Predictors of behavioral cancer risk factors and preventive behaviors among Nebraskans

1Introduction

Cancer is the second leading cause of death after heart disease in the United States and Nebraska [1] , with more than 1.9 million cancer cases and 609,360 deaths in the U.S. expected in 2022 [2] . In Nebraska, the cancer mortality rate was 180 per 100,000 population in 2018–2019 [3] . In 2018, the most common cancers were breast, lung, and colorectal in females, and prostate, lung, and colorectal in males [4] . The overall cancer incidence rate in Nebraska was higher than national average [5] .

Cancer prevention is possible through adoption of healthy lifestyle and immunization against cancer-associated viruses [6] . Yet nearly 45% of the cancer deaths in the U.S. are caused by potentially modifiable risk factors such as cigarette smoking, excess body weight, alcohol intake, physical inactivity, and unhealthy diet [7] . Nebraska population has higher incidence rates of alcohol-associated cancers (e.g., liver, esophageal, and colorectal cancers) (137.7 vs. 129.3 per 100,000), physical inactivity-associated cancers (e.g., breast, endometrial, and colon cancers) (98.3 vs. 90.8 per 100,000), and tobacco-associated cancers (e.g., lung, esophageal, and mouth and throat cancers) (185.3 vs. 178.5 per 100,000) compared to the U.S. average [8] . Additionally, the incidence rate of skin cancer (30.7 vs. 28.9 per 100,000) is higher than the U.S. average, making it the fifth most common cancer in the state [9] .

Cancer screening is another means of prevention. The U.S. Preventive Services Task Force’s (USPSTF) current screening recommendations include stool, scoping, and/or imaging tests for colorectal cancer (CRC) in average risk adults aged 45–75; prior to 2021, screening was recommended for average risk adults aged 50–75 [10] . For cervical cancer prevention, pap smear is recommended every three years for women aged 21–29, and every five years for women aged 30–65 with pap smear and high-risk HPV (hrHPV) testing [11] . For breast cancer prevention, biennial mammography is recommended for average risk women aged 50–74 [12] . Due to insufficient evidence, USPSTF does not have recommendations for skin cancer screening [13] . Unfortunately, screening rates in Nebraska are suboptimal. In 2018, the prevalence of CRC screening by colonoscopy (in the past ten years) in Nebraska adults aged 50–75 was 65.9%, the prevalence of screening by sigmoidoscopy (in the past five years) was 1.7%, and the prevalence of screening by blood stool test (in the past year) was 6.5% [8] . The prevalence of up-to-date screening for CRC using any of the three methods was 68.7% [8] . Among women, the prevalence of cervical cancer screening by pap test (in the last three years) in those aged 21–65 was 80.9% [8] . The prevalence of breast cancer screening by mammography (in the past 2 years) in women aged 50–74 was 75.4% and in women aged 40 and older was 69.3% [8] .

There exist many cancer disparities related to ethnicity, socioeconomic status, geographic location, and access to care. The five-year survival rates for CRC (1999–2018) were highest among White women and lowest among African American men [5] . Moreover, the five-year survival rates for female breast cancer were highest among White women and lowest among African American women [5] . In the Midwest, individuals living in rural areas had lower rates of cancer screening [14] . Rural residents experience higher lung, cervical, and CRC death rates than urban residents because of poverty, risky health behaviors, and lower vaccination and screening rates [15] . Moreover, rural residents were shown to consume unhealthy diets, with older rural residents leading sedentary lifestyles with less physical activity than those living in urban areas [16] .

This study aims to identify the predictors of behavioral cancer risk factors and preventive behaviors among Nebraskan residents to guide the design of interventions for improving primary and secondary cancer prevention.