1. Trends in Colorectal Cancer Incidence Rates by Race, Age and Indices of Access to Medical Care in the U.S., 1995-2004 Yongping Hao, PhD 1 Ahmedin Jemal, PhD 1 Xingyou Zhang, PhD 2 Elizabeth Ward, PhD 1 June 11, 2008 NAACCR 1 American Cancer Society 2 American Academy of Family Physicians

2. Outline Background Objectives Data sources and analyses Results Conclusions Limitations

3. Background Colorectal cancer (CRC) incidence rates decreased rapidly since 1998, following a longer-term declining trend from 1985-1995 and a 3-year stable trend in 1995-1998 The long-term and recent declines in incidence are thought to largely reflect trends in CRC screening which prevents cancer through detection and removal of precancerous polyps There are disparities in CRC screening by race, rurality, poverty, and insurance coverage --- Coughlin et al 2004; Schootman et al 2006; Meissner et al 2006

4. Background (contd.) Two studies evaluated trends in CRC incidence rates –-Singh et al, 2003; Siegel et al, 2008 (in press) SEER 9 data Race Poverty

5. Objective Explore the disparities in 1)Trends in CRC incidence rates 2)Changes in CRC endoscopic screening rates Race Age group Indices of access to medical care measured by county level primary care physician (PCP) supply, poverty, uninsuranced rate, and metro status

6. Data Sources & Analyses Incidence data,1995-2004, were from NAACCR (784,111 cases) California, Colorado, Connecticut, Florida, Hawaii, Idaho, Illinois, Iowa, Kentucky, Louisiana, Maine, Detroit, Nebraska, New Jersey, New York, Rhode Island, Texas, Utah, and Washington

7. Data Sources & Analyses Endoscopic screening data,1995-97 and 2002-04, from BRFSS (336,819 respondents) CRC screening rates were expressed as proportion screening within past 5 years --- sigmoidoscopy or colonoscopy / proctoscopy Responses coded as "don't know/not sure" or "refused" were excluded Analyses were restricted to those counties met the minimum of 50 participants required by CDC for confidentiality

8. Data Sources and Analyses (contd.) Age: Less than 50 years 50 - 64 years (recommended for CRC screening) 65 years and old (eligible for Medicare coverage)

9. Data Sources and Analyses (contd.) Race: African Americans White (by sex)

10. Data Sources and Analyses (contd.) Primary care physician (PCP): Low: < 4 per 10,000 Moderate: 4 – 7 per 10,000 High: >= 7 per 10,000 Area resource file

11. Data Sources and Analyses (contd.) Poverty: Low: < 10 % Moderate: 10% – 19.9 % High: >= 20% US Census 2000, available in NAACCR database

12. Data Sources and Analyses (contd.) Uninsured rate (under 65 years): Low: < 15% Moderate: 15% - 19.9% High: >= 20% Current Population Survey

13. Data Sources and Analyses (contd.) Metro status: Metro: 1 - 3 Nonmetro: 4 - 9 USDA 2003 rural urban continuum code, available in NAACCR database

14. Data Sources and Analyses (contd.) The analysis focused on 692,548 cases in age >=50, accounting for 82% of total cases

15. Data Sources and Analyses (contd.) Indices of access to medical care were linked to: 1)Incidence data 2)Edoscopic screening data

16. Data Sources and Analyses (contd.) Incidence rates were calculated for each category of age, race, and indices of access to medical care Endoscopic screening rates were calculated for the same categories

17. Data Sources and Analyses (contd.) Trends in CRC incidence rates (1995-2004), measured by annual percent change (APC), were analyzed by Joinpoint regression Absolute changes in screening rates between 1995-97 and 2002-04 were calculated

18. Results

19. Trends in CRC incidence rates by age and race, 1995-2004 APC = Annual percent change * p < 0.05

20. Trends in CRC incidence rates by age, race, and PCP supply, 1995-2004

21. Trends in CRC incidence rates by age, race, and Poverty, 1995-2004

22. Trends in CRC incidence rates by age, race, and uninsured rate, 1995-2004

23. Trends in CRC incidence rates by age, race, and metro status, 1995-2004

24. Absolute change (AC) in CRC screening rates by age, race, and indices of access to medical care (age >=65)

25. Theses results are consistent with the previous findings regarding the positive impact of Medicare coverage policy changes on CRC screening Meissner et al 2006; CDC MMWR 2006,2008; Seeff et al 2004; Gross et al 2006 At least two studies found that lack of physician recommendation was an important contributing factor to the underutilization of CRC screening among Medicare consumers Klabunde et al 2005,2006

26. These results may reflect the lack of a significant increase in CRC screening in areas with less access to medical care and the overall lower CRC screening rates among African American patients compared to white patients in this age group Cooper et al 1999; Ko et al 2005

27. Absolute change (AC) in CRC screening rates by age, race, and indices of access to medical care (age 50-64)

28. Similarly, the lack of decrease in CRC incidence rates in 50-64 years African Americans in general and white men and women residing in the most disadvantaged areas may in part reflect lack of access to CRC screening and early detection services

29. Several studies have shown that CRC screening rates are significantly lower in medically uninsured than insured persons, in rural than urban areas, and in poor than affluent areas Matthews et al 2005; Coughlin et al 2004; Schootman et al 2006 Studies have also shown that primary care availability to be associated with increased screening rates and early detection of CRC Roetzheim et al 1999, 2001; Rutledge et al 2006

30. Conclusions Individuals residing in poorer communities with lower access to medical care have not experienced the reduction in CRC incidence rates that have benefited more affluent communities This is likely explained in part by lower utilization of CRC screening even in older populations with coverage through Medicare

31. Limitations we used county-level indicators of access to medical care because of lack of individual level data on health insurance status, socioeconomic status or other measures of access to medical care Limitations of BRFSS data include variable response rates and reliance on self-report

32. Thanks Comments and questions?