Screening practices in cancer survivors

Deborah K Mayer amp Norma C Terrin amp Usha Menon amp Gary L Kreps amp

Kathy McCance amp Susan K Parsons amp Kathleen H Mooney

Springer Science + Business Media LLC 2007

AbstractIntroduction Ten percent of all new cancers are diagnosedin cancer survivors and second cancers are the sixth leadingcause of cancer deaths Little is known however aboutsurvivorsrsquo screening practices for other cancers The purposeof this study was to examine the impact of a cancer diagnosison survivorsrsquo screening beliefs and practices compared tothose without a cancer historyMaterials and methods This study examined cancer survi-vorsrsquo (n=619) screening beliefs and practices compared tothose without cancer (n=2141) using the National CancerInstitutersquos 2003 Health Information National Trends Survey(HINTS)

Results The typical participant was Caucasian employedmarried and female with at least a high school education

having a regular health care provider and health insuranceBeing a cancer survivor was significantly associated withscreening for colorectal cancer but not for breast or prostatecancer screening Screening adherence exceeded AmericanCancer Society recommendations national prevalence dataand Healthy People 2010 goals for individual tests for bothgroups Physician recommendations were associated with ahigher level of screening but recommendations varied(highest for breast cancer and lowest for colorectal cancerscreening)Conclusions Cancer survivors had different health beliefsand risk perceptions for screening compared to theNoCancer group While there were no differences betweensurvivorsrsquo screening for breast and prostate cancer survi-vors were more likely to screen for colorectal cancer thanthe comparison group Screening adherence met orexceeded recommendations for individual tests for bothcancer survivors and the comparison groupImplications for cancer survivors Cancer survivors shouldcontinue to work with their health care providers to receiveage and gender appropriate screening for many types ofcancers Screening for other cancers should also beincluded in cancer survivorship care plans

Keywords Mammogram Papanicolaou test

Prostate specific antigen Colorectal cancer screening

Cancer survivors Cancer screening

Introduction

Accounting for 35 of the US population there are nowover ten million cancer survivors many of whom are at

J Cancer SurvivDOI 101007s11764-007-0007-0

D K Mayer () N C Terrin S K ParsonsInstitute for Clinical Research and Health Policy StudiesTufts-New England Medical Center750 Washington Street 345 Boston MA 02111 USAe-mail dmayertufts-nemcorg

U MenonCollege of Nursing University of Illinois at ChicagoChicago IL USA

G L KrepsDepartment of CommunicationGeorge Mason UniversityFairfax VA USA

K McCance K H MooneyCollege of Nursing University of UtahSalt Lake City UT USA

greater risk than the general population for developingadditional cancers [18 49 57] Ten percent of all newcancers are diagnosed in survivors and second cancers arethe sixth leading cause of cancer deaths [32 71 72]Reducing this risk is a concern throughout the life of thesurvivor [11 54]

Screening can reduce the risk of dying from selectedcancers through earlier detection when the stage of canceris more amenable to effective treatment For screening tobe effective health care providers and the public need to beaware of value and participate in screening [50] Evi-dence-based screening tests used to detect cervical breastand colorectal cancers (CRC) have been promoted in thegeneral population to reduce cancer mortality (see Table 1)[3 8 9 50] Screening for prostate cancer is a commonpractice despite less convincing evidence about its effec-tiveness in reducing mortality [55 58] With few exceptionsthere are no specific screening guidelines for the cancersurvivor Understanding screening practices of high riskpopulations is important to identify factors that may help orhinder these practices [3] The cancer experience may affectsurvivorsrsquo beliefs and screening practices yet we are onlybeginning to explore their actual practices [4 5 7 19 2047 52 53 67]

The purpose of this study was to examine the impact of acancer diagnosis on survivorsrsquo screening beliefs andpractices compared to those without a cancer history Thespecific research questions were What are the health beliefsand screening practices of cancer survivors (CaSurvivors)when compared to a group without a personal or familyhistory of cancer (NoCancer)

The Health Belief Model (HBM) provided the concep-tual framework to explore the cancer screening beliefs andpractices of survivors and factors that may enhance orinhibit those practices According to the Health BeliefModel (HBM) people will take action to prevent screenfor or control their health conditions if they (1) believethey are susceptible to the condition (susceptibility) (2)believe the condition would have serious consequences(seriousness) (3) believe there is benefit to taking a courseof action (benefits) and (4) believe the benefits are greaterthan the barriers for taking action (barriers) and (5)believe in the ability to perform the action to control theillness (self-efficacy) [31] HBM factors associated withincreased screening practices include knowledge perceivedsusceptibility increased benefits decreased barriers havinga regular source of health care and health insurance [1415 23 25 27 39 40 45 61 62 64] The HBM has beenused in studies of cancer screening in the generalpopulation while only one study was identified in cancersurvivor [30 42 74 75] The HBM was selected for thisstudy as the best fit between the study aims and availabledata

Materials and methods

This was a cross sectional correlational study utilizing theNational Cancer Institutersquos (NCI) Health InformationNational Trends Survey I (HINTS I) a national surveyfrom list-assisted random-digit-dial (RDD) telephone inter-views about the publicrsquos use of cancer-related informationand other cancer related beliefs and behaviors [48 51]

Measures Under the guidance of an expert advisorycommittee NCI personnel developed and tested the HINTSI survey [51] The final survey consisted of 148 questionson cancer communication (35 items) cancer history andgeneral cancer knowledge (16 items) cancer specificpersonal risk and screening (54 items) risk behaviors (29items) health status and demographics (14 items)1

HINTS I procedures The HINTS data collection occurredbetween October 2002 and May 2003 following the bestpractices identified by the American Association for PublicOpinion Research [2] to minimize errors from coveragesampling non-response and measures [26 51 63] Specialefforts were made to oversample African-Americans andHispanics Telephone interviewers averaging 30 minreached 19509 households 55 completed the screeningand 628 completed the extended interview with a finalsample of 6369 After obtaining IRB exemption andregistering for access at NCI the HINTS I SAS files andcodebooks were obtained from the HINTS website (httphintsmatthewsgroupcomregisterasp) for this secondarydata analysis [51]

Sample Of the 6369 evaluable HINTS I participantsexcluding non-melanoma skin cancer 97 (n=619)identified themselves as cancer survivors when asked ifthey had ever been told they had cancer No other cancerinformation regarding current disease status stage ortreatment was collected Of the 619 CaSurvivorss 68reported having one of seven types of cancer breast (n=119) cervical (n=94) prostate (n=62) melanoma (n=61)colorectal (n=49) and endometrial cancer (n=39) Theother 32 included the following cancer types ovarian(23) lymphoma (21) head and neck (19) thyroid (16)lung (16) bladder (14) kidney (9) stomach (6) leukemias(5) pancreatic (2) bone (10) other (48) In addition 95(n=59) of CaSurvivors reported having gt1 type of cancerParticipants who did not report a personal or family historyof cancer (336 n=2141) served as the NoCancercomparison group

1 The English and Spanish versions of the HINTS I survey instrumentcan be obtained at httpcancercontrolcancergovhints

J Cancer Surviv

greater risk than the general population for developingadditional cancers [18 49 57] Ten percent of all newcancers are diagnosed in survivors and second cancers arethe sixth leading cause of cancer deaths [32 71 72]Reducing this risk is a concern throughout the life of thesurvivor [11 54]

Screening can reduce the risk of dying from selectedcancers through earlier detection when the stage of canceris more amenable to effective treatment For screening tobe effective health care providers and the public need to beaware of value and participate in screening [50] Evi-dence-based screening tests used to detect cervical breastand colorectal cancers (CRC) have been promoted in thegeneral population to reduce cancer mortality (see Table 1)[3 8 9 50] Screening for prostate cancer is a commonpractice despite less convincing evidence about its effec-tiveness in reducing mortality [55 58] With few exceptionsthere are no specific screening guidelines for the cancersurvivor Understanding screening practices of high riskpopulations is important to identify factors that may help orhinder these practices [3] The cancer experience may affectsurvivorsrsquo beliefs and screening practices yet we are onlybeginning to explore their actual practices [4 5 7 19 2047 52 53 67]

The purpose of this study was to examine the impact of acancer diagnosis on survivorsrsquo screening beliefs andpractices compared to those without a cancer history Thespecific research questions were What are the health beliefsand screening practices of cancer survivors (CaSurvivors)when compared to a group without a personal or familyhistory of cancer (NoCancer)

The Health Belief Model (HBM) provided the concep-tual framework to explore the cancer screening beliefs andpractices of survivors and factors that may enhance orinhibit those practices According to the Health BeliefModel (HBM) people will take action to prevent screenfor or control their health conditions if they (1) believethey are susceptible to the condition (susceptibility) (2)believe the condition would have serious consequences(seriousness) (3) believe there is benefit to taking a courseof action (benefits) and (4) believe the benefits are greaterthan the barriers for taking action (barriers) and (5)believe in the ability to perform the action to control theillness (self-efficacy) [31] HBM factors associated withincreased screening practices include knowledge perceivedsusceptibility increased benefits decreased barriers havinga regular source of health care and health insurance [1415 23 25 27 39 40 45 61 62 64] The HBM has beenused in studies of cancer screening in the generalpopulation while only one study was identified in cancersurvivor [30 42 74 75] The HBM was selected for thisstudy as the best fit between the study aims and availabledata

Materials and methods

This was a cross sectional correlational study utilizing theNational Cancer Institutersquos (NCI) Health InformationNational Trends Survey I (HINTS I) a national surveyfrom list-assisted random-digit-dial (RDD) telephone inter-views about the publicrsquos use of cancer-related informationand other cancer related beliefs and behaviors [48 51]

Measures Under the guidance of an expert advisorycommittee NCI personnel developed and tested the HINTSI survey [51] The final survey consisted of 148 questionson cancer communication (35 items) cancer history andgeneral cancer knowledge (16 items) cancer specificpersonal risk and screening (54 items) risk behaviors (29items) health status and demographics (14 items)1

HINTS I procedures The HINTS data collection occurredbetween October 2002 and May 2003 following the bestpractices identified by the American Association for PublicOpinion Research [2] to minimize errors from coveragesampling non-response and measures [26 51 63] Specialefforts were made to oversample African-Americans andHispanics Telephone interviewers averaging 30 minreached 19509 households 55 completed the screeningand 628 completed the extended interview with a finalsample of 6369 After obtaining IRB exemption andregistering for access at NCI the HINTS I SAS files andcodebooks were obtained from the HINTS website (httphintsmatthewsgroupcomregisterasp) for this secondarydata analysis [51]

Sample Of the 6369 evaluable HINTS I participantsexcluding non-melanoma skin cancer 97 (n=619)identified themselves as cancer survivors when asked ifthey had ever been told they had cancer No other cancerinformation regarding current disease status stage ortreatment was collected Of the 619 CaSurvivorss 68reported having one of seven types of cancer breast (n=119) cervical (n=94) prostate (n=62) melanoma (n=61)colorectal (n=49) and endometrial cancer (n=39) Theother 32 included the following cancer types ovarian(23) lymphoma (21) head and neck (19) thyroid (16)lung (16) bladder (14) kidney (9) stomach (6) leukemias(5) pancreatic (2) bone (10) other (48) In addition 95(n=59) of CaSurvivors reported having gt1 type of cancerParticipants who did not report a personal or family historyof cancer (336 n=2141) served as the NoCancercomparison group

1 The English and Spanish versions of the HINTS I survey instrumentcan be obtained at httpcancercontrolcancergovhints

J Cancer Surviv

Statistical analysis A variety of analytical approachesappropriate to the level of measurement were used toaddress each of the research question What are the healthbeliefs and screening practices of CaSurvivors compared tothe NoCancer comparison group [33 34] Replicateweights provided by the NCI were used to compute jack-knife variance estimations to adjust for non-response and tocalibrate or weight for gender age raceethnicity andeducation to allow for mean population estimates [56] Allsample sizes are reported as unweighted and all percentagesare reported as weighted which allows for the sample datato be adjusted for and be representative of US populationestimates Descriptive statistics were calculated for ques-tions related to health beliefs screening practices anddemographic variables Categorical data were analyzedusing cross-tabulations and chi-square tests and continuousdata were analyzed using means and t tests Significancetests are reported if plt005 Results from CaSurvivors werecompared to a NoCancer comparison group and also reportedby cancer diagnosis for those with gt30 by cancer type

The American Cancer Societyrsquos (ACS) recommenda-tions were used in this study to define cancer screening(Table 1) self-report for ever having been screened forcervical breast colorectal or prostate cancer is reportedFor men gt50 years of age that included having colorectalcancer (CRC) screening and a prostate specific antigen(PSA) For women gt50 years of age that includedPapanicolaou test mammogram and CRC screening

Logistic regression analyses were performed withscreening (yesno) as the dependent variable and cancersurvivor (yesno) as the independent variable for eachscreening test cervical (women gt18 years of age) breast

(women gt40 years of age) prostate (men gt50 years of age)and colorectal (men and women gt50 years of age) toevaluate screening practices by cancer status Variablesassociated (plt010) with both having had cancer andhaving screening tests in the univariate analyses werecontrolled for and included age (lt65gt65 years of age)race and ethnicity (Caucasiannon-Caucasian) regularhealth care provider (yesno) and having health insurance(yesno) SAS version 90 (Cary NC) and SUDAAN SAS91 Callable version (RTI Research Triangle Park NC)were used for all analyses [59 65]

Results

Study sample The typical participant was Caucasianemployed married female had gt a high school educationa regular health care provider and health insurance (Table 2)The two groups were different (plt0001) in age gendermarital status employment raceethnicity self-reportedgeneral health status and access to health care (having aregular HCP and health insurance) Overall the CaSurvivorsgroup was older more were retired reported poorer healthand had greater health care access than the NoCancer group

Screening practices The primary outcome for this analysiswas adherence to ACS Guidelines for cervical breastcolorectal or prostate cancer screening Both groups met orexceeded ACS recommendations 2002 national BehavioralRisk Factor Surveillance Survey (BRFSS) prevalence dataand Healthy People 2010 goals (Table 3) In additionscreening rates by type of cancer are also shown Of notephysician screening recommendations were not significantly

Table 1 ACS cancer screening recommendations current US population prevalence rates and healthy people 2010 goals

ACS cancer early detection practices minimally include the following US populationprevalence ratesa

Healthy people2010 goals

Cervical cancer all women should begin cervical cancer screening about 3 years after they beginhaving vaginal intercourse but no later than when they are 21 years old Screening should be doneevery year with the regular Pap test or every 2 years using the newer liquid-based Pap test

952 92

Breast cancer yearly mammograms starting at age 40 and continuing for as long as a woman is ingood health

634 70

Colorectal cancer beginning at age 50 both men and women should follow one of these fivetesting schedules

481 50

Yearly fecal occult blood test (FOBT)Flexible sigmoidoscopy every 5 yearsYearly fecal occult blood test plus flexible sigmoidoscopy every 5 yearsDouble-contrast barium enema every 5 yearsColonoscopy every 10 years

Prostate cancer both prostate-specific antigen (PSA) testing and digital rectal examination (DRE)should be offered annually beginning at age 50 years to men who have at least a 10-year lifeexpectancy

59 No goalestablished

a From 2002 BRFSS (Behavioral Risk Factor Surveillance Survey) data

J Cancer Surviv

Tab

le2

Dem

ograph

icsof

NoC

ancerandCaSurvivo

rs(allandby

diagno

sis)

NoC

ancer

CaSurvivors

Breast

Cervical

Prostate

Melanom

aColorectal

Endom

etrial

gt1cancer

N2141

619

119

9462

6149

3959

Age

(meanyears)

4258

6444

7161

6354

62

Gender(

male)

981(551

)179(345

)NA

NA

62(100)

32(569

)14

(427

)NA

17(324

)

Tim

esinceDiagnosis(m

eanyears)

NA

11years

116

153

63

113

84

1517

Employment

Employedself

1285(622

)228(394

)42

(372

)52

(575

)14

(298

)25

(50

)13

(415

)11

(209

)14

(263

)

Retired

295(118

)237(353

)53

(396

)11

(97)

40(618

)31

(417

)23

(427

)13

(28

)28

(443

)

Out

ofworklt1gt1year

117(69)

28(42)

7(48)

9(81)

01(32)

2(2)

1(21)

2(71)

Hom

emaker

162(72)

47(75)

8(87)

8(79)

03(4)

3(23)

6(201

)2(32)

Unableto

work

71(32)

55(112

)8(98)

11(116

)3(84)

1(12)

4(116

)6(13

)10

(192

)

Student

120(88)

6(23)

8(38)

2(52)

00

01(158

)0

Maritalstatus

Marriedpartnered

1148(614

)309(657

)49

(564

)47

(656

)38

(818

)38

(744

)19

(641

)11

(337

)27

(641

)

Divorcedseparated

304(99)

105(125

)19

(12

)27

(184

)7(74)

5(49)

8(173

)12

(282

)6(85)

Widow

ed159(44)

134(151

)42

(277

)6(59)

11(94)

12(127

)14

(143

)10

(169

)18

(222

)

Never

married

438(243

)53

(67)

8(38)

13(101

)1(15)

6(8)

4(46)

5(212

)4(53)

Raceethnicity

White

1236(619

)486(811

)93

(756

)67

(794

)46

(827

)58

(958

)40

(924

)31

(742

)47

(853

)

Black

273(113)

48(85)

13(56)

10(8)

4(51)

01(08)

6(231

)5(67)

Hispanic

395(19

)32

(47)

5(61)

10(79)

1(31)

1(08)

3(76)

02(19)

Allothers

128(78)

30(54)

7(68)

6(47)

4(91)

1(35)

01(28)

3(79)

Educatio

n

ltHS

331(207

)74

(182

)13

(187

)11

(13

)10

(25

)8(171

)4(121

)5(134

)8(216

)

HS

619(321

)207(382

)40

(376

)38

(506

)16

(286

)11

(187

)15

(388

)16

(566

)18

(344

)

gtHS

1100(472

)321(437

)65

(437

)44

(453

)31

(463

)42

(643

)26

(212

)17

(30

)30

(439

)

Income

lt$25k

604(265

)215(324

)45

(386

)39

(401

)16

(226

)12

(197

)17

(223

)12

(308

)24

(444

)

$25-lt35k

275(123

)81

(125

)14

(104

)15

(179

)11

(221

)5(53)

4(75)

7(122

)8(11

)

$35-lt50k

307(137

)83

(155

)13

(142

)16

(186

)12

(208

)14

(243

)6(291

)5(124

)4(6)

$50-75k

291(144

)74

(115

)19

(143

)9(99)

7(102

)9(143

)8(172

)4(52)

4(65)

gt$75k

373(182

)90

(156

)15

(113

)9(87)

8(128

)13

(26

)6(154

)2(58)

10(188

)

RefNADKm

iss

291(149

)76

(125

)13

(113

)6(47)

8(115

)4(86)

8(336

)8(336

)9(133

)

Health

care

access

Regular

HCP(

with

)1264(549

)519(816

)15

(869

)75

(783

)53

(805

)52

(832

)38

(875

)33

(711

)54

(943

)

Health

Insurance(

with

)1696(809

)558(925

)114(974

)72

(72

)56

(989

)61

(100)

44(991

)37

(993

)53

(913

)

Health

status

Excellent

298(138

)63

(102

)10

(53)

7(93)

5(119

)10

(154

)6(223

)5(10

)4(47)

Verygood

648(31

)158(252

)30

(229

)18

(185

)16

(277

)24

(371

)13

(256

)4(102

)17

(324

)

Good

668(338

)182(284

)39

(302

)35

(343

)18

(321

)11

(178

)13

(271

)13

(277

)18

(304

)

Fair

372(182

)150(251

)30

(336

)28

(315

)13

(19

)12

(205

)8(135

)10

(219

)10

(167)

Poor

69(32)

50(11

)9(8)

5(64)

6(94)

4(92)

5(116

)6(302

)7(158

)

Represents68

of

HIN

TScancer

survivors(ge30

subjectsspecificcancer

typesno

tinclud

ingmorethan

onecancer)

ple0

05

ple0

01

ple0

001

J Cancer Surviv

different between groups although recommendations werehighest for breast cancer (gt78) and lowest for CRCscreening (lt19)

Being a cancer survivor was not significantly associatedwith the screening practices for three of the four tests(Papanicolaou tests (Odds Ratio (OR) 185 95 Confi-dence Interval (CI) 048ndash716) mammograms (OR 183 CI082ndash405) or PSA (OR 113 CI 039ndash33) Being asurvivor did significantly and positively influence adoptionof CRC screening (OR 203 CI 129ndash32)

When asked about things people could do to reduce theirchances of getting cancer screening was identified by 16(9606) of CaSurvivors and 08 (192101) of theNoCancer Group When asked specifically about theirown desired behavior changes to reduce the chance ofgetting cancer only 05 (92103) of the NoCancer groupidentified screening

Cancer specific screening beliefs and practices Healthbeliefs (perceived risk severity benefits barriers andself-efficacy) were assessed regarding breast prostate andCRC of CaSurvivors compared to the NoCancer compar-ison group (Table 4)

Breast cancer Cancer survivors perceived themselves to beat greater risk than the NoCancer group for both absoluteand comparative risk (Table 4) The strength of associationbetween perceived absolute and comparative risk wasmoderate (r=046 plt0001) There were no differencesbetween the two groups in barriers for obtaining amammogram (n=184 χ2 67 8 df p=058) There was asignificant positive relationship between physician recom-mendations and obtaining a mammogram (n=446 χ2 891 df p=0005) While more CaSurvivors reported havingmammograms than the NoCancer group there was nodifference when controlling for age raceethnicity andaccess to health care (OR 183 CI 082ndash405)

Prostate cancer Cancer survivors perceived themselves tobe at greater absolute risk (χ2 199 4 df p=0001) andcomparative risk (χ2 126 2 df p=001) (Table 4) Thestrength of association between perceived absolute andcomparative risk was moderate (r=045 plt0001) Physi-cian recommendations about getting a PSA were associatedwith having the test (n=195 χ2 439 1 df plt0001)Although more CaSurvivors reported having PSAs than theNoCancer group there was no difference between the twogroups when controlling for age raceethnicity and accessto health care (OR 113 CI 039ndash33)

Colorectal cancer Cancer survivors perceived themselves tobe at greater risk than the NoCancer group for both absolute(χ2 503 4 df p=lt0001) and comparative (χ2 261 2 dfT

able

3Cancerscreeningpractices

Reportedever

having

aNoC

ancer

(n)

CaSurvivo

rs

(n)

BRFSS

a

Breast

N=119

Cervical

n=94

Prostate

n=62

Melanom

an=61

Colorectal

n=49

End

ometrial

n=39

gt1cancer

n=59

Papanicolaoutest(w

omenge18

years)

916

(1027

1121

)

987

(405

412

)95

2

99

(117

118

)ndash

ndash98

3

(2829

)95

9

(2730

)10

0(3737

)10

0(2828

)Mam

mog

raph

y(w

omenge40

years)

849

(299

352

)91

8

(205

323

)63

4

ndash86

6

(5159

)ndash

897

(2224

)94

7

(2730

)96

9

(3132

)10

0(1515

)PSA

(menge50

years)

587

(177

302

)

76

(100

132

)59

ndash

ndashndash

899

(2325

)74

(1012

)ndash

100

(88)

Colon

oscopy

orSigmoido

scop

yor

FOBT(m

enandwom

enge50

)69

(374

542

)

846

(362

428

)48

1

804

(8092

)85

7

(1924

)97

4

(4445

)93

8

(4245

)ndash

924

(2426

)89

1

(2933

)

Screening

criteria(egage)

basedon

theACSrsquosrecommendatio

nsforthegeneralpo

pulatio

nCaSurvivo

rsrespon

dentswereexclud

edifthey

repo

rted

having

theprim

arycancer

thescreening

testwas

used

for(egwom

enwith

breastcancer

wereexclud

edfrom

themam

mog

raph

ycalculations)

χ2comparing

CaSurvivo

rsandNoC

ancerlt

005

lt001

lt000

1aBehavioralRiskFactorSurveillance

Survey(BRFSS)20

02prevalence

rates

J Cancer Surviv

plt0001) risk for CRC The strength of associationbetween perceived absolute and comparative risk wasmoderate (r=041 plt0001) Since only 25 (n=27) ofCaSurvivors and 187 (n=41) of the NoCancer groupreported that a physician recommended either a sigmoidos-copy or colonoscopy (p=042) the relationship betweenphysician recommendation and screening was not con-ducted (Table 4) Barriers for not obtaining a colonoscopyor sigmoidoscopy were not significantly different betweenthe two groups (n=431 χ2 8 8 df p=045) There werehowever significant differences between groups in per-ceived benefits and self-efficacy (Table 4) Cancer survi-vors had significantly higher CRC screening ratescompared the NoCancer group when controlling for age

raceethnicity and access to health care Being a survivorpositively influenced CRC screening (OR 184 CI 106ndash319) and being younger age (lt65 years) negatively andindependently influenced this behavior (OR 041 CI 020ndash084)

Discussion

The NCIrsquos HINTS I provided a large nationally represen-tative random sample to explore select constructs from theHealth Belief Model about cancer survivors screeningbeliefs and practices Screening rates exceeded ACSrecommendations national BRFSS prevalence data and

Table 4 Cancer screening beliefs

CaSurvivors N=205 NoCancer N=399

Breast cancer screeningMD recommended mammography 838 781RiskaMean absolute risk in women who obtained a mammogram (1 low rarr 5 very high) 27 21Perceived absolute risk for developing breast cancer (somewhatvery high) 231 82Perceived relative risk compared to lsquoaveragersquo woman (more likely) 186 76

Barriers to getting screenedMD did not advise 88 21Did not know I needed test 21 11Prostate cancer screening CaSurvivors N=100 NoCancer N=177MD recommended PSA 645 668

RiskaMean absolute risk (1 low rarr 5 very high) 26 24Perceived absolute risk for developing prostate cancer (somewhatvery high) 165 95Perceived relative risk compared to average man (more likely) 166 7Colorectal cancer screening CaSurvivors N=362 NoCancer N=374

MD recommendedFOBT 357 361Sigmoidoscopy 85 83Colonoscopy 224 153

RiskaMean absolute risk (1 low rarr 5 very high) 24 20Perceived absolute risk for developing CRC (somewhatvery high) 131 51Perceived relative risk compared to average person (more likely) 17 69

Barriers to getting screenedMD did not advise 271 19Did not know needed it 132 229Afraid of finding cancer if tested (strongly agree) 159 141Too expensive (strongly disagreed) 289 207

Benefits to getting screenedArranging to get tested would be easy (strongly agree) 48 378Regular screening increases chance of cure (strongly agree) 92 848

Screening criteria (eg age and gender) based on the ACSrsquo recommendations for the general population CaSurvivors with the relevant primarycancer were not asked about that screening test (eg women with breast cancer were not asked about having mammograms) Parallel questionsabout health beliefs were not ascertained across the three cancers in2003 HINTSple005 ple001 lt00001a Two different risk questions were asked One question asked about perceived absolute risk lsquohow likely you are to get X cancerrsquo (1 = very low rarr5 = very high) The other asked about perceived comparative risk lsquocompared to the average manwoman lsquohow likely are you to get X cancerrsquo (1 =less likely rarr 3 = more likely on a 3 point likert scale)

J Cancer Surviv

Healthy People 2010 goals in both groups Cancersurvivors had higher perceived risk scores for breastcervical prostate and CRC screening Survivors alsoperceived greater benefits fewer barriers and greaterseriousness of CRC significantly more often than thegroup without cancer which may have contributed to theirhigher screening rates Furthermore being a survivorinfluenced CRC screening practices when controlling forage race and ethnicity and health care access Being asurvivor however was not found to influence screeningpractices for cervical breast prostate cancers whencontrolling for these variables Lack of difference betweengroups may be related to the high adherence rates Theseresults contrast with those found by Bellizzi et al in asecondary data analysis of four years of National HealthInterview Survey (NHIS) data [7] They found that cancersurvivors were more likely to receive mammogramsPapanicolaou tests and PSA when compared to thecomparison group (CRC screening was not evaluated) Inanother study using 2000 NHIS data Trask et al also foundsurvivors having higher screening rates for mammogramsclinical breast exam Papanicolaou test PSA skin examand CRC screening [67] In this study the percentage ofsurvivors having the screening tests were higher howeverthese differences were not apparent when statisticallycontrolling for other socioeconomic differences betweenthe two groups Each of these studies controlled fordifferences with different variables which may contributeto these disparities (eg our study included health careaccess as one of these variables while neither of the otherstudies did) While it was not possible to ascertain whethersurvivors were being followed by oncologists primary careproviders or both physician recommendations were asso-ciated with a higher level of screening in breast and prostatecancer

Perceived vulnerability about cancer may be a motivatoror deterrent in obtaining screening tests [6 37 39 40 4344 47 58 68 70] Associations between perceived riskand screening practices has varied [37 43 44 69 70]some have found that increased perceived vulnerabilityresulting in increased screening In this study there weremoderate associations between perceived absolute andcomparative risk for breast prostate and CRC but thoserisk perceptions were not significantly associated withhaving the relevant screening test While increased benefitsdecreased barriers and self-efficacy were associated withobtaining CRC screening these variables could not beexplored as thoroughly in cervical breast or prostatebecause there were fewer relevant HINTS questions

In a national telephone survey Schwartz et al found thatmost US adults (87) believed in screening and in thebenefits of finding a cancer [60] However very fewrespondents in either group identified screening as a way

to reduce cancer risk in general or for themselvesHistorically screening rates have varied by the type of testand have been attributed to individual factors such agegender socioeconomic status and to access to health care[9] In a recent analysis of the 2002 Behavioral Risk FactorSurveillance Survey (BRFSS) data men were more likelyto have a PSA than CRC screening [10] Men who had aPSA test and health care access (both provider andinsurance) were more likely to have CRC screening thanmen who didnrsquot In another cross sectional randomtelephone survey of Massachusettsrsquo residents predictorsof CRC screening included having a regular checkuphaving other screening tests having a family history ofCRC and vitamin supplement use [36]

Access to health care includes having a regular providerand having some type of health insurance lack of accessremains a major barrier to cancer screening [9 66] In thecurrent study CaSurvivors were more likely to have accessto health care than the NoCancer group Similar to otherstudies screening rates were significantly higher whenphysicianrsquos made recommendations Although physicianrecommendations did not differ between groups they diddiffer across cancers to be screened Many other screeningstudies cite having a physician as a significant contributorto screening behavior and found a positive relationshipsbetween having a provider recommend screening andhaving the test [10 16 28 36 41 45 46] Physicianrecommendations were highest for breast cancer screeningand lowest for CRC screening and mirrored screeningadherence patterns in both groups Clinical practicesregarding survivorsrsquo screening may also vary based on typeof health care provider (eg whether an oncologist orprimary care provider or both) [21 22] Colorectal andcervical cancer screening rates of breast cancer survivorsvaried by access to and type of health care provider theserates are substantially below the most recent US populationprevalence rates identified in the BRFSS [12] Educatinghealth care providers whether in primary care or inoncology about their impact when recommending screen-ing and creating organizational systems to support theseefforts (eg reminder systems) may be useful in increasingadherence especially for CRC screening These patternsmay also reflect public and professional exposure toscreening messages and celebrity endorsements whichbegan in the 1970s for mammography (eg Betty Fordand Happy Rockefellerrsquos breast cancer in the news) andcolonoscopy in 2000 (Katie Couricrsquos TV colonoscopy) [1735] Compared to other cancers there are more CRCscreening test options which may also make it moreconfusing for the public

Having insurance to pay for the screening test isanother important factor Mammography rates dramaticallyincreased once insurance coverage was initiated [9] While

J Cancer Surviv

still suboptimal colonoscopies rose in average risk indi-viduals from 46 to 142 after Medicare coverage in 2001[27 38] Although the ldquoCDC Screen for Life NationalColorectal Cancer Action Campaignrdquo is raising awarenessabout the need for screening it is not providing the samehealth access that the National Breast and Cervical CancerEarly Detection Program (NBCCEDP) does TheNBCCEDP initiated in 1991 has been successful inhelping low-income uninsured and underserved womengain access to Papanicolaou tests and mammograms byproviding both access and coverage

The limitations of this study are mainly related toconducting a secondary data analysis [34] As such theHINTS was not designed to evaluate survivorship issuesnor was the sampling designed to be representative of thepopulation of US cancer survivors The HBM was notevaluated for its predictive ability but was used to guide theidentification and inclusion of relevant variables in under-standing screening behavior [73] Self-report of cancerhistory and screening practices is subject to recall bias andno verification of the self-report was conducted Neverthe-less the robust sample of survivors and controls as well asrich item content provided a unique opportunity to explorethese issues within the theoretical framework of the HBMThe high screening rates and lack of variability amonggroups may also have influenced the cervical breast andprostate logistic regressions results Doubeni et al foundthat mammography rates declined over time in breastcancer survivors [19] HINTS survivors were not askedabout screening for their type of cancer (eg mammogramsfor women with breast cancer) so similar comparisonscould not be made

Cancer survivors had different health beliefs and riskperceptions for screening compared to the NoCancer groupWhile there were no differences between survivorsrsquoscreening for breast and prostate cancer survivors weremore likely to screen for colorectal cancer than thecomparison group Screening adherence met or exceededrecommendations for individual tests for both cancersurvivors and the comparison group More attention isbeing paid to the follow-up care of survivors [1 13 24 29]Much of that emphasis is on the prevention and manage-ment of late and long term effects of the disease andtreatment Screening for other cancers should also beincluded in cancer survivorship care plans [24 29]

Acknowledgements D Mayer was a recipient of the Ann OlsenDoctoral Scholarship from the ONS Foundation an American CancerSociety Doctoral Scholarship (DSCN-108161) and a National ServiceResearch Award from the National Institute of Nursing Research(NRSA 1F31 NR09137-01A1 Partially funded by NCI training grant(R25 CA093831 Kathi Mooney PI)The authors thank Dr Richard Moser and Dr Bradford Hesse of the

National Cancer Institute for their expert assistance with the HINTS

database Robert Rosofsky for programming assistance Kathy Pikoskyand Stefanie Jeruss for assistance with manuscript preparation

Reference List

1 A National Coalition for Cancer Survivorship and Institute ofMedicine National Cancer Policy Forum Workshop The LanceArmstrong Foundation and The National Cancer Institute MariaHewitt and Patricia A Ganz Rapporteurs (2007) Implementingcancer survivorship care planning Washington DC NationalAcademy

2 American Association for Public Opinion Research (2004)Standard definitions Final dispositions of case codes andoutcome rates for surveys

3 American Cancer Society (2006) Cancer facts amp figures 2006Atlanta ACS

4 Aziz N M (2002) Cancer survivorship research Challenge andopportunity Journal of Nutrition 132(11 Suppl) 3494Sndash3503S(November)

5 Aziz N M amp Rowland J H (2003) Trends and advances incancer survivorship research Challenge and opportunity Semi-nars in Radiation Oncology 13(3) 248ndash266 (July)

6 Bastani R Gallardo N V amp Maxwell A E (2001) Barriers tocolorectal cancer screening among ethnically diverse high- andaverage-risk individuals J Psychosocial Oncol 19(34) 65ndash84

7 Bellizzi K M Rowland J H Jeffery D D amp McNeel T(2005) Health behaviors of cancer survivors Examining opportu-nities for cancer control intervention Journal of Clinical Oncol-ogy 23(34) 8884ndash8893 (December 1)

8 Brawley O W amp Kramer B S (2005) Cancer screening intheory and in practice Journal of Clinical Oncology 23(2) 293ndash300 (January 10)

9 Breen N amp Meissner H I (2005) Toward a system of cancerscreening in the United States Trends and opportunities AnnualReview Of Public Health 26 561ndash582 (April 21)

10 Carlos R C Underwood W III Fendrick A M amp BernsteinS J (2005) Behavioral associations between prostate and coloncancer screening Journal of the American College of Surgeons200(2) 216ndash223 (February)

11 Center for Disease Control (2004) A national action plan for cancersurvivorship Advancing public health strategies Atlanta CDC

12 Center for Disease Control (2004) Behavioral risk factorsurveillance system httpwww cdc govbrfss

13 Centers for Disease Control and Prevention and the LanceArmstrong Foundation (2004) A national action plan for cancersurvivorship Atlanta GA CDC

14 Champion V L (1987) The relationship of breast self-examina-tion to health belief model variables Research in Nursing ampHealth 10(6) 375ndash382 (December)

15 Codori A M Petersen G M Miglioretti D L amp Boyd P(2001) Health beliefs and endoscopic screening for colorectalcancer Potential for cancer prevention Preventive Medicine 33(2Pt 1) 128ndash136 (August)

16 Coughlin S S Breslau E S Thompson T amp Benard V B(2005) Physician recommendation for papanicolaou testingamong US women 2000 Cancer Epidemiology Biomarkers ampPrevention 14(5) 1143ndash1148 (May)

17 Cram P Fendrick A M Inadomi J Cowen M E Carpenter Damp Vijan S (2003) The impact of a celebrity promotional campaignon the use of colon cancer screening The Katie Couric effectArchives of Internal Medicine 163(13) 1601ndash1605 (July 14)

18 Curtis R E Freedman D M Ron E Ries L A G Hacker DG Edwards BK et al (Eds) (2006) New malignancies among

J Cancer Surviv

Tab

le2

Dem

ograph

icsof

NoC

ancerandCaSurvivo

rs(allandby

diagno

sis)

NoC

ancer

CaSurvivors

Breast

Cervical

Prostate

Melanom

aColorectal

Endom

etrial

gt1cancer

N2141

619

119

9462

6149

3959

Age

(meanyears)

4258

6444

7161

6354

62

Gender(

male)

981(551

)179(345

)NA

NA

62(100)

32(569

)14

(427

)NA

17(324

)

Tim

esinceDiagnosis(m

eanyears)

NA

11years

116

153

63

113

84

1517

Employment

Employedself

1285(622

)228(394

)42

(372

)52

(575

)14

(298

)25

(50

)13

(415

)11

(209

)14

(263

)

Retired

295(118

)237(353

)53

(396

)11

(97)

40(618

)31

(417

)23

(427

)13

(28

)28

(443

)

Out

ofworklt1gt1year

117(69)

28(42)

7(48)

9(81)

01(32)

2(2)

1(21)

2(71)

Hom

emaker

162(72)

47(75)

8(87)

8(79)

03(4)

3(23)

6(201

)2(32)

Unableto

work

71(32)

55(112

)8(98)

11(116

)3(84)

1(12)

4(116

)6(13

)10

(192

)

Student

120(88)

6(23)

8(38)

2(52)

00

01(158

)0

Maritalstatus

Marriedpartnered

1148(614

)309(657

)49

(564

)47

(656

)38

(818

)38

(744

)19

(641

)11

(337

)27

(641

)

Divorcedseparated

304(99)

105(125

)19

(12

)27

(184

)7(74)

5(49)

8(173

)12

(282

)6(85)

Widow

ed159(44)

134(151

)42

(277

)6(59)

11(94)

12(127

)14

(143

)10

(169

)18

(222

)

Never

married

438(243

)53

(67)

8(38)

13(101

)1(15)

6(8)

4(46)

5(212

)4(53)

Raceethnicity

White

1236(619

)486(811

)93

(756

)67

(794

)46

(827

)58

(958

)40

(924

)31

(742

)47

(853

)

Black

273(113)

48(85)

13(56)

10(8)

4(51)

01(08)

6(231

)5(67)

Hispanic

395(19

)32

(47)

5(61)

10(79)

1(31)

1(08)

3(76)

02(19)

Allothers

128(78)

30(54)

7(68)

6(47)

4(91)

1(35)

01(28)

3(79)

Educatio

n

ltHS

331(207

)74

(182

)13

(187

)11

(13

)10

(25

)8(171

)4(121

)5(134

)8(216

)

HS

619(321

)207(382

)40

(376

)38

(506

)16

(286

)11

(187

)15

(388

)16

(566

)18

(344

)

gtHS

1100(472

)321(437

)65

(437

)44

(453

)31

(463

)42

(643

)26

(212

)17

(30

)30

(439

)

Income

lt$25k

604(265

)215(324

)45

(386

)39

(401

)16

(226

)12

(197

)17

(223

)12

(308

)24

(444

)

$25-lt35k

275(123

)81

(125

)14

(104

)15

(179

)11

(221

)5(53)

4(75)

7(122

)8(11

)

$35-lt50k

307(137

)83

(155

)13

(142

)16

(186

)12

(208

)14

(243

)6(291

)5(124

)4(6)

$50-75k

291(144

)74

(115

)19

(143

)9(99)

7(102

)9(143

)8(172

)4(52)

4(65)

gt$75k

373(182

)90

(156

)15

(113

)9(87)

8(128

)13

(26

)6(154

)2(58)

10(188

)

RefNADKm

iss

291(149

)76

(125

)13

(113

)6(47)

8(115

)4(86)

8(336

)8(336

)9(133

)

Health

care

access

Regular

HCP(

with

)1264(549

)519(816

)15

(869

)75

(783

)53

(805

)52

(832

)38

(875

)33

(711

)54

(943

)

Health

Insurance(

with

)1696(809

)558(925

)114(974

)72

(72

)56

(989

)61

(100)

44(991

)37

(993

)53

(913

)

Health

status

Excellent

298(138

)63

(102

)10

(53)

7(93)

5(119

)10

(154

)6(223

)5(10

)4(47)

Verygood

648(31

)158(252

)30

(229

)18

(185

)16

(277

)24

(371

)13

(256

)4(102

)17

(324

)

Good

668(338

)182(284

)39

(302

)35

(343

)18

(321

)11

(178

)13

(271

)13

(277

)18

(304

)

Fair

372(182

)150(251

)30

(336

)28

(315

)13

(19

)12

(205

)8(135

)10

(219

)10

(167)

Poor

69(32)

50(11

)9(8)

5(64)

6(94)

4(92)

5(116

)6(302

)7(158

)

Represents68

of

HIN

TScancer

survivors(ge30

subjectsspecificcancer

typesno

tinclud

ingmorethan

onecancer)

ple0

05

ple0

01

ple0

001

J Cancer Surviv

different between groups although recommendations werehighest for breast cancer (gt78) and lowest for CRCscreening (lt19)

Being a cancer survivor was not significantly associatedwith the screening practices for three of the four tests(Papanicolaou tests (Odds Ratio (OR) 185 95 Confi-dence Interval (CI) 048ndash716) mammograms (OR 183 CI082ndash405) or PSA (OR 113 CI 039ndash33) Being asurvivor did significantly and positively influence adoptionof CRC screening (OR 203 CI 129ndash32)

When asked about things people could do to reduce theirchances of getting cancer screening was identified by 16(9606) of CaSurvivors and 08 (192101) of theNoCancer Group When asked specifically about theirown desired behavior changes to reduce the chance ofgetting cancer only 05 (92103) of the NoCancer groupidentified screening

Cancer specific screening beliefs and practices Healthbeliefs (perceived risk severity benefits barriers andself-efficacy) were assessed regarding breast prostate andCRC of CaSurvivors compared to the NoCancer compar-ison group (Table 4)

Breast cancer Cancer survivors perceived themselves to beat greater risk than the NoCancer group for both absoluteand comparative risk (Table 4) The strength of associationbetween perceived absolute and comparative risk wasmoderate (r=046 plt0001) There were no differencesbetween the two groups in barriers for obtaining amammogram (n=184 χ2 67 8 df p=058) There was asignificant positive relationship between physician recom-mendations and obtaining a mammogram (n=446 χ2 891 df p=0005) While more CaSurvivors reported havingmammograms than the NoCancer group there was nodifference when controlling for age raceethnicity andaccess to health care (OR 183 CI 082ndash405)

Prostate cancer Cancer survivors perceived themselves tobe at greater absolute risk (χ2 199 4 df p=0001) andcomparative risk (χ2 126 2 df p=001) (Table 4) Thestrength of association between perceived absolute andcomparative risk was moderate (r=045 plt0001) Physi-cian recommendations about getting a PSA were associatedwith having the test (n=195 χ2 439 1 df plt0001)Although more CaSurvivors reported having PSAs than theNoCancer group there was no difference between the twogroups when controlling for age raceethnicity and accessto health care (OR 113 CI 039ndash33)

Colorectal cancer Cancer survivors perceived themselves tobe at greater risk than the NoCancer group for both absolute(χ2 503 4 df p=lt0001) and comparative (χ2 261 2 dfT

able

3Cancerscreeningpractices

Reportedever

having

aNoC

ancer

(n)

CaSurvivo

rs

(n)

BRFSS

a

Breast

N=119

Cervical

n=94

Prostate

n=62

Melanom

an=61

Colorectal

n=49

End

ometrial

n=39

gt1cancer

n=59

Papanicolaoutest(w

omenge18

years)

916

(1027

1121

)

987

(405

412

)95

2

99

(117

118

)ndash

ndash98

3

(2829

)95

9

(2730

)10

0(3737

)10

0(2828

)Mam

mog

raph

y(w

omenge40

years)

849

(299

352

)91

8

(205

323

)63

4

ndash86

6

(5159

)ndash

897

(2224

)94

7

(2730

)96

9

(3132

)10

0(1515

)PSA

(menge50

years)

587

(177

302

)

76

(100

132

)59

ndash

ndashndash

899

(2325

)74

(1012

)ndash

100

(88)

Colon

oscopy

orSigmoido

scop

yor

FOBT(m

enandwom

enge50

)69

(374

542

)

846

(362

428

)48

1

804

(8092

)85

7

(1924

)97

4

(4445

)93

8

(4245

)ndash

924

(2426

)89

1

(2933

)

Screening

criteria(egage)

basedon

theACSrsquosrecommendatio

nsforthegeneralpo

pulatio

nCaSurvivo

rsrespon

dentswereexclud

edifthey

repo

rted

having

theprim

arycancer

thescreening

testwas

used

for(egwom

enwith

breastcancer

wereexclud

edfrom

themam

mog

raph

ycalculations)

χ2comparing

CaSurvivo

rsandNoC

ancerlt

005

lt001

lt000

1aBehavioralRiskFactorSurveillance

Survey(BRFSS)20

02prevalence

rates

J Cancer Surviv

plt0001) risk for CRC The strength of associationbetween perceived absolute and comparative risk wasmoderate (r=041 plt0001) Since only 25 (n=27) ofCaSurvivors and 187 (n=41) of the NoCancer groupreported that a physician recommended either a sigmoidos-copy or colonoscopy (p=042) the relationship betweenphysician recommendation and screening was not con-ducted (Table 4) Barriers for not obtaining a colonoscopyor sigmoidoscopy were not significantly different betweenthe two groups (n=431 χ2 8 8 df p=045) There werehowever significant differences between groups in per-ceived benefits and self-efficacy (Table 4) Cancer survi-vors had significantly higher CRC screening ratescompared the NoCancer group when controlling for age

raceethnicity and access to health care Being a survivorpositively influenced CRC screening (OR 184 CI 106ndash319) and being younger age (lt65 years) negatively andindependently influenced this behavior (OR 041 CI 020ndash084)

Discussion

The NCIrsquos HINTS I provided a large nationally represen-tative random sample to explore select constructs from theHealth Belief Model about cancer survivors screeningbeliefs and practices Screening rates exceeded ACSrecommendations national BRFSS prevalence data and

Table 4 Cancer screening beliefs

CaSurvivors N=205 NoCancer N=399

Breast cancer screeningMD recommended mammography 838 781RiskaMean absolute risk in women who obtained a mammogram (1 low rarr 5 very high) 27 21Perceived absolute risk for developing breast cancer (somewhatvery high) 231 82Perceived relative risk compared to lsquoaveragersquo woman (more likely) 186 76

Barriers to getting screenedMD did not advise 88 21Did not know I needed test 21 11Prostate cancer screening CaSurvivors N=100 NoCancer N=177MD recommended PSA 645 668

RiskaMean absolute risk (1 low rarr 5 very high) 26 24Perceived absolute risk for developing prostate cancer (somewhatvery high) 165 95Perceived relative risk compared to average man (more likely) 166 7Colorectal cancer screening CaSurvivors N=362 NoCancer N=374

MD recommendedFOBT 357 361Sigmoidoscopy 85 83Colonoscopy 224 153

RiskaMean absolute risk (1 low rarr 5 very high) 24 20Perceived absolute risk for developing CRC (somewhatvery high) 131 51Perceived relative risk compared to average person (more likely) 17 69

Barriers to getting screenedMD did not advise 271 19Did not know needed it 132 229Afraid of finding cancer if tested (strongly agree) 159 141Too expensive (strongly disagreed) 289 207

Benefits to getting screenedArranging to get tested would be easy (strongly agree) 48 378Regular screening increases chance of cure (strongly agree) 92 848

Screening criteria (eg age and gender) based on the ACSrsquo recommendations for the general population CaSurvivors with the relevant primarycancer were not asked about that screening test (eg women with breast cancer were not asked about having mammograms) Parallel questionsabout health beliefs were not ascertained across the three cancers in2003 HINTSple005 ple001 lt00001a Two different risk questions were asked One question asked about perceived absolute risk lsquohow likely you are to get X cancerrsquo (1 = very low rarr5 = very high) The other asked about perceived comparative risk lsquocompared to the average manwoman lsquohow likely are you to get X cancerrsquo (1 =less likely rarr 3 = more likely on a 3 point likert scale)

J Cancer Surviv

Healthy People 2010 goals in both groups Cancersurvivors had higher perceived risk scores for breastcervical prostate and CRC screening Survivors alsoperceived greater benefits fewer barriers and greaterseriousness of CRC significantly more often than thegroup without cancer which may have contributed to theirhigher screening rates Furthermore being a survivorinfluenced CRC screening practices when controlling forage race and ethnicity and health care access Being asurvivor however was not found to influence screeningpractices for cervical breast prostate cancers whencontrolling for these variables Lack of difference betweengroups may be related to the high adherence rates Theseresults contrast with those found by Bellizzi et al in asecondary data analysis of four years of National HealthInterview Survey (NHIS) data [7] They found that cancersurvivors were more likely to receive mammogramsPapanicolaou tests and PSA when compared to thecomparison group (CRC screening was not evaluated) Inanother study using 2000 NHIS data Trask et al also foundsurvivors having higher screening rates for mammogramsclinical breast exam Papanicolaou test PSA skin examand CRC screening [67] In this study the percentage ofsurvivors having the screening tests were higher howeverthese differences were not apparent when statisticallycontrolling for other socioeconomic differences betweenthe two groups Each of these studies controlled fordifferences with different variables which may contributeto these disparities (eg our study included health careaccess as one of these variables while neither of the otherstudies did) While it was not possible to ascertain whethersurvivors were being followed by oncologists primary careproviders or both physician recommendations were asso-ciated with a higher level of screening in breast and prostatecancer

Perceived vulnerability about cancer may be a motivatoror deterrent in obtaining screening tests [6 37 39 40 4344 47 58 68 70] Associations between perceived riskand screening practices has varied [37 43 44 69 70]some have found that increased perceived vulnerabilityresulting in increased screening In this study there weremoderate associations between perceived absolute andcomparative risk for breast prostate and CRC but thoserisk perceptions were not significantly associated withhaving the relevant screening test While increased benefitsdecreased barriers and self-efficacy were associated withobtaining CRC screening these variables could not beexplored as thoroughly in cervical breast or prostatebecause there were fewer relevant HINTS questions

In a national telephone survey Schwartz et al found thatmost US adults (87) believed in screening and in thebenefits of finding a cancer [60] However very fewrespondents in either group identified screening as a way

to reduce cancer risk in general or for themselvesHistorically screening rates have varied by the type of testand have been attributed to individual factors such agegender socioeconomic status and to access to health care[9] In a recent analysis of the 2002 Behavioral Risk FactorSurveillance Survey (BRFSS) data men were more likelyto have a PSA than CRC screening [10] Men who had aPSA test and health care access (both provider andinsurance) were more likely to have CRC screening thanmen who didnrsquot In another cross sectional randomtelephone survey of Massachusettsrsquo residents predictorsof CRC screening included having a regular checkuphaving other screening tests having a family history ofCRC and vitamin supplement use [36]

Access to health care includes having a regular providerand having some type of health insurance lack of accessremains a major barrier to cancer screening [9 66] In thecurrent study CaSurvivors were more likely to have accessto health care than the NoCancer group Similar to otherstudies screening rates were significantly higher whenphysicianrsquos made recommendations Although physicianrecommendations did not differ between groups they diddiffer across cancers to be screened Many other screeningstudies cite having a physician as a significant contributorto screening behavior and found a positive relationshipsbetween having a provider recommend screening andhaving the test [10 16 28 36 41 45 46] Physicianrecommendations were highest for breast cancer screeningand lowest for CRC screening and mirrored screeningadherence patterns in both groups Clinical practicesregarding survivorsrsquo screening may also vary based on typeof health care provider (eg whether an oncologist orprimary care provider or both) [21 22] Colorectal andcervical cancer screening rates of breast cancer survivorsvaried by access to and type of health care provider theserates are substantially below the most recent US populationprevalence rates identified in the BRFSS [12] Educatinghealth care providers whether in primary care or inoncology about their impact when recommending screen-ing and creating organizational systems to support theseefforts (eg reminder systems) may be useful in increasingadherence especially for CRC screening These patternsmay also reflect public and professional exposure toscreening messages and celebrity endorsements whichbegan in the 1970s for mammography (eg Betty Fordand Happy Rockefellerrsquos breast cancer in the news) andcolonoscopy in 2000 (Katie Couricrsquos TV colonoscopy) [1735] Compared to other cancers there are more CRCscreening test options which may also make it moreconfusing for the public

Having insurance to pay for the screening test isanother important factor Mammography rates dramaticallyincreased once insurance coverage was initiated [9] While

J Cancer Surviv

still suboptimal colonoscopies rose in average risk indi-viduals from 46 to 142 after Medicare coverage in 2001[27 38] Although the ldquoCDC Screen for Life NationalColorectal Cancer Action Campaignrdquo is raising awarenessabout the need for screening it is not providing the samehealth access that the National Breast and Cervical CancerEarly Detection Program (NBCCEDP) does TheNBCCEDP initiated in 1991 has been successful inhelping low-income uninsured and underserved womengain access to Papanicolaou tests and mammograms byproviding both access and coverage

The limitations of this study are mainly related toconducting a secondary data analysis [34] As such theHINTS was not designed to evaluate survivorship issuesnor was the sampling designed to be representative of thepopulation of US cancer survivors The HBM was notevaluated for its predictive ability but was used to guide theidentification and inclusion of relevant variables in under-standing screening behavior [73] Self-report of cancerhistory and screening practices is subject to recall bias andno verification of the self-report was conducted Neverthe-less the robust sample of survivors and controls as well asrich item content provided a unique opportunity to explorethese issues within the theoretical framework of the HBMThe high screening rates and lack of variability amonggroups may also have influenced the cervical breast andprostate logistic regressions results Doubeni et al foundthat mammography rates declined over time in breastcancer survivors [19] HINTS survivors were not askedabout screening for their type of cancer (eg mammogramsfor women with breast cancer) so similar comparisonscould not be made

Cancer survivors had different health beliefs and riskperceptions for screening compared to the NoCancer groupWhile there were no differences between survivorsrsquoscreening for breast and prostate cancer survivors weremore likely to screen for colorectal cancer than thecomparison group Screening adherence met or exceededrecommendations for individual tests for both cancersurvivors and the comparison group More attention isbeing paid to the follow-up care of survivors [1 13 24 29]Much of that emphasis is on the prevention and manage-ment of late and long term effects of the disease andtreatment Screening for other cancers should also beincluded in cancer survivorship care plans [24 29]

Acknowledgements D Mayer was a recipient of the Ann OlsenDoctoral Scholarship from the ONS Foundation an American CancerSociety Doctoral Scholarship (DSCN-108161) and a National ServiceResearch Award from the National Institute of Nursing Research(NRSA 1F31 NR09137-01A1 Partially funded by NCI training grant(R25 CA093831 Kathi Mooney PI)The authors thank Dr Richard Moser and Dr Bradford Hesse of the

National Cancer Institute for their expert assistance with the HINTS

database Robert Rosofsky for programming assistance Kathy Pikoskyand Stefanie Jeruss for assistance with manuscript preparation

Reference List

1 A National Coalition for Cancer Survivorship and Institute ofMedicine National Cancer Policy Forum Workshop The LanceArmstrong Foundation and The National Cancer Institute MariaHewitt and Patricia A Ganz Rapporteurs (2007) Implementingcancer survivorship care planning Washington DC NationalAcademy

2 American Association for Public Opinion Research (2004)Standard definitions Final dispositions of case codes andoutcome rates for surveys

3 American Cancer Society (2006) Cancer facts amp figures 2006Atlanta ACS

4 Aziz N M (2002) Cancer survivorship research Challenge andopportunity Journal of Nutrition 132(11 Suppl) 3494Sndash3503S(November)

5 Aziz N M amp Rowland J H (2003) Trends and advances incancer survivorship research Challenge and opportunity Semi-nars in Radiation Oncology 13(3) 248ndash266 (July)

6 Bastani R Gallardo N V amp Maxwell A E (2001) Barriers tocolorectal cancer screening among ethnically diverse high- andaverage-risk individuals J Psychosocial Oncol 19(34) 65ndash84

7 Bellizzi K M Rowland J H Jeffery D D amp McNeel T(2005) Health behaviors of cancer survivors Examining opportu-nities for cancer control intervention Journal of Clinical Oncol-ogy 23(34) 8884ndash8893 (December 1)

8 Brawley O W amp Kramer B S (2005) Cancer screening intheory and in practice Journal of Clinical Oncology 23(2) 293ndash300 (January 10)

9 Breen N amp Meissner H I (2005) Toward a system of cancerscreening in the United States Trends and opportunities AnnualReview Of Public Health 26 561ndash582 (April 21)

10 Carlos R C Underwood W III Fendrick A M amp BernsteinS J (2005) Behavioral associations between prostate and coloncancer screening Journal of the American College of Surgeons200(2) 216ndash223 (February)

11 Center for Disease Control (2004) A national action plan for cancersurvivorship Advancing public health strategies Atlanta CDC

12 Center for Disease Control (2004) Behavioral risk factorsurveillance system httpwww cdc govbrfss

13 Centers for Disease Control and Prevention and the LanceArmstrong Foundation (2004) A national action plan for cancersurvivorship Atlanta GA CDC

14 Champion V L (1987) The relationship of breast self-examina-tion to health belief model variables Research in Nursing ampHealth 10(6) 375ndash382 (December)

15 Codori A M Petersen G M Miglioretti D L amp Boyd P(2001) Health beliefs and endoscopic screening for colorectalcancer Potential for cancer prevention Preventive Medicine 33(2Pt 1) 128ndash136 (August)

16 Coughlin S S Breslau E S Thompson T amp Benard V B(2005) Physician recommendation for papanicolaou testingamong US women 2000 Cancer Epidemiology Biomarkers ampPrevention 14(5) 1143ndash1148 (May)

17 Cram P Fendrick A M Inadomi J Cowen M E Carpenter Damp Vijan S (2003) The impact of a celebrity promotional campaignon the use of colon cancer screening The Katie Couric effectArchives of Internal Medicine 163(13) 1601ndash1605 (July 14)

18 Curtis R E Freedman D M Ron E Ries L A G Hacker DG Edwards BK et al (Eds) (2006) New malignancies among

J Cancer Surviv

different between groups although recommendations werehighest for breast cancer (gt78) and lowest for CRCscreening (lt19)

Being a cancer survivor was not significantly associatedwith the screening practices for three of the four tests(Papanicolaou tests (Odds Ratio (OR) 185 95 Confi-dence Interval (CI) 048ndash716) mammograms (OR 183 CI082ndash405) or PSA (OR 113 CI 039ndash33) Being asurvivor did significantly and positively influence adoptionof CRC screening (OR 203 CI 129ndash32)

When asked about things people could do to reduce theirchances of getting cancer screening was identified by 16(9606) of CaSurvivors and 08 (192101) of theNoCancer Group When asked specifically about theirown desired behavior changes to reduce the chance ofgetting cancer only 05 (92103) of the NoCancer groupidentified screening

Cancer specific screening beliefs and practices Healthbeliefs (perceived risk severity benefits barriers andself-efficacy) were assessed regarding breast prostate andCRC of CaSurvivors compared to the NoCancer compar-ison group (Table 4)

Breast cancer Cancer survivors perceived themselves to beat greater risk than the NoCancer group for both absoluteand comparative risk (Table 4) The strength of associationbetween perceived absolute and comparative risk wasmoderate (r=046 plt0001) There were no differencesbetween the two groups in barriers for obtaining amammogram (n=184 χ2 67 8 df p=058) There was asignificant positive relationship between physician recom-mendations and obtaining a mammogram (n=446 χ2 891 df p=0005) While more CaSurvivors reported havingmammograms than the NoCancer group there was nodifference when controlling for age raceethnicity andaccess to health care (OR 183 CI 082ndash405)

Prostate cancer Cancer survivors perceived themselves tobe at greater absolute risk (χ2 199 4 df p=0001) andcomparative risk (χ2 126 2 df p=001) (Table 4) Thestrength of association between perceived absolute andcomparative risk was moderate (r=045 plt0001) Physi-cian recommendations about getting a PSA were associatedwith having the test (n=195 χ2 439 1 df plt0001)Although more CaSurvivors reported having PSAs than theNoCancer group there was no difference between the twogroups when controlling for age raceethnicity and accessto health care (OR 113 CI 039ndash33)

Colorectal cancer Cancer survivors perceived themselves tobe at greater risk than the NoCancer group for both absolute(χ2 503 4 df p=lt0001) and comparative (χ2 261 2 dfT

able

3Cancerscreeningpractices

Reportedever

having

aNoC

ancer

(n)

CaSurvivo

rs

(n)

BRFSS

a

Breast

N=119

Cervical

n=94

Prostate

n=62

Melanom

an=61

Colorectal

n=49

End

ometrial

n=39

gt1cancer

n=59

Papanicolaoutest(w

omenge18

years)

916

(1027

1121

)

987

(405

412

)95

2

99

(117

118

)ndash

ndash98

3

(2829

)95

9

(2730

)10

0(3737

)10

0(2828

)Mam

mog

raph

y(w

omenge40

years)

849

(299

352

)91

8

(205

323

)63

4

ndash86

6

(5159

)ndash

897

(2224

)94

7

(2730

)96

9

(3132

)10

0(1515

)PSA

(menge50

years)

587

(177

302

)

76

(100

132

)59

ndash

ndashndash

899

(2325

)74

(1012

)ndash

100

(88)

Colon

oscopy

orSigmoido

scop

yor

FOBT(m

enandwom

enge50

)69

(374

542

)

846

(362

428

)48

1

804

(8092

)85

7

(1924

)97

4

(4445

)93

8

(4245

)ndash

924

(2426

)89

1

(2933

)

Screening

criteria(egage)

basedon

theACSrsquosrecommendatio

nsforthegeneralpo

pulatio

nCaSurvivo

rsrespon

dentswereexclud

edifthey

repo

rted

having

theprim

arycancer

thescreening

testwas

used

for(egwom

enwith

breastcancer

wereexclud

edfrom

themam

mog

raph

ycalculations)

χ2comparing

CaSurvivo

rsandNoC

ancerlt

005

lt001

lt000

1aBehavioralRiskFactorSurveillance

Survey(BRFSS)20

02prevalence

rates

J Cancer Surviv

plt0001) risk for CRC The strength of associationbetween perceived absolute and comparative risk wasmoderate (r=041 plt0001) Since only 25 (n=27) ofCaSurvivors and 187 (n=41) of the NoCancer groupreported that a physician recommended either a sigmoidos-copy or colonoscopy (p=042) the relationship betweenphysician recommendation and screening was not con-ducted (Table 4) Barriers for not obtaining a colonoscopyor sigmoidoscopy were not significantly different betweenthe two groups (n=431 χ2 8 8 df p=045) There werehowever significant differences between groups in per-ceived benefits and self-efficacy (Table 4) Cancer survi-vors had significantly higher CRC screening ratescompared the NoCancer group when controlling for age

raceethnicity and access to health care Being a survivorpositively influenced CRC screening (OR 184 CI 106ndash319) and being younger age (lt65 years) negatively andindependently influenced this behavior (OR 041 CI 020ndash084)

Discussion

The NCIrsquos HINTS I provided a large nationally represen-tative random sample to explore select constructs from theHealth Belief Model about cancer survivors screeningbeliefs and practices Screening rates exceeded ACSrecommendations national BRFSS prevalence data and

Table 4 Cancer screening beliefs

CaSurvivors N=205 NoCancer N=399

Breast cancer screeningMD recommended mammography 838 781RiskaMean absolute risk in women who obtained a mammogram (1 low rarr 5 very high) 27 21Perceived absolute risk for developing breast cancer (somewhatvery high) 231 82Perceived relative risk compared to lsquoaveragersquo woman (more likely) 186 76

Barriers to getting screenedMD did not advise 88 21Did not know I needed test 21 11Prostate cancer screening CaSurvivors N=100 NoCancer N=177MD recommended PSA 645 668

RiskaMean absolute risk (1 low rarr 5 very high) 26 24Perceived absolute risk for developing prostate cancer (somewhatvery high) 165 95Perceived relative risk compared to average man (more likely) 166 7Colorectal cancer screening CaSurvivors N=362 NoCancer N=374

MD recommendedFOBT 357 361Sigmoidoscopy 85 83Colonoscopy 224 153

RiskaMean absolute risk (1 low rarr 5 very high) 24 20Perceived absolute risk for developing CRC (somewhatvery high) 131 51Perceived relative risk compared to average person (more likely) 17 69

Barriers to getting screenedMD did not advise 271 19Did not know needed it 132 229Afraid of finding cancer if tested (strongly agree) 159 141Too expensive (strongly disagreed) 289 207

Benefits to getting screenedArranging to get tested would be easy (strongly agree) 48 378Regular screening increases chance of cure (strongly agree) 92 848

Screening criteria (eg age and gender) based on the ACSrsquo recommendations for the general population CaSurvivors with the relevant primarycancer were not asked about that screening test (eg women with breast cancer were not asked about having mammograms) Parallel questionsabout health beliefs were not ascertained across the three cancers in2003 HINTSple005 ple001 lt00001a Two different risk questions were asked One question asked about perceived absolute risk lsquohow likely you are to get X cancerrsquo (1 = very low rarr5 = very high) The other asked about perceived comparative risk lsquocompared to the average manwoman lsquohow likely are you to get X cancerrsquo (1 =less likely rarr 3 = more likely on a 3 point likert scale)

J Cancer Surviv

Healthy People 2010 goals in both groups Cancersurvivors had higher perceived risk scores for breastcervical prostate and CRC screening Survivors alsoperceived greater benefits fewer barriers and greaterseriousness of CRC significantly more often than thegroup without cancer which may have contributed to theirhigher screening rates Furthermore being a survivorinfluenced CRC screening practices when controlling forage race and ethnicity and health care access Being asurvivor however was not found to influence screeningpractices for cervical breast prostate cancers whencontrolling for these variables Lack of difference betweengroups may be related to the high adherence rates Theseresults contrast with those found by Bellizzi et al in asecondary data analysis of four years of National HealthInterview Survey (NHIS) data [7] They found that cancersurvivors were more likely to receive mammogramsPapanicolaou tests and PSA when compared to thecomparison group (CRC screening was not evaluated) Inanother study using 2000 NHIS data Trask et al also foundsurvivors having higher screening rates for mammogramsclinical breast exam Papanicolaou test PSA skin examand CRC screening [67] In this study the percentage ofsurvivors having the screening tests were higher howeverthese differences were not apparent when statisticallycontrolling for other socioeconomic differences betweenthe two groups Each of these studies controlled fordifferences with different variables which may contributeto these disparities (eg our study included health careaccess as one of these variables while neither of the otherstudies did) While it was not possible to ascertain whethersurvivors were being followed by oncologists primary careproviders or both physician recommendations were asso-ciated with a higher level of screening in breast and prostatecancer

Perceived vulnerability about cancer may be a motivatoror deterrent in obtaining screening tests [6 37 39 40 4344 47 58 68 70] Associations between perceived riskand screening practices has varied [37 43 44 69 70]some have found that increased perceived vulnerabilityresulting in increased screening In this study there weremoderate associations between perceived absolute andcomparative risk for breast prostate and CRC but thoserisk perceptions were not significantly associated withhaving the relevant screening test While increased benefitsdecreased barriers and self-efficacy were associated withobtaining CRC screening these variables could not beexplored as thoroughly in cervical breast or prostatebecause there were fewer relevant HINTS questions

In a national telephone survey Schwartz et al found thatmost US adults (87) believed in screening and in thebenefits of finding a cancer [60] However very fewrespondents in either group identified screening as a way

to reduce cancer risk in general or for themselvesHistorically screening rates have varied by the type of testand have been attributed to individual factors such agegender socioeconomic status and to access to health care[9] In a recent analysis of the 2002 Behavioral Risk FactorSurveillance Survey (BRFSS) data men were more likelyto have a PSA than CRC screening [10] Men who had aPSA test and health care access (both provider andinsurance) were more likely to have CRC screening thanmen who didnrsquot In another cross sectional randomtelephone survey of Massachusettsrsquo residents predictorsof CRC screening included having a regular checkuphaving other screening tests having a family history ofCRC and vitamin supplement use [36]

Access to health care includes having a regular providerand having some type of health insurance lack of accessremains a major barrier to cancer screening [9 66] In thecurrent study CaSurvivors were more likely to have accessto health care than the NoCancer group Similar to otherstudies screening rates were significantly higher whenphysicianrsquos made recommendations Although physicianrecommendations did not differ between groups they diddiffer across cancers to be screened Many other screeningstudies cite having a physician as a significant contributorto screening behavior and found a positive relationshipsbetween having a provider recommend screening andhaving the test [10 16 28 36 41 45 46] Physicianrecommendations were highest for breast cancer screeningand lowest for CRC screening and mirrored screeningadherence patterns in both groups Clinical practicesregarding survivorsrsquo screening may also vary based on typeof health care provider (eg whether an oncologist orprimary care provider or both) [21 22] Colorectal andcervical cancer screening rates of breast cancer survivorsvaried by access to and type of health care provider theserates are substantially below the most recent US populationprevalence rates identified in the BRFSS [12] Educatinghealth care providers whether in primary care or inoncology about their impact when recommending screen-ing and creating organizational systems to support theseefforts (eg reminder systems) may be useful in increasingadherence especially for CRC screening These patternsmay also reflect public and professional exposure toscreening messages and celebrity endorsements whichbegan in the 1970s for mammography (eg Betty Fordand Happy Rockefellerrsquos breast cancer in the news) andcolonoscopy in 2000 (Katie Couricrsquos TV colonoscopy) [1735] Compared to other cancers there are more CRCscreening test options which may also make it moreconfusing for the public

Having insurance to pay for the screening test isanother important factor Mammography rates dramaticallyincreased once insurance coverage was initiated [9] While

J Cancer Surviv

still suboptimal colonoscopies rose in average risk indi-viduals from 46 to 142 after Medicare coverage in 2001[27 38] Although the ldquoCDC Screen for Life NationalColorectal Cancer Action Campaignrdquo is raising awarenessabout the need for screening it is not providing the samehealth access that the National Breast and Cervical CancerEarly Detection Program (NBCCEDP) does TheNBCCEDP initiated in 1991 has been successful inhelping low-income uninsured and underserved womengain access to Papanicolaou tests and mammograms byproviding both access and coverage

The limitations of this study are mainly related toconducting a secondary data analysis [34] As such theHINTS was not designed to evaluate survivorship issuesnor was the sampling designed to be representative of thepopulation of US cancer survivors The HBM was notevaluated for its predictive ability but was used to guide theidentification and inclusion of relevant variables in under-standing screening behavior [73] Self-report of cancerhistory and screening practices is subject to recall bias andno verification of the self-report was conducted Neverthe-less the robust sample of survivors and controls as well asrich item content provided a unique opportunity to explorethese issues within the theoretical framework of the HBMThe high screening rates and lack of variability amonggroups may also have influenced the cervical breast andprostate logistic regressions results Doubeni et al foundthat mammography rates declined over time in breastcancer survivors [19] HINTS survivors were not askedabout screening for their type of cancer (eg mammogramsfor women with breast cancer) so similar comparisonscould not be made

Cancer survivors had different health beliefs and riskperceptions for screening compared to the NoCancer groupWhile there were no differences between survivorsrsquoscreening for breast and prostate cancer survivors weremore likely to screen for colorectal cancer than thecomparison group Screening adherence met or exceededrecommendations for individual tests for both cancersurvivors and the comparison group More attention isbeing paid to the follow-up care of survivors [1 13 24 29]Much of that emphasis is on the prevention and manage-ment of late and long term effects of the disease andtreatment Screening for other cancers should also beincluded in cancer survivorship care plans [24 29]

Acknowledgements D Mayer was a recipient of the Ann OlsenDoctoral Scholarship from the ONS Foundation an American CancerSociety Doctoral Scholarship (DSCN-108161) and a National ServiceResearch Award from the National Institute of Nursing Research(NRSA 1F31 NR09137-01A1 Partially funded by NCI training grant(R25 CA093831 Kathi Mooney PI)The authors thank Dr Richard Moser and Dr Bradford Hesse of the

National Cancer Institute for their expert assistance with the HINTS

database Robert Rosofsky for programming assistance Kathy Pikoskyand Stefanie Jeruss for assistance with manuscript preparation

Reference List

1 A National Coalition for Cancer Survivorship and Institute ofMedicine National Cancer Policy Forum Workshop The LanceArmstrong Foundation and The National Cancer Institute MariaHewitt and Patricia A Ganz Rapporteurs (2007) Implementingcancer survivorship care planning Washington DC NationalAcademy

2 American Association for Public Opinion Research (2004)Standard definitions Final dispositions of case codes andoutcome rates for surveys

3 American Cancer Society (2006) Cancer facts amp figures 2006Atlanta ACS

4 Aziz N M (2002) Cancer survivorship research Challenge andopportunity Journal of Nutrition 132(11 Suppl) 3494Sndash3503S(November)

5 Aziz N M amp Rowland J H (2003) Trends and advances incancer survivorship research Challenge and opportunity Semi-nars in Radiation Oncology 13(3) 248ndash266 (July)

6 Bastani R Gallardo N V amp Maxwell A E (2001) Barriers tocolorectal cancer screening among ethnically diverse high- andaverage-risk individuals J Psychosocial Oncol 19(34) 65ndash84

7 Bellizzi K M Rowland J H Jeffery D D amp McNeel T(2005) Health behaviors of cancer survivors Examining opportu-nities for cancer control intervention Journal of Clinical Oncol-ogy 23(34) 8884ndash8893 (December 1)

8 Brawley O W amp Kramer B S (2005) Cancer screening intheory and in practice Journal of Clinical Oncology 23(2) 293ndash300 (January 10)

9 Breen N amp Meissner H I (2005) Toward a system of cancerscreening in the United States Trends and opportunities AnnualReview Of Public Health 26 561ndash582 (April 21)

10 Carlos R C Underwood W III Fendrick A M amp BernsteinS J (2005) Behavioral associations between prostate and coloncancer screening Journal of the American College of Surgeons200(2) 216ndash223 (February)

11 Center for Disease Control (2004) A national action plan for cancersurvivorship Advancing public health strategies Atlanta CDC

12 Center for Disease Control (2004) Behavioral risk factorsurveillance system httpwww cdc govbrfss

13 Centers for Disease Control and Prevention and the LanceArmstrong Foundation (2004) A national action plan for cancersurvivorship Atlanta GA CDC

14 Champion V L (1987) The relationship of breast self-examina-tion to health belief model variables Research in Nursing ampHealth 10(6) 375ndash382 (December)

15 Codori A M Petersen G M Miglioretti D L amp Boyd P(2001) Health beliefs and endoscopic screening for colorectalcancer Potential for cancer prevention Preventive Medicine 33(2Pt 1) 128ndash136 (August)

16 Coughlin S S Breslau E S Thompson T amp Benard V B(2005) Physician recommendation for papanicolaou testingamong US women 2000 Cancer Epidemiology Biomarkers ampPrevention 14(5) 1143ndash1148 (May)

17 Cram P Fendrick A M Inadomi J Cowen M E Carpenter Damp Vijan S (2003) The impact of a celebrity promotional campaignon the use of colon cancer screening The Katie Couric effectArchives of Internal Medicine 163(13) 1601ndash1605 (July 14)

18 Curtis R E Freedman D M Ron E Ries L A G Hacker DG Edwards BK et al (Eds) (2006) New malignancies among

J Cancer Surviv

plt0001) risk for CRC The strength of associationbetween perceived absolute and comparative risk wasmoderate (r=041 plt0001) Since only 25 (n=27) ofCaSurvivors and 187 (n=41) of the NoCancer groupreported that a physician recommended either a sigmoidos-copy or colonoscopy (p=042) the relationship betweenphysician recommendation and screening was not con-ducted (Table 4) Barriers for not obtaining a colonoscopyor sigmoidoscopy were not significantly different betweenthe two groups (n=431 χ2 8 8 df p=045) There werehowever significant differences between groups in per-ceived benefits and self-efficacy (Table 4) Cancer survi-vors had significantly higher CRC screening ratescompared the NoCancer group when controlling for age

raceethnicity and access to health care Being a survivorpositively influenced CRC screening (OR 184 CI 106ndash319) and being younger age (lt65 years) negatively andindependently influenced this behavior (OR 041 CI 020ndash084)

Discussion

The NCIrsquos HINTS I provided a large nationally represen-tative random sample to explore select constructs from theHealth Belief Model about cancer survivors screeningbeliefs and practices Screening rates exceeded ACSrecommendations national BRFSS prevalence data and

Table 4 Cancer screening beliefs

CaSurvivors N=205 NoCancer N=399

Breast cancer screeningMD recommended mammography 838 781RiskaMean absolute risk in women who obtained a mammogram (1 low rarr 5 very high) 27 21Perceived absolute risk for developing breast cancer (somewhatvery high) 231 82Perceived relative risk compared to lsquoaveragersquo woman (more likely) 186 76

Barriers to getting screenedMD did not advise 88 21Did not know I needed test 21 11Prostate cancer screening CaSurvivors N=100 NoCancer N=177MD recommended PSA 645 668

RiskaMean absolute risk (1 low rarr 5 very high) 26 24Perceived absolute risk for developing prostate cancer (somewhatvery high) 165 95Perceived relative risk compared to average man (more likely) 166 7Colorectal cancer screening CaSurvivors N=362 NoCancer N=374

MD recommendedFOBT 357 361Sigmoidoscopy 85 83Colonoscopy 224 153

RiskaMean absolute risk (1 low rarr 5 very high) 24 20Perceived absolute risk for developing CRC (somewhatvery high) 131 51Perceived relative risk compared to average person (more likely) 17 69

Barriers to getting screenedMD did not advise 271 19Did not know needed it 132 229Afraid of finding cancer if tested (strongly agree) 159 141Too expensive (strongly disagreed) 289 207

Benefits to getting screenedArranging to get tested would be easy (strongly agree) 48 378Regular screening increases chance of cure (strongly agree) 92 848

Screening criteria (eg age and gender) based on the ACSrsquo recommendations for the general population CaSurvivors with the relevant primarycancer were not asked about that screening test (eg women with breast cancer were not asked about having mammograms) Parallel questionsabout health beliefs were not ascertained across the three cancers in2003 HINTSple005 ple001 lt00001a Two different risk questions were asked One question asked about perceived absolute risk lsquohow likely you are to get X cancerrsquo (1 = very low rarr5 = very high) The other asked about perceived comparative risk lsquocompared to the average manwoman lsquohow likely are you to get X cancerrsquo (1 =less likely rarr 3 = more likely on a 3 point likert scale)

J Cancer Surviv

Healthy People 2010 goals in both groups Cancersurvivors had higher perceived risk scores for breastcervical prostate and CRC screening Survivors alsoperceived greater benefits fewer barriers and greaterseriousness of CRC significantly more often than thegroup without cancer which may have contributed to theirhigher screening rates Furthermore being a survivorinfluenced CRC screening practices when controlling forage race and ethnicity and health care access Being asurvivor however was not found to influence screeningpractices for cervical breast prostate cancers whencontrolling for these variables Lack of difference betweengroups may be related to the high adherence rates Theseresults contrast with those found by Bellizzi et al in asecondary data analysis of four years of National HealthInterview Survey (NHIS) data [7] They found that cancersurvivors were more likely to receive mammogramsPapanicolaou tests and PSA when compared to thecomparison group (CRC screening was not evaluated) Inanother study using 2000 NHIS data Trask et al also foundsurvivors having higher screening rates for mammogramsclinical breast exam Papanicolaou test PSA skin examand CRC screening [67] In this study the percentage ofsurvivors having the screening tests were higher howeverthese differences were not apparent when statisticallycontrolling for other socioeconomic differences betweenthe two groups Each of these studies controlled fordifferences with different variables which may contributeto these disparities (eg our study included health careaccess as one of these variables while neither of the otherstudies did) While it was not possible to ascertain whethersurvivors were being followed by oncologists primary careproviders or both physician recommendations were asso-ciated with a higher level of screening in breast and prostatecancer

Perceived vulnerability about cancer may be a motivatoror deterrent in obtaining screening tests [6 37 39 40 4344 47 58 68 70] Associations between perceived riskand screening practices has varied [37 43 44 69 70]some have found that increased perceived vulnerabilityresulting in increased screening In this study there weremoderate associations between perceived absolute andcomparative risk for breast prostate and CRC but thoserisk perceptions were not significantly associated withhaving the relevant screening test While increased benefitsdecreased barriers and self-efficacy were associated withobtaining CRC screening these variables could not beexplored as thoroughly in cervical breast or prostatebecause there were fewer relevant HINTS questions

In a national telephone survey Schwartz et al found thatmost US adults (87) believed in screening and in thebenefits of finding a cancer [60] However very fewrespondents in either group identified screening as a way

to reduce cancer risk in general or for themselvesHistorically screening rates have varied by the type of testand have been attributed to individual factors such agegender socioeconomic status and to access to health care[9] In a recent analysis of the 2002 Behavioral Risk FactorSurveillance Survey (BRFSS) data men were more likelyto have a PSA than CRC screening [10] Men who had aPSA test and health care access (both provider andinsurance) were more likely to have CRC screening thanmen who didnrsquot In another cross sectional randomtelephone survey of Massachusettsrsquo residents predictorsof CRC screening included having a regular checkuphaving other screening tests having a family history ofCRC and vitamin supplement use [36]

Access to health care includes having a regular providerand having some type of health insurance lack of accessremains a major barrier to cancer screening [9 66] In thecurrent study CaSurvivors were more likely to have accessto health care than the NoCancer group Similar to otherstudies screening rates were significantly higher whenphysicianrsquos made recommendations Although physicianrecommendations did not differ between groups they diddiffer across cancers to be screened Many other screeningstudies cite having a physician as a significant contributorto screening behavior and found a positive relationshipsbetween having a provider recommend screening andhaving the test [10 16 28 36 41 45 46] Physicianrecommendations were highest for breast cancer screeningand lowest for CRC screening and mirrored screeningadherence patterns in both groups Clinical practicesregarding survivorsrsquo screening may also vary based on typeof health care provider (eg whether an oncologist orprimary care provider or both) [21 22] Colorectal andcervical cancer screening rates of breast cancer survivorsvaried by access to and type of health care provider theserates are substantially below the most recent US populationprevalence rates identified in the BRFSS [12] Educatinghealth care providers whether in primary care or inoncology about their impact when recommending screen-ing and creating organizational systems to support theseefforts (eg reminder systems) may be useful in increasingadherence especially for CRC screening These patternsmay also reflect public and professional exposure toscreening messages and celebrity endorsements whichbegan in the 1970s for mammography (eg Betty Fordand Happy Rockefellerrsquos breast cancer in the news) andcolonoscopy in 2000 (Katie Couricrsquos TV colonoscopy) [1735] Compared to other cancers there are more CRCscreening test options which may also make it moreconfusing for the public

Having insurance to pay for the screening test isanother important factor Mammography rates dramaticallyincreased once insurance coverage was initiated [9] While

J Cancer Surviv

still suboptimal colonoscopies rose in average risk indi-viduals from 46 to 142 after Medicare coverage in 2001[27 38] Although the ldquoCDC Screen for Life NationalColorectal Cancer Action Campaignrdquo is raising awarenessabout the need for screening it is not providing the samehealth access that the National Breast and Cervical CancerEarly Detection Program (NBCCEDP) does TheNBCCEDP initiated in 1991 has been successful inhelping low-income uninsured and underserved womengain access to Papanicolaou tests and mammograms byproviding both access and coverage

The limitations of this study are mainly related toconducting a secondary data analysis [34] As such theHINTS was not designed to evaluate survivorship issuesnor was the sampling designed to be representative of thepopulation of US cancer survivors The HBM was notevaluated for its predictive ability but was used to guide theidentification and inclusion of relevant variables in under-standing screening behavior [73] Self-report of cancerhistory and screening practices is subject to recall bias andno verification of the self-report was conducted Neverthe-less the robust sample of survivors and controls as well asrich item content provided a unique opportunity to explorethese issues within the theoretical framework of the HBMThe high screening rates and lack of variability amonggroups may also have influenced the cervical breast andprostate logistic regressions results Doubeni et al foundthat mammography rates declined over time in breastcancer survivors [19] HINTS survivors were not askedabout screening for their type of cancer (eg mammogramsfor women with breast cancer) so similar comparisonscould not be made

Cancer survivors had different health beliefs and riskperceptions for screening compared to the NoCancer groupWhile there were no differences between survivorsrsquoscreening for breast and prostate cancer survivors weremore likely to screen for colorectal cancer than thecomparison group Screening adherence met or exceededrecommendations for individual tests for both cancersurvivors and the comparison group More attention isbeing paid to the follow-up care of survivors [1 13 24 29]Much of that emphasis is on the prevention and manage-ment of late and long term effects of the disease andtreatment Screening for other cancers should also beincluded in cancer survivorship care plans [24 29]

Acknowledgements D Mayer was a recipient of the Ann OlsenDoctoral Scholarship from the ONS Foundation an American CancerSociety Doctoral Scholarship (DSCN-108161) and a National ServiceResearch Award from the National Institute of Nursing Research(NRSA 1F31 NR09137-01A1 Partially funded by NCI training grant(R25 CA093831 Kathi Mooney PI)The authors thank Dr Richard Moser and Dr Bradford Hesse of the

National Cancer Institute for their expert assistance with the HINTS

database Robert Rosofsky for programming assistance Kathy Pikoskyand Stefanie Jeruss for assistance with manuscript preparation

Reference List

1 A National Coalition for Cancer Survivorship and Institute ofMedicine National Cancer Policy Forum Workshop The LanceArmstrong Foundation and The National Cancer Institute MariaHewitt and Patricia A Ganz Rapporteurs (2007) Implementingcancer survivorship care planning Washington DC NationalAcademy

2 American Association for Public Opinion Research (2004)Standard definitions Final dispositions of case codes andoutcome rates for surveys

3 American Cancer Society (2006) Cancer facts amp figures 2006Atlanta ACS

4 Aziz N M (2002) Cancer survivorship research Challenge andopportunity Journal of Nutrition 132(11 Suppl) 3494Sndash3503S(November)

5 Aziz N M amp Rowland J H (2003) Trends and advances incancer survivorship research Challenge and opportunity Semi-nars in Radiation Oncology 13(3) 248ndash266 (July)

6 Bastani R Gallardo N V amp Maxwell A E (2001) Barriers tocolorectal cancer screening among ethnically diverse high- andaverage-risk individuals J Psychosocial Oncol 19(34) 65ndash84

7 Bellizzi K M Rowland J H Jeffery D D amp McNeel T(2005) Health behaviors of cancer survivors Examining opportu-nities for cancer control intervention Journal of Clinical Oncol-ogy 23(34) 8884ndash8893 (December 1)

8 Brawley O W amp Kramer B S (2005) Cancer screening intheory and in practice Journal of Clinical Oncology 23(2) 293ndash300 (January 10)

9 Breen N amp Meissner H I (2005) Toward a system of cancerscreening in the United States Trends and opportunities AnnualReview Of Public Health 26 561ndash582 (April 21)

10 Carlos R C Underwood W III Fendrick A M amp BernsteinS J (2005) Behavioral associations between prostate and coloncancer screening Journal of the American College of Surgeons200(2) 216ndash223 (February)

11 Center for Disease Control (2004) A national action plan for cancersurvivorship Advancing public health strategies Atlanta CDC

12 Center for Disease Control (2004) Behavioral risk factorsurveillance system httpwww cdc govbrfss

13 Centers for Disease Control and Prevention and the LanceArmstrong Foundation (2004) A national action plan for cancersurvivorship Atlanta GA CDC

14 Champion V L (1987) The relationship of breast self-examina-tion to health belief model variables Research in Nursing ampHealth 10(6) 375ndash382 (December)

15 Codori A M Petersen G M Miglioretti D L amp Boyd P(2001) Health beliefs and endoscopic screening for colorectalcancer Potential for cancer prevention Preventive Medicine 33(2Pt 1) 128ndash136 (August)

16 Coughlin S S Breslau E S Thompson T amp Benard V B(2005) Physician recommendation for papanicolaou testingamong US women 2000 Cancer Epidemiology Biomarkers ampPrevention 14(5) 1143ndash1148 (May)

17 Cram P Fendrick A M Inadomi J Cowen M E Carpenter Damp Vijan S (2003) The impact of a celebrity promotional campaignon the use of colon cancer screening The Katie Couric effectArchives of Internal Medicine 163(13) 1601ndash1605 (July 14)

18 Curtis R E Freedman D M Ron E Ries L A G Hacker DG Edwards BK et al (Eds) (2006) New malignancies among

J Cancer Surviv

Healthy People 2010 goals in both groups Cancersurvivors had higher perceived risk scores for breastcervical prostate and CRC screening Survivors alsoperceived greater benefits fewer barriers and greaterseriousness of CRC significantly more often than thegroup without cancer which may have contributed to theirhigher screening rates Furthermore being a survivorinfluenced CRC screening practices when controlling forage race and ethnicity and health care access Being asurvivor however was not found to influence screeningpractices for cervical breast prostate cancers whencontrolling for these variables Lack of difference betweengroups may be related to the high adherence rates Theseresults contrast with those found by Bellizzi et al in asecondary data analysis of four years of National HealthInterview Survey (NHIS) data [7] They found that cancersurvivors were more likely to receive mammogramsPapanicolaou tests and PSA when compared to thecomparison group (CRC screening was not evaluated) Inanother study using 2000 NHIS data Trask et al also foundsurvivors having higher screening rates for mammogramsclinical breast exam Papanicolaou test PSA skin examand CRC screening [67] In this study the percentage ofsurvivors having the screening tests were higher howeverthese differences were not apparent when statisticallycontrolling for other socioeconomic differences betweenthe two groups Each of these studies controlled fordifferences with different variables which may contributeto these disparities (eg our study included health careaccess as one of these variables while neither of the otherstudies did) While it was not possible to ascertain whethersurvivors were being followed by oncologists primary careproviders or both physician recommendations were asso-ciated with a higher level of screening in breast and prostatecancer

Perceived vulnerability about cancer may be a motivatoror deterrent in obtaining screening tests [6 37 39 40 4344 47 58 68 70] Associations between perceived riskand screening practices has varied [37 43 44 69 70]some have found that increased perceived vulnerabilityresulting in increased screening In this study there weremoderate associations between perceived absolute andcomparative risk for breast prostate and CRC but thoserisk perceptions were not significantly associated withhaving the relevant screening test While increased benefitsdecreased barriers and self-efficacy were associated withobtaining CRC screening these variables could not beexplored as thoroughly in cervical breast or prostatebecause there were fewer relevant HINTS questions

In a national telephone survey Schwartz et al found thatmost US adults (87) believed in screening and in thebenefits of finding a cancer [60] However very fewrespondents in either group identified screening as a way

to reduce cancer risk in general or for themselvesHistorically screening rates have varied by the type of testand have been attributed to individual factors such agegender socioeconomic status and to access to health care[9] In a recent analysis of the 2002 Behavioral Risk FactorSurveillance Survey (BRFSS) data men were more likelyto have a PSA than CRC screening [10] Men who had aPSA test and health care access (both provider andinsurance) were more likely to have CRC screening thanmen who didnrsquot In another cross sectional randomtelephone survey of Massachusettsrsquo residents predictorsof CRC screening included having a regular checkuphaving other screening tests having a family history ofCRC and vitamin supplement use [36]

Access to health care includes having a regular providerand having some type of health insurance lack of accessremains a major barrier to cancer screening [9 66] In thecurrent study CaSurvivors were more likely to have accessto health care than the NoCancer group Similar to otherstudies screening rates were significantly higher whenphysicianrsquos made recommendations Although physicianrecommendations did not differ between groups they diddiffer across cancers to be screened Many other screeningstudies cite having a physician as a significant contributorto screening behavior and found a positive relationshipsbetween having a provider recommend screening andhaving the test [10 16 28 36 41 45 46] Physicianrecommendations were highest for breast cancer screeningand lowest for CRC screening and mirrored screeningadherence patterns in both groups Clinical practicesregarding survivorsrsquo screening may also vary based on typeof health care provider (eg whether an oncologist orprimary care provider or both) [21 22] Colorectal andcervical cancer screening rates of breast cancer survivorsvaried by access to and type of health care provider theserates are substantially below the most recent US populationprevalence rates identified in the BRFSS [12] Educatinghealth care providers whether in primary care or inoncology about their impact when recommending screen-ing and creating organizational systems to support theseefforts (eg reminder systems) may be useful in increasingadherence especially for CRC screening These patternsmay also reflect public and professional exposure toscreening messages and celebrity endorsements whichbegan in the 1970s for mammography (eg Betty Fordand Happy Rockefellerrsquos breast cancer in the news) andcolonoscopy in 2000 (Katie Couricrsquos TV colonoscopy) [1735] Compared to other cancers there are more CRCscreening test options which may also make it moreconfusing for the public

Having insurance to pay for the screening test isanother important factor Mammography rates dramaticallyincreased once insurance coverage was initiated [9] While

J Cancer Surviv

still suboptimal colonoscopies rose in average risk indi-viduals from 46 to 142 after Medicare coverage in 2001[27 38] Although the ldquoCDC Screen for Life NationalColorectal Cancer Action Campaignrdquo is raising awarenessabout the need for screening it is not providing the samehealth access that the National Breast and Cervical CancerEarly Detection Program (NBCCEDP) does TheNBCCEDP initiated in 1991 has been successful inhelping low-income uninsured and underserved womengain access to Papanicolaou tests and mammograms byproviding both access and coverage

The limitations of this study are mainly related toconducting a secondary data analysis [34] As such theHINTS was not designed to evaluate survivorship issuesnor was the sampling designed to be representative of thepopulation of US cancer survivors The HBM was notevaluated for its predictive ability but was used to guide theidentification and inclusion of relevant variables in under-standing screening behavior [73] Self-report of cancerhistory and screening practices is subject to recall bias andno verification of the self-report was conducted Neverthe-less the robust sample of survivors and controls as well asrich item content provided a unique opportunity to explorethese issues within the theoretical framework of the HBMThe high screening rates and lack of variability amonggroups may also have influenced the cervical breast andprostate logistic regressions results Doubeni et al foundthat mammography rates declined over time in breastcancer survivors [19] HINTS survivors were not askedabout screening for their type of cancer (eg mammogramsfor women with breast cancer) so similar comparisonscould not be made

Cancer survivors had different health beliefs and riskperceptions for screening compared to the NoCancer groupWhile there were no differences between survivorsrsquoscreening for breast and prostate cancer survivors weremore likely to screen for colorectal cancer than thecomparison group Screening adherence met or exceededrecommendations for individual tests for both cancersurvivors and the comparison group More attention isbeing paid to the follow-up care of survivors [1 13 24 29]Much of that emphasis is on the prevention and manage-ment of late and long term effects of the disease andtreatment Screening for other cancers should also beincluded in cancer survivorship care plans [24 29]

Acknowledgements D Mayer was a recipient of the Ann OlsenDoctoral Scholarship from the ONS Foundation an American CancerSociety Doctoral Scholarship (DSCN-108161) and a National ServiceResearch Award from the National Institute of Nursing Research(NRSA 1F31 NR09137-01A1 Partially funded by NCI training grant(R25 CA093831 Kathi Mooney PI)The authors thank Dr Richard Moser and Dr Bradford Hesse of the

National Cancer Institute for their expert assistance with the HINTS

database Robert Rosofsky for programming assistance Kathy Pikoskyand Stefanie Jeruss for assistance with manuscript preparation

Reference List

1 A National Coalition for Cancer Survivorship and Institute ofMedicine National Cancer Policy Forum Workshop The LanceArmstrong Foundation and The National Cancer Institute MariaHewitt and Patricia A Ganz Rapporteurs (2007) Implementingcancer survivorship care planning Washington DC NationalAcademy

2 American Association for Public Opinion Research (2004)Standard definitions Final dispositions of case codes andoutcome rates for surveys

3 American Cancer Society (2006) Cancer facts amp figures 2006Atlanta ACS

4 Aziz N M (2002) Cancer survivorship research Challenge andopportunity Journal of Nutrition 132(11 Suppl) 3494Sndash3503S(November)

5 Aziz N M amp Rowland J H (2003) Trends and advances incancer survivorship research Challenge and opportunity Semi-nars in Radiation Oncology 13(3) 248ndash266 (July)

6 Bastani R Gallardo N V amp Maxwell A E (2001) Barriers tocolorectal cancer screening among ethnically diverse high- andaverage-risk individuals J Psychosocial Oncol 19(34) 65ndash84

7 Bellizzi K M Rowland J H Jeffery D D amp McNeel T(2005) Health behaviors of cancer survivors Examining opportu-nities for cancer control intervention Journal of Clinical Oncol-ogy 23(34) 8884ndash8893 (December 1)

8 Brawley O W amp Kramer B S (2005) Cancer screening intheory and in practice Journal of Clinical Oncology 23(2) 293ndash300 (January 10)

9 Breen N amp Meissner H I (2005) Toward a system of cancerscreening in the United States Trends and opportunities AnnualReview Of Public Health 26 561ndash582 (April 21)

10 Carlos R C Underwood W III Fendrick A M amp BernsteinS J (2005) Behavioral associations between prostate and coloncancer screening Journal of the American College of Surgeons200(2) 216ndash223 (February)

11 Center for Disease Control (2004) A national action plan for cancersurvivorship Advancing public health strategies Atlanta CDC

12 Center for Disease Control (2004) Behavioral risk factorsurveillance system httpwww cdc govbrfss

13 Centers for Disease Control and Prevention and the LanceArmstrong Foundation (2004) A national action plan for cancersurvivorship Atlanta GA CDC

14 Champion V L (1987) The relationship of breast self-examina-tion to health belief model variables Research in Nursing ampHealth 10(6) 375ndash382 (December)

15 Codori A M Petersen G M Miglioretti D L amp Boyd P(2001) Health beliefs and endoscopic screening for colorectalcancer Potential for cancer prevention Preventive Medicine 33(2Pt 1) 128ndash136 (August)

16 Coughlin S S Breslau E S Thompson T amp Benard V B(2005) Physician recommendation for papanicolaou testingamong US women 2000 Cancer Epidemiology Biomarkers ampPrevention 14(5) 1143ndash1148 (May)

17 Cram P Fendrick A M Inadomi J Cowen M E Carpenter Damp Vijan S (2003) The impact of a celebrity promotional campaignon the use of colon cancer screening The Katie Couric effectArchives of Internal Medicine 163(13) 1601ndash1605 (July 14)

18 Curtis R E Freedman D M Ron E Ries L A G Hacker DG Edwards BK et al (Eds) (2006) New malignancies among

J Cancer Surviv

still suboptimal colonoscopies rose in average risk indi-viduals from 46 to 142 after Medicare coverage in 2001[27 38] Although the ldquoCDC Screen for Life NationalColorectal Cancer Action Campaignrdquo is raising awarenessabout the need for screening it is not providing the samehealth access that the National Breast and Cervical CancerEarly Detection Program (NBCCEDP) does TheNBCCEDP initiated in 1991 has been successful inhelping low-income uninsured and underserved womengain access to Papanicolaou tests and mammograms byproviding both access and coverage

The limitations of this study are mainly related toconducting a secondary data analysis [34] As such theHINTS was not designed to evaluate survivorship issuesnor was the sampling designed to be representative of thepopulation of US cancer survivors The HBM was notevaluated for its predictive ability but was used to guide theidentification and inclusion of relevant variables in under-standing screening behavior [73] Self-report of cancerhistory and screening practices is subject to recall bias andno verification of the self-report was conducted Neverthe-less the robust sample of survivors and controls as well asrich item content provided a unique opportunity to explorethese issues within the theoretical framework of the HBMThe high screening rates and lack of variability amonggroups may also have influenced the cervical breast andprostate logistic regressions results Doubeni et al foundthat mammography rates declined over time in breastcancer survivors [19] HINTS survivors were not askedabout screening for their type of cancer (eg mammogramsfor women with breast cancer) so similar comparisonscould not be made

Cancer survivors had different health beliefs and riskperceptions for screening compared to the NoCancer groupWhile there were no differences between survivorsrsquoscreening for breast and prostate cancer survivors weremore likely to screen for colorectal cancer than thecomparison group Screening adherence met or exceededrecommendations for individual tests for both cancersurvivors and the comparison group More attention isbeing paid to the follow-up care of survivors [1 13 24 29]Much of that emphasis is on the prevention and manage-ment of late and long term effects of the disease andtreatment Screening for other cancers should also beincluded in cancer survivorship care plans [24 29]

Acknowledgements D Mayer was a recipient of the Ann OlsenDoctoral Scholarship from the ONS Foundation an American CancerSociety Doctoral Scholarship (DSCN-108161) and a National ServiceResearch Award from the National Institute of Nursing Research(NRSA 1F31 NR09137-01A1 Partially funded by NCI training grant(R25 CA093831 Kathi Mooney PI)The authors thank Dr Richard Moser and Dr Bradford Hesse of the

National Cancer Institute for their expert assistance with the HINTS

database Robert Rosofsky for programming assistance Kathy Pikoskyand Stefanie Jeruss for assistance with manuscript preparation

Reference List

1 A National Coalition for Cancer Survivorship and Institute ofMedicine National Cancer Policy Forum Workshop The LanceArmstrong Foundation and The National Cancer Institute MariaHewitt and Patricia A Ganz Rapporteurs (2007) Implementingcancer survivorship care planning Washington DC NationalAcademy

2 American Association for Public Opinion Research (2004)Standard definitions Final dispositions of case codes andoutcome rates for surveys

3 American Cancer Society (2006) Cancer facts amp figures 2006Atlanta ACS

4 Aziz N M (2002) Cancer survivorship research Challenge andopportunity Journal of Nutrition 132(11 Suppl) 3494Sndash3503S(November)

5 Aziz N M amp Rowland J H (2003) Trends and advances incancer survivorship research Challenge and opportunity Semi-nars in Radiation Oncology 13(3) 248ndash266 (July)

6 Bastani R Gallardo N V amp Maxwell A E (2001) Barriers tocolorectal cancer screening among ethnically diverse high- andaverage-risk individuals J Psychosocial Oncol 19(34) 65ndash84

7 Bellizzi K M Rowland J H Jeffery D D amp McNeel T(2005) Health behaviors of cancer survivors Examining opportu-nities for cancer control intervention Journal of Clinical Oncol-ogy 23(34) 8884ndash8893 (December 1)

8 Brawley O W amp Kramer B S (2005) Cancer screening intheory and in practice Journal of Clinical Oncology 23(2) 293ndash300 (January 10)

9 Breen N amp Meissner H I (2005) Toward a system of cancerscreening in the United States Trends and opportunities AnnualReview Of Public Health 26 561ndash582 (April 21)

10 Carlos R C Underwood W III Fendrick A M amp BernsteinS J (2005) Behavioral associations between prostate and coloncancer screening Journal of the American College of Surgeons200(2) 216ndash223 (February)

11 Center for Disease Control (2004) A national action plan for cancersurvivorship Advancing public health strategies Atlanta CDC

12 Center for Disease Control (2004) Behavioral risk factorsurveillance system httpwww cdc govbrfss

13 Centers for Disease Control and Prevention and the LanceArmstrong Foundation (2004) A national action plan for cancersurvivorship Atlanta GA CDC

14 Champion V L (1987) The relationship of breast self-examina-tion to health belief model variables Research in Nursing ampHealth 10(6) 375ndash382 (December)

15 Codori A M Petersen G M Miglioretti D L amp Boyd P(2001) Health beliefs and endoscopic screening for colorectalcancer Potential for cancer prevention Preventive Medicine 33(2Pt 1) 128ndash136 (August)

16 Coughlin S S Breslau E S Thompson T amp Benard V B(2005) Physician recommendation for papanicolaou testingamong US women 2000 Cancer Epidemiology Biomarkers ampPrevention 14(5) 1143ndash1148 (May)

17 Cram P Fendrick A M Inadomi J Cowen M E Carpenter Damp Vijan S (2003) The impact of a celebrity promotional campaignon the use of colon cancer screening The Katie Couric effectArchives of Internal Medicine 163(13) 1601ndash1605 (July 14)

18 Curtis R E Freedman D M Ron E Ries L A G Hacker DG Edwards BK et al (Eds) (2006) New malignancies among

J Cancer Surviv

cancer survivors SEER Cancer Registries 1973ndash2000 NationalCancer Institute NIH Publ no 05-5302 Bethesda MD

19 Doubeni C A Field T S Ulcickas Y M Rolnick S JQuessenberry C P Fouayzi H et al (2006) Patterns andpredictors of mammography utilization among breast cancersurvivors Cancer 106(11) 2482ndash2488 (June 1)

20 Dow K H (2003) Seventh National Conference on CancerNursing Research keynote address Challenges and opportunitiesin cancer survivorship research Oncology Nursing Forum 30(3)455ndash469 (May)

21 Earle C C amp Neville B A (2004) Under use of necessary careamong cancer survivors Cancer 101(8) 1712ndash1719 (October 15)

22 Earle C C Burstein H J Winer E P amp Weeks J C (2003)Quality of non-breast cancer health maintenance among elderlybreast cancer survivors Journal of Clinical Oncology 21(8)1447ndash1451 (April 15)

23 Evans A M Love R R Meyerowitz B E Leventhal H amp NerenzD R (1985) Factors associated with active participation in a cancerprevention clinic Preventive Medicine 14(3) 358ndash371 (May)

24 Ganz P (2006) Monitoring the physical health of cancersurvivors A survivorship focused medical history Journal ofClinical Oncology 24(32) 5105ndash5111

25 Glanz K Rimer B amp Lewis F (2002) Health behavior andhealth education (3rd ed) San Francisco Jossey-Bass

26 Groves R Biemer P Lyberg L Massey J Nicholls W ampWaksberg J (1988) Telephone survey methodology New YorkWiley

27 Harewood G C amp Lieberman D A (2004) Colonoscopypractice patterns since introduction of medicare coverage foraverage-risk screening Cliacutenica Gastroenterologiacutea amp Hepatologiacutea2(1) 72ndash77 (January)

28 Hay J L Ford J S Klein D Primavera L H Buckley T RStein T R et al (2003) Adherence to colorectal cancerscreening in mammography-adherent older women Journal ofBehavioral Medicine 26(6) 553ndash576 (December)

29 Hewitt M Greenfield S amp Stovall E (Eds) (2006) Fromcancer patient to cancer survivor Lost in transition WashingtonDC National Academy

30 Jacobs L A (2002) Health beliefs of first-degree relatives ofindividuals with colorectal cancer and participation in healthmaintenance visits A population-based survey Cancer Nursing25(4) 251ndash265 (August)

31 Janz N Champion V amp Strecher V (2002) The health beliefmodel In K Glanz B Rimer amp F Lewis (Eds) Healthbehavior and health education (pp 45ndash66) San FranciscoJossey-Bates

32 Jemal A Clegg L X Ward E Ries L Wu X Jamison PM et al (2004) Annual report to the nation on the status ofcancer 1975ndash2001 with a special feature regarding survivalCancer 101(1) 3ndash27 (July 1)

33 Kerlinger F amp Lee H (2000) Foundations of behavioralresearch Phildelphia Harcourt College Publisher

34 Kiecolt K J amp Nathan L E (1985) Secondary analysis ofsurvey data (Quantitative applications in the social sciences)Beverly Hills Sage

35 Larson R J Woloshin S Schwartz L M amp Welch H G(2005) Celebrity endorsements of cancer screening Journal ofthe National Cancer Institute 97(9) 693ndash695 (May 4)

36 Lemon S Zapka J Puleo E Luckmann R amp Chasan-TaberL (2001) Colorectal cancer screening participation Comparisonswith mammography and prostate-specific antigen screeningAmerican Journal of Public Health 91(8) 1264ndash1272

37 Leventhal H Kelly K amp Leventhal E A (1999) Population riskactual risk perceived risk and cancer control A discussion Journalof the National Cancer Institute Monographs (25) 81ndash85

38 Lillie-Blanton M amp Hoffman C (2005) The role of health

insurance coverage in reducing racialethnic disparities in healthcare Health Affairs (Millwood) 24(2) 398ndash408 (March)

39 Lipkus I M Kuchibhatla M McBride C M Bosworth H BPollak K I Siegler I C et al (2000) Relationships amongbreast cancer perceived absolute risk comparative risk andworries Cancer Epidemiology Biomarkers amp Prevention 9(9)973ndash975 (September)

40 Lipkus I M Lyna P R amp Rimer B K (2000) Colorectal cancerrisk perceptions and screening intentions in a minority populationJournal of the National Medical Association 92(10) 492ndash500

41 Mahon S M Williams M T amp Spies M A (2000) Screeningfor second cancers and osteoporosis in long-term survivorsCancer Practice 8(6) 282ndash290 (November)

42 Manne S Markowitz A Winawer S Guillem J MeropolN J Haller D et al (2003) Understanding intention toundergo colonoscopy among intermediate-risk siblings of colo-rectal cancer patients A test of a mediational model PreventiveMedicine 36(1) 71ndash84 (January)

43 McCaul K D Branstetter A D Schroeder D M amp GlasgowR E (1996) What is the relationship between breast cancer riskand mammography screening A meta-analytic review HealthPsychology 15(6) 423ndash429

44 McCaul K D Reid P A Rathge R W Rathge R W ampMartinson B (1996) Does concern about breast cancer inhibit orpromote breast cancer screening Basic and Applied SocialPsychology 18(2) 183ndash194

45 Menon U Champion V L Larkin G N Zollinger T WGerde P M amp Vernon S W (2003) Beliefs associated withfecal occult blood test and colonoscopy use at a worksite coloncancer screening program Journal of Occupational and Environ-mental Medicine 45(8) 891ndash898 (August)

46 Metsch L R McCoy C B McCoy H V Pereyra M TrapidoE amp Miles C (1998) The role of the physician as an informationsource on mammography Cancer Practice 6(4) 229ndash236 (July)

47 Mullens A B McCaul K D Erickson S C amp SandgrenA K (2004) Coping after cancer Risk perceptions worry andhealth behaviors among colorectal cancer survivors Psychooncol-ogy 13(6)367ndash376 (June)

48 National Cancer Institute (2003) HINTS 1 Final Report49 National Cancer Institute (2003) The nationrsquos investment in

cancer research for fiscal year 2004 Plans and priorities forcancer research Bethesda National Cancer Institute

50 National Cancer Policy Board (2003) Fulfilling the potential ofcancer preventon and early detection WashingtonDC NationalAcademy

51 Nelson D Rimer B Kreps G Hesse B Croyle R Willis Get al (2004) The Health Information National Trends Survey(HINTS) Development design and dissemination Journal ofHealth Communication 9(5) 443ndash460

52 Park E B Emmons K M Malloy N W amp Seifer E (2002)A qualitative exploration of health perceptions and behaviorsamong adult survivors of childhood cancers Journal of CancerEducation 17(4) 211ndash215

53 Pedro L W (2001) Quality of life for long-term survivors of cancerInfluencing variables Cancer Nursing 24(1) 1ndash11 (February)

54 Presidentrsquos Cancer Panel (2004) Living beyond cancer Finding anew balance Bethesda MD National Cancer Institute May

55 Ransohoff D F McNaughton C M amp Fowler F J (2002)Why is prostate cancer screening so common when the evidenceis so uncertain A system without negative feedback AmericanJournal of Medicine 113(8) 663ndash667 (December 1)

56 Rizzo L (2003) NCI HINTS sample design and weighting planWashington DC

57 Rowland J Mariotto A Aziz N Tesauro G amp Geurer E(2004) Cancer survivorship-United States 1971ndash2001 MMWRWeekly 53(24) 516ndash529

J Cancer Surviv

58 Rutten L Arora N Bakos A Aziz N amp Rowland J (2005)Information needs and sources of information among cancer patientsA systematic review of research (1980ndash2003) Patient Educationand Counseling 57(3) 250ndash261

59 SAS Version 91 (2004) [computer program] Cary NorthCarolina SAS

60 Schwartz L M Woloshin S Fowler F J Jr amp Welch H G(2004) Enthusiasm for cancer screening in the United States JAMA291(1) 71ndash78 (January 7)

61 Sheinfeld G S amp Albert S M (2003) The meaning of risk tofirst degree relatives of women with breast cancer Women ampHealth 37(3) 97ndash117

62 Shvartzman P Rivkind E Neville A Friger M amp SperberA D (2000) Screening intention and practice among first-degreerelatives of colorectal cancer patients in southern Israel Isr MedAssoc J 2(9) 675ndash678 (September)

63 Singer E Van Hoewyk J amp Maher M P (2000) Experimentswith incentives in telephone surveys Public Opinion Quarterly 64(2) 171ndash188

64 Skinner C S Arfken C L amp Sykes R K (1998) Knowledgeperceptions and mammography stage of adoption among olderurban womenAmerican Journal of Preventive Medicine 14(1) 54ndash63 (January)

65 SUDAAN Statistical Software SAS 9-Callable (2005) [computerprogram] Research Triangle Park NC RTI

66 Swan J Breen N Coates R J Rimer B K amp Lee N C(2003) Progress in cancer screening practices in the United StatesResults from the 2000 National Health Interview Survey Cancer97(6) 1528-1540 (March 15)

67 Trask P C Rabin C RogersM LWhiteley J Nash J FriersonG et al (2005) Cancer screening practices among cancer survivorsAmerican Journal of Preventive Medicine 28(4) 351ndash356 (May)

68 Vernon S W (1999) Risk perception and risk communication forcancer screening behaviors A review Journal of the NationalCancer Institute Monographs (25) 101ndash19

69 Weinstein N D (1984) Why it wonrsquot happen to me Perceptions ofrisk factors and susceptibility Health Psychology 3(5) 431ndash457

70 Weinstein N D amp Nicolich M (1993) Correct and incorrectinterpretations of correlations between risk perceptions and riskbehaviors Health Psychology 12(3) 235ndash245 (May)

71 Weir H K Thun M J Hankey B F Ries L Howe H LWingo P A et al (2003) Annual report to the nation on thestatus of cancer 1975ndash2000 featuring the uses of surveillancedata for cancer prevention and control Journal of the NationalCancer Institute 95(17) 1276ndash1299 (September 3)

72 Yarbroff K Lawrence W Clauser S Davis W amp Brown M(2004) Burden of illness in cancer survivors Findings from apopulation-based national sample JNCI 96(17) 1322ndash1330

73 Yarbrough S S amp Braden C J (2001) Utility of health beliefmodel as a guide for explaining or predicting breast cancer screeningbehaviours Journal of Advanced Nursing 33(5) 677ndash688 (March)

74 Yian L amp Hua W (2002) Breast cancer screening knowledgeand attitudes A pilot study of women whose relatives are beingfollowed-up at the specialist outpatient clinics in a cancer centreSingapore Nurs J 29(4) 16ndash21

75 Zimmerman V L amp Smeltzer S C (2000) Hormone therapyand breast cancer Clinical Excellence for Nurse Practitioners4(1) 30ndash34 (January)

J Cancer Surviv

58 Rutten L Arora N Bakos A Aziz N amp Rowland J (2005)Information needs and sources of information among cancer patientsA systematic review of research (1980ndash2003) Patient Educationand Counseling 57(3) 250ndash261

59 SAS Version 91 (2004) [computer program] Cary NorthCarolina SAS

60 Schwartz L M Woloshin S Fowler F J Jr amp Welch H G(2004) Enthusiasm for cancer screening in the United States JAMA291(1) 71ndash78 (January 7)

61 Sheinfeld G S amp Albert S M (2003) The meaning of risk tofirst degree relatives of women with breast cancer Women ampHealth 37(3) 97ndash117

62 Shvartzman P Rivkind E Neville A Friger M amp SperberA D (2000) Screening intention and practice among first-degreerelatives of colorectal cancer patients in southern Israel Isr MedAssoc J 2(9) 675ndash678 (September)

63 Singer E Van Hoewyk J amp Maher M P (2000) Experimentswith incentives in telephone surveys Public Opinion Quarterly 64(2) 171ndash188

64 Skinner C S Arfken C L amp Sykes R K (1998) Knowledgeperceptions and mammography stage of adoption among olderurban womenAmerican Journal of Preventive Medicine 14(1) 54ndash63 (January)

65 SUDAAN Statistical Software SAS 9-Callable (2005) [computerprogram] Research Triangle Park NC RTI

66 Swan J Breen N Coates R J Rimer B K amp Lee N C(2003) Progress in cancer screening practices in the United StatesResults from the 2000 National Health Interview Survey Cancer97(6) 1528-1540 (March 15)

67 Trask P C Rabin C RogersM LWhiteley J Nash J FriersonG et al (2005) Cancer screening practices among cancer survivorsAmerican Journal of Preventive Medicine 28(4) 351ndash356 (May)

68 Vernon S W (1999) Risk perception and risk communication forcancer screening behaviors A review Journal of the NationalCancer Institute Monographs (25) 101ndash19

69 Weinstein N D (1984) Why it wonrsquot happen to me Perceptions ofrisk factors and susceptibility Health Psychology 3(5) 431ndash457

70 Weinstein N D amp Nicolich M (1993) Correct and incorrectinterpretations of correlations between risk perceptions and riskbehaviors Health Psychology 12(3) 235ndash245 (May)

71 Weir H K Thun M J Hankey B F Ries L Howe H LWingo P A et al (2003) Annual report to the nation on thestatus of cancer 1975ndash2000 featuring the uses of surveillancedata for cancer prevention and control Journal of the NationalCancer Institute 95(17) 1276ndash1299 (September 3)

72 Yarbroff K Lawrence W Clauser S Davis W amp Brown M(2004) Burden of illness in cancer survivors Findings from apopulation-based national sample JNCI 96(17) 1322ndash1330

73 Yarbrough S S amp Braden C J (2001) Utility of health beliefmodel as a guide for explaining or predicting breast cancer screeningbehaviours Journal of Advanced Nursing 33(5) 677ndash688 (March)

74 Yian L amp Hua W (2002) Breast cancer screening knowledgeand attitudes A pilot study of women whose relatives are beingfollowed-up at the specialist outpatient clinics in a cancer centreSingapore Nurs J 29(4) 16ndash21

75 Zimmerman V L amp Smeltzer S C (2000) Hormone therapyand breast cancer Clinical Excellence for Nurse Practitioners4(1) 30ndash34 (January)

J Cancer Surviv