Variation in Colorectal Cancer Screening Practices According to Cardiovascular Disease Status and Race/Ethnicity

Abstract

Purpose:

To assess current estimates of colorectal cancer (CRC) screening practices in relation to cardiovascular disease (CVD) status, and whether this association varies by race/ethnicity.

Methods:

Cross-sectional analysis of the Behavioral Risk Factor Surveillance System data from 2012, 2014, 2016 and 2018 among US adults aged 50–75 years (n=807,937). Participants’ self-reported CRC screening practices were categorized as being up-to-date, not-up-to-date, or never screened. Multinomial logistic regression was used to assess whether self-reported prevalent CVD was associated with CRC screening practices after adjusting for several potentially confounding variables; additional analyses were stratified by race/ethnicity.

Results:

One-quarter of US adults had never been screened for CRC, while 67.0% reported being up-to-date with CRC screening. The proportion of Hispanics who had never been screened (35.3%) was higher than non-Hispanic whites (23.5%) and blacks (20.6 %). Adults with CVD were less likely to never have been screened (adjusted Odds Ratio (aOR): 0.92, 95% Confidence Interval (CI): 0.88–0.95) or not to be up-to-date (aOR: 0.90, 95% CI: 0.86–0.94) on CRC screening than those without CVD.

Conclusion:

The presence of CVD is associated with better adherence to CRC screening guidelines. Poor CRC screening utilization in Hispanics should be a priority for further investigation and intervention.

Introduction

Colorectal cancer (CRC) screening is effective in reducing incidence and mortality from the disease,¹ and is recommended for eligible adults by the US Preventive Service Task Force.¹ However, utilization rates of CRC screening in the US remain low, especially among Hispanics.² During 2016, the use of sigmoidoscopy or colonoscopy for CRC screening among whites (72.5%) and blacks (67.8%) was higher than among Hispanics (56.1%).³ Despite an overall decline in CRC incidence rates over the last 10 years, particularly among older adults, marked racial disparities in CRC incidence and mortality persist.⁴ For example, CRC incidence and mortality rates in non-Hispanic blacks were about 20% and 40% higher, respectively, than those in non-Hispanic whites in 2015.² Identifying potential barriers to CRC screening is critical, and more so among racial/ethnic minority populations, because it could allow for the development of targeted interventions.

Cardiovascular disease (CVD), the most prevalent chronic disease and leading cause of death in the US,⁵ has many risk factors in common with CRC, including obesity, poor diet, physical inactivity, and smoking.⁶ Moreover, CVD morbidity and mortality vary by race/ethnic groups, with African Americans experiencing disproportionally higher incidence and mortality from CVD than whites.⁷ A recent study found that men with CVD were 40% less likely to be up-to-date with CRC screening recommendations than men without CVD⁸, while the role of CVD on CRC screening among people by race/ethnicity has not been explored.

Managing CVD and adhering to screening recommendations for CRC are both crucial to maintaining overall health, particularly among non-Hispanic blacks who are at a higher risk for both diseases.^4,7 This study examines current estimates of CRC screening practices in a nationally representative study population and evaluates the association between having CVD and adherence to current CRC screening recommendations overall and by race/ethnicity.

Methods

Study population

This cross-sectional analysis used data from the 2012, 2014, 2016 and 2018 Behavioral Risk Factor Surveillance System (BRFSS).⁹ We combined data from four years of the study because the CRC screening module was fielded in all jurisdictions in these years, making nationally representative inferences from these data possible. Briefly, BRFSS participants are selected to participate in the telephone survey by random digit dialing of non-institutionalized adults aged ≥ 18 years residing in the US. The BRFSS collects data in all 50 states as well as the District of Columbia, Guam, Puerto Rico, and the US Virgin Islands. The BRFSS has continuously collected data on health-related behaviors, chronic health conditions, and use of preventive services since 1984. With a multistage sampling design of households, the survey selects a nationally representative sample of the civilian, non-institutionalized US population. The BRFSS is an extensive questionnaire survey monitoring various health indicators in the US population and changes in these factors over time.¹⁰ The median survey response rate for all states, territories and Washington, DC, was 45.2% (range: 27.7% - 60.4%) in 2012, 47.0%,(range: 25.1% - 60.1%) in 2014, 47.0% (range: 30.7% - 65.0%) in 2016 and 49.9% (range: 38.8% - 67.2) in 2018.⁹

Of the total 1,864,086 participants in BRFSS 2012, 2014, 2016 and 2018 combined, we excluded those who (1) were outside the recommended age range for CRC screening (i.e., younger than 50 years or older than 75 years; n = 906,603); (2) lacked self-reported data on CVD (n = 378) or CRC screening (n=48,353); (3) were not white, black or Hispanic (n=46,664); (4) or had missing data on covariates (n=54,151). Our final study population included 807,937 men and women aged 50–75 years (Supplemental Figure 1).

Operational definition of CRC screening

The outcome of our study was defined as adherence to CRC screening recommendations as defined by the 2008 US Preventive Service Task Force (USPSTF) guidelines.¹¹ BRFSS respondents were asked whether they ever had a fecal occult blood test (FOBT), sigmoidoscopy and/or colonoscopy, and the time since the most recent test was performed. Based on the responses, a composite CRC screening variable was created (up-to-date; not up-to-date; never screened). Up-to-date participants were defined as respondents who used a home FOBT kit in the previous year, had a sigmoidoscopy in the past 5 years, and/or had a colonoscopy in the past 10 years. Participants were defined as not up-to-date with screening recommendations if they had taken one or more of the three tests but none within the recommended time frame. Never-screened participants were defined as respondents who had never used any of the three tests. Previous studies assessing the reliability and validity of measures related to preventive screening have shown consistency across national surveys including the BRFSS, finding that adults could more accurately recall if they had a preventative test than the actual dates of screening.¹⁰

Operational definition of CVD

Prevalent CVD was defined by self-reported diagnosis of CVD according to the following questions: ―Has a doctor, nurse, or other health professional ever told you that you had any of the following? (1) you had a heart attack, also called a myocardial infarction? (2) you have angina or coronary heart disease? (3) you had a stroke?‖ A composite, binary CVD variable was created using the responses: presence of any CVD (if responded ―yes‖ to any of the above questions); and no CVD (if responded ―no‖ to all three questions). A self-reported diagnosis of CVD has been shown to be moderately to highly accurate in the BRFSS survey when compared to receipt of prescription drugs for treatment of CVD.¹⁰

Definition of Covariates

Race/ethnicity was defined by self-report as non-Hispanic white, non-Hispanic black, or Hispanic of any race(s). We analyzed as potential confounders other sociodemographic characteristics that have previously been found to be associated with CVD and/or CRC screening including: age (continuous), sex, educational attainment (less than high school; high school diploma or GED; some college or technical school; college graduate), marital status (married; divorced, separated, or widowed; never married; a member of an unmarried couple), and employment status (employed; unemployed/unable to work; retired/homemaker/student).⁶

Clinical characteristics previously found to be associated with CVD and/or CRC screening were also examined as potential confounders, including: self-reported general health (excellent; very good; good; fair/poor); self-reported chronic conditions, which included asthma, diabetes (excluding gestational diabetes), cancer (excluding non-melanoma skin cancer), chronic respiratory condition (including Chronic Obstructive Pulmonary Disease (COPD), emphysema or chronic bronchitis), musculoskeletal disease (including arthritis, rheumatoid arthritis, gout, lupus, or fibromyalgia), depression (including depression, major depression, dysthymia, or minor depression), and kidney disease (excluding kidney stones, bladder infection or incontinence); number of chronic conditions (0, 1–2, and >2); smoking status (current, former, never smoker); and binge drinking (males having five or more drinks or females having four or more drinks on one occasion in the past month).^6,8,12

Healthcare characteristics that were also considered as potential confounders include health insurance coverage (any coverage vs no coverage), having a personal doctor or health care provider (yes/no), reported financial barriers to healthcare access (yes/no), and having had a routine checkup within the past 12 months (yes/no).^13,14 Since the addition of these variables to the multivariable model did not materially change the effect estimates, they were not retained in the final models.

Statistical analysis

All results were weighted to be representative of the broader population of U.S. adults aged 50 – 75 years using standard BRFSS weights,⁹ adjusting for the unequal probability of being selected, noncoverage by the survey, and nonresponse. Weights for data from all years were divided by the number of years of survey data available from each jurisdiction. BRFSS sampling strata may vary from year to year, and primary sampling unit (PSU) identifiers are recycled from one year’s data collection to the next. In order to avoid treating unrelated observations as coming from related strata or PSUs simply because they were interviewed in different years, we used year-specific strata and PSU identifiers in all analyses. We described and compared sociodemographic, clinical and healthcare characteristics among participants with never, not up-to-date and up-to-date CRC screening status.

We used multinomial logistic regression models to examine the association between the presence of CVD and CRC screening status. We entered all potential covariates into the model and examined the extent to which the inclusion of the covariates changed the odds ratios (ORs). The final set of variables for statistical adjustment were selected using a combination of clinical judgment, and magnitude of change in the effect estimate greater than ten percent from univariate analyses. The final set of covariates included in the models were age, sex, race/ethnicity, marital status, binge drinking, smoking, depressive disorder, and date of last routine check-up. Since we were interested in how the association between CVD and CRC screening varied among non-Hispanics whites, non-Hispanic blacks and Hispanics, we also stratified the analyses by race/ethnicity.

Results

Study sample characteristics

After applying BRFSS weights, our weighted sample represents 78 million American adults 50–75 years of age. Within the entire population, 77% were non-Hispanic whites, nearly two-thirds were less than 65 years of age, and nearly half were women. One in eight self-reported a history of CVD. One-quarter of US adults had never been screened for CRC. Overall, 69% of adults aged 50 to 75 years had ever had a colonoscopy, and 25% had a combination of two or more tests (colonoscopy, sigmoidoscopy, and/or FOBT). Sigmoidoscopy was used the least overall (2%), followed by the FOBT (31%). Two-thirds of the population were up-to-date with CRC screening guidelines, among whom the majority reported that they had a colonoscopy (95%). Among the 7.8% of adults who were not-up-to-date with their CRC screening, 43% reported having had a colonoscopy, but not within the recommended timeline.

Characteristics of the study sample according to screening status

Two-thirds (67%) of adults who had never been screened for CRC were 50–60 years old, while 61% of those who were up-to-date reported to be 60 years or older (Table 1). One-fifth of adults who had never been screened for CRC had less than high school education, 25% reported had fair or poor health, and 18% were current smokers. In contrast, among adults who were up-to-date with CRC screening, only 10% had less than high school education, 22% had fair or poor health, and 9% were current smokers. In terms of healthcare access, among those who had never been screened for CRC, 18% had no healthcare coverage, 24% had no personal doctor, and 18% reported financial barriers to care, whereas only 8% of adults up-to-date with screening recommendations reported financial barriers to care. One-third of those who were never screened for CRC had not had a routine check-up within the past 12 months compared to 13% of those who were up-to-date with screening recommendations.

Table 1.

Sociodemographic, clinical and healthcare characteristics among US adults 50–75 years old, by colorectal cancer screening status: 2012, 2014, 2016 and 2018 Behavioral Risk Factor Surveillance System^*

	Screening up-to-date1 N=564,824 (67.0%)	Screening not up-to- date2 N=68,268 (7.8%)	Never screened3 N=174,845 (25.1%)
Age (years), percent
50–54	17.8	21.5	42.9
55–59	21.0	19.3	22.7
60–64	23.1	24.2	16.8
65–69	19.5	18.2	9.7
70–75	18.6	16.9	7.9
Women	53.7	56.5	48.7
Race/ethnicity
Non-Hispanic white	79.8	80.4	70.4
Non-Hispanic black	11.3	9.4	11.7
Hispanic	8.9	10.2	17.9
Education
Less than High School	10.1	12.4	20.8
Graduated High School	27.3	29.3	32.2
Some College or Technical School	32.1	32.2	27.7
College Graduate/Technical School	30.5	25.7	19.3
Married	67.8	60.3	58.9
Employment status
Employed	45.3	45.0	57.9
Unemployed/unable to work	13.7	16.9	19.1
Retired/ homemaker/student	41.0	38.1	22.9
Self-reported fair or poor general health status	21.7	25.7	25.2
CVD4	14.4	14.8	11.8
Self-reported chronic conditions
Asthma	10.0	10.0	7.8
Diabetes	18.8	19.1	15.4
Other cancer	12.3	9.4	5.3
Musculoskeletal disease	45.7	43.2	30.9
COPD5	10.4	11.4	8.8
Depressive disorder	20.2	21.4	16.4
Kidney disease	4.6	4.2	3.1
>2 chronic conditions	14.1	13.7	8.7
Current Smoker	9.0	13.0	18.4
Binge drinker	10.0	9.4	13.7
No healthcare coverage	3.8	9.4	18.2
No personal doctor	5.1	12.4	24.1
Couldn’t see doctor because cost	8.0	13.8	17.6
≥12 months since last time routine checkup	12.7	26.2	36.7
Survey year
2012	23.7	25.0	25.8
2014	24.2	24.4	25.5
2016	25.5	25.1	24.8
2018	26.6	25.4	23.9

^*Values presented are weighted according to BRFSS methodology. (Unweighted N = 807,937; weighted N = 77,705,559).

¹Up-to-date = used a home FOBT kit last year, had a sigmoidoscopy past 5 years or had a colonoscopy in the past 10 years (Unweighted N = 564,824, weighted N = 52,117,351);

²Not up-to-date = has used a home FOBT kit, had a sigmoidoscopy or a colonoscopy but not within recommended timeframe (Unweighted N = 68,268, weighted N = 6,050,091);

³Never screened = Never used a home FOBT kit, had a sigmoidoscopy and had a colonoscopy (Unweighted N = 174,845, weighted N = 19,540,116).

⁴CVD=Cardiovascular disease, a history of heart attack/myocardial infarction, coronary heart disease/angina, and/or stroke vs. the absence of all three conditions.

⁵COPD=Chronic Obstructive Pulmonary Disorder

Association between cardiovascular disease and colorectal cancer screening

The distribution of CRC screening status according to CVD status for the population reveals that adherence to CRC screening recommendations was higher in those with CVD than without (Figure 1). The unadjusted model of CVD with CRC screening indicated a positive association, but after adjusting for age, the association became negative, suggesting age was a major confounder of this association. After adjusting for additional selected covariates, adults with CVD were less likely than people without CVD to report never having been screened (aOR: 0.92; 95% CI: 0.88–0.95) or being not up-to-date (aOR: 0.90; 95% CI: 0.86–0.94) with CRC screening recommendations (Table 2).

Figure 1.

Self-reported cardiovascular disease and colorectal cancer screening status overall and by race/ethnicity, Behavioral Risk Factor Surveillance System data from 2012, 2014, 2016, 2018.^1,2

¹Values presented are weighted according to BRFSS methodology.

²Interaction between race/ethnicity and CVD, p-value<0.05

Table 2.

Association between self-reported cardiovascular disease and colorectal cancer screening status, overall and by race/ethnicity: data from 2012, 2014, 2016 and 2018 Behavioral Risk Factor Surveillance System.

	Crude Association with CVD [Odds Ratio (95% CI)]	OR Adjusted for Age, Sex and Race/ethnicity (95% CI)	Multivariable Adjusted*OR (95% CI)
Overall
Never screened	1.25 (1.21–1.30)	0.98 (0.95–1.02)	0.92 (0.88–0.95)
Not up-to-date	0.97 (0.92–1.00)	0.92 (0.88–0.96)	0.90 (0.86–0.94)
Up-to-date	(ref)	(ref)	(ref)
By race/ethnicity
Non-Hispanic White
Never screened	1.25 (1.21–1.30)	0.95 (0.92–0.99)	0.91 (0.87–0.94)
Not up-to-date	0.93 (0.89–0.98)	0.89 (0.84–0.93)	0.88 (0.84–0.92)
Up-to-date	(ref)	(ref)	(ref)
Non-Hispanic Black
Never screened	1.16 (1.05–1.28)	0.99 (0.90–1.10)	0.93 (0.84–1.03)
Not up-to-date	0.94 (0.81–1.10)	0.90 (0.78–1.05)	0.92 (0.78–1.07)
Up-to-date	(ref)	(ref)	(ref)
Hispanics of any race
Never screened	1.35 (1.17–1.56)	1.12 (0.96–1.30)	0.95 (0.81–1.11)
Not up-to-date	1.28 (1.03–1.59)	1.18 (0.95–1.46)|	1.13 (0.90–1.41)
Up-to-date	(ref)		(ref)

Values presented are weighted according to BRFSS methodology.

OR: odds ratio

95% CI = 95% confidence interval

^*Adjusted for age, sex, race/ethnicity, marital status, depression, current smoking, binge drinking, and having had a checkup in the past year.

Association between cardiovascular disease and colorectal cancer screening according to race/ethnicity

Regardless of the presence of CVD, nearly two-thirds of non-Hispanic whites (23.5%) and non-Hispanic blacks (20.6 %). were up-to-date with CRC screening, more than 10% higher than Hispanics (35.3%). There were not large disparities in CRC screening between non-Hispanic blacks and non-Hispanic whites, but the proportion of Hispanics who had never been screened is higher (41%) than the proportion of non-Hispanic whites (23%) and blacks (27%) (Figure 1).

Compared to non-Hispanic whites without CVD, non-Hispanic whites with CVD were 9% less likely to report having never been screened (aOR: 0.91; 95% CI: 0.87–0.94) and 12% less likely to be not up-to-date with their screening (aOR: 0.88; 95% CI: 0.84–0.92) (Table 2). Among non-Hispanic blacks, those with CVD were 7% less likely to never have been screened (aOR: 0.93; 95% CI: 0.84–1.03), and 8% less likely to not be up-to-date (aOR: 0.92; 95% CI: 0.78–1.07). Furthermore, among Hispanics, those with CVD were 5% less likely to never have been screened (aOR: 0.95; 95% CI: 0.81–1.11), and 13% more likely to not be up-to-date (aOR: 1.13; 95% CI: 0.90–1.41). Although these associations were not statistically significant among non-Hispanic blacks and Hispanics.

Discussion

CRC has a better prognosis when detected at an early stage,¹⁵ and thus, understanding the factors that influence the utilization of CRC screening and early cancer detection is important. We found that one-quarter of US adults aged 50–75 years had never been screened for CRC, and this group was more likely to be younger and Hispanic than those who had been screened for CRC. Moreover, these findings suggest that the presence of CVD is associated with better adherence to CRC screening guidelines. Relative to those without CVD, Americans with CVD were more likely to be up-to-date with CRC screening recommendations. Stratified analyses by race/ethnicity suggests similar relationships between CVD and adherence to CRC screening guidelines among non-Hispanic black and non-Hispanic white.

Estimates of colorectal cancer screening in the U.S.

In 2018, the Centers for Disease Control and Prevention reports that nearly two-thirds (65.2%) of US adults were up-to-date with CRC screening, a higher rate of screening compared to 2008 (52.1%),² and closer to the Healthy People 2020 goal of achieving a CRC screening rate of 70.5% among adults 50–75 years old.¹⁶ This increase in the CRC screening rate could be explained in part by Medicare covering CRC screening since 1990¹⁷ awareness campaigns, and implementation of the Affordable Care Act.^18,19 In addition, we found that nearly 2 in 5 Hispanics never underwent any CRC screening test, which is comparable with previous estimates.¹⁶ Reasons for underutilization of CRC screening by Hispanics is likely multifactorial and could be due to fear, cost, lack of awareness, low literacy/educational levels, and/or lack of provider recommendations.²⁰ It is possible that personal preference for type of screening test influences adherence to screening guidelines; a recent study found that patients for whom colonoscopy was recommended were less likely to complete CRC screening than those recommended FOBT or offered a choice between both.²¹

We found that screening rates were substantially lower in adults aged 60 years and under compared to those over 60 years. Recent guidelines from the American Cancer Society (2018) recommended initiating CRC screening as early as age 45 years.²² Cost could be a major barrier, especially for this age group, since colonoscopies are one of the more expensive preventive services covered under the Affordable Care Act, and the entire cost of the procedure may not be fully covered, particularly when a biopsy is required.¹⁷ One US study reported that among adults aged 50–64 years, CRC screening rates were lowest among the uninsured.¹⁸ Our study results were in line with this observation as there were four times as many people without insurance coverage among those who were never screened than adults who were up-to-date with screening guidelines.

Association between cardiovascular disease and colorectal cancer screening

Prior studies suggest patients diagnosed with several chronic diseases including CVD, arthritis, diabetes mellitus, and hypertension have suboptimal cancer screening utilization.⁸ Physicians may spend more time counseling and managing CVD or other chronic co-morbid conditions, and thus have less time to manage preventative care.²³ However, in contrast, our study provides evidence that CVD may not be a large barrier to CRC screening in U.S. adults aged 50 to 75 years. It is possible that CVD was underreported in the BRFSS study population, as some individuals may have undiagnosed CVD. However, since awareness of CVD status is unlikely to be related to CRC screening, this would result in non-differential misclassification of CVD status, and bias results towards the null.

Association between cardiovascular disease and colorectal cancer screening according to racial/ethnic groups

Consistent with prior research, we observed a large racial/ethnic disparity in CRC screening,³ with 35.3% of Hispanic, 20.6% of non-Hispanic black, and 23.5% of non-Hispanic white adults aged 50–75 having never been screened for CRC. We observed similar associations between CVD and never been screened for CRC screening practices among non-Hispanic whites, non-Hispanic blacks and Hispanics, although these associations were not statistically significant among non-Hispanic blacks and Hispanics. There are several potential explanations for this. First, racial/ethnic minority populations have less access to healthcare services than non-Hispanic whites, and as a result, it is possible that racial/ethnic minorities may be less likely to be clinically diagnosed with CVD.²⁰ This would likely bias study findings towards the null. For those with diagnosed CVD, several mechanisms are possible to explain the lack of observe association between CVD and CRC screening. It is possible that racial/ethnic minorities may receive less aggressive CVD care owing to severity of disease, access to care, or suboptimal healthcare on the basis of race relative to non-Hispanic whites.²⁴ Alternatively, it may be that racial/ethnic minorities receive similar CVD care as non-Hispanic whites, but be less adherent to CVD treatments.²⁵ It is also possible that structural impediments such as language and health literacy to CRC screening are having a greater influence over a diagnosis of CVD in non-Hispanic whites.²⁶ We may also have lacked sufficient statistical power to detect an association given that the sample size for Hispanics and non-Hispanic blacks was much smaller than that of non-Hispanic whites.

Study strengths and limitations

There are several important strengths of our study. We used contemporary data from BRFSS, a comprehensive survey of health indicators generalizable to the US population, to calculate nationally representative estimates of CRC screening practices. To our knowledge, this is the first study to analyze CRC screening in three categories (never, not up-to-date, up-to-date), which allows us to investigate potential differences in people who were never screened and those who had been screened but were not up-to-date according to USPSTF screening guidelines. The BRFSS also enabled us to examine multiple CRC screening testing modalities, and also investigate the role of CVD and race/ethnicity in the utilization of screening tests and the ability to adjust for numerous potential confounders.

These results should be interpreted in light of several limitations. The BRFSS is a cross-sectional study. As such, the temporal sequence between CRC screening and CVD diagnosis is unclear. In addition, CVD status and CRC screening utilization were self-reported. However, the diagnosis of CVD has been shown to be moderately to highly accurate in the BRFSS.¹⁰ We could not identify high-risk populations who would likely be getting CRC screening tests for reasons that are different than the general population, such as patients with colitis and Crohn’s disease, patients with a family history of Lynch syndrome/hereditary nonpolyposis CRC or other genetic conditions that predispose them to CRC, and those with a family history of other cancers. These high-risk subgroups have different screening recommendations; however, these conditions are relatively rare, and we do not expect them to greatly impact the results observed in the present study. We were not able to exclude participants with a history of CRC, since the annual core BRFSS questionnaire only asks if the respondent has ever had skin cancer or any cancer without further specifying the type. Colonoscopy or sigmoidoscopy among patients with history of CRC would likely be for surveillance of existing disease rather than for screening purposes.¹ Also, BRFSS does not ask respondents to specify the reason why these tests were conducted (e.g. for screening versus diagnostic reasons). As a result, we could only discern if the respondent had a particular test and when it was last administered, and by default, we included tests done for reasons other than screening in our analysis. For this reason, it is possible that our analysis overestimates screening rates.

Implications

To improve adherence to the USPSFT CRC screening recommendations, better communication between patients and providers, such as the use of messaging in electronic medical records, could remind patients to keep up-to-date with their screening.^27,28 Cost-sharing policies for colonoscopies and other procedures should be examined in light of the new, younger recommended age to begin CRC screening for adults aged 45–55 years.²⁹ Encouraging the use of newer, less invasive, and potentially more acceptable CRC screening tests like the fecal immuno-chemical test (FIT), high sensitivity guaiac-based FOBT and FIT DNA test may increase compliance with CRC screening guidelines among the general public.² Furthermore, efforts to expand culturally competent education programs, including peer support interventions, focusing on patient-centered care and care coordination would likely be beneficial at improving screening rates and reducing disparities, particularly among racial/ethnic minorities.³⁰

Conclusions

During the years under study, two-thirds of U.S. adults aged 50–75 years reported being up-to-date with current CRC screening recommendations. Lower rates of CRC screening utilization in Hispanics should be a priority for further investigation and intervention. Non-Hispanic whites with CVD were more likely than non-Hispanic whites without CVD to be up-to-date with CRC screening guidelines, suggesting that presence of CVD itself is not a barrier for this population in getting screened for CRC. Similar rates of CRC screening were seen in non-Hispanic blacks and Hispanics with or without CVD. Our findings underscore the need to develop methods to increase rates of CRC screening in US adults, and particularly among Hispanics. Proper clinical practice guidelines and strategies should be further suggested to physicians for the management of cancer screening in patients with CVD to ensure comprehensive care.