摘要：Objectives. Physician recommendation plays a crucial role in receiving endoscopic screening for colorectal cancer (CRC). This study explored factors associated with racial/ethnic differences in rates of screening recommendation. Methods. Data on 5900 adults eligible for endoscopic screening were obtained from the National Health Interview Survey. Odds ratios of receiving an endoscopy recommendation were calculated for selected variables. Planned, sequenced logistic regressions were conducted to examine the extent to which socioeconomic and health care variables account for racial/ethnic disparities in recommendation rates. Results. Differential rates were observed for CRC screening and screening recommendations among racial/ethnic groups. Compared with Whites, Hispanics were 34% less likely ( P < .01) and Blacks were 26% less likely ( P < .05) to receive this recommendation. The main predictors that emerged in sequenced analysis were education for Hispanics and Blacks and income for Blacks. After accounting for the effects of usual source of care, insurance coverage, and education, the disparity reduced and became statistically insignificant. Conclusions. Socioeconomic status and access to health care may explain major racial/ethnic disparities in CRC screening recommendation rates. Colorectal cancer (CRC) is the third most common cause of cancer death in the United States and a major cause of cancer morbidity. 1 Annually in the United States, an estimated 150 000 people are diagnosed and 50 000 people die from this disease. 2 With early detection and removal of precancerous polyps, CRC can be preventable, with a 5-year survival rate as high as 90%. 3,4 Current CRC screening guidelines consist of sigmoidoscopy every 5 years and colonoscopy every 10 years for those aged 50 to 75 years. 4 Although an annual fecal occult blood test is also recommended, sigmoidoscopy and colonoscopy have higher sensitivity and specificity for the detection of cancerous lesions. 5 Sensitivity ranges from 25% to 87% for fecal occult blood test, compared with 92% to 95% for endoscopy (sigmoidoscopy and colonoscopy). 6 Colonoscopy, the most widely used test for CRC detection and prevention, is considered the gold standard because it can detect and remove precancerous polyps, and a positive result from any other screening test must be followed by this advanced modality. 1,7,8 Endoscopy has played a major role in the decreasing trend of CRC mortality in the United States 9,10 Still, minority groups—especially Blacks—carry a disproportionately higher CRC burden. 1,11 From the 1980s to 2007—a period of advance in early detection and treatment—the inequality between Blacks and Whites increased to a 44% difference in CRC mortality rates. 1 This disparity could be attributable in part to the fact that, compared with Whites, members of racial/ethnic minority groups were less likely to be screened and diagnosed at the localized, more treatable stage of CRC. 1 These lower screening rates partially account for the higher rates of late stage detection and subsequent increases in CRC morbidity and mortality rates among racial/ethnic minorities and low-income populations. 1,10,12 Thus, it is necessary to promote utilization of effective screening methods, such as endoscopy, to detect CRC in its early stages, especially among minority groups. Trends in CRC screening from 1992 to 2005 show widening gaps between Whites and minority groups: the disparity increased to 10.3% for Blacks and to 20.5% for Hispanics. 13,14 Lower rates of cancer screening, including CRC screening, have been strongly associated with lower rates of physician recommendation, particularly among low-income populations, racial/ethnic minority groups, and women. 15,16 The health care provider’s role in CRC screening is essential because a physician recommendation is necessary for endoscopic screening. 17,18 A study found that more than 90% of people who did not undergo endoscopic screening reported not receiving the necessary recommendation. 16 A systematic review discovered that patients identified physician recommendation as the sole CRC-screening facilitator and absence of recommendation as the only barrier. 19 It is thus crucial to identify factors that influence the likelihood of receiving a CRC screening recommendation. The present study seeks to build on the work of 2 previous analyses of CRC-screening barriers and predictors among respondents to the 2000 National Health Interview Survey (NHIS). Seeff et al. found that “frequent doctor visits in the past year” was the strongest predictor of CRC screening. 20 Among the barriers, a “lack of awareness of the need to be screened” was most common, followed by “not receiving a physician recommendation.” 20 In bivariate analysis, Coughlin and Thompson found that, among screening-eligible adults who had visited a physician in the past year, members of racial/ethnic minority groups were less likely than Whites to receive an endoscopy recommendation. 21 The study mainly focused on reasons for having CRC screenings. We used multivariate analyses and planned sequenced logistic regression to explore patient factors that may explain unequal rates of physician recommendation for endoscopy among Blacks and Hispanics compared with Whites. Factors deemed to have relative importance in terms of statistical significance may help indicate areas of intervention to improve rates of physician recommendation for CRC screening in disadvantaged populations.
