1. Understanding Those Who Do and Do Not Plan to Get Colorectal Cancer (CRC) Screening Costanza ME, White MJ, Stark JR, Stoddard AM, Avrunin JS, Luckmann R, and Clemow L University of Massachusetts Medical School Worcester, MA

2. Facts about CRC 2nd leading cause of cancer-specific deaths for men and women in the U.S. 57,000 CRC deaths in 2003

3. Facts about CRC Screening CRC screening reduced mortality by > 30% < 50% of U.S. men and women over age 50 are current with screening guidelines CRC screening recommendations are more complex than those for other cancers (e.g., breast, cervical)

4. ACS Preferred CRC Screening Guidelines (Beginning at age 50 for those at average risk) Annual fecal occult blood test (FOBT) and sigmoidoscopy every 5 years Colonoscopy every 10 years Double-contrast barium enema every 5-10 years

5. Factors that Predict Adherence to the Guidelines Basic knowledge about CRC screening Individual risk Lack of barriers to screening (i.e. embarrassment, fear of pain or abnormal results) Intention to be screened – useful for tailoring interventions

6. Methods Baseline mailed survey for a RCT of telephone counseling to increase CRC screening Theoretical Framework – Weinstein’s Precaution Adoption Process Model (PAPM), a stage-based model of health behavior Study Participants –2,934 male & female patients from 37 primary care practices –50-75 years old –Had visited their PCP during the past 2 years

7. Methods Survey Measures –CRC screening history and screening intention –PAPM stage –Pros and Cons –Perceived vulnerability and worry –Sociodemographic and other characteristics Data Analysis –Frequency distributions, cross classifications & logistic regression –Bivariate & multivariate associations – to develop a main effects model

8. Survey Response – 69%

9. Characteristics of Study Sample (n=1370) n (%) n (%) Age50-6465-75 1039 (75%) 352 (25%) GenderMaleFemale 545 (40%) 818 (60%) Race/Ethnicity White, non-Hispanic Non-White 1312 (94%) 82 (6%) Marital Status Married/Partner Not Married/Partner 1069 (77%) 314 (23%)

10. Characteristics of Study Sample (n=1370) n (%) n (%) Highest Level of Education < High School Graduate High School Graduate/ Tech/ Vocational School Some College College Grad Post-College Grad 69 ( 5%) 333 (24%) 326 (24%) 297 (22%) 353 (26%) Yearly income <$25,000 $25,000 - <$40,000 $40,000 - <$65,000 $65,000+ 208 (16%) 201 (16%) 268 (21%) 603 (47%)

11. Characteristics of Study Sample (n=1370) n (%) n (%) Historical Screening Status Meets ACS preferred guidelines 499 (36%) PAPM Stage of Adoption Unaware 94 (7%) Unengaged 220 (16%) Relapsed 51 (4%) Decided No 10 (1%) Undecided 142 (10%) Decided Yes 354 (26%) Action/Maintenance 499 (36%)

12. Characteristics of Study Sample (n=1370) n (%) n (%) Provider Recommendation Advised to have CRC screening 697 (51%) Not advised to have CRC screening/don’t know 678 (49%) Family History Blood relatives with CRC 153 (11%) No blood relatives with CRC/don’t know 1222 (89%)

13. Factors Associated with Intention to Get CRC Screening p=<.0001

14. Factors Associated with Intention to Get CRC Screening p=<.0001

15. Factors Associated with Intention to Get CRC Screening p=<.0001

16. Factors Associated with Intention to Get CRC Screening p=<.0001

17. Factors Associated with Intention to Get CRC Screening (Mean) Unaware, Unengaged or Relapsed Deciding Decided Yes Action/ Maintenance p-Value Perceived Vulnerability -0.3 -0.3-0.040.04 0.2 0.2<0.0001

18. Multivariable Logistic Regression (Odds Ratio, overall p-Value) Action/Maintenance/ Decided Yes vs. Undecided/Not Thinking About Undecidedvs. Not Thinking About Age 50-64 vs. 65-75 0.64 0.01 0.64 0.01 MD Recommendation Yes vs. No/DK 1.93 <0.0001 1.93 <0.0001 1.74 0.02 1.74 0.02 Family History Yes vs. No/DK 2.83 <0.0002 2.83 <0.0002 Pros & Cons of Screening 1.13 <0.0001 1.13 <0.0001 1.05 <0.0001 1.05 <0.0001

19. Discussion The study sample is highly educated and not very diverse Men and women are evenly distributed by stage MD recommendation is powerful in motivating patients to action

20. Discussion Increasing positive trends were seen in –Perceived vulnerability: increases at least 10-fold between each stage closer to action –Pros & Cons: score increases significantly from unaware, unengaged or relapsed group to action/maintenance indicating a growing positive perception of CRC screening

21. Discussion Implications for an intervention to accelerate the adoption of CRC screening –Those current with screening (36%) and those who intend to be screened (26%) may require only a postcard reminder –Those not intending to get screened may benefit from an intervention tailored to PAPM stage

22. Discussion A tailored intervention could focus on –Increasing their knowledge about CRC & CRC screening –Addressing their barriers & cons to screening –Encouraging them to get screened using motivational interviewing

23. Discussion Public Health Implications Those who are unaware, unengaged, undecided or who have relapsed or decided not to be screened represent a significant number of people between 50- 75 years of age in the U.S. population Accelerating CRC screening adoption will reduce mortality & morbidity from this disease