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Cancer Fatalism and Poor Self-Rated Health Mediate the Association between Socioeconomic Status and Uptake of Colorectal Cancer Screening in England

Scope of the Problem

The incidence of colorectal cancer (CRC)rankssecond and thirdas the most common cancer in women and men respectively, worldwide (Jemal, et al, 2011). While CRC death rates are decreasing in many Western countries due to advances in treatment options, increased awareness and early detection, the death rates, in many countries, are increasing due to limited resources and health infrastructure (Center, et al. 2009). In the United States, barriers to CRC screening by the primary physician and patient have been identified. Physician barriers include inadequate clinician skill set, inadequate knowledge of guidelines and lack of time (Wender, 2002). For patients the barriers can span from lack of physician recommendation, low income, and low education level to aversion to stool testing or fear of pain (Wender, 2002).

Miles and colleagues (2011) identified that little is known about the psychological predictors of CRC screening in England. Thus they hypothesized that efficacy beliefs, cancer fatalism, depression and self-rated health would mediate associations between CRC screening uptake and socioeconomic status (SES). They collected data between August 2005 and January 2006 from 529 adults between the ages of 60 and 69 years who had completed a mailed survey on attitudes toward health and worry. During this time, national screening for CRC was not available. Fecal occult blood testing (FOBT) was introduced in England in 2006 through mailing eligible adults aged 60-69 years a FOBT kit to be returned in a prepaid envelope.If the envelope was not returned, a reminder kit was sent 28 days later. The investigators linked survey data to FOBT uptake and were permitted to contact people within certain provisions to inquire on whether they had returned a FOBT.

Study Facts (Miles, 2011)

  • A variety of measures were employed including: screening uptake, demographic characteristics, health and emotional well-being, perceived threat, efficacy beliefs and cancer fatalism
  • Of the 529 participants, 296 completed FOBT screening while 233 did not
  • Screening uptake (participation in the first round of screening) was 56% and was higher among people with a higher SES, better self-rated health, higher self-efficacy beliefs and lower cancer fatalism
  • There were no associations between uptake and any other threat constructs  or between uptake and response efficacy, age, gender or ethnicity
  • Both poorer self-rated health and higher cancer fatalism were associated with lower uptake of FOBT screening
  • There were indirect pathways from SES to uptake via depression, self-rated health and fatalism
  • Efficacy beliefs did not predict uptake in multivariate analysis

The authors concluded that SES differences in uptake of FOBT screening in England can be partially explained by differences in cancer fatalism, self-rated health and depression.

ManageCRC Commentary

The associations between poorer self-rated health based on a 4-point scale (1 being excellent and 4 being poor) and higher cancer fatalism scores measured with the 15 –item Powe Fatalism Index (Powe, 1995) brings up the question of whether there is a correlation between health expectations and outcomes. High cancer fatalism scores have been linked to decreased uptake of cancer prevention strategies and have increasingly become the target for intervention in cancer control (Niederdeppe, 2007). Research identifying contributions to health expectations and cancer fatalism could potentially augment understanding and assist in identifying appropriate intervention strategies to improve CRC screening uptake as well as participation in cancer prevention lifestyle behaviors.


Center, M.M., Jemal, A., Smith, R.A., & Ward, E. (2009). Worldwide variations in colorectal cancer.
CA A Cancer Journal for Clinicians,59,366-378.doi:10.3322/caac.20038Link to free full text article: http://onlinelibrary.wiley.com/doi/10.3322/caac.20038/pdf

Jemal, A., Bray, F., Center, M. M., Ferlay, J., Ward, E., & Forman, D.(2011). Global cancer statistics. CA A Cancer Journal for Clinicians, published online before print February 4, 2011. doi:10.3322/caac.20107  Link to free full text article: http://caonline.amcancersoc.org/cgi/content/full/caac.20107v1

Miles, A., Rainbow, S., & vonWagner C. (2011). Cancer fatalism and poor self-rated health mediate the association between socioeconomic status and uptake of colorectal cancer screening in England. Cancer Epidemiology, Biomarkers & Prevention, 20, 2132-2140. doi:10.1158/1055-9965.EPI-11-0453 Link to abstract: http://cebp.aacrjournals.org/content/20/10/2132.abstract

Niederdeppe, J., & Levy, A.G. (2007). Fatalistic beliefs about cancer prevention and three prevention behaviors. Cancer Epidemiology, Biomarkers and Prevention,16, 998-1003.doi: 10.1158/1055-9965.EPI-06-0608 Link to free full text article: http://cebp.aacrjournals.org/content/16/5/998.long

Powe, B.D. (1995). Fatalism among elderly African Americans: Effects on colorectal cancer screening. Cancer Nursing, 18,385–392. Link to abstract http://www.ncbi.nlm.nih.gov/pubmed/7585493

Wender, R. (2002). Barriers to screening for colorectal cancer. Gastrointestinal Endoscopy Clinics of North America, 12, 145 – 170. doi:10.1016/S1052-5157(03)00064-3 Link to free full text article: http://www.sciencedirect.com/science/article/pii/S1052515703000643


Article Created On : 12/19/2011 9:18:53 AM             Article Updated On : 12/19/2011 9:18:53 AM