reimbursement cover costs? Ann Intern Med 1999;130:525--30.
- US Preventive Services Task Force. Guide to clinical preventive services. 2nd
ed. Baltimore, Maryland: Williams and Wilkins, 1996.
- Mandel JS, Church TR, Bond JH, et al. The effect of fecal occult-blood screening on
the incidence of colorectal cancer. N Engl J Med 2000;343:1603--7.