Cancer screening guidelines have been used for several decades and are well-accepted by the medical community.22
Physician recommendation of cancer screening has been proven effective in overcoming patient barriers.9,13,23
We found that physicians serving the Chinese immigrant community in NYC were inadequately following the cancer screening guidelines proposed by the American Cancer Society or The National Cancer Institute.
According to the NYC Department of Health, 74% of all eligible Asian women living in NYC were screened for breast cancer with a mammogram during the prior two years.24
In our study, 72% of physicians reported following breast cancer screening guidelines, the largest compared with reported screening practices for other cancer types. The high rate of adherence with breast cancer screening guidelines could be the result of interventions that target providers with educational programs to increase physician referral and help overcome patient barriers for breast cancer screening.25,26
Chinese women in the United States have a lower cervical cancer screening rate than Hispanic, African American, and non-Hispanic White women.1,27,28
Several studies have reported that Chinese women in the United States have high rates of invasive cervical cancer.29,30
Physicians in our study showed limited adherence to guidelines for cervical cancer screening. Only 35% reported screening practices in keeping with the guidelines. Although several barriers to cervical cancer screening have been described for this population,31,32
low physician adherence to the correct guidelines could be the rate-limiting factor in screening Chinese immigrant women for cervical cancer.
Colorectal cancer screening rates remain the lowest for all cancer screening.6
Only 45% of the eligible population is screened in the United States, and Asian immigrants have the lowest screening rates of all races/ethnicities.27
Coughlin et al. found that large percentages of patients were not referred for colorectal cancer screening by their physicians or were not recommended FOBT, with similar results among all races/ethnicities.12
Although the majority of physicians in the study reported recommending FOBT to their patients in accordance with the guidelines, we found that only 45% of physicians reported following the correct guidelines on all screening tests for CRC and that respondents demonstrated a large, although not statistically significant, discrepancy between female and male patients. We also found a group of physicians in the study that recommend CRC screening tests more often than specified by the guidelines, revealing another sort of confusion about those guidelines. There are several patient barriers that must be overcome to increase the rate of colorectal cancer screening among Chinese immigrants9,33,34
but, again, our results indicate that there is a great need to clarify guidelines among physicians.
We found that almost 30% of the physicians included in this study were not satisfied with their patients’ rates of cancer screening. These physicians may be particularly receptive to programs that will help them improve their cancer screening practices. Identifying these physicians, and tailoring educational strategies to them, will facilitate cancer screening among the Chinese immigrant population.
In our study, 35% of physicians had not attended an educational workshop during the previous 10 years and only 34% of those who had attended one had done so during the previous year. Continuing medical education (CME) has been proven to be effective in modifying physician’s behaviors and increasing cancer screening rates,35,36
and should be used to increase cancer screening in this population. Almost 80% of the physicians believed that CME would be helpful to this end. Ethnically-specific physician membership organizations could work to increase education and disseminate computer-based reminder systems among physicians who care for Chinese immigrants. In addition, physicians in the study identified time constraints, low reimbursement rates for screening tests, and lack of cancer screening information in the Chinese language as difficulties for cancer screening among their Chinese immigrant patients. Increasing the availability and awareness of educational materials in Chinese language, providing low-cost services, and delivering these services at times that the immigrant population is available would be important interventions.
There are limitations to our study. The sample of providers included was obtained randomly from a list of providers identified from Chinese physicians’ organizations, the state medical society, or community-based organization networks’ physician lists, omitting providers not associated with these institutions. It is likely that some of the results are underestimated due to the response rate. The lack of survey anonymity may have made it more likely for those adhering to screening guidelines to respond. Some providers may not have responded due to lack of knowledge or lack of adherence with screening guidelines. Additionally, self-report is likely to have led to an overestimation of correct practices.
This study reveals several areas where tailored interventions can help overcome cancer health disparities among the Chinese immigrant population in the United States. Our results indicate that cancer screening rates can likely be improved by targeting physicians to increase their awareness of the proposed guidelines and their current practices and to facilitate the use of any or better systems to increase cancer screening rates.