Objective: Priorities of the Centers for Disease Control and Prevention's 6|18 Initiative include outpatient asthma self-management education (ASME) and home-based asthma visits (home visit) as interventions for children with poorly-controlled asthma. ASME and home visit intervention programs are currently not widely available. This project was to assess the economic sustainability of these programs for state asthma control programs reimbursed by Medicaid.Methods: We used a simulation model based on parameters from the literature and Medicaid claims, controlling for regression to the mean. We modeled scenarios under various selection criteria based on healthcare utilization and age to forecast the return on investment (ROI) using data from New York. The resulting tool is available in Excel or Python.Results: Our model projected health improvement and cost savings for all simulated interventions. Compared against home visits alone, the simulated ASME alone intervention had a higher ROI for all healthcare utilization and age scenarios. Savings were primarily highest in simulated program participants who had two or more asthma-related emergency department visits or one inpatient visit compared to those participants who had one or more asthma-related emergency department visits. Segmenting the selection criteria by age did not significantly change the results.Conclusions: This model forecasts reduced healthcare costs and improved health outcomes as a result of ASME and home visits for children with high urgent healthcare utilization (more than two emergency department visits or one inpatient hospitalization) for asthma. Utilizing specific selection criteria, state based asthma control programs can improve health and reduce healthcare costs.

The American College of Preventive Medicine (ACPM) collaborated with the Centers for Disease Control and Prevention (CDC) in a cooperative 5-year agreement to improve population health through primary care and public health integration. As part of the last 2 years of the cooperative agreement, the CDC's 6|18 Initiative was identified as a critical project for ACPM to promote among its membership. Information on the CDC's 6|18 Initiative is available here: www.cdc.gov/sixeighteen/index.html. | | This paper reflects work done as part of the cooperative agreement between ACPM and CDC, with the intention of informing the preventive medicine community about the CDC's 6|18 Initiative, identifying physician barriers to adoption of the initiative, and providing examples from across the country of various 6|18 interventions implemented in the physician practice or healthcare setting. The purpose of this manuscript is to highlight existing physician practices related to the 6|18 Initiative, to increase physician awareness of the 6|18 Initiative, and to identify potential opportunities for ACPM physicians to incorporate elements of this initiative into their practice settings. This manuscript does not represent a policy statement from ACPM.

CONTEXT: As the US health care system continues to undergo dynamic change, the increased alignment between health care quality and payment has provided new opportunities for public health and health care sectors to work together. PROGRAM: The Centers for Disease Control and Prevention's 6|18 Initiative accelerates cross-sector collaboration between public health and health care purchasers, payers, and providers and highlights 6 high-burden conditions and 18 associated interventions with evidence of cost reduction/neutrality and improved health outcomes. This evidence can inform payment, utilization, and quality of prevention and control interventions. IMPLEMENTATION: The Centers for Disease Control and Prevention focused initially on public payer health insurance interventions for asthma control, unintended pregnancy prevention, and tobacco cessation. Nine state Medicaid and public health agency teams-in Colorado, Georgia, Louisiana, Massachusetts, Michigan, Minnesota, New York, Rhode Island, and South Carolina-participated in the initiative because they had previously prioritized the health condition(s) and specific intervention(s) and had secured state-level leadership support for state agency collaboration. The Centers for Disease Control and Prevention, the Centers for Medicare & Medicaid Services, the Center for Health Care Strategies, the Robert Wood Johnson Foundation, and other partners supported state implementation and dissemination of early lessons learned. EVALUATION: The Centers for Disease Control and Prevention conducted exploratory interviews to guide improvement of the 6|18 Initiative and to understand facilitators, barriers, and complementary roles played by each sector. Monthly technical assistance calls conducted with state teams documented collaborative activities between state Medicaid agencies and health departments and state processes to increase coverage and utilization. DISCUSSION: The 6|18 Initiative is strengthening partnerships between state health departments and Medicaid agencies and contributing to state progress in helping improve Medicaid coverage and utilization of effective prevention and control interventions. This initiative highlights early successes for others interested in strengthening collaboration between state agencies and between public and private sectors to improve payment, utilization, and quality of evidence-based interventions.

Electronic information technology standards facilitate high-quality, uniform collection of data for improved delivery and measurement of health care services. Electronic information standards also aid information exchange between secure systems that link health care and public health for better coordination of patient care and better-informed population health improvement activities. We developed international data standards for healthy weight that provide common definitions for electronic information technology. The standards capture healthy weight data on the "ABCDs" of a visit to a health care provider that addresses initial obesity prevention and care: assessment, behaviors, continuity, identify resources, and set goals. The process of creating healthy weight standards consisted of identifying needs and priorities, developing and harmonizing standards, testing the exchange of data messages, and demonstrating use-cases. Healthy weight products include 2 message standards, 5 use-cases, 31 LOINC (Logical Observation Identifiers Names and Codes) question codes, 7 healthy weight value sets, 15 public-private engagements with health information technology implementers, and 2 technical guides. A logic model and action steps outline activities toward better data capture, interoperable systems, and information use. Sharing experiences and leveraging this work in the context of broader priorities can inform the development of electronic information standards for similar core conditions and guide strategic activities in electronic systems.

BACKGROUND: Many individuals have not received recommended colorectal cancer (CRC) screening before they become Medicare eligible at the age of 65. We aimed to estimate the long-term implications of increased CRC screening in the pre-Medicare population (50-64 y) on costs in the pre-Medicare and Medicare populations (65+ y). METHODS: We used 2 independently developed microsimulation models [Microsimulation Screening Analysis Colon (MISCAN) and Simulation Model of CRC (SimCRC)] to project CRC screening and treatment costs under 2 scenarios, starting in 2010: "current trends" (60% of the population up-to-date with screening recommendations) and "enhanced participation" (70% up-to-date). The population was scaled to the projected US population for each year between 2010 and 2060. Costs per year were derived by age group (50-64 and 65+ y). RESULTS: By 2060, the discounted cumulative total costs in the pre-Medicare population were $35.7 and $28.1 billion higher with enhanced screening participation, than in the current trends scenario ($252.1 billion with MISCAN and $239.5 billion with SimCRC, respectively). Because of CRC treatment savings with enhanced participation, cumulative costs in the Medicare population were $18.3 and $32.7 billion lower (current trends: $423.5 billion with MISCAN and $372.8 billion with SimCRC). Over the 50-year time horizon an estimated 60% (MISCAN) and 89% (SimCRC) of the increased screening costs could be offset by savings in Medicare CRC treatment costs. CONCLUSION: Increased CRC screening participation in the pre-Medicare population could reduce CRC incidence and mortality, whereas the additional screening costs can be largely offset by long-term Medicare treatment savings.

This article explores how the ACA's community health needs assessment requirement and the Community Reinvestment Act can encourage collaboration among tax-exempt hospitals, public health agencies, financial institutions, and communities to improve population health through aligned health improvement planning and initiatives to address social, economic, and environmental factors that affect health.

The findings described in this supplement can help improve collaboration among public health and other stakeholders who influence infant, child, and adolescent health (e.g., parents or guardians and their employers, health plans, health professionals, schools, child care facilities, community groups, and voluntary associations) to increase the use of selected clinical preventive services among U.S. infants, children, and adolescents. Increased use can substantially reduce illness and long-term disability and improve health and quality of life. This supplement underscores that the use of the clinical preventive services among U.S. infants, children, and adolescents is not optimal and is variable, ranging from <10% to approximately 85%, depending on the particular service. Use was particularly low for developmental screening and receipt of dental preventive services in young children, and for human papillomavirus (HPV) vaccination and tobacco cessation assistance, including counseling, in adolescents; however, opportunities exist to improve use of all of these services. Children and adolescents with no insurance and those with no usual source of health care (if available for analysis) were the groups least likely to have used the services. Use among the uninsured ranged from 1-39 percentage points below the general population averages, suggesting that improvements in insurance coverage that will result from the implementation of health-care reform are likely to increase use of these clinical preventive services. In 2012, a total of 4.9 million children (6.6% of children) were uninsured at the time of interview, and approximately 15% of eligible children in the United States are not enrolled in Medicaid and Children's Health Insurance Program (CHIP) programs. In addition, although opportunities exist for greater insurance coverage and for use of recommended clinical preventive services under the Patient Protection and Affordable Care Act of 2010 (P.L. 111-148), as amended by the Health Care and Education Reconciliation Act of 2010 (P.L. 111-152, together referred to as the Affordable Care Act [ACA]), a survey among the uninsured found a low level of awareness of the Health Insurance Marketplace (or Health Insurance Exchange) that can be used by families to acquire insurance or Medicaid coverage. The survey highlights the importance of focused efforts by governmental health agencies and other stakeholders to enroll uninsured children and adolescents in health plans. Also, although use of clinical preventive services in insured populations was greater than among the uninsured, use among the insured was generally <85%, and often much less. Therefore, having health insurance coverage alone might not be sufficient to optimize use of clinical preventive services, and additional measures to improve use probably will be necessary.

Colorectal cancer (CRC) is the second leading cause of cancer-related deaths in the United States among cancers that affect both men and women. Screening for CRC reduces incidence and mortality. In 2008, the U.S. Preventive Services Task Force (USPSTF) recommended that persons aged 50-75 years at average risk for CRC be screened for the disease by using one or more of the following methods: fecal occult blood testing (FOBT) every year, sigmoidoscopy every 5 years (with high-sensitivity FOBT every 3 years), or colonoscopy every 10 years.

BACKGROUND: The Centers for Disease Control and Prevention (CDC) initiated the Colorectal Cancer Screening Demonstration Program (CRCSDP) to explore the feasibility of establishing a large-scale colorectal cancer screening program for underserved populations in the United States. The authors of the current report provide a detailed description of the total program costs (clinical and nonclinical) incurred during both the start-up and service delivery (screening) phases of the 4-year program. METHODS: Tailored cost questionnaires were completed by staff at the 5 CRCSDP sites. Cost data were collected for clinical services and nonclinical programmatic activities (program management, data collection, and tracking, etc). In-kind contributions also were measured and were assigned monetary values. RESULTS: Nearly $11.3 million was expended by the 5 sites over 4 years, and 71% was provided by the CDC. The proportion of funding spent on clinical service delivery and service delivery/patient support comprised the largest proportion of cost during the implementation phase (years 2-4). The per-person nonclinical cost comprised a substantial portion of total costs for all sites. The cost per person screened varied across the 5 sites and by screening method. Overall, economies of scale were observed, with lower costs resulting from larger numbers of individuals screened. CONCLUSIONS: Programs incur substantial variable costs related to clinical services and semivariable costs related to nonclinical services. Therefore, programs that serve large populations are likely to achieve a lower cost per person. Cancer 2013;119(15 suppl):2855-62. (c) 2013 American Cancer Society.

BACKGROUND: The Centers for Disease Control and Prevention (CDC) established and supported a 4-year Colorectal Cancer Screening Demonstration Program (CRCSDP) from 2005 to 2009 for low-income, under- or uninsured men and women aged 50-64 at 5 sites in the United States. METHODS: A multiple methods evaluation was conducted including 1) a longitudinal, comparative case study of program implementation, 2) the collection and analysis of client-level screening and diagnostic services outcome data, and 3) the collection and analysis of program- and patient-level cost data. RESULTS: Several themes emerged from the results reported in the series of articles in this Supplement. These included the benefit of building on an existing infrastructure, strengths and weakness of both the 2 most frequently used screening tests (colonoscopy and fecal occult blood tests), variability in costs of maintaining this screening program, and the importance of measuring the quality of screening tests. Population-level evaluation questions could not be answered because of the small size of the participating population and the limited time frame of the evaluation. The comprehensive evaluation of the program determined overall feasibility of this effort. CONCLUSIONS: Critical lessons learned through the implementation and evaluation of the CDC's CRCSDP led to the development of a larger population-based program, the CDC's Colorectal Cancer Control Program (CRCCP). Cancer 2013;119(15 suppl):2940-6. (c) 2013 American Cancer Society.

BACKGROUND: To the authors's knowledge, there are few published prospective cohort studies of colonoscopy complications in patients at average risk for colorectal cancer who received colorectal cancer screening from a community-based program. In this article, the authors report the rate of colonoscopy complications in the Centers for Disease Control and Prevention (CDC)'s Colorectal Cancer Screening Demonstration Program (CRCSDP), which provided colorectal cancer screening to a medically underserved population aged 50 years to 64 years for screening, diagnostic follow-up after positive stool blood tests, and surveillance purposes. METHODS: Clinical data were collected prospectively from 5 community-based colorectal cancer screening programs. Complications were identified by reviewing the standardized clinical data and medical complication reporting forms submitted by the programs to the CDC. Serious complications were defined as conditions or symptoms that resulted in hospital admission within 30 days after the procedure, including perforation, gastrointestinal bleeding requiring or not requiring blood transfusion, cardiopulmonary events, postpolypectomy syndrome, excessive abdominal pain, or death. RESULTS: A total of 3215 individuals underwent 3355 colonoscopies. Of these, 89% of the colonoscopies were conducted for screening, 9% were conducted for diagnostic follow-up, and 2% were conducted for surveillance purposes. The mean age of the individuals was 55.9 years. Eight individuals experienced serious complications, for an incidence of 2.38 per 1000 colonoscopies. Three patients experienced bowel perforations that required surgery, 1 patient was hospitalized for postpolypectomy bleeding, 3 patients experienced cardiopulmonary events, and 1 patient visited the emergency room for excessive abdominal pain and underwent surgery for an identified colorectal mass. No deaths were reported. CONCLUSIONS: In the CDC's CRCSDP, in which a total of 3215 individuals underwent 3355 colonoscopies, the overall incidence of serious complications from colonoscopy was found to be low.

BACKGROUND: Gaps in screening quality in community practice have been well documented. The authors examined recommended indicators of screening quality in the Centers for Disease Control and Prevention's Colorectal Cancer Screening Demonstration Program (CRCSDP), which provided colorectal cancer screening and diagnostic services between 2005 and 2009 for asymptomatic, low-income, underinsured, or uninsured individuals at 5 sites around the United States. METHODS: For each client screened in the CRCSDP, a standardized set of colorectal cancer clinical data elements was collected. Data regarding client age, screening history, risk level, screening test indication, results, and recommendation for the next test were analyzed. For colonoscopies, data were analyzed regarding whether the cecum was reached, bowel preparation was adequate, and identified lesions were completely removed. RESULTS: Overall, 53% of the fecal occult blood tests (FOBTs) (2295 tests) distributed were completed and returned. At the 2 sites with adequate numbers of FOBTs, 77% and 97%, respectively, of clients with positive results received follow-up colonoscopies. Site-specific cecal intubation rates ranged from 90% to 98%. Adenoma detection rates were 32% for men and 21% for women. For approximately one-third of colonoscopies, the recommended interval to the next test was shorter than recommended by national guidelines. At some sites, endoscopists failed to report on the adequacy of bowel preparation and completeness of polyp removal. CONCLUSIONS: Cecal intubation rates and adenoma detection rates met recommended levels. The authors identified the need for improvements in the follow-up of positive FOBTs, documentation of important elements in colonoscopy reports, and recommendations for rescreening or surveillance intervals after colonoscopy. Monitoring quality indicators is important to improve screening quality.

BACKGROUND: The Centers for Disease Control and Prevention initiated the Colorectal Cancer Screening Demonstration Program (CRCSDP) to explore the feasibility of establishing a large-scale colorectal cancer (CRC) screening program for underserved populations in the United States. The authors of this report assessed the clinical costs incurred at each of the 5 participating sites during the demonstration period. METHODS: By using data on payments to providers by each of the 5 CRCSDP sites, the authors estimated costs for specific clinical services and overall clinical costs for each of the 2 CRC screening methods used by the sites: colonoscopy and fecal occult blood test (FOBT). RESULTS: Among CRCSDP clients who were at average risk for CRC and for whom complete cost data were available, 2131 were screened by FOBT, and 1888 were screened by colonoscopy. The total average clinical cost per individual screened by FOBT (including costs for screening, diagnosis, initial surveillance, office visits, and associated clinical services averaged across all individuals who received screening FOBT) ranged from $48 in Nebraska to $149 in Greater Seattle. This compared with an average clinical cost per individual for all services related to the colonoscopy screening ranging from $654 in St. Louis to $1600 in Baltimore City. CONCLUSIONS: Variations in how sites contracted with providers and in the services provided through CRCSDP affected the cost of clinical services and the complexity of collecting cost data. Health officials may find these data useful in program planning and budgeting.

BACKGROUND: Colorectal cancer remains the second leading cause of cancer-related deaths among US men and women. Screening rates have been slow to increase, and disparities in screening remain. METHODS: To address the disparity in screening for this high burden but largely preventable disease, the Centers for Disease Control and Prevention (CDC) designed and established a 4-year Colorectal Cancer Screening Demonstration Program (CRCSDP) in 2005 for low-income, under-insured or uninsured men and women aged 50 to 64 years in 5 participating US program sites. In this report, the authors describe the design of the CRCSDP and the overall clinical findings and screening test performance characteristics, including the positive fecal occult blood testing (FOBT) rate; the rates of polyp, adenoma, and cancer detection with FOBTs and colonoscopies; and the positive predicative value for polyps, adenomas, and cancers. RESULTS: In total, 5233 individuals at average risk and increased risk were screened for colorectal cancer across all 5 sites, including 44% who underwent screening FOBT and 56% who underwent screening colonoscopy. Overall, 77% of all individuals screened were women. The FOBT positivity rate was 10%. Results from all screening or diagnostic colonoscopies indicated that 75% had negative results and required a repeat screening colonoscopy in 10 years, 16% had low-risk adenomas and required surveillance colonoscopy in 5 to 10 years, 8% had high-risk adenomas and required surveillance colonoscopy in 3 years, and 0.6% had invasive cancers. CONCLUSIONS: This report documents the successes and challenges in implementing the CDC's CRCSDP and describes the clinical outcomes of this 4-year initiative, the patterns in program uptake and test choice, and the comparative test performance characteristics of FOBT versus colonoscopy. Patterns in final outcomes from the follow-up of positive screening tests were consistent with national registry data.

This report briefly summarizes 13 articles in this dedicated supplement to Cancer documenting the full implementation and evaluation of CDC's Colorectal Cancer Screening Demonstration Program (CRCSDP). The supplement includes 3 articles that describe clinical and quality outcomes; 2 articles that describe programmatic and clinical costs; 3 that were based on a multiple case study, using qualitative methods to describe the overall implementation experience of this initiative; and 4 articles written by and about individual program sites. The comprehensive, multi-methods evaluation conducted alongside the program produced many important lessons regarding the design, start-up, and implementation of colorectal cancer screening in this high-need population, and paved the way for the CDC to establish a larger, population-based colorectal cancer control initiative, broadly aligned with expectations of the Patient Protection and Affordable Care Act through its population-based emphasis on using a health systems approach to increase colorectal cancer screening.

BACKGROUND: Recommended CRC screening tests for adults ages 50-75 include home FOBT, sigmoidoscopy with FOBT, and colonoscopy. A newer test, computed tomographic (CT) colonography, has been recommended by some, but not all, national organizations. METHODS: We analyzed 2010 National Health Interview Survey data, including new CT colonography questions, from respondents ages 50-75 (N=8952). We assessed: 1) prevalence of CRC test use overall, by test type, and by sociodemographic and health care access factors, and 2) reported reasons for not having a CRC test. RESULTS: The age-standardized percentage of respondents reporting FOBT, sigmoidoscopy or colonoscopy within recommended time intervals was 58.3% (95% CI, 57.0-59.6). Colonoscopy was the most commonly reported test (within past 10 years: 54.6% (95% CI, 53.2-55.9)). Home FOBT and sigmoidoscopy with FOBT were less frequently used (FOBT within past year: 8.8% (95% CI, 8.1-9.6); sigmoidoscopy within past 5 years with FOBT within past 3 years: 1.3% (95% CI, 1.0-1.6)). CT colonography was rare: 1.3% (95% CI, 1.0-1.7). Increasing age, education, income, having health insurance, and having a usual source of health care were associated with higher CRC test use. Test use within recommended time intervals was particularly low among individuals ages 50-64 without health insurance (21.2% (95% CI, 18.3-24.4)). The most common reason for non-use was "no reason or never thought about it." CONCLUSIONS: About 40% of Americans ages 50-75 do not meet recommendations for having CRC screening tests. Impact: Expanded health care coverage and greater awareness of CRC screening are needed to further decrease CRC mortality.

Of the types of cancer that affect both men and women, colorectal cancer is the second leading cause of cancer-related deaths in the United States (1). Screening reduces colorectal cancer incidence and mortality (2). The U.S. Preventive Services Task Force recommended in 2008 that persons aged 50--75 years at average risk for colorectal cancer be screened for the disease by using one or more of the following methods: fecal occult blood testing (FOBT) every year, sigmoidoscopy every 5 years (with high-sensitivity FOBT every 3 years), or colonoscopy every 10 years (1). | | To estimate disparities in rates of use of colorectal cancer tests and evaluate changes in test use, CDC compared data from the 2002, 2004, 2006, and 2008 Behavioral Risk Factor Surveillance System (BRFSS) surveys (3). BRFSS is a state-based, random-digit--dialed telephone survey of the noninstitutionalized, U.S. civilian population aged ≥18 years. Survey data were available for all 50 states (except for Hawaii in 2004) and the District of Columbia. The median response rate, based on Council of American Survey and Research Organizations (CASRO) guidelines,* was 58.3% in 2002, 52.7% in 2004, 51.4% in 2006, and 53.3% in 2008 (3). The median cooperation rate, based on CASRO guidelines, was 76.7% in 2002, 74.3% in 2004, 74.5% in 2006, and 75.0% in 2008 (3). Respondents who refused to answer, had a missing answer, or did not know the answer to a question were excluded from analysis of that specific question. Of persons aged ≥50 years who responded, approximately 3% of 108,028 persons were excluded from 2002 results, approximately 3% of 146,794 were excluded from 2004 results, approximately 4.5% of 195,318 were excluded from 2006 results, and approximately 4.1% of 251,623 were excluded from 2008 results.

BACKGROUND: The Centers for Disease Control and Prevention (CDC) initiated the Colorectal Cancer Screening Demonstration Program (CRCSDP) in 2005 to explore the feasibility of establishing a colorectal cancer screening program for underserved US populations. We provide a detailed overview of the evaluation and an assessment of the costs incurred during the service delivery (screening) phase of the program. METHODS: Tailored cost questionnaires were completed by staff at the five CRCSDP sites for the first 2 years of the program. We collected cost data for clinical and programmatic activities (program management, data collection and tracking, etc.). We also measured in-kind contributions and assigned values to them. RESULTS: During the first 2 years of the demonstration excluding the start-up cost, the average cost per person was $2569. Per person cost of clinical services alone ranged from $264 to $1385, while per person programmatic costs ranged from $545 to $3017. CONCLUSION: Colorectal cancer screening programs can incur substantial costs for some non-clinical activities, such as data collection/tracking, and these support activities should be managed carefully to control costs and ensure successful program implementation. Our findings highlight the importance of performing economic evaluation to guide the design of future colorectal cancer screening programs.

Colorectal cancer control has long been a focus area for Comprehensive Cancer Control programs and their coalitions, given the high burden of disease and the availability of effective screening interventions. Colorectal cancer control has been a growing priority at the national, state, territorial, tribal, and local level. This paper summarizes several national initiatives and features several Comprehensive Cancer Control Program colorectal cancer control successes.

Colorectal cancer is the second-leading cause of cancer | deaths among U.S. adults among cancers that affect both | men and women, and primarily affects persons age 50 and | older.1 In 2005, more than 141,000 new cases of colorectal | cancer were diagnosed across the U.S., and 53,000 people | died from the disease.1 | Screening for colorectal cancer has a tremendous potential | to save lives. It is estimated that 76 to 90 percent of new | colorectal cancer cases would be reduced, and 70 to 90 percent | of colorectal cancer deaths reduced if all precancerous | colorectal polyps were identified and removed.2,3 Most | colorectal cancers develop from precancerous polyps, or | growths inside the colon, which slowly develop into | colorectal cancer. Screening tests can identify and remove | polyps, preventing the development of colorectal cancer | altogether, and can also detect early cancers, which can be | treated more effectively and at a lesser cost. Unrealized | financial savings are also possible through the prevention | and earlier detection of colorectal cancer.

BACKGROUND: The American Cancer Society, the Centers for Disease Control and Prevention (CDC), the National Cancer Institute (NCI), and the North American Association of Central Cancer Registries (NAACCR) collaborate annually to provide updated information regarding cancer occurrence and trends in the United States. This year's report includes trends in colorectal cancer (CRC) incidence and death rates and highlights the use of microsimulation modeling as a tool for interpreting past trends and projecting future trends to assist in cancer control planning and policy decisions. METHODS: Information regarding invasive cancers was obtained from the NCI, CDC, and NAACCR; and information on deaths was obtained from the CDC's National Center for Health Statistics. Annual percentage changes in the age-standardized incidence and death rates (based on the year 2000 US population standard) for all cancers combined and for the top 15 cancers were estimated by joinpoint analysis of long-term trends (1975-2006) and for short-term fixed-interval trends (1997-2006). All statistical tests were 2-sided. RESULTS: Both incidence and death rates from all cancers combined significantly declined (P < .05) in the most recent time period for men and women overall and for most racial and ethnic populations. These decreases were driven largely by declines in both incidence and death rates for the 3 most common cancers in men (ie, lung and prostate cancers and CRC) and for 2 of the 3 leading cancers in women (ie, breast cancer and CRC). The long-term trends for lung cancer mortality in women had smaller and smaller increases until 2003, when there was a change to a nonsignificant decline. Microsimulation modeling demonstrates that declines in CRC death rates are consistent with a relatively large contribution from screening and with a smaller but demonstrable impact of risk factor reductions and improved treatments. These declines are projected to continue if risk factor modification, screening, and treatment remain at current rates, but they could be accelerated further with favorable trends in risk factors and higher utilization of screening and optimal treatment. CONCLUSIONS: Although the decrease in overall cancer incidence and death rates is encouraging, rising incidence and mortality for some cancers are of concern.

BACKGROUND & AIMS: The risk of serious complications after colonoscopy has important implications for the overall benefits of colorectal cancer screening programs. We evaluated the incidence of serious complications within 30 days after screening or surveillance colonoscopies in diverse clinical settings and sought to identify potential risk factors for complications. METHODS: Patients age 40 and over undergoing colonoscopy for screening, surveillance, or evaluation based an abnormal result from another screening test were enrolled through the National Endoscopic Database (CORI). Patients completed a standardized telephone interview approximately 7 and 30 days after their colonoscopy. We estimated the incidence of serious complications within 30 days of colonoscopy and identified risk factors associated with complications using logistic regression analyses. RESULTS: We enrolled 21,375 patients. Gastrointestinal bleeding requiring hospitalization occurred in 34 patients (incidence 1.59/1000 exams; 95% confidence interval [CI], 1.10-2.22). Perforations occurred in 4 patients (0.19/1000 exams; 95% CI, 0.05-0.48), diverticulitis requiring hospitalization in 5 patients (0.23/1000 exams; 95% CI, 0.08-0.54), and postpolypectomy syndrome in 2 patients (0.09/1000 exams; 95% CI, 0.02-0.30). The overall incidence of complications directly related to colonoscopy was 2.01 per 1000 exams (95% CI, 1.46-2.71). Two of the 4 perforations occurred without biopsy or polypectomy. The risk of complications increased with preprocedure warfarin use and performance of polypectomy with cautery. CONCLUSIONS: Complications after screening or surveillance colonoscopy are uncommon. Risk factors for complications include warfarin use and polypectomy with cautery.