Patient Knowledge of and Barriers to Breast, Colon, and Cervical Cancer Screenings: A Cross-Sectional Survey of TRICARE Beneficiaries
To better understand barriers to screening, respondents were asked to identify reasons they might not have sought cervical cancer screening. The majority (84%) reported that they typically scheduled appointments and that the question was not applicable. However, among 228 respondents who provided an open-ended response and who had not previously undergone a hysterectomy, 8% stated that they had received no reminder or that they lacked sufficient information to schedule the appointment, 21% forgot to schedule, 18% reported a scheduling conflict or difficulty in receiving care, and 13% noted that they did not believe in annual screening (Table 2).
Colorectal Cancer Screening
Eighty-seven percent of eligible respondents (n = 1,734) reported having ever had a sigmoidoscopy and/or colonoscopy. Respondents were asked for their understanding of the recommended age for men and women to begin CRC screening.6 Nearly three-quarters of respondents provided a correct response (n = 1,225), compared with 23% of respondents (n = 407) who answered incorrectly and 6% (n = 102) who did not provide a response or stated they did not know. Correct responses were numerically higher among white respondents (73%) compared with black (62%) and other (62%) respondents as well as among persons aged < 60 years (73%) vs those aged > 60 years (67%).
Respondents aged between 51 and 64 years were asked how often the average person should receive colon cancer screenings. The most common response was that screening should occur every 5 years (33%) followed by every 10 years (26%). This aligns with the U.S. Preventive Services Task Force’s recommendations for flexible sigmoidoscopy every 5 years or colonoscopy every 10 years.
Eligible respondents were asked to identify reasons they did not seek CRC screening. Eighty-six percent of respondents indicated that they typically scheduled CRC screening and that the question was not applicable. Among respondents who provided an open-ended response, 26% cited feeling uncomfortable with the procedure, 15% cited forgetting to schedule a screening, 15% noted a lack of information on screening, and 11% reported no need for screening (Table 2). Among the 1,734 respondents, 80% reported that they would prefer a fecal occult blood test (FOBT) over either a colonoscopy or a sigmoidoscopy. Only 51% reported that their PCM had previously discussed the different types of CRC screenings at some point.
Discussion
The purpose of this large, representative survey was to obtain information on beneficiaries’ knowledge, perceived barriers, and beliefs regarding breast, cervical, and colorectal cancer screenings to identify factors contributing to low completion rates. As far as is known, this is the first study to address these questions in a TRICARE population. Overall, the findings suggest that beneficiaries consider cancer screening important, largely relying on their PCM or their research to better understand how and when to obtain such screenings. The majority received 1 or more screenings prior to the survey, but there were some common knowledge gaps about how to schedule screening appointments, relevant TRICARE medical benefits, and the current recommendations regarding screening timing and frequency. A commonly reported issue across all surveyed groups was inconvenient screening times.
More than half (55%) of respondents correctly noted that breast cancer screening begins at age 40 years (based on recommendations at the time the survey was conducted), and 72% understood when screening should occur. Despite access to care, inconvenient schedules and testing locations were considered the biggest barriers to regularly obtaining a mammogram. There are few studies on knowledge of breast cancer screening in an insured population available for comparison.7-10 One study of medically insured black and non-Hispanic women aged 43 to 49 years showed that lack of reminders or knowledge about the need for mammograms, cost, being too busy, and forgetting to schedule appointments were all factors associated with nonadherence to repeat mammography examinations.8 In an integrative review published in 2000, authors cited that among 8 of 13 relevant studies, the major barrier to receiving a recommended mammogram was lack of physician recommendation.7
For cervical cancer screening, few respondents (1%) correctly identified the age for initiation of screening, and just 12% correctly identified the frequency of screening. These findings are consistent with those of other studies, suggesting a general misunderstanding
about Pap tests in the U.S. and among low-income women.11,12 Reported barriers to screening were uncommon but included scheduling conflicts and lack of reminders or information and were consistent with barriers cited in prior studies.13,14 A few respondents (13%) noted that they did not believe in annual screening, which is similar to the findings of Decker and colleagues who cited lack of knowledge about the test and belief that screening is of no benefit as reasons for failure to get a recommended Pap test.13 These findings suggest a need to improve patientprovider communication and to provide more patient educational materials about the importance of cervical cancer screening.
A large proportion (71%) gave the correct response regarding the appropriate age to initiate CRC screening. Discomfort with the procedure, belief that the screening is unnecessary, or lack of physician’s recommendation were noted barriers to CRC screening. These findings are similar to those reported elsewhere in non-TRICARE populations.15-20 Two focus groups included participants with little knowledge about CRC screening, such as risk factors and symptoms, and expressed fear and embarrassment about CRC and screening. Few of the focus group participants were aware of the available options for screening, and some were confused about the purpose and benefits of the various screening modalities.16
A Health Information National Trends survey reported that 24% participants had not received a colonoscopy or a sigmoidoscopy because their PCM did not order it or say that it was necessary.15 The reported perceived barriers included fear of an adverse finding, injury to the colon from screening, and embarrassment. A study performed in 1,901 Medicare-insured individuals with no history of CRC cited lack of knowledge/awareness and no physician order as the most common reasons for not undergoing CRC screening.18
Strengths and Limitations
A major strength of the current survey is the 56% completion rate, which far exceeds other survey participation rates that were as low as 9%.21 A second strength is the scope of the survey to capture information on not 1 but 3 different cancer screening practices in a unique population who receive preventive screenings at low to no cost.
There are a few study limitations. The majority of respondents identified as white (80%), which does not fully align with the racial distribution of the TRICARE Prime population in the West Region, which is about 68% white. This higher proportion of white respondents may affect the ability to generalize findings to other populations. However, given the open access to care, race should not be a major factor contributing to screening decisions. Another potential limitation to the generalizability of the study is that the age of the respondents was capped at 64 years. Considering that some of the reported barriers to screening were “too busy” or “scheduling conflict,” a study population that included respondents aged ≥ 65 years (who might be more likely to be retired) might report lower rates of these schedule-related barriers.
A third limitation is that most questions about prior screenings pertained to any time in the past, and, therefore, limited the ability to identify current factors leading to lower screening rates. Last, the survey was developed prior to the 2012 changes in cervical and breast cancer screening recommendations and was therefore scored based on prior recommendations. Given that the goal was to assess knowledge and barriers, results are not expected to differ greatly if they are scored using the newer guidelines.
Conclusion
Findings from this cross-sectional survey indicate high levels of knowledge among TRICARE West Region beneficiaries regarding when and how often screening for breast cancer, cervical cancer, and CRC should occur. To encourage TRICARE beneficiaries to seek and obtain recommended and covered cancer screenings, further efforts are needed, including more education about the importance of screening and how to obtain screening. The survey results suggest that TRICARE Prime beneficiaries view cancer screening as important for overall health but they require (and also may desire) more frequent scheduling reminders, education, and more options for scheduling. Newer modalities for communicating with beneficiaries, such as automated telephone appointment reminders, reminder texts, online appointment scheduling, educational blogs, podcasts on cancer screening, extended appointment hours, or unconventional strategies to bundle screening services, are tools that could be used by providers to achieve greater compliance with cancer screening recommendations.
Author Disclosure
The authors report no actual or potential conflicts of interest with regard to this article.
Disclaimer
The opinions expressed herein are those of the authors and do not necessarily reflect those of Federal Practitioner, Frontline Medical Communications Inc., the U.S. Government, or any of its agencies.
