# Presentation: 175696

## Covariates of perceived colon cancer risk

- Jennifer Hay, Ph.D., Elliot Coups, Ph.D., &
- Jennifer Ford, Ph.D.
- Department of Psychiatry & Behavioral Sciences
- Memorial Sloan-Kettering Cancer Center
- HINTS Data Users Conference, 2005

## Colorectal cancer screening is efficacious but underutilized

- Colorectal cancer is the third most common cancer among both men and women in the United States, and it accounts for 10% of all cancer deaths (ACS, 2005).
- Screening strategies for colorectal cancer may prevent up to 90% of colorectal cancer mortality, and reduce colorectal cancer incidence (Rex et al., 2000; Smith et al., 2001).
- Approximately half (40% to 50%) of the general population is adherent with recommended screening guidelines for colorectal cancer (CDCP, 2003; Seef et al., 2004; Swan et al., 2003).

**Colorectal cancer screening is efficacious but underutilized**

**Notes:**
Colorectal cancer is the second leading cause of death attributable to cancer in the US – behind lung/breast for women, lung/prostate for men.

Efficacious screening strategies exist and have the potential to greatly reduce or wipe out mortality from colorectal cancer, additionally identified precancerous adenomatous polyps can be removed, in essence preventing their development into malignant polyps.   

Unfortunately, slightly less than half of the US general population is adherent with recommended screening strategies, which include... .

## Colorectal cancer screening guidelines for the general population*

- For individuals age 50 and older, one of the following:
- Annual home fecal occult blood testing (FOBT) or fecal immunochemical test (FIT) every year
- Flexible sigmoidoscopy every five years
- Double-contrast barium enema every five years
- Colonoscopy every ten years

**Colorectal cancer screening guidelines for the general population*******

- ______________________
- *United States Preventive Services Task Force (USPSTF). *Screening for colorectal cancer: Recommendation and Rationale*. Ann Intern Med, 2002.

**Notes:**
Annual FOBT, flexible sigmoidoscopy/double contrast barium enema every five years, colonoscopy every 10 years, 

Combined testing is preferred over FOBT or Flexible sigmoidoscopy alone.

## Evidence-based behavioral risk factors for colorectal cancer*

- High fat, low fiber diet
- Heavy alcohol use
- Excessive body weight/low physical activity
- Cigarette smoking

**Evidence-based behavioral risk factors for colorectal cancer***

- ______________________
- *Bingham, *Proc Nutr Soc*, 1999; Giovannucci, *CEBP*, 2001; Martinez et al., *JNCI,* 1995; Sesink et al., *Carcinogenesis,* 2001 .

**Notes:**
Additionally, many of the risk factors for colorectal cancer are behaviorally controlled and include:

diet
avoiding red meat 
Alcohol
increasing fiber, fruits and vegetables

Maintaining normal body weight

Avoiding smoking 

Additionally, the use of hormone replacement therapy and antiinflammatory drugs such as aspirin may be protective against the development of 

## Perceptions of risk for colorectal cancer

- A theoretically and empirically important construct in motivating the adoption of health actions, including colorectal cancer screening.
- Increased perception of colorectal cancer risk is *prospectively* related to increased colorectal cancer screening intentions (McCrae et al., 1984; Watts et al., 2003).
- Low rates of physician screening recommendation, and patient beliefs that the test is not needed if they are asymptomatic, highlight the need to address risk perceptions for colorectal cancer (Janz et al., 2003; Seeff et al., 2004).

**Notes:**
Risk perceptions are an important factor theoretically and empirically, as they may help to determine galvanize motivation for screening and risk reduction for colorectal cancer. 

Prospective studies bear out the fact that risk perceptions for colorectal cancer lead to subsequent  increased intentions to adhere to screening recommendations.

Rates of physician recommendations for colorectal cancer screening differ by method (55-65% for FOBT) to (20-35%) for colonoscopy screening, and also differ by racial/ethnic subgroup, but are not universal for any method,

Given this, as well as the fact that an important misconception being that lack of symptoms being a barrier to screening, risk perceptions are a potentially important route to patient-initiation of screening tests, as well as risk reduction strategies, for colorectal cancer.

## Perceived risk for colorectal cancer: Cross-sectional correlates

**Perceived risk for colorectal cancer: Cross-sectional correlates**

- Demographics
- 	Female vs. male						+
- 	White vs. nonwhite						+
- 	Age				_		_
- 	Marital status						ns
- 	SES						+
- Medical
- 	Family history crc						+		+
- 	Poorer  subjective health		+		+
- 	Physical symptoms				+		+
- Lifestyle behaviors
- 	Tobacco use status						+		+
- 	Physical activity						_
- Affect
- 	General anxiety						+
- 	Colorectal cancer worry						+
- Family support for screening					+
- Support for behavior chnge		ns

- 			Clipp, et al. 		Robb et al.	Vernon et al.
- _	__	__Cancer, 2004__	_	_CEBP, 2004_	_CEBP, 2001_
*N*=1247, ages 40-75, 		*N*=18,447 		*N*=5042
- 			h/o polyps			ages 55-64 	White Males

**Notes:**
Here, I have summarized the existing literature on cross-sectional covariates of risk perceptions for colorectal cancer.

Clipp study: individuals subsequent to removal of colorectal polyps

Robb study: Individuals registered with general practitioners in the UK.

Vernon study: white male automotive employees, with and without a personal history of colorectal polyps, average age mid 50s. For Vernon, only the men without polyps, perceived risk is related to being a current smoker.  All other results are similar for men with and without polyps.   

The current study will advance our understanding by allowing us to examine risk perceptions across US racial/ethnic subgroups, a diverse range of lifestyle risk behaviors, and further specify subgroups that may be the priority for tailored colorectal cancer risk communication strategies.

Risk measurement:
Clipp: Unlikely, 50:50 chance/unknown; Likely
Robb: Lower/about the same/higher than others your age and sex 
Vernon: Dichotomized scale: at risk; not at risk.

## Study aims

- To examine risk perceptions for colon cancer in a national representative sample of US adults.
- To examine the relationship of demographic, medical, risk behavior, and affective covariates of colon cancer risk perceptions.
- To examine the relative contribution of significant covariates of colon cancer risk perceptions.

**Study aims**

**Notes:**
Therefore, the study aims are to examine the levels of perceived risk for colon cancer, and covariates of risk perceptions, in the US general population.

We considered potential demographic, medical, risk behavior, and emotional covariates of colorectal cancer risk perceptions. 

## Sample

- Full HINTS sample, *N* = 6369
- Participation included if:
- Aged 45 and older
- Not missing data on risk perception
- Final study *N* = 3041

**Sample**

## Design and analytic approach

- Cross-sectional complex sample survey design
- Data weighted
- Jackknife technique for variance estimation
- Analysis conducted using SUDAAN
- Univariate ordinal regressions
- Multivariate ordinal regression

**Design and analytic approach**

**Notes:**
The data for this study are from the Health Information National Trends Survey (HINTS).  The HINTS is a national probability survey of the US adult, non-institutionalized civilian population and was conducted by the National Cancer Institute in 2003-2003.  Participants in the HINTS were selected using random-digit dialing methods and completed a one-time interview.  The overall response rate was 33.05%.  The HINTS used a cross-sectional complex sample survey design,  with oversampling of Black and Hispanic populations.  The data were weighted (including non-response and post-stratification adjustments) and a jackknife technique was used for  variance estimation.  To take into account the complex sample survey design of the HINTS, we used SUDAAN to conduct all analyses. 

## Frequencies for Selected Descriptive Variables (N = 3041)

- Gender				Income
- 	Male 		46.6		< $25,000		30.0
- 	Female		53.4		$25,000 - $34,999		13.9
- 	Missing (*N*)			0		$35,000 - $49,999		16.2						$50,000 - $74,999		17.4
- Age					_>_ $75,000		22.4
- 	45-54		40.7		Missing (*N*)		357
- 	55-64 		26.8
- 	65-74		20.0	Race/ethnicity
- 	_>_75		12.4		Non-Hispanic white	79.1
- 	 Missing (*N*)			0 		Non-Hispanic black		8.8
- 						Non-Hispanic other			4.5
- Education					Hispanic			7.6
- 	_<_ High school 12th grade		17.7 		Missing (*N*)		122
- 	High school graduate		33.6
- 	Some college		23.8
- 	College graduate		24.9
- 	Missing (*N*)* **	**	*80

**Frequencies for Selected Descriptive Variables (N = 3041)**

**Notes:**
The final sample was almost evenly distributed on gender, education, and income, at the younger end of the age distribution, and 79% Caucasian.

## How likely do you think it is that you will develop colon cancer in the future? 

**How likely do you think it is that you will ****develop colon cancer in the future?**

**Notes:**
Using verbal response categories, 58% of the sample assessed their risk of colon cancer as very/somewhat low.

202 people either reported that they did not know, or did not provide an answer. 

## Compared to the average man/woman your age, would you say that you are... to get colon cancer?

**Notes:**
Consistent with Weinstein’s work on susceptibility to health problems, nearly half of the sample assessed their colon cancer risk as less than others their age and sex. 

Given that relative risk judgements for colon cancer have been found to be related to objective risk factors for colon cancer, more responsive to risk communication feedback, and to be less difficult to provide than numerical risk estimates for colon cancer, we used this relative risk judgement as the primary dependent variable of the study. AND excluded those who responded don’t know.

## Univariate covariates of perceived risk for colon cancer

- Gender						 Education
- 	Male	1.00 				_<_ High school 12th grade	1.00
- 	Female	0.94 (0.81-1.09)		High school graduate			0.88 (0.66-1.17)
- 									Some college			0.67 (0.48-0.93)
- Race/ethnicity							College graduate			0.77 (0.58-1.02)
- 	Non-Hispanic white	1.00
- 	Non-Hispanic black	0.99 (0.70-1.40) 	 Family cancer history
- 	Non-Hispanic other	0.78 (0.50-1.21) 	 	 Negative			1.00
- 	Hispanic	1.58 (1.21-2.07) 		 Positive			1.54 (1.30-1.83)
- Age							 Personal cancer history
- 	45-54 	1.00 				 Negative			1.00
- 	55-64	1.06 (0.88-1.28)		 Positive			1.29 (1.03-1.61)
- 	65-74 	0.74 (0.61-0.90)
- 	≥ 75	0.79 (0.60-1.05)
- Married/Partnered
- 	No	1.00
- 	Yes	1.16 (0.98-1.38)
- Income
- < $25,000	1.00
-  $25,000 - < $35,000	0.82 (0.60-1.13)
-  $35,000 - < $50,000	0.83 (0.58-1.19)
-  $50,000 - < $75,000	0.91 (0.67-1.23)
- ≥ $75,000 	0.84 (0.67-1.04)

**Univariate covariates of perceived risk for colon cancer**

- OR (95% CI)				OR (95% CI)

## Univariate covariates of perceived risk for colon cancer (cont.)

**Univariate covariates of perceived risk for colon cancer (cont.)**

- OR (95% CI)			OR (95% CI)

- Overall health status 						 	General anxiety
- 	Poor	  1.00					None of the time 	 	1.00
- 	Fair 	  0.64 (0.38-1.08) 			A little of the time		1.39 (1.17- 1.66)
- 	Good	  0.38 (0.23-0.65) 			Sometimes		2.08 (1.67- 2.59)
- 	Very good	  0.31 (0.19-0.52)			Most of the time		3.67 (2.52- 5.33)
- 	Excellent	  0.18 (0.11-0.30)			All the time		3.13 (1.75-5.58)
- Cigarette smoking 				 	 		Colon cancer worry
- 	Never 		1.00 					Rarely/never		1.00
-  	Former		1.03 (0.87-1.24) 	 	 	Sometimes		3.10 (2.52-3.81)
- 	Current 		1.20 (0.96-1.49) 			Often		4.79 (2.50-9.19)
- 		 	 							All the time	24.16 (7.22-80.77)
- Physical activity
- 	≥ once / week		1.00
- 	< once / week		1.34 (1.10-1.62)
- Body mass index
- 	Normal		1.00
- 	Overweight		1.04 (0.84-1.29)
-  	Obese		1.33 (1.02- 1.73)
- Fruits and vegetables
- consumption
- 	 ≥ five per day		1.00
- 	 < five per day		1.27 (0.99-1.64)

## Significant multivariate covariates of perceived risk for colon cancer

**Significant multivariate covariates of perceived risk for colon cancer**

- OR (95% CI)				OR (95% CI)

- Age
- 	45-54 		1.00
- 	55-64		1.03 (0.83-1.29)
- 	65-74 		0.69 (0.55-0.88)
- 	≥ 75		0.72 (0.52-1.01)

-  Family cancer history
- 	Negative	1.00
- 	Positive	1.41 (1.17-1.69)

- General anxiety
- 		None of the time 	 	1.00
- 		A little of the time		1.19 (0.97- 1.44)
- 		Sometimes		1.42 (1.12- 1.81)
- 		Most of the time		2.17 (1.40- 3.36)
- 		All the time		1.44 (0.68- 3.05)

- Colon cancer  worry
- 		 Rarely/never		1.00
- 	 	 Sometimes		2.67 (2.10-  3.40)
- 		 Often		4.30 (2.25-  8.22)
- 		 All the time	19.71 (5.26-73.84)

- Overall health status
- 	Poor	1.00
- 	Fair	0.77 (0.43-1.41)
- 	Good	0.52 (0.28-0.94)
- 	Very good	0.45 (0.24-0.83)
- 	Excellent	0.28 (0.16-0.50)

*Note: *Other covariates in the analysis included: race/ethnicity, physical activity, personal cancer history.

## Differences in perceived risk by age

**Percentage responding**

## 	Physical activity						_ 		ns

**Summary of current findings**

- Demographics
- 	Female vs. male						+		ns
- 	White vs. nonwhite						+		ns
- 	Age			_			_		_
- 	Marital status						ns		ns
- 	SES						+		ns
- Medical
- 	Family history crc						+	+	+
- 	Poorer  subjective health		+			+		+
- 	Physical symptoms			+			+
- Lifestyle behaviors
- 	Tobacco use status						+	+	ns
- 	Physical activity						_ 		ns
- Affect
- 	General anxiety						+		+
- 	Colorectal cancer worry						+	+
- Family support for screening					+
- Support for behavior chnge		ns

- 			Clipp, et al. 		Robb et al.	Vernon et al.
- 	_	__	__Cancer, 2004__	_	_CEBP, 2004_	_CEBP, 2001 _	_HINTS  _
*	**N*=1247, ages 40-75, 		*N*=18,447 		*N*=5042 	*N*=3041
- 			h/o polyps			ages 55-64 	White Males	ages ≥ 45

## Conclusions

- Age is the primary risk factor for colorectal cancer.  This represents a subgroup in need of specific risk communication and education concerning their *ongoing* risk.
- Those with good subjective health, and behavioral risk factors for colorectal cancer, are additional subgroups that should be prioritized in communication strategies for the general population.
- Affective variables require further investigation, and may indicate salience of cancer risk vulnerability in the individual.
- Study limitation: Assessing relative risk perceptions (same age/sex) across different age groups.
- Additional planned analyses.

**Conclusions**

**Notes:**
More than 90% of all colorectal cancer occurs in those age 50 and over.  

## Acknowledgments 

- This research was conducted with the support of NCI KO7 CA98106 (Jennifer Hay, PI), and Memorial Sloan-Kettering Prevention, Control, & Population Research Pilot funding (Jamie Ostroff, PI).