Colorectal cancer screening in the United States: Trends from 2008 to 2015 and variation by health insurance coverage☆
Introduction
Colorectal cancer (CRC) is the third most commonly diagnosed cancer in men and women and the second leading cause of death from cancers affecting both men and women in the United States (Siegel et al., 2016; U.S. Cancer Statistics Working Group, 2017). Regular screening may prevent CRC and is recommended for detecting early stage disease and reducing CRC mortality (Lin et al., 2016). Since 2008 (and through 2015), the US Preventive Services Task Force (USPSTF) has recommended that adults aged 50–75, who are not considered high risk, screen for CRC using one of three approaches: annual high-sensitivity fecal occult blood testing (FOBT), sigmoidoscopy every 5 years combined with high-sensitivity FOBT every 3 years, or colonoscopy every 10 years (Screening for colorectal cancer, 2008). The USPSTF considers CRC screening a grade “A” recommendation, indicating that the net benefit is substantial.
Recommendation-consistent CRC screening use has increased substantially over the last two decades, rising from 38.6% in 2000 to 54.6% in 2008 (Sinicrope et al., 2012; Klabunde et al., 2011; Fedewa et al., 2015). However, rates remain below the National Colorectal Cancer Roundtable goal of 80% of eligible adults having recommendation-consistent CRC screening by 2018 (80% by 2018: working toward the shared goal of 80% screened for colorectal cancer by 2018, n.d.). Likewise, for most population subgroups, screening rates are below the Healthy People 2020 target of 70.5% (Healthy people 2020 cancer objectives, n.d.). The lowest screening rates are observed among the uninsured and underinsured, people without a usual source of care, and recent immigrants, (Sinicrope et al., 2012; Klabunde et al., 2011; Fedewa et al., 2015) which suggests that screening decisions may be influenced by access to health care and cost considerations (Wools et al., 2016; Honein-AbouHaidar et al., 2016; Gupta et al., 2014).
With recent changes to health insurance coverage in the United States, evaluating the trends in CRC screening use and factors associated with recommendation-consistent use can be informative. For example, non-grandfathered health insurance plans, with plan-years beginning on or after September 23, 2010, are required to provide coverage without patient cost-sharing for preventive services that have a rating of “A” or “B” in the recommendations of the USPSTF (Patient Protection and Affordable Care Act, 42 U.S.C. § 18001, 2010). Likewise, effective January 1, 2011, the Medicare program eliminated cost-sharing for most preventive services with a USPSTF grade of “A” or “B” (Patient Protection and Affordable Care Act, 42 U.S.C. § 18001, 2010). Changes to health insurance laws have also expanded access to health insurance options for people who were previously uninsured (Blumenthal and Collins, 2014). However, cost-sharing for adults with Medicaid coverage continues to vary by state. It is worth noting that coverage requirements apply only to preventive CRC screening. CRC tests performed for surveillance or diagnostic purposes or when a polyp is detected and removed during screening colonoscopy may have cost-sharing requirements imposed (Coverage of Colonoscopies Under the Affordable Care Act's prevention benefit, 2012). Nevertheless, despite expanded access to health insurance and the absence of cost-sharing for most health plans, many eligible adults are not screening according to USPSTF recommendations (White et al., 2017).
This paper had two main objectives. The first was to characterize national trends in recommendation-consistent CRC screening from 2008 to 2015, reflecting a time-period that encompasses changes to health care legislation in the United States. The second was to explore potential differences in the prevalence of CRC screening according to type of health insurance coverage, using data from 2015, the most recent year of cancer screening data available from the National Health Interview Survey (NHIS).
Section snippets
Data source
Data were obtained from the 2008, 2010, 2013, and 2015 NHIS and NHIS Cancer Control Supplement. The NHIS is administered by the National Center for Health Statistics, and data are collected on a broad range of health topics through in-person household interviews. The Cancer Control Supplement is administered periodically to a single adult in each household that participated in NHIS (i.e., the sample adult) and captures information about practices, knowledge, and attitudes regarding
Trends in CRC screening
Fig. 1 shows trends in CRC screening rates. In 2008, 51.6% of adults were up-to-date with CRC screening. From 2008 to 2010, screening rates increased by 6.7 percentage points to 58.3% (p < 0.05). Although CRC rates were essentially unchanged from 2010 to 2013 (58.3% to 57.3%), they increased an additional four percentage points to 61.3% between 2013 and 2015 (p < 0.05). Recommendation-consistent CRC screening is largely driven by colonoscopy, which was used more frequently than other screening
Discussion
Since 2008, the proportion of the adult population aged 50–75 years in the United States who received recommendation-consistent CRC screening increased by almost 10 percentage points, to 61.3% in 2015. Concerns about a plateau in screening rates from 2010 to 2013, previously expressed in another report, were not borne out in our study, (Sabatino et al., 2015) as overall screening rates increased by four percentage points from 2013 to 2015 (White et al., 2017). Between 2008 and 2015, the
Limitations
This study had several limitations. CRC screening was self-reported and not verified by medical records or claims data. Individuals were considered to have screened according to recommendations if they had the recommended tests for any reason. Thus, “screening” prevalence includes people who may have had the test for diagnostic purposes. Health insurance coverage was measured at the time of the interview, which may not have been the type of insurance payer at the time the person received
Conclusions
We conducted a more detailed analysis of CRC screening use by health insurance type in 2015 than has been previously undertaken. We distinguished between employer-sponsored private insurance and direct-purchase private plans, and we further examined traditional and high-deductible options within these plans. Our findings document that CRC screening rates in the U.S. continue to increase. Although segments of the population are screening at recommended levels, screening rates among groups that
References (32)
Impact of provider-patient communication on cancer screening adherence: a systematic review
Prev. Med.
(2016)- 80% by 2018: working toward the shared goal of 80% screened for colorectal cancer by 2018. [cited 2017 August, 30,...
- et al.
Health care coverage under the affordable care act--a progress report
N. Engl. J. Med.
(2014) - et al.
Health insurance coverage: Early release of estimates from the National Health Interview Survey, 2016
(May 2017) Coverage of Colonoscopies Under the Affordable Care Act's prevention benefit
(2012)Explore Sudaan 11: Statistical Software for Weighting, Imputing, and Analyzing Data: RTI International; 2016 [cited 2016 8/8/2016]
Elimination of cost-sharing and receipt of screening for colorectal and breast cancer
Cancer
(2015)Screening for colorectal Cancer: US preventive services task force recommendation statement
JAMA
(2016)How can we boost colorectal and hepatocellular cancer screening among underserved populations?
Curr. Gastroenterol. Rep.
(2015)Challenges and possible solutions to colorectal cancer screening for the underserved
J. Natl. Cancer Inst.
(2014)
Systematic review and meta-study synthesis of qualitative studies evaluating facilitators and barriers to participation in colorectal cancer screening
Cancer Epidemiol. Biomark. Prev.
Adherence to colorectal cancer screening: a randomized clinical trial of competing strategies
Arch. Intern. Med.
Trends in colorectal cancer test use among vulnerable populations in the United States
Cancer Epidemiol. Biomark. Prev.
Screening for colorectal cancer: updated evidence report and systematic review for the US preventive services task force
JAMA
Citizenship, length of stay, and screening for breast, cervical, and colorectal cancer in women, 2000–2010
Cancer Causes Control
Cited by (0)
- ☆
The authors declare there is no conflict of interest. The findings and conclusions in this report are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention, the National Institutes of Health, or the Department of Health and Human Services.
- 1
Permanent address: K Yabroff is currently affiliated with the Surveillance and Health Services Research Program, American Cancer Society, Atlanta, GA. C Altice is currently affiliated with the Division of MCH Workforce Development, Maternal and Child Health Bureau, Health Resources and Service Administration