1. Medicine

US women screen at low rates for both cervical and colorectal cancers than a single cancer: a cross-sectional population-based observational study

  1. Diane M Harper  Is a corresponding author
  2. Melissa Plegue
  3. Masahito Jimbo
  4. Sherri Sheinfeld Gorin
  5. Ananda Sen
  1. Department of Family Medicine, University of Michigan, United States
  2. Department of Obstetrics and Gynecology, University of Michigan, United States
  3. Department of Women's and Gender Studies, University of Michigan, United States
  4. Department of Family and Community Medicine, University of Illinois, United States
  5. Department of Biostatistics, University of Michigan, United States
https://doi.org/10.7554/eLife.76070
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Cite this article
  1. Diane M Harper
  2. Melissa Plegue
  3. Masahito Jimbo
  4. Sherri Sheinfeld Gorin
  5. Ananda Sen
(2022)
US women screen at low rates for both cervical and colorectal cancers than a single cancer: a cross-sectional population-based observational study
eLife 11:e76070.
https://doi.org/10.7554/eLife.76070
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2 figures, 5 tables and 2 additional files

Figures

Figure 1
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Graphical abstract.

Screening rates differ by calculation approach. A patient-centered approach considers the total number of screens each woman has, whereas a population-centered system documents each single test completion. Our data show much lower women-centered cervical cancer and colorectal cancer (CRC) screening rates than a population-based screening approach. This difference is especially relevant as women may be able to do these two cancer screenings at home by themselves.

Appendix 1—figure 1
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Consort diagram.

Tables

Table 1
Demographic characteristics of the study population.
Weighted %Eligible for analysis (n = 40,511)
Age, n (%)
50–5435.812,165 (30.0)
55–5931.313,757 (34.0)
60–6432.914,589 (36.0)
Race, n (%)
NH White67.431,340 (77.4)
NH Black10.63401 (98.4)
NH Other/Multiracial6.92484 (6.1)
Hispanic13.52836 (7.0)
Unknown/Refused1.5450 (1.1)
Marital, n (%)
Married/partnered63.425,022 (61.8)
Unmarried*35.915,335 (37.9)
Unknown/refused0.7154 (0.4)
Education, n (%)
Less than high school11.62293 (5.7)
High school25.19447 (23.3)
Attended college/Tech school31.111,066 (27.3)
Graduated college/Tech school32.117,671 (43.6)
Refused/don’t know0.234 (0.1)
Location, n (%)
Urban92.733,500 (82.7)
Rural6.26292 (15.5)
Unknown/missing1.1719 (1.8)
Income, n (%)
<50,00036.514,870 (36.7)
50,000+46.420,295 (50.1)
Don’t know/refused17.15346 (13.2)
Employment status†, n (%)
Employed/self-employed59.525,289 (62.4)
Unemployed, looking5.41866 (4.6)
Unemployed, not looking21.38392 (20.7)
Unable to work12.74763 (11.8)
Refused1.2201 (0.5)
  1. *

    Unmarried includes divorced, widowed, separated, and never married.

  2. †

    ‘Unemployed, not looking’ includes ‘Homemaker, Student, and Retired’, ‘Unemployed, looking’ includes out of work over a year and out of work less than a year.

Table 2
Up-to-date screening status by woman by screening modality.
Dual screened, n = 24,678; 58.2% (57.1, 59.4)Current for colorectal only, n = 22225.4% (4.9, 5.9)
Pap only, within last 3 yearsHPV only, within last 5 yearsPap and HPV, within last 5 years
Blood stool only,
last year		5.0 (4.3, 5.8)0.1 (0.001, 0.2)3.0 (2.5, 3.6)10.0 (7.7, 13.1)
Sigmoidoscopy only,
last 5 years		0.6 (0.4, 0.8)<0.1%0.4 (0.3, 0.5)1.2 (0.6, 2.3)
Colonoscopy only,
last 10 years		54.6 (53.2, 55.9)1.9 (1.4, 2.5)27.2 (26.0, 28.3)83.3 (79.4, 86.6)
Two CRC tests3.8 (3.4, 4.3)<0.1%3.3 (2.8, 4.0)5.5 (3.4, 8.6)
Current for cervical cancer only, n = 10,051
27.1% (26.0, 28.2)		66.5 (64.2, 68.6)2.9 (2.2, 3.7)30.7 (28.6, 32.8)100%
Not current for either, n = 3560; 9.3% (8.7, 9.9)

  1. Women receiving only one of the two screens

  2. CRC: The left-hand column lists the types of colorectal cancer screening that a woman could report. The far right-hand column presents the weighted screening proportions (95% CI) of women with only CRC screening by that modality. For instance, 10.0% of the 5.4% of women who were only current for CRC indicated they had been screened with a blood stool test within the last year but had no other CRC screen and no other cervical cancer screen. Likewise, 83.3% of the 5.4% of women who were only current on CRC screening (but had no other CRC screen and no other cervical cancer screen) indicated that they had a colonoscopy within the past 10 years.

  3. Cervical: The second to bottom row indicates the weighted screening proportions (95% CI) of women who only were up- to -date with cervical cancer screening by the columnar headings for types of cervical cancer screening modalities. For instance, 66.5% of the 27.1% of women who only had cervical cancer screening received a Pap test within the past 3 years. Likewise, 30.7% of the 27.1% of women who only had cervical cancer screening had received co-testing within the past 5 years.

  4. Women who had both screens by modality

  5. The top row indicates that 58.2% of all women were up-to-date with both cervical cancer and colorectal cancer screening (dual-screening). The inner 12 cells indicate the weighted percentage of women with dual-screening by modality. For instance, 54.6% of the 58.2% of women having both screens up-to-date did so with a colonoscopy and a Pap test. Likewise, 27.4% of 58.7% of women having both screens up-to-date did so with colonoscopy and cotesting.

  6. Women not up-to-date with either screen

  7. The bottom row indicates that 9.3% of the analytic cohort received neither screen because of underscreening or no screening.

  8. CI, confidence interval; CRC, colorectal cancer.

Table 3
Sociodemographic descriptors by screening category.
TotalDual-screeningCervical cancer screening aloneCRC screening aloneNeither screening
n = 40,511N = 24,678N = 10,051N = 2222N = 3560
NUnweighted row %Weighted row %NUnweighted row %Weighted row %NUnweighted row %Weighted row %NUnweighted row %Weighted row %
Age, (n, row %)
50–54612150.347.4460337.840.03552.93.110868.99.5
55–59886464.462.5289321.022.77785.75.212228.99.6
60–64969366.466.0255517.517.310897.57.912528.68.8
Race (n, row %)
White19,50762.260.3734523.424.817995.75.626898.69.3
Black219864.660.785625.226.61374.05.42106.27.4
Other*133553.759.270628.425.21355.43.030812.412.6
Hispanic138148.746.5102536.139.41264.45.230410.78.8
Education (n, row %)
Less than high school graduate96542.141.077533.836.81526.66.940117.515.3
High school graduate510954.152.9257427.327.75836.26.5118112.512.8
Attended college/Tech school658759.560.0282025.526.26796.15.49898.98.4
Graduated college/Tech school11,99467.967.0387621.924.28164.63.89855.65.1
Income (n, row %)
<$50K777952.349.7412727.829.810216.96.7194313.113.8
≥$50K13,71167.665.7456222.524.59304.64.310925.45.5
Marital status (n, row %)
Married or partnered15,96663.861.0601424.026.312304.95.018127.27.7
Single*863056.353.7399526.128.29796.46.0173111.312.1
Occupational status (n, row %)
Employed15,61361.758.6656626.028.611264.54.419847.98.4
Unemployed, looking†97552.352.353328.628.8111605.624713.213.4
Unemployed, not looking†532763.562.5175821.023.35436.55.87649.19.0
Unable to work266255.953.5113223.825.64359.19.253411.211.7
Location (n, row %)
Urban20,90362.458.9810524.226.817625.35.327308.29.0
Rural347955.352.0166226.428.44316.97.272011.412.4
Chronic conditions (n, row %)
ANY16,16863.260.7572422.424.516316.46.420528.08.4
Cardiac111756.555.145723.123.51768.98.422811.513.1
Stroke74558.660.629323.124.21018.05.213210.49.9
Lung403960.258.5153922.925.64797.16.36559.89.6
Arthritis979964.362.9323721.322.310496.97.211487.57.6
Kidney75162.363.224220.119.5968.05.21179.712.1
Diabetes298858.654.8123324.228.94138.17.64689.28.7
Depression598762.260.2213322.224.56957.26.78058.48.5
Skin cancer218270.468.454017.418.71896.15.11906.17.8
Other cancer228269.367.264819.722.82096.36.31564.73.7

  1. CRC, colorectal cancer.

  2. *

    Single includes divorced, widowed, separated, and never married.

  3. †

    ‘Unemployed, not looking’ includes ‘Homemaker, Student, and Retired’, ‘Unemployed, looking’ includes out of work over a year and out of work less than a year.

Table 4
Multinomial multivariate regression.
N = 42,701Weighted n = 19,849,774Referent outcome: neither screenReferent outcome: dual screensReferent outcome:cervical only
Dual screenCervical onlyCRC onlyCervical onlyCRC onlyCRC only
aOR (95% CI)aOR (95% CI)aOR (95% CI)aOR (95% CI)aOR (95% CI)aOR (95% CI)
Age
50–54RefRefRefRefRefRef
55–591.35 (1.09, 1.67)0.60 (0.48, 0.76)1.76 (1.25, 2.47)0.44 (0.39, 0.51)1.30 (0.98, 1.74)2.93 (2.17, 3.96)
60–641.46 (1.18, 1.79)0.45 (0.36, 0.56)2.55 (1.81, 3.58)0.31 (0.27, 0.36)1.75 (1.30, 2.35)5.63 (4.14, 7.66)
Race
WhiteRefRefRefRefRefRef
Black2.25 (1.62, 3.13)1.73 (1.22, 2.44)1.58 (0.95, 2.61)0.77 (0.64, 0.92)0.70 (0.46, 1.07)0.91 (0.59, 1.41)
Other*0.72 (0.46, 1.12)0.76 (0.47, 1.21)0.37 (0.21, 0.64)1.05 (0.74, 1.50)0.51 (0.33, 0.80)0.49 (0.30, 0.80)
Hispanic1.68 (1.25, 2.25)2.34 (1.72, 3.18)1.42 (0.77, 2.63)1.39 (1.10, 1.77)0.84 (0.48, 1.50)0.61 (0.34, 1.10)
Education
Less than high schoolRefRefRefRefRefRef
High school graduate1.37 (1.02, 1.83)1.08 (0.80, 1.46)1.14 (0.65, 1.98)0.78 (0.61, 1.01)0.83 (0.49, 1.39)1.06 (0.62, 1.80)
Attended college/Tech school1.98 (1.46, 2.69)1.47 (1.07, 2.00)1.30 (0.76, 2.22)0.74 (0.58, 0.95)0.65 (0.40, 1.07)0.88 (0.53, 1.46)
Graduated college/Tech school3.35 (2.33, 4.81)2.02 (1.39, 2.94)1.66 (0.94, 2.93)0.60 (0.46, 0.79)0.50 (0.31, 0.81)0.82 (0.49, 1.36)
Income
<$50KRefRefRefRefRefRef
≥$50K3.32 (2.64, 4.18)2.19 (1.71, 2.80)2.13 (1.54, 2.96)0.66 (0.58, 0.75)0.64 (0.49, 0.84)0.98 (0.74, 1.29)
Chronic conditions†
Arthritis1.83 (1.54, 2.18)1.28 (1.06, 1.55)2.17 (1.65, 2.87)0.70 (0.61, 0.80)1.19 (0.94, 1.50)1.70 (1.31, 2.19)
Diabetes1.34 (1.06, 1.69)1.34 (1.03, 1.75)1.79 (1.25, 2.55)1.00 (0.83, 1.22)1.33 (0.98, 1.81)1.33 (0.95, 1.86)
Depression1.35 (1.11, 1.63)1.05 (0.85, 1.29)1.47 (1.09, 1.99)0.78 (0.68, 0.89)1.09 (0.85, 1.41)1.41 (1.07, 1.84)
Skin cancer1.04 (0.73, 1.48)0.78 (0.53, 1.15)0.75 (0.48, 1.17)0.75 (0.61, 0.92)0.72 (0.54, 0.97)0.97 (0.69, 1.36)
Other cancer2.90 (2.09, 4.05)2.28 (1.57, 3.31)3.08 (1.94, 4.91)0.78 (0.62, 0.99)1.06 (0.75, 1.51)1.35 (0.90, 2.03)

  1. aOR, adjusted odds ratio; CI, confidence interval; CRC, colorectal cancer. Bold values = statistically significant.

  2. *

    Other means American Indian, Native Hawaiian, Asian, Multiracial, and 'Other'.

  3. †

    Persons may have more than one condition or cancer.

Appendix 1—table 1
Unadjusted multinomial regression.
Referent outcome: neither screenReferent outcome: dual screensReferent outcome:cervical only
Dual screensCervical onlyCRC onlyCervical onlyCRC onlyCRC only
OR (95% CI)OR (95% CI)OR (95% CI)OR (95% CI)OR (95% CI)OR (95% CI)
Age
50–54RefRefRefRefRefRef
55–591.29 (1.07, 1.56)0.55 (0.45,0.68)1.68 (1.24, 2.29)0.43 (0.37, 0.49)1.30 (1.01, 1.69)3.05 (2.31, 4.01)
60–641.48 (1.24, 1.78)0.45 (0.37, 0.56)2.74 (2.04, 3.70)0.31 (0.27, 0.35)1.85 (1.44, 2.39)6.04 (4.60, 7.93)
Race
WhiteRefRefRefRefRefRef
Black1.28 (0.98, 1.67)1.33 (1.01, 1.76)1.20 (0.77, 1.86)1.04 (0.88, 1.22)0.93 (0.64, 1.36)0.90 (0.61, 1.33)
Other*0.73 (0.49, 1.09)0.76 (0.49, 1.17)0.35 (0.21, 0.60)1.04 (0.77, 1.40)0.49 (0.32,0.74)0.47 (0.29, 0.74)
Hispanic0.80 (0.64, 1.00)1.63 (1.25, 2.12)0.96 (0.62, 1.51)2.04 (1.67, 2.50)1.21 (0.80,1.83)0.59 (0.38, 0.91)
Education
Less than high schoolRefRefRefRefRefRef
High school graduate1.54 (1.20, 1.98)0.90 (0.67, 1.21)1.14 (0.76, 1.72)0.58 (0.46, 0.75)0.74 (0.51, 1.08)1.27 (0.84, 1.91)
Attended college/Tech school2.62 (2.03, 3.37)1.29 (0.96, 1.74)1.42 (0.96, 2.11)0.49 (0.39, 0.63)0.54 (0.38, 0.78)1.10 (0.75, 1.62)
Graduated college/Tech school4.84 (3.67, 6.38)1.96 (1.43, 2.69)1.64 (1.09, 2.45)0.41 (0.32, 0.52)0.34 (0.24, 0.48)0.83 (0.57, 1.22)
Income
<$50KRefRefRefRefRefRef
>$50K3.30 (2.79, 3.90)2.07 (1.72, 2.48)1.60 (1.24, 2.07)0.63 (0.56, 0.70)0.49 (0.39, 0.60)0.78 (0.62, 0.97)
Marital status
Married or partneredRefRefRefRefRefRef
Single†0.56 (0.48, 0.66)0.68 (0.57,0.81)0.78 (0.61, 0.99)1.21 (1.08, 1.35)1.38 (1.13,1.69)1.14 (0.92, 1.42)
Occupational status
EmployedRefRefRefRefRefRef
Unemployed, looking‡0.56 (0.41, 0.78)0.64 (0.46, 0.88)0.81 (0.51, 1.28)1.12 (0.87, 1.45)1.43 (0.95, 2.17)1.27 (0.83, 1.94)
Unemployed, not looking‡0.99 (0.83, 1.19)0.76 (0.60, 0.96)1.22 (0.92, 1.63)0.76 (0.64, 0.91)1.23 (0.97, 1.57)1.61 (1.22, 2.13)
Unable to work0.64 (0.52,0.79)0.64 (0.50, 0.81)1.52 (1.10, 2.10)0.99 (0.84, 1.16)2.36 (1.81, 3.08)2.39 (1.78, 3.20)
Location
UrbanRefRefRefRefRefRef
Rural0.64 (0.52, 0.78)0.76 (0.61, 0.95)0.97 (0.72, 1.30)1.20 (1.04, 1.39)1.52 (1.20, 1.94)1.27 (0.98, 1.65)
Chronic conditions§
Cardiac0.64 (0.48, 0.87)0.59 (0.42,0.83)1.11 (0.74, 1.65)0.92 (0.74, 1.14)1.72 (1.26, 2.35)1.87 (1.33, 2.64)
Stroke0.96 (0.64, 1.42)0.80 (0.52, 1.23)0.90 (0.54, 1.51)0.84 (0.64, 1.10)0.94 (0.63, 1.39)1.12 (0.73, 1.72)
Lung0.95 (0.80, 1.14)0.89 (0.70, 1.13)1.15 (0.87, 1.53)0.93 (0.77, 1.12)1.21 (0.95, 1.54)1.30 (0.97, 1.74)
Arthritis1.51 (1.30, 1.76)0.99 (0.83, 1.18)2.27 (1.80, 2.86)0.65 (0.58, 0.74)1.50 (1.24, 1.81)2.29 (1.85, 2.82)
Kidney0.84 (0.57, 1.23)0.56 (0.36, 0.87)0.76 (0.44, 1.30)0.66 (0.49, 0.91)0.90 (0.59, 1.39)1.36 (0.83, 2.23)
Diabetes1.04 (0.83, 1.29)1.18 (0.89, 1.58)1.72 (1.24, 2.38)1.66 (1.27, 2.15)1.66 (1.27, 2.15)1.46 (1.05, 2.01)
Depression1.16 (0.99, 1.37)0.97 (0.79, 1.20)1.56 (1.21, 2.01)0.84 (0.72, 0.98)1.34 (1.08, 1.65)1.60 (1.25, 2.05)
Skin cancer1.41 (1.01, 1.95)0.80 (0.56, 1.14)1.11 (0.73, 1.67)0.57 (0.48, 0.68)0.79 (0.60, 1.04)1.38 (1.01, 1.88)
Other cancer3.03 (2.26, 4.06)2.16 (1.54, 3.03)3.14 (2.07, 4.77)0.71 (0.58, 0.88)1.04 (0.75, 1.43)1.45 (1.01, 2.09)

  1. Significant results are shown in bold italic font.

  2. *

    Other means American Indian, Native Hawaiian, Asian, Multiracial and ‘Other’.

  3. †

    Single includes divorced, widowed, separated, and never married.

  4. ‡

    ‘Unemployed, not looking’ includes ‘Homemaker, Student, and Retired’, ‘Unemployed, looking’ includes out of work over a year and out of work less than a year.

  5. §

    Persons may have more than one condition or cancer.

Additional files

MDAR checklist
https://cdn.elifesciences.org/articles/76070/elife-76070-mdarchecklist1-v1.docx
Reporting standard 1

STROBE statement.

https://cdn.elifesciences.org/articles/76070/elife-76070-repstand1-v1.docx

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  1. Diane M Harper
  2. Melissa Plegue
  3. Masahito Jimbo
  4. Sherri Sheinfeld Gorin
  5. Ananda Sen
(2022)
US women screen at low rates for both cervical and colorectal cancers than a single cancer: a cross-sectional population-based observational study
eLife 11:e76070.
https://doi.org/10.7554/eLife.76070