Colon cancer fact

Abstract: African American women are more likely to die of colorectal cancer than are women of any other racial or ethic group. Early diagnosis depends on routine examination and screening. However, studies have shown that African American women are not utilizing available screening tools. African American women age fifty or older were questioned about their risk factors and frequency of CRC screening. The conceptual framework used was the Health Belief Model. Women who perceived fewer barriers, more benefits, higher perceived susceptibility, and increased confidence in the accuracy of screening, were likely to undergo screening. Implications for nursing practice are discussed especially focused on the role of advanced practice nurses as primary care providers. Utilization of a faith-based approach to reaching this population was also suggested.

Key Words: Colon Cancer Screening: Black Females

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Colorectal carcinoma (CRC) is the second most common cause of cancer mortality in the United States. Despite the fact that it is highly preventable, approximately 147,500 new cases of CRC were predicted to be diagnosed in 2003 with 57,100 people dying from the disease (Cancer Research and Prevention Foundation, 2004). Although this cancer can be cured if detected early, over half of all cases are diagnosed with distal disease, decreasing the 5-year survival. African Americans had higher incidence and mortality rates from 1998 through 2000, while these rates decreased for Caucasians (American Cancer Society [ACS], 2003). American women are more likely to die of colon cancer than are women of any other racial or ethic group (ACS, 2003). These women often tall in the high risk category because of multiple risk factors including obesity, low fiber, high protein diets and low physical activity levels (Cancer Prevention and Research Foundation, 2004).

Colorectal cancer screening (CRC) offers potential for both primary and secondary prevention. A combination of three screening methods is used to accomplish early detection of colorectal cancer. These include rectal examination, fecal occult blood testing (FOBT) and a test used to evaluate the colon and rectum, the flexible sigmoidoscopy, colonoscopy, or barium enema. Scientific evidence supports the effectiveness of CRC in reducing mortality (Helm, Russo, Biddle, Simpsin, Ranoboff, & Sandler, 2000).

The ACS offers three options for regular colorectal surveillance screening beginning at age 50:

1. Baseline FOBT and flexible sigmoidoscopy initially, then FOBT repeated annually and sigmoidoscopy repeated every five years after initial screening.

2. Baseline total colon exam (TCE) with Distal Colon Barium Enema (DCBE) every five years.

3. Baseline TCE with colorectal every ten years.

These guidelines are based on a normal first exam. A strong personal and/or family history of colorectal cancer or polyps should prompt colorectal screening earlier.

Unfortunately, while African American women are at high risk, they are less likely than Caucasian women to receive this screening (ACS, 2003).

Several studies have addressed the health of minorities and women, regarding knowledge and participation in primary prevention activities such as cancer screening. (cf: Mann, Sherman, Clayton et al., 2002; Felton, 2000; Shanker, 1995). Specifically related to CRC, Lipkus (1996) found that over half of a sample of 1,318 African American, the age of 50 plus, placed themselves at average or low risk for CRC and over a third did not know their risk for CRC. Half also believed it was "better to not know" if one had CRC and perceived "being healthy" as negating the need to be screened. These beliefs were held more strongly by the women. In addition, qualitative studies related to the cancer screening behaviors of African American women from 1980 to 1996 have been critically reviewed by Hoffman and Goetz (1997). They support the lack of education about cancer screening and risk factors as influencing women not getting CRC screening. Further, they suggest that the low priority women placed on their personal preventive screening behavior and the important of social networks in the flow of cancer information influenced screening behavior

Given the disproportionate burden that faces African American women regarding CRC, the purpose of this study was to examine the knowledge, attitudes and beliefs of CRC screening, as well as frequency of screening, in this population. The Health Belief Model (HBM), revised by Champion (1999) for use in low income African American populations, served as the framework for the study.

RESEARCH QUESTIONS

1. What is the frequency of colorectal cancer screening performance among selected African American women age 50 and older?

2. What is the relationship between the concepts of perceived susceptibility, seriousness, benefit, barriers, confidence and health motivation in the Health Belief Model and frequency of colorectal cancer screening?

METHODOLOGY

Research Design

The design utilized in this study was descriptive/correlative using a non-experimental survey approach. Four primarily African American churches in four quadrants of a north Florida city were sites for the study.

Instruments

The main instrument utilized in this study was the HBM Scale (Champion, 1999). Permission was obtained from Champion for use. The scale measures the concepts of perceived benefits, perceived barriers, perceived susceptibility, perceived confidence and health motivation, in relation to CRC screening in African American women. Subscales measure each of the six dominions. Each item is rated on a a 5-point scale with 5 equaling "strongly agree" and a score of 1 equaling "strongly disagree." The HBM Scale yields a total score and an individual score for each of the subscales. The questionnaire consists of 45 items, each of which contributes to the total score and the summative score of one of the 6 subscales. All items particular to each subscale are scored and averaged to calculate each subscale score. Reported reliability for internal consistency and test retest ranges from 68 to 90 (Champion, 1999). Demographic information and data regarding health history and health practices were also elicited.

Protection of Human Subjects

The appropriate Institutional Review Board Approval was obtained. An informed consent cover letter explaining the purpose, risks, and benefits of the study was included in the survey packet. Participants were informed of their anonymity and of their right to refuse to participate, without penalty. The survey did not ask tot participant's name or other sources of identification and individual's responses remained confidential. Completion of the survey was considered as consent to participate in the study.

Procedure

A list of the female congregation members was provided by each of the directors of the churches. All African American women ages 50 and older were identified. Of these 150 were randomly selected to be mailed questionnaires. This included a return addressed, stamped envelope. To maintain anonymity the return address on each envelope was the church from which they were selected. The packet included the description of the research, human subjects information, and the survey with instructions on filling it out and returning it. Data collection lasted six weeks.

RESULTS

Sample

A total of 150 questionnaires were mailed out from four churches. Fifty-three questionnaires were returned of which forty-nine were usable, yielding a return rate of 35%. Approximately, 25 to 30% of the participants in each age group with the exception of eighty and older (15%). Noteworthy, was that 69 of the participants either had high school or less education (divided equally). Over half reported that their insurance covered the cost of colorectal cancer screening, while 20% did not know. Fifty five percent stated their primary care provider (PCP) had recommended colorectal cancer screening. However, 15% did not even have a provider. For a summary of participant characteristics, see Table 1.

Personal history data included questions about the incidence of colorectal cancer genetic or immune disorders of the ovary, uterus, or breast, and prolonged exposure to toxic fumes. Ten percent reported a history of colon cancer, 4% a genetic or immune disorder and 18% a history of ovarian, breast or uterine cancer. Sixty seven-percent reported having had prolonged exposure to toxic fumes during their lifetime. Twenty-three percent reported having a family medical history of a genetic or immune disorder while 38% identified history of ovarian, breast, or uterine cancer.