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Background: Screening has become one of our best tools for early detection and prevention of cancer. The group-randomized trial is the most rigorous experimental design for evaluating multilevel interventions. However, identifying the proper sample size for a group-randomized trial requires reliable estimates of intraclass correlation (ICC) for screening outcomes, which are not available to researchers. We present crude and adjusted ICC estimates for cancer screening outcomes for various levels of aggregation (physician, clinic, and county) and provide an example of how these ICC estimates may be used in the design of a future trial., Methods: Investigators working in the area of cancer screening were contacted and asked to provide crude and adjusted ICC estimates using the analysis of variance method estimator., Results: Of the 29 investigators identified, estimates were obtained from 10 investigators who had relevant data. ICC estimates were calculated from 13 different studies, with more than half of the studies collecting information on colorectal screening. In the majority of cases, ICC estimates could be adjusted for age, education, and other demographic characteristics, leading to a reduction in the ICC. ICC estimates varied considerably by cancer site and level of aggregation of the groups., Conclusions: Previously, only two articles had published ICCs for cancer screening outcomes. We have complied more than 130 crude and adjusted ICC estimates covering breast, cervical, colon, and prostate screening and have detailed them by level of aggregation, screening measure, and study characteristics. We have also demonstrated their use in planning a future trial and the need for the evaluation of the proposed interval estimator for binary outcomes under conditions typically seen in GRTs.

Objective: To report on the effect of the Breast and Cervical Cancer Intervention Study (BACCIS), a multicomponent intervention conducted in the San Francisco Bay Area between 1992 and 1997., Methods: BACCIS targeted approximately 25,000 multiethnic, underserved women in eight neighborhoods and the public health clinics that served them. An outreach intervention using lay health worker peers and clinic provider inreach intervention to improve breast and cervical cancer screening were evaluated in a quasi-experimental, controlled trial with pretest and posttest household surveys of 1,599 and 1,616 women, respectively. Surveys were conducted in English, Spanish, Mandarin, and Cantonese., Results: Analyses of community survey results showed no significant improvement in reported screening behaviors. Reports of mammography in the intervention areas in the previous 2 years, or for Pap smear in the previous 3 years, did not differ significantly (73-71% and 84-87%, respectively, for pretest and posttest surveys)., Conclusion: High baseline screening rates, lack of sensitive measures of change at the population level, contamination of the control group, and an imbalance of predictive factors at baseline contributed to the difficulty of assessing the value of the intervention. Lessons learned from this inconclusive study may be of value to future community intervention studies of cancer screening and other health behaviors in multiethnic underserved urban populations.

Introduction: Studies show that the recommendations of a primary care physician for colorectal cancer screening may be one important influence on an individual's use of screening. However, another possible influence, the effect of regional differences in physicians' beliefs and recommendations on screening use, has not been assessed., Methods: We linked data from the National Health Interview Survey on the use of colorectal cancer screening by respondents aged 50 years or older, by hospital-referral region, with data from the Survey of Colorectal Cancer Screening Practices on the colorectal cancer screening recommendations of primary care physicians, by region. Our principal independent variables were the proportion of physicians in a region who recommended screening at age 50 and continuing screening at the recommended frequency., Results: On average, 53.3% of physicians in a region correctly recommended initiating colorectal cancer screening, and 64.8% advised screening at the recommended frequency. Of adults who lived in regions where less than 30% of physicians correctly recommended initiating screening, 47.3% had been screened, in contrast to 54.8% in areas where 70% or more of physicians made correct recommendations. Seventy-one percent of respondents living in regions where less than 30% of physicians advised screening at the recommended frequency were current on screening, in contrast to 79.9% of respondents living in regions where 70% or more of physicians made this recommendation. These differences were statistically significant after adjustment for individual characteristics., Conclusion: Strategies to improve colorectal cancer screening recommendations of primary care physicians may improve the use of screening for millions of Americans.

Behaviors associated with cancer screening have been the focus of intensive research over the past 2 decades, primarily in the form of intervention trials to improve screening based in both clinical and community settings. Meta-analyses and literature reviews have synthesized and organized the resulting literature. From the accumulated work, this review distilled lessons learned from cancer screening intervention research in community settings. The authors posed the question, "What do we know about the development of effective community-based interventions (the level of good over harm achieved in real-world conditions)?" Framed around the concept of focal points (the simultaneous combination of target population, behavioral objective, and setting for an intervention), 13 lessons were derived. One lesson was cross-cutting, and the other lessons addressed the three focal-point components and the major intervention categories (access-enhancing strategies, mass media, small media, one-on-one and small-group education, and combinations of these categories). To build more systematically on existing research, recommendations are made for new directions in basic behavioral and intervention research.

To compare the risks of developing invasive squamous cell cervical cancer associated with screening intervals of 1, 2, and 3 years after a negative cervical smear. We conducted a matched case-control study of invasive squamous cell cervical cancer patients (n = 482) diagnosed between 1983 and 1995 among long-term members of a large health maintenance organization. Controls were matched for age, length of membership, and race (n = 934). Screening interval was time between the last negative cervical smear and the case diagnosis date. The main outcome measure was the relative odds of invasive disease associated with 1-year, 2-year, and 3-year intervals. The odds ratio for a 2-year versus a 1-year interval was 1.72 (95% confidence interval 1.12, 2.64, P =.013) and for a 3-year versus a 1-year interval was 2.06 (95% confidence interval 1.21, 3.50, P =.007). The odds ratio for a 3-year versus a 2-year interval was 1.20 (95% confidence interval 0.65, 2.21, P =.561). Controlling for ever having had an abnormal cervical smear or a previous consecutive negative smear did not substantially change these results. In this large health plan, the relative risks of invasive squamous cell cervical cancer were significantly greater for 2-year and 3-year cervical cancer screening intervals compared with a 1-year interval, but not for a 3-year interval compared with a 2-year interval. Our findings need to be placed in the context of the low absolute risks of developing invasive cervical cancer during the first 3 years after a negative cervical smear before making policy recommendation.

The National Health Interview Survey (NHIS) has provided data about health behaviors at the national level since 1957. The 1987 and 1992 Cancer Control Supplements to the NHIS, along with other supplemental surveys administered intermittently on self-reported cancer-related behaviors, have contributed to important research and public health purposes. In this article, we reviewed 73 papers published between 1980 and 2001 that used NHIS data, including the first report from the 1998 NHIS, to examine what has been learned from past surveys. Our goal was to facilitate future analyses of recently released data on cancer screening practices from the Cancer Control Supplement to the 2000 NHIS, which is now known as the Cancer Control Module. We categorized the papers according to which of the following three study approaches they used: trends in screening rates, correlates of these rates with factors that may influence screening, and linkages or comparisons of NHIS data with other surveys or sources of information. We summarize knowledge gained in cancer screening for each of these three categories and identify areas that could benefit from more research. We highlight some of the new information available for the first time on the Cancer Control Module of the 2000 NHIS as fresh opportunities for cancer control research. Finally, we describe how the Cancer Control Supplements to the NHIS are integrated with the objectives of and developments in national cancer surveillance research that have emerged from federal planning efforts and collaborations with national partners in cancer surveillance in recent years.

Objectives: To determine how screening for breast and cervical cancer in public health clinics was associated with overall clinic utilization., Methods: Evidence of screening and clinic visits between June 1989 and May 1992 was obtained by medical record audit for a random sample of 1825 women aged 40 to 75 attending eight public health clinics in the San Francisco Bay Area., Results: With an average number of visits (4 per year), women who did not receive a physical examination were much less likely than those who did to obtain a clinical breast examination (OR = 0.03), mammography referral (OR = 0.1), or a mammogram (OR = 0.4) within 2 years, or a Papanicolaou smear (OR = 0.1) within 3 years. Without a physical examination, the odds of screening or referral increased with the first visit (OR = 1.2 for referral, breast examination, and Pap; 1.3 for mammography), but with a decreasing marginal effect of each additional visit (ratio of successive one-visit OR values = 0.992 for referral and breast examination; 0.995 for Pap; 0.98 for mammography). With a physical exam, visits were associated with mammography only (first visit OR = 1.2; OR ratio = 0.992)., Conclusions: In public health clinics, screening is associated either with receipt of routine care or repeated visits for treatment. Women who fall through the cracks are those who come to the clinic with a medical problem but otherwise receive few services. Interventions in public health clinics need to facilitate the provider's ability to use medically related visits as opportunities to increase adherence to screening recommendations.

Objectives: To determine associations between advancing age and screening behavior and prognosis in long-term members of a prepaid health plan diagnosed with invasive cervical cancer (ICC)., Design: Case series., Setting: Prepaid health plan., Participants: All women diagnosed with ICC at Kaiser Permanente Medical Care Program-Northern California health plan from 1988 to 1994., Measurements: From medical records, we recorded participants' age, stage at diagnosis, tumor histology, and results of and reasons for all previous cervical smears. We limited our analysis to women who had been members of the health plan for at least 30 of the 36 months preceding diagnosis (n = 455)., Results: Women in older age groups were less likely than younger women to have been screened within the 3 years before diagnosis (P = .005 for trend). Nonadherence to follow-up of abnormal cervical smears was uncommon (17/455, 3.7%) and not age related (P = .932 for trend). The proportions of ICC that were interval cancers, defined as ICC diagnosed within 3 years of a negative screening smear, were highest in women under age 30 (P = .004 for trend). In multivariate analyses controlling for stage at diagnosis, women age 60 and older were not more likely to die of ICC within 3 years of diagnosis than were women younger than age 60 (odds ratio 1.30, 95% confidence interval 0.75-2.28)., Conclusion: The disproportionate burden of cervical cancer observed in older women appears to be largely attributable to lack of screening within the 3 years before diagnosis.

Background: Underutilization of breast and cervical cancer screening has been observed in many ethnic groups and underserved populations. Effective community-based interventions are needed to eliminate disparities in screening rates and thus to improve prospects for survival., Methods: The Breast and Cervical Cancer Intervention Study was a controlled trial of three interventions in the San Francisco Bay Area from 1993 to 1996: (1) community-based lay health worker outreach; (2) clinic-based provider training and reminder system; and (3) patient navigator for follow-up of abnormal screening results. Study design and a description of the interventions are reported along with baseline results of a household survey conducted in four languages among 1599 women, aged 40-75., Results: Seventy-six percent of women ages 40 and over had had at least one mammogram, and most had had a clinical breast examination (88%) and Pap smear (89%). Rates were significantly lower for non-English-speaking Latinas and Chinese women (56 and 32%, respectively, for mammography), and maintenance screening (three mammograms in the past 5 years) varied from 7% (non-English-speaking Chinese) to 53% (Blacks). Pap smear screening in the past 3 years was low among non-English-speaking Latinas (72%) and markedly lower among non-English-speaking Chinese women (24%). The strongest predictors of screening behavior were having private health insurance and frequent use of medical services. Having a regular clinic and speaking English were also important. Race/ethnicity, education, household income, and employment status were, overall, not significant predictors of screening behavior., Conclusions: These baseline results support the importance of cancer screening interventions targeted to persons of foreign origin, particularly those less acculturated., (Copyright 2001 American Health Foundation and Academic Press.)

Objective: To identify potential missed opportunities and to suggest interventions for cervical cancer screening in members of a prepaid health plan by examining the membership histories and medical records of women who had no Pap smear performed in the 3 years prior to the diagnosis of ICC., Methods: Medical records of all 642 members of a prepaid health plan developing ICC during the period from 1988 to 1994 were reviewed and details of patient interaction with the health care system were abstracted. Assessment of screening history and history of clinic visits was limited to the period 36 months prior to diagnosis, but excluded the last 6 months prior to diagnosis, so as to avoid including smears or visits which were part of the evaluation that led to the recognition of ICC., Results: Of women developing ICC, 384/642 (60%) had not had a smear in the period from 36 months to 6 months preceding the diagnosis. Of these 384 unscreened women, 241 (63%) had been insured by our HMO for at least 30 of the 36 months prior to diagnosis. Contact with the medical system in one of the primary care outpatient clinics was documented in 180/241 (75%) of these long-standing members during the specified period. Considering only Internal Medicine and Family Practice clinic visits, 169/241 (70%) had been seen at least once and 101/241 (42%) had been seen 3 or more times., Conclusion: Most long-standing HMO members developing ICC without benefit of recent Pap smear screening were seen in primary care outpatient clinics in the 3 years preceding their diagnosis., (Copyright 1998 Academic Press.)

Background: Research has been critical in understanding human behavior related to the early detection of cancer., Methods: Based on the literature and the author's experience, this paper reviews behavioral research accomplishments in the past decade and needs for the future., Results: Accomplishments have included an improved understanding of the barriers to screening, methods to improve the provision of tests by practitioners, and progress in the development and application of community interventions. Outstanding needs are summarized in 12 areas that include a continued focus on underserved populations and an examination of the use of screening tests in the presence of incomplete evidence of efficacy, translational research that explores the behavioral consequences of genetic susceptibility testing, continued development and use of computer-based technologies in the delivery of preventive services, and studies of the potential negative consequences of screening. Critical changes in the delivery of health care in the era of managed care call for increased behavioral research in health services and health care policy., Conclusion: Although this review of research needs is not exhaustive, it is clear that the challenges and opportunities for behavioral research are substantial, and this effort will be a critical part of the overall national research agenda for cancer control.

Background: We evaluated the effectiveness of 2 reminder interventions to increase the use of screening mammograms and Papanicolaou (Pap) smears among female members of a large health maintenance organization., Methods: Seven thousand seventy-seven female health maintenance organization members (aged 50-74 years with no prior mammogram in the previous 30 months or aged 20-64 years with no prior Pap smear in the previous 36 months) were randomized to receive one of the following: a letter inviting them to make an appointment for a mammogram or a Pap smear; in addition to the letter, a reminder manually placed in the patient's medical chart alerting providers of that member's need for screening; or their usual care., Results: Compared with women who did not receive the reminder letter, women who did receive the letter were more likely to obtain mammograms (16.0% vs 25.5%, respectively; P < .001) or Pap smears (9.1% vs 19.5%, respectively; P < .001) in the 6 months following their entry into the study. Compared with women who received only the reminder letter, women who received a reminder letter and had a reminder placed in their medical chart were more likely to obtain mammograms (26.5% vs 30.9%, respectively; P = .02) and marginally more likely to receive Pap smears (19.5% vs 22.8%, respectively; P = .04)., Conclusions: We recommend the use of patient reminder letters as a first step in a mammography or Pap smear screening outreach program. Further research is needed to evaluate a cost-effective provider reminder system and additional outreach strategies directed to women who do not use health care services.

Objective: To evaluate screening urinalysis for its efficacy in preventing fatal bladder cancer., Methods: A case-control study of 290 case subjects with fatal bladder cancer upsilon 290 age and sex matched control subjects, with ascertainment of urinalyses by medical record review., Results: In the five years before the symptoms that led to the detection of bladder cancer, case subjects had significantly fewer routine (screening) urinalyses than controls (matched odds ratio for one or more urinalyses upsilon none = 0.60 [95% confidence interval (CI) 0.41 to 0.87], adjusted for cigarette smoking and occupational bladder cancer risk). However urinalyses for urinary symptoms and problems before those that led to bladder cancer diagnosis were more frequent in the cases; hence there was only a small statistically non-significant deficit in cases of urinalyses for all reasons combined (corresponding adjusted odds ratio 0.94, 95% CI 0.61 to 1.46). Since urinalyses for symptoms and problems could have led to the detection of bladder cancer, the latter finding appears more applicable. Methodological problems included: difficulty in assigning the reason for urinalysis; the possibility that clinically indicated urinalyses led to a reduction in screening urinalyses; and difficulty in identifying the detectable and curable preclinical phase for targeting ascertainment of urinalyses. Reducing potential efficacy, haematuria on urinalysis, particularly transient or mild asymptomatic microhaematuria, was often not followed up by cystoscopy., Conclusions: This study did not show that ordinary urinalysis was effective in preventing fatal bladder cancer but because of methodological problems a clear answer may require a randomised controlled trial.

Screening urine for microhematuria as an indicator of serious disease is controversial because of the low positive predictive value of such screening and the costs and risks of the associated evaluation. To further evaluate test properties, we retrospectively examined the outcomes of 20,571 men aged > or = 35 years and women aged > or = 55 years who voluntarily had a Personal Health Appraisal in 1980 as members of a large prepaid health plan. Hematuria was detected by dipstick in 876 cases (4.3%); 278 were excluded because of evidence of previous urological disease which could cause hematuria. Review of the medical records of 598 patients with asymptomatic microhematuria as shown by a positive dipstick result indicated that 99% had a follow-up evaluation within 3 months of positive test results for hematuria and had various levels of urological evaluation thereafter. However, urological cancers (2 prostate, 1 bladder) developed in only 3 patients within the next 3 years. On the basis of San Francisco-Oakland Surveillance, Epidemiology, and End Results program data, rates of urological cancer were evaluated among patients whose test results were negative for hematuria, and these cancer rates were found to be almost the same as the rate among patients with asymptomatic microhematuria. Sensitivity of a single dipstick urinalysis result using microhematuria to indicate urological cancer within 3 years was 2.9%; specificity was 96.7%; and positive predictive value was 0.5%. Multivariate analysis which adjusted for age, gender, and race showed that the relative risk of 2.1 (95% confidence interval, 0.7-6.6) for urological cancer was not significantly elevated among patients with asymptomatic microhematuria compared with patients who had negative test results. These findings based on a single test are consistent with the current lack of recommendations for screening for microhematuria among asymptomatic adults.

Objective: To evaluate self-reported use of cancer screening tests by Latino and Anglo prepaid health plan members, we conducted telephone interviews about the knowledge of, use of, and reason for Papanicolaou (Pap) smear, clinical breast examination, mammogram, rectal examination, fecal occult blood test, and sigmoidoscopy., Methods: Cross-sectional telephone survey of randomly selected Kaiser Permanente Medical Care Program members in San Francisco and Alameda Counties, California. A total of 844 Latinos (432 men and 412 women) and 510 Anglos (208 men and 302 women), between 35 and 74 years of age, completed the interview., Results: Overall, 97.4% of Latinas reported having had at least one Pap smear compared with 99.7% of Anglo women; 90% in each group reported a Pap smear within 3 years. A clinical breast examination within 2 years was reported by 87% of Latina and 90% of Anglo women. Seventy-six percent of Latina and 85% of Anglo women aged 35 years or more reported having had at least one mammogram; and 65% of Latina and 75% of Anglo women reported a mammogram within 2 years. Among members 40 to 74 years of age, a lower proportion of Latinos compared with Anglos reported having had at least one digital rectal examination (67% vs 80%) and one fecal occult blood test (46% vs 54%); among those 50 to 74 years of age, fewer Latinos reported at least one sigmoidoscopy (29% vs 41%). After adjusting for age, education, employment, perceived health status, marital status, and county of residence, Latinos were significantly less likely to report having had at least one digital rectal examination (odds ratio; 0.60, 95% confidence interval, 0.45, 0.79), fecal occult blood test (odds ratio, 0.77; 95% confidence interval, 0.59-1.01), and sigmoidoscopy (odds ratio, 0.70; 95% confidence interval, 0.52, 0.95). After adjusting for the same variables, Latinos were more likely than Anglos to claim forgetfulness/carelessness (75% vs 60%; odds ratio, 1.84; 95% confidence interval, 1.41-2.40) as a reason for not obtaining cancer screening tests., Conclusion: These data suggest that, within this prepaid health plan without direct financial barriers to cancer screening services, Latinos are less likely than Anglos to obtain selected recommended cancer screening tests.

Background: Self-reported data about the interval since last cancer screening are often used to determine whether individuals are due for periodic screening and to monitor adherence to guidelines for early cancer detection., Purpose: In a study conducted within the Kaiser Permanente Medical Care Program, we examined the concordance of self-reported information and medical record documentation about recency of and reasons for six procedures for early cancer detection. We also assessed the concordance of population-level estimates of screening rates based on these two sources., Methods: Data were obtained from a mailed questionnaire or telephone interview completed by 779 men and women. The data from these randomly selected study participants (431 women and 348 men), who had been members of the health plan for the previous 5 years, were compared with information obtained from their medical charts. Intersource agreement about whether each procedure was done within the last 2 years was evaluated, with the medical record used as the gold standard. To assess the accuracy of patient self-reporting, we also calculated sensitivity, false-positive and false-negative results, and Kappa statistics., Results: Concordance between self-reported data and medical record documentation was greater for procedures that generated a test report (mammogram, Pap smear, fecal occult blood test, and sigmoidoscopy) than for those generating a physician's note (clinical breast examination and digital rectal examination). Kappa statistics showed a similar pattern. Sensitivity of self-reported data was more than 90% for mammogram, clinical breast examination, Pap smear, and fecal occult blood test and nearly 80% for sigmoidoscopy and digital rectal examination. However, false-positive results were above 40%, except for fecal occult blood test and sigmoidoscopy. For all six procedures, estimated population-level rates of screening within the past 2 years would have been significantly higher (P < .0001) if self-reported data were used instead of medical record audit data., Conclusions: Self-reported data may overestimate the percentage of the population that has been screened and underestimate the interval since the last cancer detection procedures., Implications: Such data should be used cautiously for clinical decision making, research, and surveillance activities at both individual and population levels. Also, comparability of data should be considered when population screening rates are evaluated on the basis of different data sources.