Abstract
Regular cancer screening can prevent the development of some cancers and increase patient survival for other cancers. We evaluated the reported cancer screening prevalence among a nationally representative sample of all US workers with data from the 2000 and 2005 Cancer Screening Supplements of the National Health Interview Survey. Overall, workers with the lowest rates of health insurance coverage (in particular, Hispanic workers, agricultural workers, and construction workers) reported the lowest cancer screening. There was no significant improvement from 2000 to 2005.
The American Cancer Society1–3 and other groups4 recommend regular professional screening examinations for the prevention of cervical and colorectal cancer through removal of precancerous lesions and for the early detection of these and other cancers (e.g., breast, prostate) to reduce mortality (Table 1). A key Healthy People 2010 objective is “to eliminate health disparities among segments of the population including differences that occur by gender, race, or ethnicity, geographic location, or sexual orientation.”5 However, as noted by Barbeau et al.,6 occupation is not identified as a significant predictor of health disparities. We used a nationally representative database to examine health disparities and reported cancer screening behaviors of US workers in 2000 and 2005.
TABLE 1.
American Cancer Society Cancer Screening Recommendations for Years 2000 and 2005 and Healthy People 2010 Cancer Screening Recommendations
| Cancer Site | Breast Cancer (Women) | Colorectal Cancer | Cervical Cancer (Women) | Prostate Cancer (Men) |
| American Cancer Society cancer screening recommendations for 2000 and 2005 | ||||
| ACS (2000) | Clinical breast examination every 3 years, aged 20–39; annually, aged ≥ 40. Mammography annually, aged ≥ 40. | Start at age 50. Annual fecal occult blood test and flexible sigmoidoscopy every 5 years, or double contrast barium enema, every 5–10 years, or colonoscopy every 10 years. | Sexually active women or those ≥ 18 years, annual Pap test and pelvic examination. After more than 3 consecutive satisfactory normal annual examinations, the Pap test may be performed less frequently at the discretion of the physician. | Annual digital rectal examination and PSA test should be offered to men starting at age 50. |
| ACS (2005) | Clinical breast examination as part of a periodic health examination, preferably at least every 3 years, aged 20–39; annually, ≥ 40 years. Mammography annually, age ≥ 40. | Start at age 50. Fecal occult blood test, fecal immunochemical test annually, or flexible sigmoidoscopy or fecal occult blood test annually and flexible sigmoidoscopy, or double contrast barium enema every 5 years, or colonoscopy every 10 years. | Begin approximately 3 years after a woman begins having vaginal intercourse, but no later than age 21. Every year with conventional Pap tests or every 2 years using liquid-based Pap tests. At or after age 30, women who have had 3 normal test results in a row may be screened every 2 to 3 years with cervical cytology alone, or every 3 years with a human papillomavirus DNA test plus cervical cytology. Women ≥ 70 years who have had 3 or more normal Pap tests and no abnormal Pap tests in the last 10 years and women who have had a total hysterectomy may choose to stop cervical cancer screening. | Digital rectal examination and PSA test should be offered annually, starting at age 50, for men who have a life expectancy of at least 10 years. |
| Healthy People 2010 objectives and target screening rates | ||||
| Objectives | Reduce the breast cancer death rate. Increase the proportion of women ≥ 40 years who have received a mammogram within the preceding 2 years. | Reduce the colon cancer death rate. Increase the proportion of adults who receive a colorectal cancer screening examination. | Increase the proportion of women who receive a Pap test. | Reduce the prostate cancer death rate. |
| Baseline (1998) and target screening rates | 67% of women ≥ 40 years received a mammogram within the preceding 2 years. Target: 70%. | 35% of adults ≥ 50 years received a fecal occult blood test within the preceding 2 years. Target: 50%. 37% of adults ≥ 50 years have ever received a sigmoidoscopy. Target: 50%. | 92% of women ≥ 18 years have ever received a Pap test. Target: 97%. 79% of women ≥ 18 years received a Pap test within the preceding 3 years. Target: 90%. | Efforts aimed at reducing deaths through screening and early detection remain controversial because of the uncertain benefits and potential risks of screening, diagnosis, and treatment. Digital rectal examination and the PSA test are two commonly used methods for detecting prostate cancer. |
Note. ACS = American Cancer Society; PSA = prostate-specific antigen; Pap = Papanicolaou.
METHODS
The National Health Interview Survey (NHIS) is an annual, cross-sectional household survey of the US civilian noninstitutionalized population conducted by the National Center for Health Statistics (NCHS). The NHIS Cancer Control Module was administered to all NHIS participants in 2000 and 2005 and included questions on reported regular cancer screening examinations. The conditional response rates to the 2000 and 2005 sample adult component of the NHIS (and their Cancer Control Modules) were 82.6% and 80.1%, respectively.
Variables
Detailed employment information coded by occupation and industry was collected on all participants older than 18 years who reported working (paid and unpaid) during the week before the NHIS survey.7 Standard industry codes were grouped into the new National Institute of Occupational Safety and Health National Occupational Research Agenda (NORA) industry groups representing 8 sectors of industry.8 Occupation type was derived from detailed US Census occupation codes and collapsed into the 4 occupational status groups used by NCHS.9
Participants were asked if they had ever had a particular cancer screening examination by a doctor or other health professional. Screening was evaluated in different gender-specific age groups per contemporary national recommendations (Table 1): home or office stool blood (combined for study purposes) and colorectal screening (sigmoidoscopy, colonoscopy, or proctoscopy) for men and women, mammogram for women 40 years or older, manual breast examination for women 20 years or older, Papanicolaou test for women 18 years or older, and prostate-specific antigen (PSA) testing for men 50 years or older. The question on PSA testing was asked somewhat differently in 2000 and 2005, but results of both surveys were included.
Statistical Analysis
All worker and gender-specific prevalences were created depending on the specific screening test reported. We tested statistical differences, comparing 95% confidence intervals for all prevalences within a year as well as between years; we calculated these confidence intervals with SUDAAN version 9.0 (Research Triangle Institute, Research Triangle Park, NC) by multiplying the standard error of each prevalence by 1.96. To create total estimates of US workers (including the subpopulations), we applied the annual sample–person weights and summed them over each annual group and the associated subgroups. Because of the complex sample survey design, we used SAS version 9.1.3 (SAS Institute Inc, Cary, NC) and SUDAAN for all analyses, with adjustment for case weights and design effects.10
RESULTS
The NHIS Cancer Control Module was administered to 19 702 (2000) and 18 422 (2005) employed participants of an estimated 128 480 200 and 133 103 520 US workers, respectively. The results are displayed by race/ethnicity, NORA industry sector (Table 2), and occupational status (Table 3) for each age- and gender-specific appropriate subgroup. Of note, between-year comparisons (i.e., 2000 vs 2005) did not show uniform improvement and were significantly different for all workers only for colorectal screening (32.4% vs 43.2%), manual breast examination (89.0% vs 83.3%), and PSA (50.8% vs 58.4%).
TABLE 2.
Reported Cancer Screening and Health Insurance Rates Among Workers, by Race/Ethnicity and Industry Sector: National Health Interview Survey (NHIS) Cancer Screening Supplements, 2000–2005
| US Worker Population Estimatea |
NHIS Sample, No. |
Screening Prevalence |
|||||||||
| All Workers |
Hispanic Workers |
Black Workers |
|||||||||
| NORA industry sector | 2000 | 2005 | 2000 | 2005 | 2000, % (95% CI) | 2005, % (95% CI) | 2000, % (95% CI) | 2005, % (95% CI) | 2000, % (95% CI) | 2005, % (95% CI) | |
| Home or office blood stool screen (age ≥ 50 y) | |||||||||||
| All sectors | 28 395 332 | 32 338 326 | 4 480 | 4 755 | 43.3 (41.7, 44.9) | 41.0 (39.2, 42.8) | 25.0b (20.3, 29.8) | 24.5b (19.8, 29.2) | 42.4 (37.7, 47.0) | 34.6 (29.7, 39.5) | |
| Agriculture, forestry, fishing | 782 140 | 561 163 | 129 | 80 | 37.4 (27.1, 47.8) | 27.6 (16.3, 38.9) | 6.5bc (0.0, 16.2) | 0.0bc (0.0, 0.0) | 18.8c (0.0, 51.7) | 65.1c (2.1, 128.1) | |
| Construction | 1 506 923 | 1 863 858 | 235 | 253 | 27.0 (20.8, 33.3) | 35.5 (28.5, 42.4) | 7.3bc (0.0, 16.0) | 15.1c (0.6, 29.6) | 17.8c (0.8, 34.8) | 18.1c (5.5, 30.7) | |
| Health care and social assistance | 3 925 453 | 4 029 784 | 657 | 646 | 52.1 (47.1, 56.5) | 50.0 (45.7, 54.2) | 40.2b (23.7, 56.7) | 42.6 (26.0, 59.2) | 46.7 (36.3, 57.1) | 39.4 (29.4, 49.3) | |
| Manufacturing | 3 984 625 | 3 951 865 | 601 | 563 | 44.4 (40.0, 48.8) | 35.1 (30.0, 40.2) | 23.8b (12.6, 35.0) | 18.7b (7.5, 29.9) | 49.4d (33.7, 65.2) | 19.1bd (9.4, 28.9) | |
| Mining | 130 696 | 125 662 | 22c | 13c | 49.8c (25.4, 74.1) | 27.8c (1.0, 54.5) | 28.5c (0.0, 62.7) | 100.0c (100.0, 100.0) | 61.5c (0.0, 100.0) | … | |
| Services | 11 287 847 | 15 661 653 | 1 781 | 2 310 | 43.9 (41.4, 46.5) | 42.4 (39.8, 45.0) | 28.0b (19.2, 36.9) | 24.1b (17.8, 30.3) | 41.2 (34.0, 48.5) | 33.8 (26.9, 40.8) | |
| Transportation, warehousing, utilities | 2 116 953 | 1 916 296 | 318 | 262 | 39.1 (33.3, 44.9) | 35.8 (29.2, 42.5) | 20.2c (1.9, 38.4) | 33.0c (12.3, 53.8) | 56.3 (39.8, 72.7) | 56.1 (38.7, 73.5) | |
| Wholesale and retail trade | 4 660 695 | 4 228 045 | 737 | 628 | 41.4 (37.5, 45.4) | 39.9 (35.9, 43.9) | 26.3b (15.3, 37.3) | 19.4b (5.6, 33.2) | 29.4bd (6.3, 17.0) | 35.4d (19.8, 51.5) | |
| Colorectal screening (age ≥ 50 y) | |||||||||||
| All sectors | 28 474 998 | 32 459 969 | 4 489 | 4 773 | 32.4d (30.8, 34.1) | 43.2d (41.4, 44.9) | 23.7b (18.5, 29.0) | 27.0b (22.4, 31.7) | 29.7 (25.5, 33.9) | 36.7b (32.3, 41.0) | |
| Agriculture, forestry, fishing | 780 304 | 567 951 | 128 | 81 | 23.2 (15.0, 31.3) | 40.5 (28.6, 52.4) | 4.3bc (0.0, 12.8) | 8.3bc (0.0, 23.6) | 0.0bc (0.0, 0.0) | 0.0bc (0.0, 0.0) | |
| Construction | 1 510 182 | 1 863 858 | 236 | 253 | 27.0 (20.4, 33.6) | 38.1 (30.5, 45.6) | 3.2bc (0.0, 9.3) | 10.6bc (0.0, 23.0) | 47.6c (26.7, 68.4) | 22.5c (0.0, 45.4) | |
| Health care and social assistance | 3 953 598 | 4 054 575 | 660 | 650 | 37.2 (33.2, 41.2) | 43.5 (38.7, 48.3) | 34.2 (19.4, 49.1) | 31.3 (18.6, 44.1) | 25.5 (17.7, 33.2) | 33.7 (23.5, 44.0) | |
| Manufacturing | 3 984 625 | 3 960 412 | 601 | 564 | 30.5 (26.5, 34.4) | 38.7 (34.0, 43.3) | 21.2 (8.6, 33.8) | 30.8 (17.5, 44.0) | 39.5 (25.8, 53.1) | 36.9 (24.8, 49.1) | |
| Mining | 130 696 | 125 662 | 22c | 13c | 44.0c (18.5, 69.4) | 60.3c (24.9, 95.8) | 28.5cd (0.0, 62.7) | 100.0bcd (100.0, 100.0) | 100.0bc (100.0, 100.0) | … | |
| Services | 11 299 854 | 15 702 632 | 1 782 | 2 318 | 34.6d (32.1, 37.1) | 45.5d (43.0, 47.9) | 34.6 (25.1, 44.2) | 29.8b (22.7, 37.0) | 29.3 (23.0, 35.6) | 36.2 (29.2, 43.2) | |
| Transportation, warehousing, utilities | 2 136 908 | 1 936 266 | 320 | 264 | 27.6 (21.7, 33.5) | 38.5 (31.6, 45.3) | 19.1 (2.9, 35.3) | 27.6c (5.0, 50.3) | 38.1 (20.4, 55.7) | 49.7 (34.1, 65.3) | |
| Wholesale and retail trade | 4 678 831 | 4 248 613 | 740 | 630 | 30.1c (26.3, 33.9) | 42.8d (38.8, 46.8) | 15.4b (6.9, 24.0) | 17.0b (6.1, 27.8) | 13.2bd (3.8, 22.7) | 42.9d (27.0, 61.9) | |
| Manual breast examination (age ≥ 20 y) | |||||||||||
| All sectors | 42 770 837 | 41 921 192 | 7 312 | 6 549 | 89.0d (88.2, 89.9) | 83.3d (82.1, 84.4) | 74.5bd (71.1, 77.8) | 62.2bd (57.9, 66.4) | 88.7d (86.4, 90.9) | 78.2bd (75.3, 81.2) | |
| Agriculture, forestry, fishing | 533 309 | 267 285 | 83 | 41c | 88.3 (81.8, 94.7) | 72.7c (52.3, 93.0) | 57.5c (31.7, 83.3) | 55.4c (20.6, 90.2) | 80.4c (42.4, 118.3) | 100.0bc (100.0, 100.0) | |
| Construction | 553 811 | 519 873 | 85 | 82 | 90.2 (84.4, 95.9) | 81.5 (82.1, 84.4) | 44.2c (0.0, 88.5) | 75.1c (50.6, 99.6) | 69.0c (20.4, 100.0) | 83.5c (59.0, 100.0) | |
| Health care and social assistance | 9 969 626 | 9 324 157 | 1 679 | 1 468 | 91.1d (89.5, 92.7) | 86.3d (84.4, 88.2) | 79.4b (72.8, 86.1) | 70.0b (61.4, 78.6) | 87.8 (83.8, 91.9) | 79.3b (74.3, 84.3) | |
| Manufacturing | 4 441 044 | 3 652 163 | 747 | 570 | 86.9d (84.0, 89.7) | 78.7d (74.4, 83.0) | 65.2b (56.4, 74.0) | 53.2b (41.4, 65.3) | 92.1 (86.6, 97.7) | 74.3 (62.1, 86.4) | |
| Mining | 43 391 | 23 633 | 7c | 5c | 100.0c (100.0, 100.0) | 100.0c (100.0, 100.0) | 100.0c (100.0, 100.0) | 100.0c (100.0, 100.0) | … | … | |
| Services | 18 656 428 | 21 805 997 | 3 182 | 3 385 | 90.1d (88.9, 91.3) | 83.1d (81.5, 84.6) | 77.5bd (72.7, 82.4) | 61.1bd (56.3, 66.0) | 88.2d (84.4, 92.0) | 77.9d (73.6, 82.3) | |
| Transportation, warehousing, utilities | 1 930 167 | 1 216 315 | 361 | 184 | 89.0 (84.9, 93.1) | 86.1 (80.5, 91.7) | 80.0 (65.4, 94.7) | 80.7 (65.3, 96.1) | 94.3 (89.3, 99.4) | 80.6 (64.3, 96.9) | |
| Wholesale and retail trade | 6 643 061 | 5 111 769 | 1 168 | 814 | 84.4 (82.0, 86.8) | 82.0 (85.4, 87.7) | 69.3b (61.6, 76.9) | 60.6b (50.7, 70.5) | 87.4 (80.1, 94.6) | 77.4b (73.6, 82.3) | |
| Mammogram (age ≥ 40 y) | |||||||||||
| All sectors | 28 308 100 | 30 055 295 | 4 732 | 4 604 | 86.2 (85.0, 87.4) | 86.5 (85.4, 87.7) | 77.5b (72.9, 82.0) | 75.2b (70.3, 80.0) | 82.4 (79.3, 85.6) | 82.9 (79.6, 86.2) | |
| Agriculture, forestry, fishing | 371 981 | 201 226 | 57 | 32c | 88.2 (80.3, 96.0) | 81.7c (66.7, 96.8) | 87.5c (68.6, 106.4) | 53.2c (9.4, 97.0) | 100.0bc (100.0, 100.0) | … | |
| Construction | 330 203 | 346 400 | 54 | 52 | 77.1 (65.3, 88.9) | 89.9 (81.7, 98.1) | 51.1c (0.0, 120.4) | 35.5c (0.0, 84.6) | 100.0bc (100.0, 100.0) | 100.0bc (100.0, 100.0) | |
| Health care and social assistance | 6 463 462 | 6 715 778 | 1 081 | 1 035 | 87.7 (85.5, 90.0) | 87.5 (85.0, 90.0) | 86.2 (78.8, 93.6) | 86.0 (75.5, 96.4) | 77.5b (71.0, 84.1) | 81.4 (75.3, 87.6) | |
| Manufacturing | 2 915 633 | 2 628 304 | 483 | 403 | 86.7 (83.0, 90.4) | 84.0 (80.2, 87.9) | 78.1 (68.3, 87.9) | 72.7 (60.2, 85.1) | 87.6 (79.0, 96.3) | 88.0 (78.0, 98.1) | |
| Mining | 43 391 | 15 151 | 7c | 2c | 100.0c (100.0, 100.0) | 100.0c (100.0, 100.0) | 100.0c (100.0, 100.0) | … | … | … | |
| Services | 12 630 107 | 15 657 159 | 2 090 | 2 382 | 87.2 (85.5, 88.9) | 87.4 (85.9, 89.0) | 74.4b (67.0, 81.8) | 72.4b (65.6, 79.1) | 86.3 (82.2, 90.4) | 82.8 (77.9, 87.6) | |
| Transportation, warehousing, utilities | 1 289 004 | 880 918 | 235 | 131 | 83.5 (78.1, 89.0) | 85.3 (78.9, 91.7) | 89.9 (78.9, 100.0) | 69.9 (42.0, 97.8) | 84.0 (71.8, 96.2) | 80.2 (60.2, 100.0) | |
| Wholesale and retail trade | 4 264 319 | 3 610 359 | 725 | 567 | 81.7 (78.4, 85.0) | 82.7 (79.2, 86.1) | 69.4 (57.6, 81.3) | 79.5 (69.4, 89.6) | 74.4 (63.2, 85.6) | 84.3 (74.1, 94.4) | |
| Papanicolaou test (age ≥ 18 y) | |||||||||||
| All sectors | 57 334 753 | 55 574 383 | 9 585 | 8 413 | 93.9 (93.2, 94.6) | 94.0 (93.3, 94.7) | 85.2b (82.3, 88.0) | 87.6b (85.1, 90.1) | 96.7b (95.5, 97.9) | 94.2 (92.5, 95.8) | |
| Agriculture, forestry, fishing | 702 746 | 329 877 | 108 | 54 | 92.8 (86.6, 98.9) | 89.2 (77.2, 100.0) | 75.8c (54.1, 97.5) | 55.9c (24.4, 87.4) | 100.0bc (100.0, 100.0) | 100.0c (100.0, 100.0) | |
| Construction | 722 085 | 590 327 | 107 | 94 | 87.1 (74.8, 99.3) | 97.4 (93.8, 100.0) | 44.5c (0.6, 88.4) | 74.4c (40.6, 100.0) | 100.0bc (100.0, 100.0) | 100.0c (100.0, 100.0) | |
| Health care and social assistance | 12 820 735 | 11 986 787 | 2 118 | 1 838 | 96.0 (94.8, 97.1) | 96.4 (95.3, 97.4) | 86.5bd (80.9, 92.0) | 96.0d (93.2, 98.8) | 97.6 (95.6, 99.6) | 93.8 (90.5, 97.0) | |
| Manufacturing | 5 589 303 | 4 336 918 | 929 | 665 | 93.7 (91.6, 95.7) | 92.4 (89.1, 95.7) | 80.9b (73.6, 88.3) | 77.9b (67.0, 88.7) | 98.9 (97.6, 100.0) | 92.7 (85.8, 99.6) | |
| Mining | 44 976 | 32 794 | 8c | 6c | 100.0c (100.0, 100.0) | 100.0c (100.0, 100.0) | 100.0c (100.0, 100.0) | 100.0c (100.0, 100.0) | … | … | |
| Services | 24 273 222 | 29 190 844 | 4 101 | 4 400 | 94.6 (93.7, 95.5) | 93.3 (92.3, 94.4) | 88.8b (85.7, 91.9) | 86.6b (83.2, 90.0) | 97.0 (95.2, 98.7) | 94.2 (91.6, 96.8) | |
| Transportation, warehousing, utilities | 2 358 298 | 1 501 921 | 441 | 223 | 97.1 (95.1, 99.1) | 96.7 (93.5, 99.8) | 96.5 (92.3, 100.8) | 97.1c (91.5, 100.0) | 100.0b (100.0, 100.0) | 94.7c (84.6, 100.0) | |
| Wholesale and retail trade | 10 823 388 | 7 604 915 | 1 773 | 1 133 | 89.8 (87.6, 92.1) | 93.2 (91.4, 95.0) | 81.3bd (75.2, 87.4) | 91.9d (87.9, 95.9) | 91.1 (85.4, 96.7) | 95.3 (93.1, 97.5) | |
| Prostate-specific antigen test (age ≥ 50 y) | |||||||||||
| All Sectors | 15 197 015 | 17 126 936 | 2 215 | 2 315 | 50.8d (48.4, 53.3) | 58.4d (55.9, 60.8) | 37.4b (30.0, 44.7) | 44.7b (37.1, 51.6) | 53.4 (45.5, 61.4) | 54.6 (47.3, 61.9) | |
| Agriculture, forestry, fishing | 571 801 | 430 922 | 98 | 59 | 46.8 (35.5, 58.0) | 50.5 (36.9, 64.1) | 27.1d (7.0, 47.1) | 0.0bd (0.0, 0.0) | 30.8c (0.0, 70.0) | 0.0bc (0.0, 0.0) | |
| Construction | 1 324 176 | 1 768 617 | 204 | 236 | 43.8 (35.8, 51.8) | 55.2 (48.0, 62.4) | 29.2 (10.8, 47.6) | 24.5b (7.5, 41.5) | 44.3c (22.3, 66.2) | 68.3c (50.3, 86.4) | |
| Health care and social assistance | 942 961 | 778 879 | 141 | 110 | 69.5 (60.4, 78.7) | 69.1 (59.4, 78.8) | 42.8 (3.9, 81.6) | 86.2 (68.9, 100.0) | 24.7bc (7.6, 41.8) | 46.1c (16.7, 75.5) | |
| Manufacturing | 2 705 524 | 2 760 395 | 386 | 366 | 40.1d (35.0, 45.2) | 53.1d (47.5, 58.7) | 28.2 (12.5, 43.8) | 42.6 (26.5, 58.7) | 34.9c (16.0, 53.8) | 35.4c (19.4, 51.3) | |
| Mining | 111 290 | 122 931 | 19c | 12c | 71.0c (46.2, 95.8) | 47.6c (7.9, 87.4) | 62.9cd (29.9, 95.9) | 100.0bcd (100.0, 100.0) | 100.0bc (100.0, 100.0) | … | |
| Services | 5 237 270 | 7 329 845 | 756 | 1 001 | 55.5 (51.5, 59.8) | 60.0 (56.3, 63.7) | 49.0 (33.7, 64.4) | 44.9b (34.0, 55.8) | 61.2 (48.2, 74.2) | 57.2 (45.6, 68.7) | |
| Transportation, warehousing, utilities | 1 700 407 | 1 564 300 | 234 | 207 | 51.2 (43.8, 58.5) | 55.9 (48.1, 63.7) | 41.3 (15.4, 67.1) | 58.6 (37.1, 80.2) | 72.4c (58.3, 86.6) | 79.4c (66.4, 92.4) | |
| Wholesale and retail trade | 2 603 586 | 2 371 047 | 377 | 324 | 49.3d (43.6, 55.0) | 61.8d (55.8, 67.7) | 38.3 (21.6, 55.1) | 51.7 (30.6, 72.9) | 56.8c (38.0, 75.6) | 36.4bc (16.8, 56.1) | |
| Current health insurance (age ≥ 18 y) | |||||||||||
| All sectors | 127 320 464 | 127 810 983 | 19 527 | 17 642 | 84.5d (83.9, 85.2) | 82.4d (81.6, 83.1) | 61.8b (59.0, 64.6) | 59.0b (56.7, 61.3) | 80.4b (78.5, 82.2) | 78.0b (75.5, 80.5) | |
| Agriculture, forestry, fishing | 3 188 852 | 1 721 820 | 497 | 243 | 67.7 (62.4, 72.9) | 69.6 (62.5, 76.7) | 29.9b (20.2, 39.6) | 33.7b (19.6, 47.7) | 69.0c (47.1, 90.8) | 75.5c (40.2, 110.7) | |
| Construction | 8 622 806 | 10 516 444 | 1 234 | 1 350 | 68.5d (65.6, 71.5) | 60.9d (57.5, 64.2) | 37.6b (30.7, 44.6) | 30.6b (24.6, 36.6) | 71.4 (61.8, 81.0) | 55.0 (43.0, 66.9) | |
| Health care and social assistance | 16 885 458 | 15 794 791 | 2 717 | 2 349 | 89.1 (87.9, 90.3) | 86.6 (85.0, 88.2) | 77.9b (72.2, 83.6) | 71.8b (65.6, 78.1) | 81.9b (78.3, 85.5) | 74.4b (69.3, 79.5) | |
| Manufacturing | 18 472 477 | 15 079 398 | 2 711 | 2 008 | 90.2 (88.8, 91.6) | 89.8 (88.2, 91.4) | 72.4b (68.0, 76.7) | 72.0b (66.6, 77.4) | 85.2 (80.4, 90.0) | 91.0 (86.9, 95.1) | |
| Mining | 444 848 | 413 475 | 66 | 52 | 88.7 (81.8, 96.2) | 88.6 (80.2, 97.0) | 84.5c (65.4, 103.7) | 75.6c (53.6, 97.6) | 100.0bc (100.0, 100.0) | 100.0bc (100.0, 100.0) | |
| Services | 46 156 829 | 59 549 626 | 7 287 | 8 305 | 87.8 (86.9, 88.6) | 83.4 (82.4, 84.5) | 67.4b (63.7, 71.2) | 61.6b (58.2, 65.0) | 82.0b (79.5, 84.5) | 78.2b (74.5, 81.8) | |
| Transportation, warehousing, utilities | 9 271 769 | 6 620 522 | 1 377 | 889 | 88.3 (86.4, 90.3) | 86.5 (84.1, 88.8) | 80.1 (73.2, 87.1) | 69.9b (62.0, 77.7) | 87.3 (83.0, 91.6) | 86.7 (81.2, 92.3) | |
| Wholesale and retail trade | 24 277 425 | 18 114 907 | 3 638 | 2 446 | 77.2d (75.6, 78.9) | 81.0d (79.1, 82.9) | 52.1b (45.9, 58.3) | 62.6b (57.1, 68.1) | 69.7b (64.4, 75.0) | 73.7 (67.5, 79.8) | |
Note. CI = confidence interval; NORA = National Occupational Research Agenda. Industry sectors were based on the National Institute of Occupational Safety and Health NORA classification.
Worker estimates based on NHIS sampling weights and estimates vary by screening age cutoff and nonresponse to screening questions.
Statistically different compared with all workers within the same year.
Sample size was under 45, which is considered unstable by the NHIS.
Statistically different between years.
TABLE 3.
Reported Cancer Screening and Health Insurance Rates Among Workers, by Race, Ethnicity, and Occupational Status: National Health Interview Survey Cancer (NHIS) Screening Supplements, 2000–2005
| US Worker Population Estimatea |
NHIS Sample, No. |
Screening Prevalence |
||||||||
| All Workers |
Hispanic Workers |
Black Workers |
||||||||
| Occupational status | 2000 | 2005 | 2000 | 2005 | 2000, % (95% CI) | 2005, % (95% CI) | 2000, % (95% CI) | 2005, % (95% CI) | 2000, % (95% CI) | 2005, % (95% CI) |
| Home or office blood stool screen (age ≥ 50 y) | ||||||||||
| All workers | 28 562 316 | 32 309 880 | 4510 | 4753 | 43.3 (41.7, 44.9) | 41.0 (39.3, 42.8) | 24.9b (20.2, 29.7) | 24.9b (20.2, 29.6) | 42.3 (37.6, 46.9) | 34.4 (29.5, 39.3) |
| White collar | 18 082 862 | 19 981 996 | 2793 | 2885 | 48.2 (46.1, 50.3) | 45.4 (43.2, 47.6) | 34.4b (25.4, 43.4) | 30.6b (22.4, 38.8) | 44.7 (38.7, 51.2) | 39.2 (32.1, 46.2) |
| Service | 3 272 511 | 5 099 729 | 595 | 834 | 36.6 (32.4, 40.7) | 38.5 (34.7, 42.3) | 21.4b (12.6, 30.3) | 31.6 (22.1, 41.0) | 39.1 (30.4, 47.9) | 33.9 (25.2, 42.7) |
| Farm worker | 751 355 | 249 062 | 129 | 37c | 35.4 (25.3, 45.5) | 21.5c (7.2, 35.8) | 2.4bc (0.0, 7.4) | 0.0bc (0.0, 0.0) | 24.4c (0.0, 57.2) | 68.8c (9.3, 128.3) |
| Blue collar | 6 455 588 | 6 979 093 | 993 | 997 | 33.8 (30.3, 37.2) | 31.1 (27.7, 34.4) | 19.2b (12.1, 26.3) | 14.0b (8.1, 20.0) | 42.2 (33.5, 50.9) | 26.9 (19.1, 34.8) |
| Colorectal screening (age ≥ 50 y) | ||||||||||
| All workers | 28 641 982 | 32 431 523 | 4519 | 4771 | 32.3d (30.6, 34.0) | 43.3d (41.6, 45.0) | 23.7b (18.4, 28.9) | 27.6b (22.9, 32.3) | 29.6 (25.5, 33.8) | 36.7b (32.3, 41.1) |
| White collar | 18 139 063 | 20 063 939 | 2799 | 2897 | 36.6d (34.5, 38.7) | 48.4d (46.2, 50.6) | 37.8 (28.5, 47.1) | 36.4b (27.7, 45.2) | 31.4 (25.5, 37.2) | 42.6 (35.6, 49.5) |
| Service | 3 279 957 | 5 119 459 | 596 | 838 | 24.7d (20.7, 28.7) | 38.2d (34.2, 42.2) | 21.6 (10.8, 32.4) | 23.4b (16.2, 30.7) | 18.3 (11.7, 25.0) | 32.5 (23.7, 41.2) |
| Farm worker | 749 519 | 249 062 | 128 | 37c | 20.8 (12.9, 28.8) | 30.8c (14.5, 47.1) | 4.5c (0.0, 13.3) | 9.2c (0.0, 26.1) | 0.0bc (0.0, 0.0) | 0.0c (0.0, 0.0) |
| Blue collar | 6 473 443 | 6 999 063 | 996 | 999 | 25.6d (22.6, 28.6) | 32.9d (29.6, 36.3) | 11.3b (5.7, 16.8) | 22.1 (14.7, 29.6) | 39.4b (31.0, 47.9) | 31.5 (23.7, 39.4) |
| Manual breast examination (age ≥ 20 y) | ||||||||||
| All workers | 42 929 966 | 41 933 057 | 7344 | 6556 | 89.1d (88.2, 89.9) | 83.3d (82.2, 84.5) | 74.5bd (71.1, 77.9) | 62.2bd (58.0, 66.4) | 88.7d (86.4, 90.9) | 78.5bd (75.7, 81.4) |
| White collar | 31 438 346 | 30 387 403 | 5225 | 4559 | 91.8d (90.9, 92.6) | 86.6d (85.3, 87.8) | 84.5bd (80.4, 88.6) | 74.1bd (69.0, 79.3) | 92.0d (89.8, 94.3) | 81.4bd (77.8, 85.0) |
| Service | 6 952 627 | 8 079 865 | 1304 | 1414 | 82.1d (79.7, 84.5) | 75.8d (73.1, 78.5) | 63.3b (56.5, 70.1) | 49.8b (42.7, 56.9) | 80.7 (75.1, 86.2) | 76.0 (71.0, 81.0) |
| Farm worker | 346 588 | 117 500 | 59 | 23c | 84.1 (74.5, 93.7) | 67.0c (44.0, 90.0) | 50.9c (24.2, 77.5) | 53.2c (23.4, 83.0) | 82.3c (47.0, 100.0) | 45.5c (0.0, 100.0) |
| Blue collar | 4 192 405 | 3 408 289 | 756 | 560 | 80.8 (77.3, 84.3) | 73.1 (68.5, 87.8) | 62.3b (54.2, 70.5) | 47.9b (38.0, 57.7) | 89.5bd (84.7, 94.3) | 70.0d (59.7, 80.3) |
| Mammogram (age ≥ 40 y) | ||||||||||
| All workers | 28 398 360 | 30 088 247 | 4753 | 4604 | 86.2 (85.0, 87.5) | 86.4 (85.3, 87.6) | 77.5b (73.0, 82.1) | 75.6b (70.7, 80.5) | 82.5 (79.3, 85.6) | 83.0b (79.6, 86.3) |
| White collar | 20 928 158 | 21 843 139 | 3402 | 3223 | 88.8 (87.4, 90.1) | 88.4 (87.1, 89.7) | 84.1 (79.0, 89.1) | 80.9b (75.1, 86.7) | 87.2 (84.0, 90.4) | 84.3 (80.0, 88.6) |
| Service | 4 513 855 | 5 688 639 | 829 | 974 | 76.1 (72.5, 79.7) | 81.9 (78.8, 85.0) | 67.1 (58.4, 75.9) | 72.4 (63.3, 81.5) | 70.5 (62.7, 78.3) | 80.1 (73.8, 86.3) |
| Farm worker | 222 687 | 89 054 | 40 | 17c | 82.5 (69.2, 95.8) | 61.2c (33.5, 88.8) | 88.4c (71.0, 100.0) | 44.7c (5.8, 83.6) | 100.0bc (100.0, 100.0) | 100.0bc (100.0, 100.0) |
| Blue collar | 2 733 660 | 2 467 415 | 482 | 390 | 83.9 (80.4, 87.3) | 80.7 (76.0, 85.5) | 74.8 (66.0, 83.6) | 67.9 (56.3, 79.6) | 88.2 (81.2, 95.1) | 84.0 (74.4, 93.6) |
| Papanicolaou test (age ≥ 18 y) | ||||||||||
| All workers | 57 527 535 | 55 612 395 | 9624 | 8416 | 93.9 (93.2, 94.6) | 94.0 (93.3, 94.7) | 85.2b (82.3, 88.0) | 87.6b (85.1, 90.1) | 96.7 (95.5, 97.9) | 94.2 (92.5, 95.8) |
| White collar | 41 762 462 | 39 164 261 | 6836 | 5742 | 95.4 (94.7, 96.0) | 95.9 (95.3, 96.6) | 89.8 (87.3, 92.3) | 93.8 (91.7, 95.8) | 97.2 (95.9, 98.5) | 94.9 (93.3, 96.4) |
| Service | 9 915 550 | 12 032 430 | 1773 | 1965 | 89.8 (87.9, 91.6) | 90.2 (88.3, 92.1) | 80.1 (75.1, 85.1) | 84.0 (79.3, 88.7) | 95.5 (92.5, 98.5) | 93.2 (89.7, 96.7) |
| Farm worker | 451 797 | 170 362 | 81 | 33c | 90.5 (83.4, 97.7) | 79.1c (58.5, 99.7) | 82.7c (75.1, 85.1) | 66.8c (38.2, 95.4) | 100.0c (100.0, 100.0) | 100.0c (100.0, 100.0) |
| Blue collar | 5 397 726 | 4 245 342 | 934 | 676 | 90.7 (87.0, 94.3) | 87.7 (83.9, 91.5) | 77.7 (68.5, 86.9) | 76.5 (67.5, 85.6) | 96.3 (92.5, 100.0) | 92.8 (86.7, 98.8) |
| Prostate-specific antigen test (age ≥ 50 y) | ||||||||||
| All workers | 15 314 204 | 17 098 683 | 2233 | 2313 | 50.8d (48.3, 53.2) | 58.4d (55.9, 60.8) | 37.4b (30.4, 44.7) | 44.6 (37.8, 51.5) | 53.2 (45.3, 61.6) | 54.5 (47.1, 61.8) |
| White collar | 8 328 019 | 9 090 371 | 1162 | 1187 | 56.3d (53.0, 59.6) | 64.6d (61.3, 67.9) | 48.1 (33.4, 62.8) | 55.1 (40.9, 69.3) | 60.5 (47.6, 73.4) | 54.0 (42.6, 65.5) |
| Service | 1 138 305 | 1 911 844 | 190 | 292 | 46.8 (38.1, 55.4) | 53.1 (46.3, 59.8) | 41.2c (15.8, 66.5) | 40.6 (25.4, 55.8) | 44.0 (29.2, 58.8) | 55.6 (36.1, 75.2) |
| Farm worker | 631 672 | 206 027 | 108 | 27c | 52.8 (42.0, 63.7) | 60.2c (38.5, 82.0) | 16.2bcd (5.9, 26.5) | 0.0bcd (0.0, 0.0) | 47.4cd (1.1, 93.6) | 0.0cd (0.0, 0.0) |
| Blue collar | 5 216 208 | 5 890 441 | 773 | 807 | 42.5d (38.8, 46.2) | 50.4d (46.5, 54.3) | 32.1 (22.3, 41.9) | 42.0 (32.2, 51.7) | 52.3 (41.7, 62.8) | 54.9 (44.4, 65.4) |
| Current health insurance (age ≥ 18 y) | ||||||||||
| All workers | 127 943 300 | 127 771 802 | 19 633 | 17 640 | 84.5d (83.8, 85.2) | 82.3d (81.6, 83.1) | 61.7b (59.0, 64.5) | 59.1b (56.8, 61.4) | 80.3b (78.5, 82.1) | 78.0b (75.5, 80.5) |
| White collar | 76 445 923 | 74 241 954 | 11 701 | 10 152 | 91.0 (90.4, 91.6) | 89.4 (88.7, 90.2) | 78.4b (75.4, 81.4) | 79.1b (75.8, 82.3) | 86.1b (84.2, 88.0) | 83.7b (81.0, 86.3) |
| Service | 16 960 933 | 22 269 921 | 2813 | 3338 | 71.1 (69.1, 73.0) | 71.0 (69.1, 72.9) | 48.9b (42.9, 54.8) | 49.3b (45.0, 53.6) | 68.7 (64.4, 73.0) | 67.9 (63.0, 72.7) |
| Farm worker | 2 958 645 | 969 731 | 486 | 146 | 64.8 (59.2, 70.3) | 61.8 (52.0, 71.6) | 30.4b (21.1, 39.6) | 37.6 (22.8, 52.4) | 66.5c (47.8, 85.3) | 66.9c (21.6, 100.0) |
| Blue collar | 31 577 799 | 30 290 196 | 4633 | 4004 | 77.8 (76.4, 79.2) | 73.9 (72.2, 75.6) | 55.1b (51.5, 58.8) | 48.8b (45.1, 52.6) | 78.7 (75.1, 82.4) | 77.2 (72.9, 81.5) |
Note. CI = confidence interval.
Worker estimates based on NHIS sampling weights and estimates vary by screening age cutoff and nonresponse to screening questions.
Statistically different compared with all workers within the same year.
Sample size was under 45, which is considered unstable by the NHIS.
Statistically different between years.
Race/Ethnicity
Both male and female Hispanic workers reported the lowest prevalence of cancer screening for all screening examinations. These differences were statistically significant and included home or office blood stool screening (2005: 24.5% Hispanics vs 41.0% all US workers), colorectal screening (2000: 23.7% vs 32.4%), manual breast examination (2005: 62.2% vs 83.3%), mammogram (2005: 75.2% vs 86.5%), Papanicolaou test (2000: 85.2% vs 93.9%), and PSA (2005: 37.4% vs 50.8%). In general, Black workers reported cancer screening rates between those of Hispanics and all US workers (including Blacks and Hispanics).
Industry and Occupation
Among the National Institute of Occupational Safety and Health NORA industry sectors (Table 2) for all workers; those in agriculture, forestry, or fishing; and those in construction had the lowest reported rates of cancer screening. These included home or office blood stool screening (2000: construction workers, 27.0%; 2005: agricultural workers, 27.6%), colorectal screening (2000: agricultural workers, 23.2%), manual breast examination (2005: agricultural workers, 72.7%), mammogram (2000: construction workers, 77.1%), and Papanicolaou test (2000: construction workers, 87.1%). However, manufacturing workers reported the lowest rates of PSA testing in 2000 (40.1%).
Among the NCHS occupational status (Table 3) for all workers, farm workers in general had the lowest reported rates of cancer screening, although blue collar and service-industry worker rates were also low. These included home or office blood stool screening (2005: farm workers, 21.5%), colorectal screening (2000: farm workers, 20.8%), manual breast examination (2005: farm workers, 67.0%), mammogram (2005: farm workers, 61.2%), and Papanicolaou test (2005: farm workers, 79.1%). However, blue collar workers reported the lowest rates of PSA testing in 2000 (42.5%).
Health Insurance
With respect to respondents’ reports of having current health insurance, Hispanic workers had the lowest statistically significant reported rates compared with all workers within the same year (2005: 59.1% vs 82.3%). For the NORA sectors, Hispanic workers in agriculture, forestry, or farming had the lowest rates (29.9%) of health insurance coverage in 2000, and Hispanic construction workers had the lowest rates (30.6%) of health insurance coverage in 2005. For occupational status, Hispanic farm workers had the lowest rates (30.4%) of health insurance coverage in 2000.
DISCUSSION
These results from a nationally representative sample demonstrate substantial health disparities in reported cancer screening behavior among US workers by race/ethnicity and by industry or occupational group. In general, taking into account small sample sizes, Hispanic workers and workers in the farming and construction industry or occupations reported the lowest rates of cancer screening. These same workers also reported the lowest rates of health insurance coverage. The reported lack of health insurance is particularly worrisome given that the US health care system relies heavily on health insurance from employers to cover not only the worker but also the worker's family.
A major limitation of the NHIS survey is that the data are self-reported and may misrepresent true rates of screening or health insurance coverage. For example, based on a review of studies that compared self-reported chronic conditions in the NHIS with physicians’ records, there is considerable underreporting and some overreporting by the participants.11,12 However, results for US workers in terms of both self-reported health insurance and cancer screening behavior are consistent with other national survey sources.13 A second limitation is with sample size in some occupational and race/ethnicity categories. The NCHS considers sample sizes of fewer than 45 to be unstable; however, we included small samples in the tables to provide important national data on the National Institute of Occupational Safety and Health NORA industrial sectors and on occupational status for the occupational health and primary care communities. Finally, these are cross-sectional data; therefore, we cannot conclude, for example, that the low reported prevalence of health insurance coverage among Hispanic workers is responsible for the low use of cancer screening among these same workers.
Although cancer screening behavior has been shown to depend on many factors,14–16 our results suggest that access to care is a major obstacle. Health insurance and cancer screening are increasingly made available through the workplace.17,18 Therefore, results from this study can be used to target workplace cancer screening programs, particularly those that serve the subpopulations of workers who lack health insurance.
Acknowledgments
This study was funded in part through the National Institute of Occupational Safety and Health (grant R01 OH03915).
Human Participant Protection
This study was approved by the University of Miami's Miller School of Medicine institutional review board.
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