• We are sorry, but NCBI web applications do not support your browser and may not function properly. More information
Logo of amjphAmerican Journal of Public Health Web SiteAmerican Public Health Association Web SiteSubmissionsSubscriptionsAbout Us
Am J Public Health. 2006 December; 96(12): 2246–2253.
PMCID: PMC1698159

Telephone Outreach to Increase Colorectal Cancer Screening in an Urban Minority Population


Objectives. We compared the effectiveness of a telephone outreach approach versus a direct mail approach in improving rates of colorectal cancer (CRC) screening in a predominantly Black population.

Methods. A randomized trial was conducted between 2000 and 2003 that followed 456 participants in the New York metropolitan area who had not had recent CRC screening. The intervention group received tailored telephone outreach, and the control group received mailed printed materials. The primary outcome was medically documented CRC screening 6 months or less after randomization.

Results. CRC screening was documented in 61 of 226 (27.0%) intervention participants and in 14 of 230 (6.1%) controls (prevalence rate difference=20.9%; 95% CI = 14.34, 27.46). Compared with the control group, the intervention group was 4.4 times more likely to receive CRC screening within 6 months of randomization.

Conclusions. Tailored telephone outreach can increase CRC screening in an urban minority population.

The estimated 5-year survival rate from colorectal cancer (CRC) is greater than 90% for localized disease (stage 1),1,2 yet in 2005, CRC is expected to cause 56290 deaths in the United States1 and result in more than $6.5 billion in health care costs.3 Regular screening by the fecal occult blood test with follow-up treatment has been shown to reduce populationwide mortality by as much as 15% to 33%.47 Screening can also reduce CRC incidence by the removal of precursor lesions.8,9 On the basis of these data from randomized trials, CRC screening for individuals older than 50 years has been advocated by governmental,10 professional,11 and private organizations12 and has been shown to be cost-effective.1316 Nonetheless, the prevalence of CRC screening remains low,1720 particularly in low-income and minority populations,2124 who experience the highest rates of CRC mortality.17,2533

Black men and women have the highest incidence and mortality from CRC. During the period from 1992 to 2001, the annual CRC incidence was 13.2% greater for Black than for White men (72.9 vs 64.4 per 100000) and 21.7% greater for Black than for White women (56.1 vs 46.1 per 100000).26 During this period, the annual CRC mortality was 34% greater for Black than for White men (35.0 vs 26.1 per 100000) and 38% greater for Black than for White women (24.9 vs 18.0 per 100000).26

Several factors may contribute to these higher mortality rates within the Black population, including disparities in participation in CRC screening and consequent later stages at diagnosis3439 and lower rates of receipt of standard therapies and follow-up care.38,4043 Of the 35 randomized trials of interventions to increase CRC screening published between 1978 and 2004 that we identified,4478 only 6 included a substantial number of Black participants.45,46,50,51,70,72

Only 3 studies evaluated a tailored telephone intervention,63,64,77 and none of these included large numbers of Black participants. The effectiveness of telephone outreach on several cancer screening behaviors has been demonstrated,79,80 but no randomized trial to evaluate telephone outreach as a method to increase CRC screening in a predominantly Black population has been conducted. We therefore conducted a randomized trial to evaluate tailored telephone outreach compared with mailed printed material to increase CRC screening in a predominantly Black population of low to moderate income.


Study Design

A 2-group randomized trial with blinded ascertainment of outcomes was conducted. Eligibility was assessed by telephone, a baseline interview was completed, and individuals were invited to participate. Consenting participants were randomized in a 1:1 ratio to receive a tailored telephone educational intervention or mailed printed materials about CRC screening. Six months after randomization, medical claims and records were reviewed.

Setting and Participants

The study was conducted in the New York City metropolitan area. The sampling frame was constructed from membership lists of a health benefit fund comprising approximately 250000 members (or beneficiaries). Through the benefit fund, all these individuals had health insurance coverage that included coverage for CRC screening. Inclusion criteria were: age older than 52 years, no self-report of a recent CRC screening (defined as a home stool test within the past 2 years, a flexible sigmoidoscopy within the past 5 years, or a colonoscopy or barium enema within the past 10 years), no scheduled appointment for a CRC screening test, accessibility by telephone, ability to identify a current primary care physician, and consent to participate. Exclusion criteria included self-report of prior diagnosis of colorectal polyps, inflammatory bowel disease, colorectal cancer, or other cancer that had been treated within the past 5 years; stated intention to travel or to move away from the region within the subsequent 6 months; being unemployed, retired, or unable to work because of disability; enrollment of someone else in the household into the study; or another medical condition that precluded meaningful participation in the study.

Enrollment and Randomization

Individuals were blocked according to gender and age (52 to 54, 55 to 59, 60 to 64, 65 to 69, 70 to 74, and 75 to 79 years) and assigned randomly within blocks to 1 of the 2 treatment groups. Between November 1, 2000, and June 30, 2002, a total of 6214 individuals were contacted by telephone to assess eligibility and interest in the study. Of these, 2210 (35.6%) were not interested, 3548 (57.1%) were interested but not eligible, and 456 (7.3%) were interested, eligible, and randomized. Randomization was conducted with a table of random permutations.81 The enrollment cascade is shown in Figure 1 [triangle]. There were no significant differences between the intervention (n=226) and control (n=230) groups with respect to demographic characteristics (Table 1 [triangle]). The sample was more than 70% female, almost two thirds were Black, approximately 62% were married or living together, and almost half were aged between 55 and 59 years. More than half had a high-school degree or less, whereas approximately 35% had some college or technical school. Although more than 94% of the sample were employed full time, 71% reported an annual household income of less than $50,000.

Recruitment, randomization, intervention delivery, and follow-up of individuals participating in an evaluation of telephone outreach to increase colorectal cancer screening.
Demographic Characteristics of Participants in a Randomized Trial of Telephone Outreach Versus Mailed Information to Increase Colorectal Cancer Screening: New York City Metropolitan Area, 2000–2003


The control group received printed materials sent by first-class mail within a week of randomization, and none of these mailed materials were returned. These materials consisted of a cover letter welcoming participants into the study and a brochure published by the Centers for Disease Control and Prevention.82 The brochure included information about CRC, how it can be prevented through early detection and treatment, the asymptomatic nature of the disease, descriptions of the various kinds of recommended screening tests, and a message to the reader to talk with his or her physician and to seek screening.

The intervention group received tailored telephone education based on several behavioral sciences and educational theories.83 The intervention began within 2 weeks of randomization with the intent of attaining the following goals: establishing a positive and trusting rapport with the recipient; reinforcing accurate knowledge and healthful beliefs, correcting misconceptions, and bolstering motivation to obtain a CRC screening on the basis of the participant’s readiness and individual cognitive factors; addressing identified barriers (e.g., fear, transportation) and skill deficits that could impede CRC screening; providing social and emotional support for obtaining CRC screening; and eliciting a verbal commitment to obtain CRC screening. Emphasis was placed on positive reinforcement, enhancement of perceived self-efficacy to overcome barriers, and the message that there is support from scientists, medical doctors, and health organizations for recommended screening. The intervention was semistructured, and the frequency and duration of contact varied considerably among participants. The median number of intervention calls was 5, and the median number of total telephone minutes spent per participant was 23.5. The telephone intervention was implemented (1 or more calls completed) in 216 of 226 (95.6%) of those assigned to intervention. Ten intervention group participants declined participation after randomization.

Outcome Criteria and Sample Size Determination

The primary outcome was receipt of CRC screening within 6 months of randomization. The outcome criteria were met by receipt of a 3-day fecal occult blood test (defined as 2 samples from each of 3 consecutive bowel movements), sigmoidoscopy, colonoscopy, or a barium enema. A single stool test (defined as a single sample of stool obtained and tested for occult blood during a medical examination) was not considered an acceptable CRC screening outcome.10,84

Because of exclusion of those who had received CRC screening in the period before randomization, the sample size determination was based on the assumption that baseline prevalence rates of CRC screening would be zero in both groups. We projected that in the control group, 25% of men and 20% of women would receive CRC screening within 6 months of randomization and that in the telephone outreach group 40% of men and 30% of women would receive screening within 6 months of randomization. The necessary sample sizes per group for a power of 0.80 were found to be 207 for men and 395 for women on the basis of these effect sizes, for a 1-tailed test with α =.01.81 In December 2001, on the basis of an unplanned interim analysis, self-reported CRC screening outcomes in each group were reported to the funding agency. At that time 306 participants had been randomized. The interim analysis showed that the screening rate among controls was much lower than anticipated and that the absolute and proportional difference between groups was greater than expected. These data, which were not shared with the staff, and budgetary reductions made by the funding agency led to a decision to stop recruitment in June 2002 and to analyze the data using a 2-sided α level of .05, without further adjustment for the interim analysis. At that time the total number of randomized participants was 456.

Data Collection and Measures

In a baseline prerandomization telephone interview, trained interviewers used a structured interview format to collect demographic data. Race/ethnicity was based on self-classification. Determination of prerandomization CRC screening was based on the telephone interview. Six months after randomization, we interviewed all participants by telephone and read a description of a single office stool test, a home stool test, flexible sigmoidoscopy, and colonoscopy. Participants were asked whether or not they had had each test within the past year. Participants who responded affirmatively were asked the date of the test, where the test was conducted, and the health care provider’s name, address, and telephone number. Subjects who did not complete a 6-month follow-up survey (26 or 5.7% of the 456 randomized participants; 16 intervention and 10 control participants) were assumed not to have had a CRC screening test. A total of 85 intervention and 21 control participants reported having either a home stool test, flexible sigmoidoscopy, or colonoscopy within 6 months of being randomized. Research staff, unaware of the participants’ intervention status, contacted the provider by telephone to verify each self-report of a CRC screening test. Physicians, who were not told which CRC screening test the participant had reported, were asked to complete, sign, and return a faxed form to verify whether or not their patient had had a CRC screening test within the specified dates. Physicians were asked to document the specific test, the date of examination, and whether or not there were positive findings. Repeated contacts were made (either by telephone or in person) as necessary. For participants who reported CRC screening and for whom verification through a medical record was not obtained, we relied on the health benefit fund’s billing claims files. These billing claims files were audited on a regular basis for all CRC-related procedures incurred throughout the study period. The health benefit billing claims files were used only to verify a colonoscopy or flexible sigmoidoscopy when medical record data were not obtained. Billing claims files were not used to verify a home stool test because the claims data could not distinguish between a single or home stool test. Data from physicians and billing claims files were coded by research staff and confirmed by the project director. Among the 75 verified CRC screening tests, 64 tests were confirmed on the basis of medical records and 11 tests were confirmed through the health benefit fund’s billing claims files.

Statistical Analysis

Rates of CRC screening between the 2 groups were calculated. Estimates of the relative risks and 95% confidence intervals were computed with the FREQ procedure of SAS (version 9.1.2; SAS Institute Inc, Cary, NC); these were used to assess differences between the groups for the total sample and subgroups. All analyses were based on intention to treat.


Table 2 [triangle] presents the percentage screened for CRC in the intervention and control groups, the relative risk of screening for intervention versus control, and a 95% confidence interval for the relative risk 6 months after randomization. The first line shows that in the total sample of 456, 27% (n=61) of the intervention group and 6.1% (n=14) of the control group received screening for CRC. Thus, screening rates were 4.4 times higher (95% confidence interval [CI]=2.6, 7.7) for the intervention group than the control group; the absolute difference between the screening rates was 20.9% (95% CI=14.34, 27.46). The screened percentages and relative risks are also shown separately for gender, age, race, education level, marital status, and income. There was an intervention effect within each of the subgroups.

Participants Screened for Colorectal Cancer and Relative Risk, by Intervention/Control Group and Demographic Characteristics: New York City Metropolitan Area, 2000–2003.

Of the 61 individuals in the intervention group who had a verified test, 29 had a 3 day fecal occult blood test, 29 had a colonoscopy, 2 had a flexible sigmoidoscopy, and 1 had a 3-day fecal occult blood test followed by a colonoscopy. Among the 14 controls who received CRC screening, 13 had a colonoscopy and 1 had a 3-day fecal occult blood test followed by a sigmoidoscopy. Seven of 226 intervention participants and 13 of 230 controls reported having only a rectal examination and single stool test in the physician’s office.

On the basis of claims data, we identified 21 individuals (18 intervention participants and 3 controls) who received medically significant diagnoses or subsequent medical treatment or both as a result of CRC screening. In the intervention group, of the 29 who had a colonoscopy and 2 who had a flexible sigmoidoscopy, 1 was found to have malignant cancer of the rectosigmoid junction and 1 was found to have malignant colon cancer. Eleven were found to have a benign neoplasm of the colon, 2 were found to have a benign neoplasm of the colon, rectum, or anal cavity as well as internal hemorrhoids, 2 were found to have internal hemorrhoids, and 1 was found to have a benign neoplasm of the rectum or anal cavity. Among the 13 controls who had a colonoscopy and 1 who had a flexible sigmoidoscopy, 2 had a benign neoplasm of the colon removed and 1 was found to have non-infectious gastroenteritis and colitis.


To our knowledge, this is the first study to demonstrate that telephone outreach can increase the rate of CRC screening in an urban minority population. The magnitude of the intervention effect was dramatic, compared with the mailed information, as measured by relative risk estimates or differences between groups in the proportion of the population screened. The intervention effect was consistent for all the demographic subgroups examined.

We found that some patients received a single fecal occult blood test in the physician’s office. Randomized trial data49 and consensus recommendations1012 for CRC screening supporting the use of fecal occult blood testing to screen for CRC were based on 3-day samples collected at home. Individuals in the intervention group were more likely to receive 1 of the recommended CRC screening procedures and were also less likely to receive a single test in the physician’s office (7 of 226 vs 13 of 230), consistent with the interpretation that patient education and motivation through telephone outreach can influence physicians’ decisionmaking.

Despite the increase in recommended screening in the intervention group, a large percentage did not receive screening within the 6-month window, even after tailored telephone outreach. In our population, we enrolled only individuals who had not recently received recommended CRC screening. Thus, enrolled individuals were less likely to receive this preventive care than the larger population in our sampling frame. All study participants were employed and had health insurance (with zero copayments for CRC screening), so the barriers to CRC screening in our sample were independent of direct medical costs to participants. An earlier analysis of barriers to CRC screening8588 in this population revealed several impediments to asymptomatic individuals seeking CRC screening, including difficulty accessing the 3-day fecal occult blood test despite having health insurance, other health issues that took precedence over CRC screening, lack of familiarity with CRC screening guidelines and tests, and lack of support from significant others. Collectively, these barriers reflect the challenges in increasing rates of CRC screening behavior in this population. A considerable proportion (35.6%, n=2210) of the target population who were approached (n= 6214) chose not to participate. This group may be even more difficult to reach.

The great majority of colon cancers arise from adenomatous polyps that have progressed from smaller to larger nonmalignant polyps, followed by dysplasia and malignancy. Progression generally occurs over 10 years or more.89 The recognition that adenomatous polyps are precursors for colorectal cancer, together with the long time period over which progression generally occurs, provides the biological rationale for screening. The optimal strategy for CRC screening remains a subject of ongoing investigation. Currently recommended modalities include direct or radiographic visualization, in which the goal is to identify and remove locally confined cancers and polyps. Alternatively, because many locally confined cancers and polyps bleed, fecal testing for occult blood, followed by colonic visualization if positive, has been found in clinical trials to be an effective screening strategy.47 Screening strategies generally target those older than 50 years because approximately 90% of cases of CRC occur after this age.90 Despite publication more than 12 years ago of clinical trial data showing that CRC screening reduces cause-specific mortality,4 national data from the Centers for Disease Control and Prevention Behavioral Risk Factor Surveillance System indicate that the reported rates of CRC screening remain low. In 2001, for those aged 50 and older, these rates were 23.5% reporting receipt of fecal occult blood testing within the previous year and 38.7% reporting lower endoscopy within the previous 5 years.91 CRC screening rates are lower among Black Medicare beneficiaries than among Whites.92

Of the 35 CRC intervention studies we identified published between 1978 and 2004, none evaluated tailored telephone outreach in a predominantly Black population. Many of these studies promoted a specific screening test, such as the fecal occult blood test4446,4952,5673,76 or sigmoidoscopy,48,53,78 some promoted both the fecal occult blood test and sigmoidoscopy,47,54,55,70,74,75,77 and 2 promoted other preventive health behaviors in addition to CRC screening.46,54

Of the 32 studies promoting the fecal occult blood test, only 1 did not distribute the fecal occult blood test kit or recruit participants with office visits already scheduled; however, the study relied on a self-reported outcome.46 Our study did not specify a specific procedure or distribute kits but rather encouraged the participants to select a screening test after discussion with their physician, as suggested by some researchers.9396

Three studies to date represent the best developed efforts to evaluate tailored telephone communications as part of an overall strategy to promote CRC screening.63,64,77 These studies involved distribution of fecal occult blood test kits through mail63,64,77 or in-person pickup at worksites.77 In the first study by Myers et al.,63 participants (n=837) were randomly assigned to 1 of 4 conditions. Those who received only a reminder letter reported low rates of screening (27%), participants who received telephone calls to address questions and prompt them to complete the test reported significantly higher rates of testing (37%), and participants who had 2 reminder calls plus a discussion of barriers to nonadherence and counseling to overcome those barriers reported even higher rates of testing (48%). In the second study by Myers et al.,64 participants (n=646) were randomly assigned to 1 of 2 conditions. Those who received a reminder letter, an education booklet, and a tailored educational phone call had higher rates of testing (50%) than those who received only a reminder letter (29%).

In the third study, by Tilley et al.,77 participants (n=5042) were randomly assigned by worksite to 1 of 2 conditions. Those who received a standard worksite program plus a tailored education booklet and 2 tailored phone calls had a higher rate of compliance (23%) than control participants receiving a standard program (19%).

These studies demonstrated that educational telephone calls are effective at increasing adherence to CRC screening. However, these studies were conducted among primarily White participants, included printed materials along with telephone outreach so that independent effects of each could not be determined and did not encourage interaction with physicians because fecal occult blood test kits were distributed.

There were several strengths of our study. Our outcome ascertainment method included verification of screening by the use of medical records or, in some instances of a colonoscopy, billing claims, rather than self-report. These data were ascertained by staff blinded to the participant’s intervention status. Limitations of the study include following participants for only 6 months after randomization and intervening only with patients and not providers. The study population all had health insurance and a physician, and this is both a strength and a limitation. This characteristic of the study sample allowed us to focus on characteristics of the patient and health care system rather than insurance and medical costs to patients. Tailored telephone outreach may not be equally effective among patients without health insurance or access or among patients with large copayments.

The participation rate reflects both the method of recruitment (by telephone) and the reluctance of the target population to address CRC screening. It is likely that those who agreed to participate were more predisposed, or less indisposed, to CRC screening than those who did not participate. Nonetheless, there were low rates of CRC screening in the sampled population, and none of the randomized participants had received recent CRC screening.

In summary, to our knowledge, this is the first randomized trial demonstrating that a tailored telephone outreach intervention increases CRC screening in a predominantly minority sample. This increase was achieved without direct distribution of fecal occult blood test kits. The intervention was intended to create patient demand for appropriate CRC screening through interaction with physicians, rather than to promote a specific method of screening. Disparities in CRC mortality in Black populations, which can partly be explained by disparities in early detection and treatment, may be addressed in part by provider organizations or health plans making use of telephone outreach to patients to promote CRC screening. Further research is needed to identify low-cost methods for increasing CRC screening uptake, especially in Black populations at increased risk for CRC mortality.


This research was supported by the National Cancer Institute of the National Institutes of Health (grants CA81932, P30 CA13696).

Human Participation Protection
The study was approved by the institutional review boards of Teachers College, Columbia University, and the Columbia University Medical Center. Informed consent was obtained from all participants.


Peer Reviewed

C.E. Basch originated the study, supervised all aspects of its implementation, interpreted the study findings, and led the writing of the article. R.L. Wolf provided day-to-day leadership and management of the study and direct supervision of study personnel and assisted with interpretation of findings, data analysis, and writing. C.H. Brouse assisted with the development and implementation of the intervention, data collection, and writing. C. Shmukler and A. Neugut assisted with the development and implementation of study protocols and provided medical oversight. L.T DeCarlo conducted data analyses and assisted with the interpretation of findings. S. Shea assisted with study design, development of study protocols, interpretation of study findings, and writing.


1. Jemal A, Murray T, Ward E, et al. Cancer statistics, 2005. CA Cancer J Clin. 2005;55:10–30. [PubMed]
2. O’Connell JB, Maggard MA, Ko CY. Colon cancer survival rates with the new American Joint Committee on Cancer sixth edition staging. J Natl Cancer Inst. 2004;96:1420–1425. [PubMed]
3. Redaelli A, Cranor CW, Okano GJ, Reese PR. Screening, prevention and socioeconomic costs associated with the treatment of colorectal cancer. Pharmacoeconomics. 2003;21:1213–1238. [PubMed]
4. Mandel JS, Bond JH, Church TR, et al. Reducing mortality from colorectal cancer by screening for fecal occult blood. Minnesota Colon Cancer Control Study [Published correction appears in N Engl J Med. 1993; 329:672]. N Engl J Med. 1993;328:1365–1371. [PubMed]
5. Mandel JS, Church TR, Ederer F, Bond JH. Colorectal cancer mortality: effectiveness of biennial screening for fecal occult blood. J Natl Cancer Inst. 1999;91:434–437. [PubMed]
6. Kronborg O, Fenger C, Olsen J, Jorgensen OD, Sondergaard O. Randomised study of screening for colorectal cancer with faecal-occult-blood test. Lancet. 1996;348:1467–1471. [PubMed]
7. Hardcastle JD, Chamberlain JO, Robinson MH, et al. Randomised controlled trial of faecal-occult-blood screening for colorectal cancer. Lancet. 1996;348:1472–1477. [PubMed]
8. Mandel JS, Church TR, Bond JH, et al. The effect of fecal occult-blood screening on the incidence of CRC. N Engl J Med. 2000;343:1603–1607. [PubMed]
9. Kronborg O. Colon polyps and cancer. Endoscopy. 2002;34:69–72. [PubMed]
10. Pignone M, Rich M, Teutsch SM, Berg AO, Lohr KN. Screening for colorectal cancer in adults at average risk: a summary of evidence for the US Preventive Services Task Force. Ann Intern Med. 2002;137:132–141. [PubMed]
11. Winawer S, Fletcher R, Rex D, et al. Colorectal cancer screening and surveillance: clinical guidelines and rationale—update based on new evidence. Gastroenterology. 2003;124:544–560. [PubMed]
12. Smith RA, Cokkinides V, Eyre HJ. American Cancer Society guidelines for the early detection of cancer, 2003. CA Cancer J Clin. 2003;53:27–43. [PubMed]
13. Theuer CP, Wagner JL, Taylor TH, et al. Racial and ethnic colorectal cancer patterns affect the cost-effectiveness of colorectal cancer screening in the United States. Gastroenterology. 2001;120:848–856. [PubMed]
14. Frazier AL, Colditz GA, Fuchs CS, Kuntz KM. Cost-effectiveness of screening for colorectal cancer in the general population. JAMA. 2000;284:1954–1961. [PubMed]
15. Sonnenberg A, Delco F, Inadomi JM. Cost-effectiveness of colonoscopy in screening for colorectal cancer. Ann Intern Med. 2000;133:573–584. [PubMed]
16. O’Leary BA, Olynyk JK, Neville AM, Platell CF. Cost-effectiveness of colorectal cancer screening: comparison of community-based flexible sigmoidoscopy with fecal occult blood testing and colonoscopy. J Gastroenterol Hepatol. 2004;19:38–47. [PubMed]
17. Balluz L, Ahluwalia IB, Murphy W, Mokdad A, Giles W, Harris VB. Surveillance for certain health behaviors among selected local areas—United States, Behavioral Risk Factor Surveillance System, 2002. MMWR Surveill Summ. 2004;53:1–100. [PubMed]
18. Shapiro JA, Seeff LC, Nadel MR. Colorectal cancer-screening tests and associated health behaviors. Am J Prev Med. 2001;21:132–137. [PubMed]
19. Nadel MR, Blackman DK, Shapiro JA, Seeff LC. Are people being screened for colorectal cancer as recommended? Results from the National Health Interview Survey. Prev Med. 2002;35:199–206. [PubMed]
20. Seeff LC, Nadel MR, Klabunde CN, et al. Patterns and predictors of colorectal cancer test use in the adult US population. Cancer. 2004;100:2093–2103. [PubMed]
21. Whynes DK, Frew EJ, Manghan CM, Scholefield JH, Hardcastle JD. Colorectal cancer, screening and survival: the influence of socio-economic deprivation. Public Health. 2003;117:389–395. [PubMed]
22. Cooper GS, Koroukian SM. Racial disparities in the use of and indications for colorectal procedures in Medicare beneficiaries. Cancer. 2004;100:418–424. [PubMed]
23. Richards RJ, Reker DM. Racial differences in use of colonoscopy, sigmoidoscopy, and barium enema in Medicare beneficiaries. Dig Dis Sci. 2002;47:2715–2719. [PubMed]
24. Hegarty V, Burchett BM, Gold DT, Cohen HJ. Racial differences in use of cancer prevention services among older Americans. J Am Geriatr Soc. 2000;48:735–740. [PubMed]
25. Ward E, Jemal A, Cokkinides V, et al. Cancer disparities by race/ethnicity and socioeconomic status. CA Cancer J Clin. 2004;54:78–93. [PubMed]
26. Jemal A, Clegg LX, Ward E, et al. Annual report to the nation on the status of cancer, 1975–2001, with a special feature regarding survival. Cancer. 2004;101:3–27. [PubMed]
27. Bach PB, Schrag D, Brawley OW, Galaznik A, Yakren S, Begg CB. Survival of blacks and whites after a cancer diagnosis. JAMA. 2002;287:2106–2113. [PubMed]
28. Marcella S, Miller JE. Racial differences in colorectal cancer mortality. The importance of stage and socioeconomic status. J Clin Epidemiol. 2001;54:359–366. [PubMed]
29. Rex DK, Rawl SM, Rabeneck L, Rex EK, Hamilton F. Colorectal cancer in African Americans. Rev Gastroenterol Disord. 2004;4:60–65. [PubMed]
30. Ries LA, Wingo PA, Miller DS, et al. The annual report to the nation on the status of cancer, 1973–1997, with a special section on colorectal cancer. Cancer. 2000;88:2398–2424. [PubMed]
31. Cooper GS, Koroukian SM. Racial disparities in the use of and indications for colorectal procedures in Medicare beneficiaries. Cancer. 2004;100:418–424. [PubMed]
32. Cooper GS, Yuan Z, Rimm AA. Racial disparity in the incidence and case-fatality of colorectal cancer: analysis of 329 United States counties. Cancer Epidemiol Biomarkers Prev. 1997;6:283–285. [PubMed]
33. Cooper GS, Yuan Z, Landefeld CS, Rimm AA. Surgery for colorectal cancer: race-related differences in rates and survival among Medicare beneficiaries. Am J Public Health. 1996;86:582–586. [PMC free article] [PubMed]
34. Cress RD, Morris C, Ellison GL, Goodman MT. Secular changes in colorectal cancer incidence by sub-site, stage at diagnosis, and race/ethnicity, 1992–2001. Cancer. 2006;107(supp 5):1142–1152. [PubMed]
35. Chen VW, Fenoglio-Preiser CM, Wu XC, et al. Aggressiveness of colon carcinoma in blacks and whites. National Cancer Institute Black/White Cancer Survival Study Group. Cancer Epidemiol Biomarkers Prev. 1997;6:1087–1093. [PubMed]
36. Polednak AP. Trends in late-stage breast, cervical and colorectal cancers in blacks and whites. Ethn Dis. 2000;10:60–68. [PubMed]
37. Anderson WF, Umar A, Brawley OW. Colorectal carcinoma in black and white race. Cancer Metastasis Rev. 2003;22:67–82. [PubMed]
38. Morris AM, Billingsley KG, Baxter NN, Baldwin LM. Racial disparities in rectal cancer treatment: a population-based analysis. Arch Surg. 2004;139:151–155. [PubMed]
39. Rogers SO, Ray WA, Smalley WE. A population-based study of survival among elderly persons diagnosed with colorectal cancer: does race matter if all are insured? (United States). Cancer Causes Control. 2004; 15:193–199. [PubMed]
40. Ball JK, Elixhauser A. Treatment differences between blacks and whites with colorectal cancer. Med Care. 1996;34:970–984. [PubMed]
41. Potosky AL, Harlan LC, Kaplan RS, Johnson KA, Lynch CF. Age, sex, and racial differences in the use of standard adjuvant therapy for colorectal cancer. J Clin Oncol. 2002;20:1192–1202. [PubMed]
42. Ellison GL, Warren JL, Knopf KB, Brown ML. Racial differences in the receipt of bowel surveillance following potentially curative colorectal cancer surgery. Health Serv Res. 2003;38:1885–1903. [PMC free article] [PubMed]
43. Demissie K, Oluwole OO, Balasubramanian BA, Osinubi OO, August D, Rhoads GG. Racial differences in the treatment of colorectal cancer: a comparison of surgical and radiation therapy between whites and blacks. Ann Epidemiol. 2004;14:215–221. [PubMed]
44. Church TR, Yeazel MW, Jones RM, et al. A randomized trial of direct mailing of fecal occult blood tests to increase colorectal cancer screening. J Natl Cancer Inst. 2004;96:770–780. [PubMed]
45. Friedman LC, Everett TE, Peterson L, Ogbonnaya KI, Mendizabal V. Compliance with fecal occult blood test screening among low-income medical outpatients: a randomized controlled trial using videotaped intervention. J Cancer Educ. 2001;16:85–88. [PubMed]
46. Campbell M, James A, Hudson MA, et al. Improving multiple behaviors for colorectal cancer prevention among African American church members. Health Psychol. 2004;23:492–502. [PubMed]
47. Pignone M, Harris R, Kinsinger L. Videotape-based decision aid for colon cancer screening: a randomized controlled trial. Ann Intern Med. 2000;133:761–769. [PubMed]
48. Schroy PC, Heeren T, Bliss CM, Pincus J, Wilson S, Prout M. Implementation of on-site screening sigmoidoscopy positively influences utilization by primary care providers. Gastroenterology. 1999;117:304–311. [PubMed]
49. Thompson NJ, Boyko EJ, Dominitz JA, et al. A randomized controlled trial of clinic-based support staff intervention to increase the rate of fecal occult blood test ordering. Prev Med. 2000;30:244–251. [PubMed]
50. Powe BD. Promoting fecal occult blood testing in rural African American women. Cancer Pract. 2002; 10:139–146. [PubMed]
51. Powe BD, Ntekop E, Barron M. An intervention study to increase colorectal cancer knowledge and screening among community elders. Public Health Nurs. 2004;21:435–442. [PubMed]
52. Vinker S, Nakar S, Roserberg E, Kitai E. The role of family physicians in increasing annual fecal occult blood test screening coverage: a prospective intervention study. Isr Med Assoc J. 2002;4:424–425. [PubMed]
53. Wardle J, Williamson S, McCaffery K, et al. Increasing attendance at colorectal cancer screening: testing the efficacy of a mailed psychoeducational intervention in a community sample of older adults. Health Psychol. 2003;22:99–105. [PubMed]
54. Williams RB, Boles M, Johnson RE. A patient-initiated system for preventive health care: a randomized trial in community-based primary care physicians. Arch Fam Med. 1998;7:338–345. [PubMed]
55. Bejes C, Marvel MK. Attempting the improbable: offering colorectal cancer screening to all appropriate patients. Fam Pract Res J. 1992;12:83–90. [PubMed]
56. Elwood TW, Erickson A, Lieberman S. Comparative educational approaches to screening for colorectal cancer. Am J Public Health. 1978;68:135–138. [PMC free article] [PubMed]
57. Hardcastle JD, Armitage NC, Chamberlain J, Amar SS, James PD, Balfour TW. Fecal occult blood screening for colorectal cancer in the general population. Results of a controlled trial. Cancer. 1986;58:397–403. [PubMed]
58. King J, Fairbrother G, Thompson C, Morris DL. Colorectal cancer screening: optimal compliance with postal faecal occult blood test. Aust N Z J Surg. 1992; 62:714–719. [PubMed]
59. Lallemand RC, Vakil PA, Pearson P, Box V. Screening for asymptomatic bowel cancer in general practice. BMJ. 1984;288:31–33. [PMC free article] [PubMed]
60. Lee CY. A randomized controlled trial to motivate worksite fecal occult blood testing. Yonsei Med J. 1991; 32:131–138. [PubMed]
61. Lee FI. Screening for colorectal cancer in a factory-based population with Fecatest. Br J Cancer. 1983;48:843–847. [PMC free article] [PubMed]
62. Mant D, Fuller A, Northover J, et al. Patient compliance with colorectal cancer screening in general practice. Br J Gen Pract. 1992;42:18–20. [PMC free article] [PubMed]
63. Myers RE, Ross EA, Wolf TA, et al. Behavioral interventions to increase adherence in colorectal cancer screening. Med Care. 1991;29:1039–1050. [PubMed]
64. Myers RE, Ross E, Jepson C, et al. Modeling adherence to colorectal cancer screening. Prev Med. 1994;23:142–151. [PubMed]
65. Nichols S, Koch E, Lallemand RC, et al. Randomized trial of compliance with screening for colorectal cancer. BMJ. 1986;293:107–110. [PMC free article] [PubMed]
66. Plaskon PP, Fadden MJ. Cancer screening utilization: is there a role for social work in cancer prevention? Soc Work Health Care. 1995;21:59–70. [PubMed]
67. Pye G, Christie M, Chamberlain JO, Moss SM, Hardcastle JD. A comparison of methods for increasing compliance within a general practitioner based screening project for colorectal cancer and the effect of practitioner workload. J Epidemiol Community Health. 1988; 42:66–71. [PMC free article] [PubMed]
68. Slater PE, Fich A, Zimmerman J, Ever-Hadani P, Rachmilewitz D. Recruitment of subjects for fecal occult blood screening: a comparison of two methods in Jerusalem. J Clin Gastroenterol. 1985;7:51–54. [PubMed]
69. Sontag SJ, Durczak C, Aranha GV, Chejfec G, Frederick W, Greenlee HB. Fecal occult blood screening for colorectal cancer in Veterans Administration hospital. Am J Surg. 1983;145:89–94. [PubMed]
70. Struewing JP, Pape DM, Snow DA. Improving colorectal cancer screening in a medical residents’ primary care clinic. Am J Prev Med. 1991;7:75–81. [PubMed]
71. Thompson RS, Michnich ME, Gray J, Friedlander L, Gilson B. Maximizing compliance with hemoccult screening for colon cancer in clinical practice. Med Care. 1986;24:904–914. [PubMed]
72. Weinrich SP, Weinrich MC, Stromborg MF, Boyd MD, Weiss HL. Using elderly educators to increase colorectal cancer screening. Gerontologist. 1993;33:491–496. [PubMed]
73. Hart AR, Jestico B, Antill C, Taylor M, Mayberry JF. Blood donor centres can effectively publicise cancer screening. Public Health. 1996;110:247–249. [PubMed]
74. Kelly RB, Shank JC. Adherence to screening flexible sigmoidoscopy in asymptomatic patients. Med Care. 1992;30:1029–1042. [PubMed]
75. Neale AV, Demers RY, Herman S. Compliance with colorectal cancer screening in a high risk occupational group. J Occup Med. 1989;31:1007–1012. [PubMed]
76. Thomas W, White CM, Mah J, Geisser MS, Church TR, Mandel JS. Longitudinal compliance with annual screening for fecal occult blood. Minnesota Colon Cancer Control Study. Am J Epidemiol. 1995; 142:176–182. [PubMed]
77. Tilley BC, Vernon S, Myers R, et al. The Next Step Trial: impact of a worksite colorectal cancer screening promotion program. Prev Med. 1999;28:276–283. [PubMed]
78. Selby JV, Friedman GD, Collen MF. Sigmoidoscopy and mortality from colorectal cancer: the Kaiser Permanente Multiphasic Evaluation Study. J Clin Epidemiol. 1988;41:427–434. [PubMed]
79. Vernon SW. Participation in colorectal cancer screening: a review. J Natl Cancer Inst. 1997;89:1406–1422. [PubMed]
80. Stoddard AM, Fox SA, Costanza ME, et al. NCI Breast Screening Consortium. Effectiveness of telephone counseling for mammography: results from five randomized trials. Prev Med. 2002;34:90–99. [PubMed]
81. Fleiss JL. Statistical Methods for Rates and Proportions. 2nd ed. New York, NY: Wiley; 1981.
82. Colorectal Cancer: Let’s Break the Silence. Atlanta, Ga: Centers for Disease Control and Prevention; 1999. CDC publication 099–6010; HCFA publication 10126.
83. Glanz K, Lewis FM, Rimer BK, eds. Health Behavior and Health Education: Theory, Research, and Practice. 3rd ed. San Francisco, Calif: Jossey-Bass; 2002.
84. Collins JF, Lieberman DA, Durbin TE, Weiss DG. Veterans Affairs Cooperative Study #380 Group. Accuracy of screening for fecal occult blood on a single stool sample obtained by a digital rectal examination: a comparison with recommended sampling practice. Ann Intern Med. 2005;142:81–85. [PubMed]
85. Wolf RL, Zybert PA, Neugut AI, et al. Knowledge, beliefs and barriers relevant to colorectal cancer screening in an urban population: a pilot study. Fam Community Health. 2001;24:34–47. [PubMed]
86. Brouse CH, Basch CE, Wolf RL, Shmukler C, Neugut AI, Shea S. Barriers to colorectal cancer screening with fecal occult blood testing in a predominantly minority urban population: a qualitative study. Am J Public Health. 2003;93:1268–1271. [PMC free article] [PubMed]
87. Brouse CH, Basch CE, Wolf RL, Shmukler C. Barriers to colorectal cancer screening: an educational diagnosis. J Cancer Educ. 2004;19:170–173. [PubMed]
88. Brouse CH, Basch CE, Wolf RL, Shmukler C. Barriers to colorectal cancer screening in a low income, urban population: a descriptive study. Health Educ. 2004;104:68–76.
89. Eddy DM. Screening for colorectal cancer. Ann Intern Med. 1990;113:373. [PubMed]
90. Jemal A, Tiwari RC, Murray T, et al. Cancer statistics, 2004. CA Cancer J Clin. 2004;54:8. [PubMed]
91. Colorectal cancer test use among persons aged 50 years—United States, 2001. MMWR Morb Mortal Wkly Rep. 2003;52:193. [PubMed]
92. Cooper GS, Koroukian SM. Racial disparities in the use of and indications for colorectal procedures in Medicare beneficiaries. Cancer. 2004;100:418–424. [PubMed]
93. Leard LE, Savides TJ, Ganias TG. Patient preferences for colorectal cancer screening. J Fam Pract. 1997;45:211–218. [PubMed]
94. Dominitz JA, Provenzale D. Patient preferences and quality of life associated with colorectal cancer screening. Am J Gastroenterol. 1997;92:2171–2178. [PubMed]
95. Pignone M, Bucholtz D, Harris R. Patient preferences for colon cancer screening. J Gen Intern Med. 1999;14:432–437. [PMC free article] [PubMed]
96. Ling BS, Moskowitz MA, Wachs D, Pearson B, Schroy P. Attitudes toward colorectal cancer screening tests. J Gen Intern Med. 2001;16:822–830. [PMC free article] [PubMed]

Articles from American Journal of Public Health are provided here courtesy of American Public Health Association
PubReader format: click here to try


Related citations in PubMed

See reviews...See all...

Cited by other articles in PMC

See all...


  • Cited in Books
    Cited in Books
    PubMed Central articles cited in books
  • MedGen
    Related information in MedGen
  • PubMed
    PubMed citations for these articles

Recent Activity

Your browsing activity is empty.

Activity recording is turned off.

Turn recording back on

See more...