Compliance with Recommended Cancer Screening among Emergency Department Patients: A Multicenter Survey Adit A. Ginde, MD, MPH, Jennifer C. Millen, MD, MPH, Jennifer S. Love, Jessica M. Pang, BA, Carlos A. Camargo Jr., MD, DrPH
Abstract Objectives: The objectives were to measure compliance with, and possible sociodemographic disparities for, cancer screening among emergency department (ED) patients. Methods: This was a cross-sectional survey in three academic EDs in Boston. The authors enrolled consecutive adult patients during two 24-hour periods at each site. Self-reported compliance with standard recommendations for cervical, breast, testicular, and prostate cancer screening were measured. The chisquare test was used test to evaluate associations between demographic variables and cancer screening compliance. Results: The authors enrolled 387 patients (81% of those eligible). The participants had a mean (±standard deviation) age of 44 (±18) years and were 52% female, 16% Hispanic, and 65% white. Sixty-seven percent (95% confidence interval [CI] = 60% to 73%) of all women reported Pap smear examinations in the past 3 years, 92% (95% CI = 85% to 96%) of women aged ‡40 years reported clinical breast examinations, and 88% (95% CI = 81% to 94%) of women aged ‡40 years reported mammography. Fifty-one percent (95% CI = 40% to 61%) of men aged 18–39 years reported testicular self-examinations, and among men aged ‡40 years, 79% (95% CI = 69% to 87%) reported digital rectal examinations (DREs) and 51% (95% CI = 40% to 61%) reported prostate-specific antigen (PSA) testing. Racial and ethnic minorities reported slightly lower rates of clinical breast examinations and testicular self-examinations. Conclusions: Most women and a majority of men in our ED-based study were compliant with recommended measures of cervical, breast, testicular, and prostate cancer screening. No large sociodemographic disparities in our patient population were identified. Based on these data, and the many other pressing public health needs of our ED population, the authors would be reluctant to promote ED-based cancer screening initiatives at this time. ACADEMIC EMERGENCY MEDICINE 2008; 15:483–486 ª 2008 by the Society for Academic Emergency Medicine Keywords: cancer, screening, emergency medicine, public health, preventive medicine
ancer is the second leading cause of death in the United States, accounting for 560,000 deaths and costing $219 billion each year.1 Evidencebased cancer screening, particularly in the medically underserved, has the potential to substantially reduce the burden of disease and subsequent morbidity.2 For this reason, Healthy People 2010 has targeted improved rates of cancer screening, particularly for breast, cervi-
From the Department of Emergency Medicine, University of Colorado School of Medicine (AAG), Aurora, CO; and the Department of Emergency Medicine, Massachusetts General Hospital (JCM, JSL, JMP, CAC), Boston, MA. Received January 3, 2008; revisions received January 28 and January 29, 2008; accepted January 29, 2008. Address for correspondence: Carlos A. Camargo, Jr., MD, DrPH; e-mail: [email protected]
ª 2008 by the Society for Academic Emergency Medicine doi: 10.1111/j.1553-2712.2008.00103.x
cal, and prostate cancer, as a national public health goal.3 Additionally, significant racial and ethnic and socioeconomic disparities exist in cancer prevention, leading to higher morbidity in these underserved populations.4 The emergency department (ED) role as the ‘‘safety net’’ for medically disenfranchised people makes it an attractive location to capture patients for screening and other preventive services.5 Many patients may not receive these services at all, if not in the ED. Additionally, more than 50% of ED visits are for nonemergent issues, and many ED patients often spend hours waiting,6 which provides a potential opportunity for the education and delivery of preventive services in the ED. Preliminary data from single institutions suggest that ED-based cervical and breast cancer education, referral, and screening programs may be feasible.7–9 In this multicenter survey, we measured compliance with recommended screening for cervical, breast,
ISSN 1069-6563 PII ISSN 1069-6563583
testicular, and prostate cancer among ED patients. We hypothesized that a substantial proportion of our ED patient population would report noncompliance with cancer screening, particularly among racial ⁄ ethnic minorities and uninsured patients.
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associations of sociodemographic variables with compliance with cancer screening modalities using the chisquare test. All p-values are two-tailed with p < 0.05 considered statistically significant. RESULTS
METHODS Study Design and Population This study was a multicenter, cross-sectional survey of adult ED patients. The institutional review boards at all sites approved the protocol and waiver of written informed consent. During July ⁄ August 2007, we collected data at three urban, academic EDs in Boston with a combined annual visit volume of 160,000. All sites are participants in the Emergency Medicine Network (http://www.emnet-usa. org/), which coordinated the study. Survey Content and Administration In a standardized manner, trained research assistants administered surveys (available as an online Data Supplement at http://www.blackwell-synergy.com/doi/ suppl/10.1111/j.1553-2712.2008.000103.x) to consecutive patients for two 24-hour periods (one weekday and one weekend) at each site. Research assistants were familiar with the survey, but blinded to the primary objective and hypothesis. We monitored patient enrollment using standardized tracking forms and recorded the reasons for exclusion ⁄ nonenrollment. After data collection, we assessed the number of missed patients by comparing our records to the final log of registered ED patients. All ED patients 18 years and older were eligible for enrollment. We excluded patients with high acuity ⁄ distress, insurmountable language barrier, altered mentation, or possible sexual assault. Spanish-speaking research assistants were available at all sites. We collected demographic information, income, insurance, and presence of current primary care provider. For women, we measured self-reported compliance and timing of Pap smear examination, breast examination performed by self and health care provider, and mammography. For clinical breast exam and mammography, we asked only those age ‡40, based on current recommendations.10 For men, we measured self-reported compliance with testicular self-examination (ages 18–39 years), digital rectal examination (DRE; age ‡40 years), and prostate-specific antigen (PSA) testing (age ‡40 years). Data Analysis Our primary hypothesis was based on a descriptive outcome (i.e., prevalence of noncompliance with recommended cancer screening). Thus, we based our estimated sample size requirements on the stability of 95% confidence intervals (CIs) around the prevalence of noncompliance with screening at increasing sample sizes. We calculated that an overall sample size of approximately 400 would yield CIs of £10%, which we deemed adequate precision for this study. We performed statistical analyses using Stata 9.0 (Stata Corp., College Station, TX) and summarized data using descriptive statistics. We measured univariate
Of the 876 ED patients who presented during the data collection periods, 475 met selection criteria for enrollment. The most common reasons for ineligibility were altered mentation and clinician discretion because of patient distress from pain or illness. We surveyed 387 (81%) of the eligible patients (42 refused, 46 missed). Feeling ill and lack of interest were the most common reasons for refusal to complete the survey. Rapid disposition from ED and inability to locate the patient accounted for the missed patients. Nonenrolled eligible patients were older than enrolled patients (mean age 51 years vs. 44 years, respectively), but did not significantly differ by gender, Hispanic ethnicity, or race (data not shown). Table 1 shows characteristics of the study participants and their rates of compliance with common modalities of cervical, breast, testicular, and prostate cancer screening. African American women aged ‡40 years were less likely to have clinical breast exams than white ⁄ other (83% [95% CI = 63% to 95%] vs. 98% [95% CI = 95% to 100%], p = 0.02), but were equally likely to have breast self-exams (80% vs. 83%, p = 0.82), mammography (84% vs. 92%, p = 0.31), and Pap smear examinations (79% vs. 84%, p = 0.68). Additionally, there were no univariate associations between age, ethnicity, income, and limited access to care (i.e., no insurance and ⁄ or no primary care provider) on women’s cancer screening. Non-white men aged 18–39 years were less likely to perform testicular self-examinations than white men, although the difference was not statistically significant (34% [95% CI = 16% to 56%] vs. 55% [95% CI = 42% to 66%], p = 0.07). Additionally, Hispanic men reported testicular self-examination less frequently than non-Hispanic men (11% vs. 56%, p = 0.01). Among men aged ‡40 years, those aged 40–59 years were less likely to report DRE and PSA testing than those aged ‡60 years (74% and 40% vs. 90% and 67%, p = 0.05 and 0.01, respectively). There were no other significant differences in testicular or prostate cancer screening among demographic subgroups, including those with limited access to care. DISCUSSION In our survey of three academic EDs in Boston, we found high self-reported rates of compliance with cancer screening that were comparable to (or possibly higher than) those reported for the general population.1 A large majority of age-appropriate women reported Pap smear examinations within the past 3 years, self- and clinical breast examinations, and mammography. These rates were significantly higher than those previously reported in single-center studies, in which less than half of participants reported compliance with recommended cervical and breast cancer screening.7–9 Additionally, more than half of age-appropriate men reported
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Table 1 Demographic Characteristics of Participants and Compliance with Recommended Cancer Screening
Variable Total Demographics Age (yr) 18–39 40–59 ‡60 Female gender Hispanic ethnicity Race White African American Other ⁄ multiracial Household income £$40,000 >$40,000 Refused Insurance Any private Medicare only Medicaid and ⁄ or Medicare No insurance Has primary care provider Cigarette smoking Current Former Never Women (n = 202) Last pap smear 3 yr ⁄ never Don’t know Ever done breast self-exam All Age ‡40 yr (n = 113) Ever had clinical breast exam (age ‡40 yr only; n = 113) Ever had mammogram (age ‡40 yr only; n = 113) Men (n = 185) Ever done testicular self-exam (age 18–39 yr only; n = 91) Ever had DRE for prostate cancer (age ‡40 yr only; n = 94) Ever had PSA test (age ‡40 yr only; n = 94)
% (95% CI)
182 132 75 202 59
47 34 19 52 16
250 71 62
65 (60, 70) 19 (15, 22) 16 (13, 19)
117 141 129
30 (26, 35) 36 (32, 41) 33 (29, 38)
201 27 117
55 (50, 60) 7 (5, 10) 32 (27, 37)
6 (4, 9) 83 (79, 86)
78 106 166
30 (25, 35) 22 (18, 27) 47 (42, 53)
113 22 28 39
56 11 14 19
162 100 104
80 (74, 85) 88 (81, 94) 92 (85, 96)
88 (81, 94)
51 (40, 61)
(42, (29, (15, (47, (12,
52) 39) 23) 57) 19)
been reported for the general population,4 our findings agree with other ED-based studies, which did not find significant sociodemographic disparities in the compliance rates with recommended cervical and breast cancer screening. Integration of educational or interventional cancer screening programs in the complex ED environment is challenging. In theory, interventions such as Pap smear during pelvic examinations and DRE during rectal examinations performed as part of clinical care would not add significant time to the patient encounter; however, problems with efficiency, follow-up for diagnostic testing and treatment, and cost-effectiveness may limit effectiveness of these programs. Our data suggest that cancer screening should not be a public health priority in these Boston EDs. The U.S. Preventive Services Task Force strongly recommends cervical and breast cancer screening,10 but we found a very high rate of compliance with these measures. While our data suggest lower rates of testicular and prostate cancer screening, these are more controversial and should only be administered in selected patients, at clinician discretion. Thus, screening may not even be indicated in many of the men who did not report screening. LIMITATIONS
(49, 63) (7, 16) (9, 19) (14, 25)
The sites were geographically limited, and our sample had higher socioeconomic status and lower racial ⁄ ethnic diversity compared to many urban EDs, which limits the generalizability of the findings. However, we did not find large disparities in reported compliance with cancer screening, which limits the potential for major changes to the overall findings. The presence of nonrespondents in this cross-sectional study may bias estimates of limited health literacy and associations observed. However, consecutive sampling during data collection days and the overall high response rate limits the possibility for such bias. Finally, this study relied on self-report, which may lead to overestimation of reported compliance rates. CONCLUSIONS
79 (69, 87)
51 (40, 61)
CI = confidence interval; DRE = digital rectal examination; PSA = prostate-specific antigen.
testicular self-exam and prostate cancer screening. Although we are not aware of prior ED-based studies of compliance with testicular and prostate cancer screening, our reported rates are higher than anticipated. We identified a few small racial ⁄ ethnic disparities in clinical breast examinations and testicular self-examinations, but overall, there were no major disparities for cancer screening in our patient population. Although significant disparities in cancer screening rates have
Most women and a majority of men in our ED-based study were in compliance with recommended measures of cervical, breast, testicular, and prostate cancer screening. We did not identify any large sociodemographic disparities in our patient population. Based on these data, and the many other pressing public health needs of our ED population, we would be reluctant to promote EDbased cancer screening initiatives at this time. The authors thank Angela Anderson, Kate Delaney, Daniel Pallin, and Scott Weiner for their help in the conduct of this multicenter study.
References 1. American Cancer Society. Cancer Facts and Figures 2007. Atlanta, GA: American Cancer Society, 2007. Available at: http://www.cancer.org. Accessed Dec 26, 2007.
2. Haynes MA, Smedley BD. The Unequal Burden of Cancer: An Assessment of NIH Research and Programs for Ethnic Minorities and the Medically Underserved. Washington, DC: The National Academies Press, 1999. 3. U.S. Department of Health and Human Services. Healthy People 2010, 2nd ed. Washington, DC: U.S. Government Printing Office, 2000. Available at: http://www.healthypeople.gov/document. Accessed Dec 26, 2007. 4. Phillips JM, Williams-Brown S. Cancer prevention among racial ethnic minorities. Semin Oncol Nurs. 2005; 21:278–85. 5. Rhodes KV, Gordon JA, Lowe RA. Preventive care in the emergency department, part I: clinical preventive services–are they relevant to emergency medicine? Acad Emerg Med. 2000; 7:1036– 41. 6. Nawar EW, Niska RW, Xu J. National Hospital Ambulatory Medical Care Survey: 2005 emergency department summary. Adv Data. 2007; 386:1–32. 7. Takakuwa KM, Ernst AA, Weiss SJ, Nick TG. Breast cancer knowledge and preventive behaviors: An urban emergency department-based survey. Acad Emerg Med. 2000; 7:1393–8.
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8. Mandelblatt J, Freeman H, Winczewski D, et al. Implementation of a breast and cervical cancer screening program in a public hospital emergency department. Ann Emerg Med. 1996; 28:493–8. 9. Hogness CG, Engelstad LP, Linck LM, Schorr KA. Cervical cancer screening in an urban emergency department. Ann Emerg Med. 1992; 32:933–9. 10. U.S. Preventive Services Task Force. Guide to Clinical Preventive Services. Section: Cancer. Available at: http://www.ahrq.gov/clinic/cps3dix.htm. Accessed Dec 26, 2007. Supplementary Material The following supplementary material is available for this article: Data Supplement S1. Survey. This material is available as part of the online article from: http://www.blackwell-synergy.com/doi/abs/10.1111/ j.1553-2712.2008.00103.x (This link will take you to the article abstract). Please note: Blackwell Publishing are not responsible for the content or functionality of any supplementary materials supplied by the authors. Any queries (other than missing material) should be directed to the corresponding author for the article.