Abstract
Introduction:
The U.S. Preventive Services Task Force recommends breast, cervical and colorectal cancer (CRC) screening to reduce mortality from these cancers, but screening use has been below national targets. The purpose of this study is to examine the proportion of screening-eligible adults up-to-date with these screenings, and how screening use compares to Healthy People 2020 (HP2020) targets.
Methods:
Data from the 2019 National Health Interview Survey (NHIS) were used to examine percentages up-to-date with breast cancer screening among women aged 50‒74 years without prior breast cancer; cervical cancer screening among women aged 21‒65 years without prior cervical cancer or hysterectomy; and CRC screening among adults aged 50‒75 years without prior CRC. Estimates are presented by sociodemographic characteristics and healthcare access factors. Analyses were conducted in 2021.
Results:
Percentages of adults up-to-date were 76.2% (95%CI 75.0–77.5) for breast cancer screening, 76.4% (95%CI 75.2%−77.6%) for cervical cancer screening, and 68.3% (95%CI 67.3%−69.3%) for CRC screening. Although some population subgroups met breast and CRC screening targets (81.1% and 70.5%, respectively), many did not, and cervical cancer screening was below the target for all examined subgroups. Lower education and income, non-metropolitan county of residence (which included rural counties), no usual source of care or health insurance coverage, and Medicaid coverage were associated with lower screening test use.
Conclusions:
Estimated use of breast, cervical and CRC screening tests based on the 2019 NHIS were below national targets. Continued monitoring may allow examination of screening trends, inform interventions, and track progress in eliminating disparities.
INTRODUCTION
The U.S. Preventive Services Task Force (USPSTF) recommends breast, cervical, and colorectal cancer (CRC) screening.1 Screening use has been below national targets, with disparities among some population groups.2,3 This analysis uses the most recent National Health Interview Survey (NHIS) data to examine use of these screenings. Findings are compared with Healthy People 2020 (HP2020) targets.4 The USPSTF recommends lung cancer screening for some adults;1 however, this information was not collected in 2019.
METHODS
Study Sample
Data came from the 2019 NHIS, a survey of a nationally representative sample of the civilian, noninstitutionalized U.S. population.5 NHIS underwent survey redesign in 2019, including changes in some questions and response options, imputation methods, weighting and other changes.5 Screening questions (Table 1) were asked of 1 randomly selected adult from each household (final response rate 59.1%). For each screening type, screening-eligible adults per USPSTF recommendations were included (breast: n=7,289; cervical: n=11,763; CRC: n=13,989) (Table 2).1 Respondents with personal or unknown history of that cancer (breast: n=447; cervical: n=171; CRC: n=138), unknown screening status (breast: n=76; cervical: n=530; CRC: n=414), and for cervical screening previous or unknown hysterectomy (n=1,787) were excluded.
Table 1.
2019 National Health Interview Survey (NHIS) Questions on Breast, Cervical, and Colorectal Cancer Screening
| Cancer screening/NHIS survey universe | Survey question |
|---|---|
|
| |
| Breast cancer | |
| Females aged ≥30 years | Have you ever had a mammogram? |
| If yes: About how long has it been since your most recent mammogram? | |
| Cervical cancer | |
| Females aged ≥18 years | Have you ever had a test to check for cervical cancer? |
| If yes: When did you have your most recent test to check for cervical cancer? | |
| At your most recent cervical cancer screening, did you have a Pap test? | |
| At your most recent cervical cancer screening, did you have an HPV test? | |
| Colorectal cancer | |
| Adults aged ≥40 years | Colonoscopy and sigmoidoscopy are exams to check for colon cancer. Have you ever had either of these exams? |
| If yes: Have you had a colonoscopy, a sigmoidoscopy, or both? | |
| Adults aged ≥40 years who ever had sigmoidoscopy or both colonoscopy and sigmoidoscopy | When was your most recent sigmoidoscopy? |
| Adults aged ≥40 years who ever had colonoscopy or both colonoscopy and sigmoidoscopy | About how long has it been since your most recent colonoscopy? |
| Adults aged ≥40 years who ever had colonoscopy or sigmoidoscopy but don’t know which type | When was your most recent colonoscopy or sigmoidoscopy? |
| Adults aged ≥40 years | Have you ever had any other kind of test for colorectal cancer, such as virtual colonoscopy, CT colonography, blood stool test, FIT-DNA or Cologuard test? |
| Adults aged ≥40 years who had a test other than colonoscopy or sigmoidoscopy | Have you ever had a CT colonography or virtual colonoscopy? |
| If yes: When was your most recent CT colonography or virtual colonoscopy? | |
| Have you ever had a blood stool or FIT test, using a home test kit? | |
| If yes: When was your most recent blood stool or FIT test, using home test kit? | |
| Adults aged ≥40 years who ever had a home blood stool or FIT test | Have you ever had a Cologuard test? |
| If yes: Was the blood stool or FIT test you reported earlier conducted as part of a Cologuard test? | |
| When did you have your most recent Cologuard test? (not released) | |
HPV, human papillomavirus; CT, computed tomography; FIT, fecal immunochemical test.
Table 2.
Definitions of Up-to-Date With Cancer Screening, by Cancer Screening Type
| Screening type | Age and sex eligibility criteria | Definition of up-to-date with screening |
|---|---|---|
|
| ||
| Breast cancer | Women aged 50‒74 years | Mammography within 2 years |
| Cervical cancer | Women aged 21‒65 years | Papanicolaou (Pap) test within 3 years among women aged 21‒65 years, or human papillomavirus (HPV) test only or with Pap (co-test) within 5 years among ages 30‒65 years |
| Colorectal cancer | Adults aged 50‒75 years | Colonoscopy within 10 years, sigmoidoscopy or CT colonography within 5 years, home blood stool (FOBT) or fecal immunochemical (FIT) test within 1 year, or FIT-DNAa within 3 years |
Survey responses to the NHIS question about time since most recent FIT-DNA were not released because it was not asked of some respondents. For this analysis, respondents were considered up-to-date with FIT-DNA if their most recent FOBT/FIT was reported to have been part of FIT-DNA and received within 3 years, and not up-to-date if they never had FOBT/FIT or FIT-DNA, or if they had FIT-DNA and their most recent FOBT/FIT occurred more than 3 years prior.
NHIS, National Health Interview Survey.
Measures
Up-to-date screening included tests for any reason within USPSTF-recommended intervals. For CRC tests, responses about time since most recent fecal immunochemical test (FIT) with stool deoxyribonucleic acid tests (FIT-DNA) were not released by the National Center for Health Statistics (NCHS). Therefore, timing of home blood stool (FOBT) or FIT test was used to classify FIT-DNA status (Table 2).
Estimates are presented by sociodemographic characteristics and healthcare access factors (Tables 3‒4).5,6 Ethnicity includes Hispanic and non-Hispanic groups. Income is presented as percentage of poverty thresholds. County metropolitan status in NHIS includes 4 groups based on the 2013 NCHS Urban-Rural Classification Scheme for Counties.5 Usual source of care includes places respondents usually go when sick or needing healthcare. No usual source included no place, no one place most often, emergency rooms, urgent care centers, or grocery or drug store clinics.
Table 3.
Percentage of Women Up-to-Date With Breast and Cervical Cancer Screening ‒ U.S., 2019
| Characteristics | Breast cancer screening | Cervical cancer screening | ||||||
|---|---|---|---|---|---|---|---|---|
|
|
||||||||
| Sample n | Weighted % (95%CI) | p-valuea | HP2020 target | Sample n | Weighted % (95%CI) | p-valuea | HP2020 target | |
|
| ||||||||
| 81.1% | 93.0% | |||||||
| Overall ‒ unadjusted | 6,766 | 76.2 (75.0, 77.5) | 9,275 | 76.4 (75.2, 77.6) | ||||
| Overall ‒ age-standardizedb | 6,766 | 76.2 (74.9, 77.5) | 9,275 | 76.8 (75.6, 77.9) | ||||
| Age, years | 0.122 | <0.001 | ||||||
| 21‒30 | 2,017 | 71.1 (68.3, 73.8) | ||||||
| 31‒40 | 2,466 | 81.9 (79.9, 83.8) | ||||||
| 41‒50 | 1,896 | 79.3 (77.0, 81.5) | ||||||
| 51‒65 | 2,896 | 74.4 (72.4, 76.3) | ||||||
| 50‒64 | 4,085 | 75.5 (73.9, 77.2) | ||||||
| 65‒74 | 2,681 | 77.7 (75.5, 79.7) | ||||||
| Race | 0.109 | 0.001 | ||||||
| AIAN | 104 | 64.3 (52.2, 75.2) | 183 | 75.6 (63.6, 85.2) | ||||
| Asian only | 266 | 72.3 (64.7, 79.0) | 620 | 67.3 (62.4, 71.9) | ||||
| Black/African American only | 788 | 79.0 (74.9, 82.6) | 1,206 | 77.8 (74.7, 80.7) | ||||
| White only | 5,293 | 76.0 (74.5, 77.4) | 6,569 | 77.9 (76.5, 79.2) | ||||
| Other single and multiple race | 60 | 80.8 (68.2, 90.0) | 145 | 70.6 (60.2, 79.6) | ||||
| Missing/Unknown | 255 | 80.6 (74.0, 86.2) | 552 | 70.8 (65.5, 75.7) | ||||
| Ethnicityc | 0.308 | <0.001 | ||||||
| Non-Hispanic | 6,103 | 76.0 (74.6, 77.3) | 7,744 | 78.0 (76.7, 79.2) | ||||
| Hispanic | 663 | 78.1 (74.0, 81.8) | 1,531 | 69.9 (66.9, 72.9) | ||||
| Mexican/Mexican American | 341 | 77.3 (71.4, 82.5) | 876 | 70.2 (66.0, 74.1) | ||||
| All other Hispanic groupsd | 311 | 79.0 (72.9–84.2) | 642 | 69.4 (64.9–73.5) | ||||
| Education | <0.001 | <0.001 | ||||||
| <High school | 580 | 68.1 (62.9, 72.9) | 610 | 59.3 (54.1, 64.2) | ||||
| High school/GED | 1,710 | 73.2 (70.7, 75.7) | 1,965 | 68.9 (66.2, 71.5) | ||||
| Some college | 2,151 | 75.9 (73.7, 78.0) | 2,743 | 77.3 (75.3, 79.2) | ||||
| College degree | 2,304 | 82.5 (80.6, 84.3) | 3,933 | 85.1 (83.7, 86.4) | ||||
| Missing/Unknown | 21 | h | 24 | h | ||||
| Income, % poverty threshold | <0.001 | <0.001 | ||||||
| ≤138% | 1,225 | 66.9 (63.4, 70.3) | 1,808 | 64.6 (61.6, 67.6) | ||||
| >138%‒250% | 1,297 | 70.7 (67.3, 73.8) | 1,752 | 71.2 (68.3, 73.9) | ||||
| >250%‒400% | 1,320 | 75.1 (71.9, 78.0) | 1,947 | 77.8 (75.1, 80.2) | ||||
| >400% | 2,923 | 82.9 (81.2, 84.4) | 3,768 | 84.3 (82.8, 85.7) | ||||
| Duration of U.S. residence | 0.088 | <0.001 | ||||||
| <10 years | 58 | h | 372 | 56.4 (49.9, 62.7) | ||||
| ≥10 years | 869 | 77.4 (73.7, 80.8) | 1,335 | 73.4 (70.5, 76.2) | ||||
| Born in U.S. | 5,709 | 76.6 (75.2, 78.0) | 7,364 | 78.6 (77.3, 79.9) | ||||
| Missing/Unknown | 130 | 65.7 (54.8, 75.5) | 204 | 64.4 (55.4, 72.7) | ||||
| County metropolitan statuse | 0.002 | 0.033 | ||||||
| Large central metropolitan | 1,794 | 77.3 (74.8, 79.7) | 2,994 | 77.1 (75.1, 79.0) | ||||
| Large fringe metropolitan | 1,592 | 78.5 (75.9, 80.9) | 2,146 | 78.6 (76.3, 80.7) | ||||
| Medium/small metropolitan | 2,182 | 76.6 (74.3, 78.7) | 2,910 | 75.3 (73.1, 77.4) | ||||
| Nonmetropolitan | 1,198 | 70.5 (67.0, 73.8) | 1,225 | 72.9 (69.2, 76.4) | ||||
| Sexual orientation | 0.797 | 0.381 | ||||||
| Lesbian or gay | 61 | 72.1 (56.0, 84.9) | 138 | 72.3 (61.6, 81.4) | ||||
| Straight | 6,476 | 76.5 (75.2, 77.8) | 8,581 | 77.2 (76.0, 78.4) | ||||
| Bisexual | 37 | h | 244 | 72.3 (64.3, 79.3) | ||||
| Other | 16 | h | 48 | h | ||||
| Missing/Unknown | 176 | 68.0 (58.9, 76.1) | 264 | 58.6 (50.8, 66.0) | ||||
| Usual source of care | <0.001 | <0.001 | ||||||
| Yes | 6,136 | 79.3 (78.0, 80.6) | 7,582 | 79.6 (78.3, 80.8) | ||||
| No | 628 | 47.4 (42.3, 52.6) | 1,688 | 63.4 (60.5, 66.2) | ||||
| Missing/Unknown | 2 | h | 5 | h | ||||
| Insurancef | ||||||||
| Age <65 years | <0.001 | <0.001 | ||||||
| Private | 2,888 | 80.0 (78.2, 81.7) | 6,273 | 81.5 (80.2, 82.7) | ||||
| Medicaid/Other Public | 550 | 74.6 (70.0, 78.8) | 1,346 | 70.9 (67.6, 74.0) | ||||
| Other coverage | 282 | 78.5 (72.3, 83.9) | 396 | 78.1 (72.1, 83.3) | ||||
| Uninsured | 360 | 43.2 (37.0, 49.5) | 1,039 | 57.4 (53.6, 61.1) | ||||
| Missing/Unknown | 5 | h | 12 | h | ||||
| Age ≥65 yearsg | <0.001 | 0.799 | ||||||
| Private | 1,175 | 79.8 (76.5, 82.9) | 94 | 67.4 (55.0, 78.3) | ||||
| Medicare + Medicaid | 202 | 66.3 (57.1, 74.7) | 15 | h | ||||
| Medicare Advantage | 789 | 83.5 (80.1, 86.6) | 52 | 69.0 (54.0, 81.5) | ||||
| Medicare only | 365 | 66.5 (60.1, 72.6) | 29 | h | ||||
| Other coverage | 117 | 76.5 (66.5, 84.7) | 12 | h | ||||
| Uninsured | 26 | h | 7 | h | ||||
| Missing/Unknown | 7 | h | 0 | h | ||||
Notes: Boldface indicates statistical significance (p<0.05).
P-value from Wald F tests testing for any differences across groups excluding missing/unknown.
Overall percentages were age-standardized to the 2000 U.S. standard population. Percentages by sociodemographic characteristics and access to care factors are unadjusted.
P-value testing for differences between Hispanic and non-Hispanic groups.
Estimates are provided for Mexican/Mexican American adults. Separate information was not available from NHIS for other subgroups.
County metropolitan status in the 2019 NHIS includes 4 groups based on the 2013 NCHS Urban-Rural Classification Scheme for Counties.5,6
Within each age group, insurance was categorized hierarchically in order of categories listed.
Findings for cervical cancer screening include only women aged 65 years because USPSTF does not recommend routine cervical cancer screening after age 65 years.
Estimates suppressed because they did not meet National Center for Health Statistics reliability standards.7
AIAN, American Indian/Alaska Native (includes AIAN only or in combination); HP2020, Healthy People 2020; NHIS, National Health Interview Survey; NCHS, National Center for Health Statistics; USPSTF, U.S. Preventive Services Task Force.
Table 4.
Percentage of Adults Aged 50‒75 Years Up-to-Date With Colorectal Cancer Screening ‒ U.S., 2019
| Colorectal cancer screening | ||||
|---|---|---|---|---|
| Characteristics | Sample n | Weighted % (95% CI) | p-valuea | HP2020 target |
|
| ||||
| Overall ‒ unadjusted | 13,437 | 68.3 (67.3, 69.3) | 70.5% | |
| Overall ‒ age-standardizedb | 13,437 | 67.9 (66.9, 68.9) | ||
| Age, years | <0.001 | |||
| 50‒64 | 7,979 | 62.2 (60.9, 63.6) | ||
| 65‒75 | 5,458 | 79.7 (78.3, 81.0) | ||
| Sex | 0.002 | |||
| Male | 6,202 | 66.7 (65.2, 68.2) | ||
| Female | 7,235 | 69.8 (68.4, 71.0) | ||
| Race | <0.001 | |||
| AIAN | 216 | 62.8 (53.8, 71.1) | ||
| Asian only | 524 | 57.6 (51.9, 63.3) | ||
| Black/African American only | 1,461 | 69.5 (66.6, 72.2) | ||
| White only | 10,677 | 69.8 (68.7, 70.9) | ||
| Other single and multiple race | 97 | 62.6 (51.1, 73.1) | ||
| Missing/Unknown | 462 | 56.0 (50.3, 61.6) | ||
| Ethnicityc | <0.001 | |||
| Non-Hispanic | 12,202 | 70.3 (69.3, 71.3) | ||
| Hispanic | 1,235 | 53.8 (50.1, 57.4) | ||
| Mexican/Mexican American | 627 | 50.0 (45.3, 54.6) | ||
| All other Hispanic groupsd | 585 | 57.6 (52.1, 63.0) | ||
| Education | <0.001 | |||
| <High school | 1,235 | 52.2 (48.4, 56.0) | ||
| High school/GED | 3,496 | 64.5 (62.7, 66.3) | ||
| Some college | 4,034 | 71.0 (69.2, 72.7) | ||
| College degree | 4,616 | 76.3 (74.7, 77.9) | ||
| Missing/Unknown | 56 | g | ||
| Income, % poverty threshold | <0.001 | |||
| ≤138% | 2,253 | 53.7 (50.8, 56.5) | ||
| >138%‒250% | 2,454 | 62.1 (59.5, 64.7) | ||
| >250%‒400% | 2,615 | 68.7 (66.2, 71.1) | ||
| >400% | 6,115 | 75.8 (74.3, 77.2) | ||
| Duration of U.S. residence | <0.001 | |||
| <10 years | 107 | 29.0 (19.7, 39.8) | ||
| ≥10 years | 1,703 | 57.8 (54.9, 60.7) | ||
| Born in U.S. | 11,341 | 71.4 (70.4, 72.4) | ||
| Missing/Unknown | 286 | 57.5 (49.9, 64.9) | ||
| County metropolitan statuse | 0.002 | |||
| Large central metropolitan | 3,564 | 65.7 (63.6, 67.8) | ||
| Large fringe metropolitan | 3,233 | 70.5 (68.5, 72.4) | ||
| Medium/small metropolitan | 4,262 | 69.8 (67.9, 71.5) | ||
| Nonmetropolitan | 2,378 | 66.6 (63.9, 69.1) | ||
| Sexual orientation | 0.041 | |||
| Lesbian or gay | 172 | 77.4 (69.5, 84.1) | ||
| Straight | 12,778 | 68.5 (67.5, 69.6) | ||
| Bisexual | 67 | g | ||
| Other | 32 | g | ||
| Missing/Unknown | 388 | 57.5 (51.5, 63.4) | ||
| Usual source of care | <0.001 | |||
| Yes | 12,029 | 71.9 (70.9, 72.9) | ||
| No | 1,404 | 39.4 (36.4, 42.4) | ||
| Missing/Unknown | 4 | g | ||
| Insurancef | ||||
| Age <65 years | <0.001 | |||
| Private | 5,600 | 67.4 (65.9, 68.9) | ||
| Medicaid/Other public | 950 | 54.7 (50.4, 58.9) | ||
| Other coverage | 659 | 70.3 (66.0, 74.3) | ||
| Uninsured | 758 | 31.1 (27.1, 35.2) | ||
| Missing/Unknown | 12 | g | ||
| Age ≥65 years | <0.001 | |||
| Private | 2,350 | 85.4 (83.6, 87.0) | ||
| Medicare + Medicaid | 369 | 64.9 (57.9, 71.4) | ||
| Medicare Advantage | 1,506 | 82.2 (79.7, 84.6) | ||
| Medicare only | 714 | 68.8 (64.7, 72.7) | ||
| Other coverage | 461 | 79.1 (73.9, 83.8) | ||
| Uninsured | 47 | g | ||
| Missing/Unknown | 11 | g | ||
Notes: Boldface indicates statistical significance (p<0.05).
P-value from Wald F tests testing for any differences across groups excluding missing/unknown.
Overall percentages were age-standardized to the 2000 U.S. standard population. Percentages by sociodemographic characteristics and access to care factors are unadjusted.
P-value testing for differences between Hispanic and non-Hispanic groups.
Estimates are provided for Mexican/Mexican American adults. Separate information was not available from NHIS for other subgroups.
County metropolitan status in the 2019 NHIS includes 4 groups based on the 2013 NCHS Urban-Rural Classification Scheme for Counties.5,6 Differences between non-metropolitan counties and large fringe metropolitan counties (p=0.016) and medium/small metropolitan counties (p=0.045) were statistically significant.
Within each age group, insurance was categorized hierarchically in order of categories listed.
Estimates suppressed because they did not meet National Center for Health Statistics reliability standards.7
AIAN, American Indian/Alaska Native (includes AIAN only or in combination); HP2020, Healthy People 2020; NHIS, National Health Interview Survey; NCHS, National Center for Health Statistics.
Statistical Analysis
Estimates are presented as percentages with Korn-Graubard CIs. Overall percentages were age-standardized to the 2000 U.S. standard population. Wald F tests were used to test differences across groups. Design variables and survey weights were used to account for the complex sample design. Estimates not meeting NCHS standards for reliability were suppressed.7 SAS (version 9.4) and SUDAAN (version 11.0.03) were used in analyses conducted in 2021.
RESULTS
For breast cancer screening (Table 3), 76.2% of women were up-to-date (age-adjusted 76.2%), below the HP2020 target (81.1%). Lower use was associated with lower educational attainment and income, nonmetropolitan county, and no usual source of care or health insurance coverage. Use was generally lowest among women without a usual source of care (47.4%) or aged <65 years without health insurance coverage (43.2%).
For cervical cancer screening, 76.4% of women were up-to-date (age-adjusted 76.8%), below the HP2020 target (93.0%). Use was generally lowest among women without a high school education (59.3%), with U.S. residence <10 years (56.4%), and aged <65 years without health insurance coverage (57.4%).
For CRC screening (Table 4), 68.3% of adults were up-to-date (age-adjusted 67.9%), below the HP2020 target (70.5%). Use was generally lowest among those with U.S. residence <10 years (29.0%), no usual source of care (39.4 %) and aged <65 years without health insurance coverage (31.1%).
DISCUSSION
Based on 2019 NHIS estimates, three-quarters of women eligible for breast and cervical cancer screening and two-thirds of those eligible for CRC screening were up-to-date. Each was below HP2020 targets, although CRC test use approached its target. Some population subgroups exceeded breast and CRC targets while many did not. Screening disparities were observed by education, income, health insurance coverage, and U.S. residence duration, as previously reported.2,3 Nonmetropolitan counties had lower test use, a finding relevant to rural health. Lack of healthcare access has been associated with lower cancer screening uptake.8‒12 Consistent with this, lacking health insurance coverage or a usual source of care were strongly associated with lower test use. Although the disparities in the current analysis are not new,2,3 their persistence and the continued failure to meet national targets for screening test use are important. Such results can help inform efforts to implement strategies to address screening barriers and healthcare inequities. As the population grows and ages, more adults will be at risk for cancer13 and in need of screening, further underscoring efforts around promoting and facilitating recommended screening.
The 2019 NHIS redesign5 has implications for interpreting findings. The extent to which changes in questions and methods may have influenced estimates is uncertain, and changes limit direct comparison with prior years.14 Differences between 2019 estimates for breast and cervical cancer screening and those based on the 2018 NHIS (72.4% and 82.9%, respectively)2 could reflect changes in test use, survey changes, or both. Little change was reported in these 2 screenings from 2005 to 2018.2 In 2018, the USPSTF added human papillomavirus (HPV) testing alone as a cervical cancer screening option for women aged 30‒65 years.15 This option was included in this analysis and not the 2018 analysis,2 but this unlikely explains the lower proportion up-to-date in 2019. In general, increasing guideline complexity presents greater opportunity for missing or incomplete self-reported information about tests; differences in handling missing information could result in different estimates across studies. For CRC screening, differences between 2019 estimates and those using 2018 data (66.9%)2 were smaller. CRC screening use has increased over time,2 and findings could reflect that trend or survey changes. Although the redesign limits comparisons with earlier years, examining trends in future years will enable monitoring of screening use.
In March 2020, the WHO declared COVID-19 a pandemic,16 and subsequent reports documented reductions in cancer screening,17‒20 leading to concerns about the effects of delayed or canceled screenings on health outcomes.21,22 Evidence suggests at least a partial recovery in screening use over time.17,19,20 These 2019 findings can serve as a pre-pandemic baseline to compare with future estimates to assess recovery and growth in screening use.
Limitations
Findings are subject to limitations. Information is self-reported and not verified using medical records. Previous research demonstrated generally good validity for self-reported screening for breast, cervical and CRC, although some over-reporting has been noted.23‒25 Less is known about self-reported HPV tests for cervical cancer screening, suggesting an area for future research. Some variables had missing information for some respondents; thus, caution may be warranted in interpretating some subgroup estimates. The final sample adult response rate was 59.1%; therefore, nonresponse bias may be present despite survey weight adjustments. Up-to-date screening was defined as a relevant test for any reason among eligible adults within USPSTF-recommended intervals, consistent with HP2020 measures and earlier studies.2‒4,8,26 Furthermore, having a diagnostic test might result in being considered screened in effect. In an analysis of 2018 NHIS data, 95% of women who reported a recent mammogram said it was part of a “routine exam”,2 suggesting relatively few may be diagnostic. Similarly, an NHIS analysis examining CRC screening suggested most respondents indicated tests were done for screening purposes.8
CONCLUSIONS
Estimated breast, cervical and CRC screening test use based on the 2019 NHIS remained below national targets. Continued monitoring will help to examine progress in screening uptake and eliminating disparities, and track recovery from changes in use resulting from the pandemic.
ACKNOWLEDGMENTS
The findings and conclusions in this report are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention or the National Cancer Institute. Use of trade names and commercial sources is for identification only and does not imply endorsement by the U.S. Department of Health and Human Services. The National Health Interview Survey was funded by the U.S. government. All authors are federal government employees. Dr. Croswell reports spousal stock ownership in Johnson and Johnson. The authors report no other conflicts of interest.
Footnotes
Credit Statement
Susan Sabatino: Conceptualization, Methodology, Formal Analysis, Writing – Original Draft, Writing – Review & Editing, Project Administration. Trevor Thompson: Methodology, Software, Formal analysis, Data Curation, Writing – Review & Editing, Visualization. Mary White: Conceptualization, Methodology, Writing – Review & Editing. Jean Shapiro: Conceptualization, Methodology, Formal Analysis, Writing – Review & Editing. Tainya Clarke: Software, Validation, Writing – Review & Editing. Jennifer Croswell: Conceptualization, Writing – Review & Editing. Lisa Richardson: Writing - Review & Editing.
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REFERENCES
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