Clinical Practice Guidelines for Colorectal Cancer Screening: New Recommendations and New Challenges

The impact of the affordable care act and Medicaid expansion on colorectal cancer screening: Evidence from the 5th year of Medicaid expansion

BACKGROUND

Colorectal cancer screening rates remain suboptimal, particularly among low-income populations. Our objective was to evaluate the long-term effects of Medicaid expansion on colorectal cancer screening.

DESIGN, SETTING, AND PARTICIPANTS

This cross-sectional study analyzed data from 354,384 individuals aged 50-64 with an income below 400% of the federal poverty level (FPL), who participated in the Behavioral Risk Factors Surveillance System from 2010 to 2018. A difference-in-difference analysis was employed to estimate the effect of Medicaid expansion on colorectal cancer screening. Subgroup analyses were conducted for individuals with income up to 138% of the FPL and those with income between 139% and 400% of the FPL. The effect of Medicaid expansion on colorectal cancer screening was examined during the early, mid, and late expansion periods.

MAIN OUTCOMES AND MEASURES

The primary outcome was the likelihood of receiving colorectal cancer screening for low-income adults aged 50-64.

RESULTS

Medicaid expansion was associated with a significant 1.7 percentage point increase in colorectal cancer screening rates among adults aged 50-64 with income below 400% of the FPL (p < 0.05). A significant 2.9 percentage point increase in colorectal cancer screening was observed for those with income up to 138% the FPL (p < 0.05), while a 1.5 percentage point increase occurred for individuals with income between 139% and 400% of the FPL. The impact of Medicaid expansion on colorectal cancer screening varied based on income levels and displayed a time lag for newly eligible beneficiaries.

CONCLUSIONS

Medicaid expansion was found to be associated with increased colorectal cancer screening rates among low-income individuals aged 50-64. The observed variations in impact based on income levels and the time lag for newly eligible beneficiaries receiving colorectal cancer screening highlight the need for further research and precision public health strategies to maximize the benefits of Medicaid expansion on colorectal cancer screening rates.

Oxineur, a novel peptide from Caspian cobra Naja naja oxiana against HT-29 colon cancer

Colon cancer ranks fourth in mortality. This cancer is still an important clinical challenge worldwide due to its high prevalence and poor prognosis. Proteomic studies revealed that snake venom is a diverse and variable mixture of enzymatic and non-enzymatic proteins and peptides. Despite the toxic effects of these molecules, several proteins and peptides have been isolated that have practical applications and appear to induce apoptosis and prevent cell metastasis. In this study, we worked on cytotoxic effects and anticancer activity of Naja naja oxiana (Iranian Caspian cobra) snake venom components on HT-29 cell line colon cancer. Separated Fraction-5 by FPLC indicated the high cytotoxicity on HT-29 cell line colon cancer by MTT test. Further isolation of F5 by HPLC showed that the purified peak 2, nominated as Oxineur that contains a cytotoxic effect on HT-29 cells and reduces cell viability at 8 μg/ml to 4% in 24 h. Oxineur has the least cytotoxic effect on HEK-293 normal cells. Further studies on Oxineur peptide confirmed the apoptotic effects with high expression of CASP9 gene and DNA fragmentation in cancerous cells. The partial sequence of Oxineur revealed 71% homology with the neurotoxin II from Naja naja oxiana. Since our target molecule is a peptide in the molecular weight range of 7 kDa, it has potentially a therapeutic value.

What Constitutes Evidence? Colorectal Cancer Screening and the U.S. Preventive Services Task Force

The United States Preventive Services Task Force is perhaps America's best-known source of evidence-based medicine (EBM) recommendations. This paper reviews aspects of the history of one such recommendation-screening for colorectal cancer (CRC)-to explore how the Task Force evaluates the best available evidence to reach its conclusions.Although the Task Force initially believed there was inadequate evidence to recommend CRC screening in the 1980s, it later changed its mind. Indeed, by 2002, it was recommending screening colonoscopy for those aged 50 and older, "extrapolating" from the existing evidence as there were no randomized controlled trials of the procedure. By 2016, due in part to the use of an emerging analytic modality known as modeling, the Task Force supported four additional CRC screening tests that lacked randomized data. Among the reasons the Task Force gave for these decisions was the desire to improve adherence for a strategy-screening healthy, asymptomatic individuals-that it believed saved lives.During these same years, the Task Force diverged from other organizations by declining to advocate screening otherwise healthy Black patients earlier than age 50-despite the fact that such individuals had higher rates of CRC than the general population, higher mortality from the disease and earlier onset of the disease. In declining to extrapolate in this instance, the Task Force underscored the lack of reliable data that proved that the benefits of such testing would outweigh the harms.The history of CRC screening reminds us that scientific evaluation relies not only on methodological sophistication but also on a combination of intellectual, cognitive and social processes. General internists-and their patients-should realize that EBM recommendations are often not definitive but rather thoughtful data-based advice.

Circulating miR-449a predicts survival outcome for colorectal cancer following curative resection: An observational study

Previous studies showed that microRNA (miR)-449a may function as a tumor suppressor. However, the expression pattern and value of circulating miR-449a in colorectal cancer (CRC) remain unclear. Therefore, the purpose of this study was to measure circulating miR-449a level of CRC patients and evaluate its value for predicting prognosis.Plasma samples of 343 consecutive CRC patients and 162 healthy controls were obtained. Circulating miR-449a levels were measured by using real-time quantitative reverse transcription polymerase chain reactions. All enrolled patients were followed up in a regular interval after surgery. The clinical data and survival outcome of all 343 patients were collected. The correlation between circulating miR-449a level and survival outcomes was analyzed by univariate and multivariate analysis.Circulating miR-449a level in CRC patients was significantly decreased (P < .05) comparing with healthy controls. Low miR-449a was significantly associated with CEA and CA19-9 level (both P < .05). Furthermore, patients with a decreased miR-449a level had a lower 5-years overall survival (OS) rate than those with a high miR-449a (67.4% vs 76.9%, P = .03). Low circulating miR-449a level also been demonstrated as an independent risk factor for CRC in multivariate COX analysis (HR, 2.56; 95%CI: 1.15-8.63; P < .05).Circulating miR-449a was significantly decreased in CRC patients and closely related to poor prognosis, suggesting that miR-449a might can be used as a useful diagnostic and prognostic marker for CRC.

Multitarget Stool mRNA Test for Detecting Colorectal Cancer Lesions Including Advanced Adenomas

Current approved non-invasive screening methods for colorectal cancer (CRC) include FIT and DNA-FIT testing, but their efficacy for detecting precancerous lesions that are susceptible to progressing to CRC such as advanced adenomas (AA) remains limited, thus requiring further options to improve the detection of CRC lesions at earlier stages. One of these is host mRNA stool testing. The aims of the present study were to identify specific stool mRNA targets that can predict AA and to investigate their stability under a clinical-like setting. A panel of mRNA targets was tested on stool samples obtained from 102 patients including 78 CRC stage I-III and 24 AA as well as 32 healthy controls. Area under the receiver operating characteristic (ROC) curves were calculated to establish sensitivities and specificities for individual and combined targets. Stability experiments were performed on freshly obtained specimens. Six of the tested targets were found to be specifically increased in the stools of patients with CRC and three in the stools of both AA and CRC patients. After optimization for the choice of the 5 best markers for AA and CRC, ROC curve analysis revealed overall sensitivities of 75% and 89% for AA and CRC, respectively, for a ≥95% specificity, and up to 75% and 95% for AA and CRC, respectively, when combined with the FIT score. Targets were found to be stable in the stools up to 3 days at room temperature. In conclusion, these studies show that the detection of host mRNA in the stools is a valid approach for the screening of colorectal cancerous lesions at all stages and is applicable to a clinical-like setup.

Colorectal cancer screening among Hispanics in the United States: Disparities, modalities, predictors, and regional variation

Hispanics represent the largest and one of the fastest growing minority populations in the U.S. and have lower survival from colorectal cancer (CRC) than non-Hispanic Whites (NHW). We aimed to examine screening modalities, predictors, and regional disparities among Hispanics and NHW in the U.S. by conducting a cross-sectional analysis of Hispanic participants age 50 to 75 from the 2016 Behavioral Risk Factor Surveillance System (BRFSS) survey. The primary outcome was self-reported CRC screening status. We used the Rao-Scott Chi-square test to compare screening rates and modalities in NHWs and Hispanics. We also used univariable and multivariable logistic regression to determine predictors of screening among Hispanics and calculated Hispanic-NHW screening rate differences for each U.S. state/territory as a measure of regional screening disparities. The screening rate was 53.4% for Hispanics (N = 12,395), compared to 70.4% for NHWs (N = 186,331) (p < 0.001). Among Hispanics, colonoscopy was most common (75.9%). Uninsured status (aOR = 0.51; 95% CI = 0.38-0.70) and limited access to medical care (aOR = 0.38; 95% CI = 0.29-0.49) predicted lack of screening. States/territories with the largest screening disparities were North Carolina (33.9%), Texas (28.3%), California (25.1%), and Nebraska (25.6%). Disparities were smallest in New York (2.6%), Indiana (3.1%), and Delaware (4.0%). In Ohio and Guam, Hispanics had higher screening rates than NHWs. In conclusion, Hispanics have lower CRC screening rates than NHWs across most U.S. states/territories; however, the disparity varies by region. Future efforts must address multi-level barriers to screening among Hispanics and target regions with low rates to improve CRC outcomes in this growing population.

Predicting pathology on small bowel capsule endoscopy: a good FIT

Background and study aims  Small bowel capsule endoscopy [SBCE) has an established role in investigating suspected small bowel bleeding [SSBB). Identification of a biomarker to predict pathology would maximize utility of this valuable diagnostic modality. This study aimed to investigate if fecal immunochemical test [FIT) could predict likelihood of small bowel pathology on SBCE. Patients and methods  Patients referred for SBCE to investigate anaemia or suspected small bowel bleeding were prospectively recruited. All patients had negative upper and lower endoscopy prior to referral. A FIT ≥ 45 ug Hb/g was considered positive. SBCE was positive if a potential source of SSBB was identified. The primary endpoint was correlation between FIT and positive SBCE. Secondary endpoints were correlation between anemia and SBCE and a combination of anemia plus FIT and SBCE. Results  Fifty-one patients were included in the final study cohort. 29.4 % had a positive FIT, 33.3 % were anemic, and 25.5 % patients had significant SBCE findings. There was a statistically significant association between positive FIT and pathology on SBCE (OR 12, 95 % CI [2.8 - 51.9), P  = 0.001). Sensitivity and specificity of positive FIT in predicting SBCE findings were 69 % and 84 %, respectively. A normal Hb had an NPV of 83 % (OR 0.30, P  = 0.09). Combining Hb and FIT was statistically significant in predicting pathology on SBCE (OR 9.14, 67 % PPV, 82 % NPV, P  = 0.025). Conclusion  FIT ≥ 45 ug Hb/g is a useful tool in predicting small bowel pathology on SBCE. Use of this biomarker alone, or in combination with serum haemoglobin, has value as a screening tool and may help to better triage patients referred for SBCE.

The impact of screening on the survival of colorectal cancer in Shanghai, China: a population based study

Background

Shanghai is one of the earliest cities in developing countries to introduce an organized colorectal screening program for its residents to fight against the rising disease burden of colorectal cancer (CRC). This study aims to investigate the impact of the Shanghai screening program implemented in 2013 on the survival rates of CRC patients.

Methods

We calculated up to 5-year survival rates for 18,592 CRC patients from a representative district of Shanghai during 2002–2016, using data from the Shanghai Cancer Registry. We performed joinpoint regressions to examine temporal changes in the trends of the CRC survival rates. We then conducted Kaplan-Meier and Cox proportional hazards modelling to study the association of the survival rates with screening behaviors of the patients. In all the model specifications, we took into account the gender, age and TNM stage at diagnosis, and level of treatment hospital of the patients.

Results

We find that the annual percentage changes of the survival rates increased faster after somewhere around 2013, however, the differential trends were not significant. Results from the Cox multivariate regression analysis suggest that patients who did not participate in the screening program showed significantly lower cancer-specific survival (hazard ratio (HR) = 1.46; 95% confidence interval (CI): 1.12–1.91) and all-causes survival (HR = 1.37; 95% CI: 1.05–1.77), compared to those who did. Among program participants, delayed colonoscopy was associated with poor cancer-specific survival (hazard ratio (HR) = 2.93; 95% confidence interval (CI): 1.64–5.23) and all-causes survival (HR = 3.29; 95% CI: 1.85–5.84).

Conclusion

Screening participation and high level of colonoscopy compliance can improve the survival of CRC participants.

Electronic supplementary material

The online version of this article (10.1186/s12889-019-7318-8) contains supplementary material, which is available to authorized users.

Colorectal Cancer in the Young: Does Screening Make Sense?

PURPOSE OF REVIEW

Colorectal cancer (CRC) screening is recommended to reduce CRC mortality. This review outlines key factors to consider when recommending screening, including disease burden, screening benefits and harms, and remaining knowledge gaps.

RECENT FINDINGS

In response to increasing rates of CRC incidence among younger (age < 50 years) adults, the American Cancer Society published guidelines in May 2018 recommending average-risk CRC screening beginning at age 45 (vs. 50) years. Rates of young-onset CRC have increased in the USA since the early 1990s. However, there is very little empirical evidence of screening effectiveness in younger adults, and few studies have reported harms of routine screening in this age group. Further, we know little about the natural history of CRC in younger adults. Uncertainty surrounding the efficacy of CRC screening in younger adults suggests the benefits may be small. Precision cancer screening-or modified screening regimens based on risk-may improve the balance of screening benefits and harms beyond conventional age-based strategies.

Serum level of miR-142-3p predicts prognostic outcome for colorectal cancer following curative resection

OBJECTIVE

MicroRNA (miR)-142-3p may function as a tumor suppressor in the development of various cancers. In this study, we measured serum levels of miR-142-3p in patients with colorectal cancer (CRC) to evaluate the diagnostic and prognostic value of miR-142-3p.

METHODS

Serum samples from 363 consecutive CRC patients and 156 healthy controls were retrospectively collected. Serum miR-142-3p levels were measured using real-time quantitative reverse transcription polymerase chain reaction. All patients were followed up regularly after tumor resection. The correlation between serum miR-142-3p level and survival outcomes was analyzed.

RESULTS

Serum levels of miR-142-3p were significantly lower in CRC patients than in healthy volunteers. A low serum miR-142-3p level was significantly associated with advanced cancer. Survival analysis demonstrated that patients with a low serum miR-142-3p had a lower 5-year overall survival rate than patients with a high serum miR-142-3p level (67.4% vs. 76.9%). Serum miR-142-3p level was also shown to be an independent risk factor for CRC in multivariate analysis (hazard ratio, 2.68; 95% confidence interval: 1.21-7.95).

CONCLUSIONS

Serum miR-142-3p might serve as a useful diagnostic and prognostic marker for CRC.

Role of screening colonoscopy for colorectal tumors in Helicobacter pylori-related chronic gastritis with MDM2 SNP309 G/G homozygous: A prospective cross-sectional study in Thailand

BACKGROUND/AIMS

Helicobacter pylori infection is a risk factor for gastric cancer and colorectal cancer (CRC). MDM2 SNP309 G/G homozygosity is known to be the genetic background that influences the severity of inflammation in the gastric mucosa, and it corresponds to CRC development. We examined the role of screening colonoscopy in H. pylori-related chronic gastritis and the association of patients who have MDM2 SNP309 G/G homozygosity and advanced colorectal neoplasia (CRN) susceptibility.

MATERIALS AND METHODS

A prospective cross-sectional study was used to investigate H. pylori-related gastritis in 331 consecutive asymptomatic patients who had MDM2 SNP309 G/G homozygosity and who were enrolled from November 2014 to July 2017. The MDM2 SNP309 polymorphism was genotyped by real-time PCR hybridization probe assay.

RESULTS

Totally, there were 331 patients with H. pylori-related gastritis, of whom 39 (8.76%) had advanced CRN. The H. pylori-positive group comprised 180 patients (54.36%). H. pylori infection was associated with advanced CRN (OR: 2.09, 95% CI: 1.56-2.80; p=0.01) and had an increased risk of advanced CRN (OR: 4.24, 95% CI: 1.76-5.21; p=0.01) after adjusting for confounding factors. Patients with H. pylori infection had a significantly increased risk of high-grade dysplasia or invasive adenocarcinoma (OR: 2.96, 95% CI: 1.48-4.17; p=0.03).

CONCLUSION

Chronic gastritis patients infected with H. pylori and who had MDM2 SNP309 G/G homozygosity had an increased risk of advanced CRN, particularly high-grade dysplasia including invasive adenocarcinoma. Screening colonoscopy in these patients might benefit colorectal polyp diagnosis and prevention and early CRC treatment in the Thai population.

Barriers to Follow-up Colonoscopies for Patients With Positive Results From Fecal Immunochemical Tests During Colorectal Cancer Screening

BACKGROUND & AIMS

Colorectal cancer is common yet largely preventable. The fecal immunochemical test (FIT) is a highly recommended screening method, but patients with positive results must receive a follow-up colonoscopy to determine if they have precancerous or cancerous lesions. We characterized colonoscopic follow-up evaluations and reasons for lack of follow-up in a Veterans Affairs (VA) cohort.

METHODS

We conducted a retrospective cross-sectional analysis of patients 50 to 75 years old with a positive FIT result from January 1, 2014, through May 31, 2016, in a network of 12 VAs sites in southern California. We determined the proportion of patients who received a follow-up colonoscopy, median time to colonoscopy, and colonoscopy findings. For patients who did not undergo colonoscopy, we determined the documented reason for lack of colonoscopy and factors associated with declining the colonoscopy examination.

RESULTS

Of the 10,635 FITs performed, 916 (8.6%) produced positive results; 569 of these (62.1%) were followed by colonoscopy. The median time to colonoscopy after a positive FIT result was 83 days (interquartile range, 54-145 d), which did not vary between veterans who received a colonoscopy at a VA facility (81 d; interquartile range, 52-143 d) vs a non-VA site (87 d; interquartile range, 60-154 d) (P = .2). For the 347 veterans (37.9%) who did not undergo follow-up colonoscopy, the reasons were patient-related (49.3%), provider-related (16.4%), system-related (12.1%), or multifactorial (22.2%). Overall, patient decline of colonoscopy (35.2%) was the most common reason.

CONCLUSIONS

In a cohort of veterans with positive results from FITs during CRC screening, reasons for lack of follow-up colonoscopy varied and included patient, provider, and system factors. These findings can be used to reduce barriers to follow-up colonoscopy and to address system-level challenges in scheduling and attrition for colonoscopy.

Factors Associated With the Overuse of Colorectal Cancer Screening: A Systematic Review

This systematic review examined factors associated with overuse of colorectal cancer (CRC) screening. The authors searched MEDLINE and EMBASE from January 1998 to March 2017. Studies were included if they were written in English, contained original data, involved a US population, and examined factors potentially associated with overuse of CRC screening. Paired reviewers independently screened abstracts, assessed quality, and extracted data. In 8 studies, the associations between patient factors, including age, sex, race, and number of comorbidities, were tested and were inconsistently associated with CRC screening overuse. Overuse of screening was greater in the Northeast/Mid-Atlantic regions and in urban areas and was lower in academically affiliated centers. Although the literature supports important overuse of CRC screening, it remains unclear what drives these practices. Future research should thoroughly explore these factors and test the impact of interventions to reduce overuse of screening.

Medical Overtreatment: Friend or Foe?

"Overtreatment" is a neologism coined some 15 years ago to denote medical and surgical interventions that are unnecessary. It is a topical term for an old concept. However, it has rapidly become a shibboleth for those inclined toward finger-pointing and blaming in matters of health policy. As such, it is a "foe" that heats up rather than modulates debate. But if one examines the notion in the context of the contemporary patient-physician dialogue, it is anything but a foe. Overtreatment and its fellow travelers, overutilization and overprescription, face off with contrary notions when a patient contends with the challenge of evaluating any clinical option.

A Stool Multitarget mRNA Assay for the Detection of Colorectal Neoplasms

Noninvasive screening methods for the detection of colorectal cancers (CRC) at curable stages rely on the identification of specific biomarkers. Our group has shown that mRNA stool assays represent a powerful and robust approach for the prediction of colorectal neoplasms. In this methodological chapter, we describe the procedures to isolate good quality stool RNA and the steps to evaluate the levels of specific host mRNA markers such as ITGA6, MYC, and GADD45B using TaqMan-based quantitative and droplet digital PCR approaches.

A panel of microRNA signature in serum for colorectal cancer diagnosis

Dysregulated expression of specific microRNAs (miRNAs) in serum has been recognised as promising diagnostic biomarkers for colorectal cancer (CRC). In the initial screening phase, a total of 32 differentially expressed miRNAs were selected by quantitative reverse transcription polymerase chain reaction (qRT-PCR) based Exiqon panel with 3 CRC pool samples and 1 normal control (NC) pool. Using qRT-PCR, selected serum miRNAs were further confirmed in training (30 CRC VS. 30 NCs) and testing stages (136 CRC VS. 90 NCs). We identified that serum levels of miR-19a-3p, miR-21-5p and miR-425-5p were significantly higher in patients with CRC than in NCs. The areas under the receiver operating characteristic (ROC) curve of the three-miRNA panel were 0.86, 0.74 and 0.87 for the training, testing and the external validation stages (30 CRC VS. 18 NCs), respectively. Significantly, elevated expression of the three miRNAs was also observed in CRC tissues (n = 24). Furthermore, the expression levels of the three miRNAs were significantly elevated in exosomes from CRC serum samples (n = 10). In conclusion, we identified a serum three-miRNA panel for the diagnosis of CRC.

The Association Between Primary Source of Healthcare Coverage and Colorectal Cancer Screening Among US Veterans

BACKGROUND

Colorectal cancer (CRC) is a deadly but largely preventable disease. Screening improves outcomes, but screening rates vary across healthcare coverage models. In the Veterans Health Administration (VA), screening rates are high; however, it is unknown how CRC screening rates compare for Veterans with other types of healthcare coverage.

AIMS

To determine whether Veterans with Veteran-status-related coverage (VA, military, TRICARE) have higher rates of CRC screening than Veterans with alternate sources of healthcare coverage.

METHODS

We conducted a cross-sectional analysis of Veterans 50-75 years from the 2014 Behavioral Risk Factor Surveillance System survey. We examined CRC screening rates and screening modalities. We performed multivariable logistic regression to identify the role of coverage type, demographics, and clinical factors on screening status.

RESULTS

The cohort included 22,138 Veterans. Of these, 76.7% reported up-to-date screening. Colonoscopy was the most common screening modality (83.7%). Screening rates were highest among Veterans with Veteran-status-related coverage (82.3%), as was stool-based screening (10.8%). The adjusted odds of up-to-date screening among Veterans with Veteran-status-related coverage were 83% higher than among Veterans with private coverage (adjusted OR = 1.83, 95% CI = 1.52-2.22). Additional predictors of screening included older age, black race, high income, access to medical care, frequent medical visits, and employed or married status.

CONCLUSIONS

CRC screening rates were highest among Veterans with Veteran-status-related coverage. High CRC screening rates among US Veterans may be related to system-level characteristics of VA and military care. Insight to these system-level characteristics may inform mechanisms to improve CRC screening in non-VA settings.

Exo70 is an independent prognostic factor in colon cancer

Exo70, a key component of the Exocyst complex, plays important roles in human cancer progression beyond exocytosis. However, the expression of Exo70 and its prognostic value for patients with colon cancer has not been well investigated to date. In this study, we observed that the mRNA and protein levels of Exo70 were upregulated in 11 of 13 colon cancer tissues, compared with their normal counterparts, which was validated by immunohistochemical analysis in a tissue microarray containing 89 pairs of colon cancer tissues and the matched adjacent normal tissues. Statistical analysis revealed that Exo70 expression is positively correlated with tumor size, invasion depth, TNM stage and distant metastasis. Kaplan-Meier survival analysis showed that colon cancer patients with higher Exo70 expression have a poorer clinical outcome than those with lower Exo70 expression. Multivariate Cox regression analysis revealed that Exo70, age and distant metastasis were there independent prognostic factors for overall survival rate of colon cancer patients. Through gain- and loss of Exo70 in colon cancer cells, we found that Exo70 could enhance the migration ability of colon cancer cells. Taken together, our studies revealed that Exo70 might be a promising negative prognostic factor and a potential therapeutic target for colon cancer.

Effect of Combined Patient Decision Aid and Patient Navigation vs Usual Care for Colorectal Cancer Screening in a Vulnerable Patient Population: A Randomized Clinical Trial

IMPORTANCE

Colorectal cancer (CRC) screening is underused, especially among vulnerable populations. Decision aids and patient navigation are potentially complementary interventions for improving CRC screening rates, but their combined effect on screening completion is unknown.

OBJECTIVE

To determine the combined effect of a CRC screening decision aid and patient navigation compared with usual care on CRC screening completion.

DESIGN, SETTING, AND PARTICIPANTS

In this randomized clinical trial, data were collected from January 2014 to March 2016 at 2 community health center practices, 1 in North Carolina and 1 in New Mexico, serving vulnerable populations. Patients ages 50 to 75 years who had average CRC risk, spoke English or Spanish, were not current with recommended CRC screening, and were attending primary care visits were recruited and randomized 1:1 to intervention or control arms.

INTERVENTIONS

Intervention participants viewed a CRC screening decision aid in English or Spanish immediately before their clinician encounter. The decision aid promoted screening and presented colonoscopy and fecal occult blood testing as screening options. After the clinician encounter, intervention patients received support for screening completion from a bilingual patient navigator. Control participants viewed a food safety video before the encounter and otherwise received usual care.

MAIN OUTCOMES AND MEASURES

The primary outcome was CRC screening completion within 6 months of the index study visit assessed by blinded medical record review.

RESULTS

Characteristics of the 265 participants were as follows: their mean age was 58 years; 173 (65%) were female, 164 (62%) were Latino; 40 (15%) were white non-Latino; 61 (23%) were black or of mixed race; 191 (78%) had a household income of less than $20 000; 101 (38%) had low literacy; 75 (28%) were on Medicaid; and 91 (34%) were uninsured. Intervention participants were more likely to complete CRC screening within 6 months (68% vs 27%); adjusted-difference, 40 percentage points (95% CI, 29-51 percentage points). The intervention was more effective in women than in men (50 vs 21 percentage point increase, interaction P = .02). No effect modification was observed across other subgroups.

CONCLUSIONS AND RELEVANCE

A patient decision aid plus patient navigation increased the rate of CRC screening completion in compared with usual care invulnerable primary care patients.

TRIAL REGISTRATION

clinicaltrials.gov Identifier: NCT02054598.

Ethical issues with colorectal cancer screening-a systematic review

RATIONALE, AIMS, AND OBJECTIVES

Colorectal cancer (CRC) screening is widely recommended and implemented. However, sometimes CRC screening is not implemented despite good evidence, and some types of CRC screening are implemented despite lack of evidence. The objective of this article is to expose and elucidate relevant ethical issues in the literature on CRC screening that are important for open and transparent deliberation on CRC screening.

METHODS

An axiological question-based method is used for exposing and elucidating ethical issues relevant in HTA. A literature search in MEDLINE, Embase, PsycINFO, PubMed Bioethics subset, ISI Web of Knowledge, Bioethics Literature Database (BELIT), Ethics in Medicine (ETHMED), SIBIL Base dati di bioetica, LEWI Bibliographic Database on Ethics in the Sciences and Humanities, and EUROETHICS identified 870 references of which 114 were found relevant according to title and abstract. The content of the included papers were subject to ethical analysis to highlight the ethical issues, concerns, and arguments.

RESULTS

A wide range of important ethical issues were identified. The main benefits are reduced relative CRC mortality rate, and potentially incidence rate, but there is no evidence of reduced absolute mortality rate. Potential harms are bleeding, perforation, false test results, overdetection, overdiagnosis, overtreatment (including unnecessary removal of polyps), and (rarely) death. Other important issues are related to autonomy and informed choice equity, justice, medicalization, and expanding disease.

CONCLUSION

A series of important ethical issues have been identified and need to be addressed in open and transparent deliberation on CRC screening.

Use of NCCN Guidelines, Other Guidelines, and Biomarkers for Colorectal Cancer Screening

Colorectal cancer (CRC) remains a common cancer and significant public health burden. CRC-related mortality is declining, partly due to the early detection of CRC through robust screening. NCCN has established the NCCN Guidelines for CRC Screening to help healthcare providers make appropriate screening recommendations according to the patient's risk of developing CRC. This review describes the evolution of CRC screening guidelines for average-risk individuals, discusses the role of NCCN Guidelines for CRC Screening in cancer prevention, and comments on the current and emerging use of biomarkers for CRC screening.

Population-Based Precision Cancer Screening: A Symposium on Evidence, Epidemiology, and Next Steps

Precision medicine, an emerging approach for disease treatment that takes into account individual variability in genes, environment, and lifestyle, is under consideration for preventive interventions, including cancer screening. On September 29, 2015, the National Cancer Institute sponsored a symposium entitled "Precision Cancer Screening in the General Population: Evidence, Epidemiology, and Next Steps". The goal was two-fold: to share current information on the evidence, practices, and challenges surrounding precision screening for breast, cervical, colorectal, lung, and prostate cancers, and to allow for in-depth discussion among experts in relevant fields regarding how epidemiology and other population sciences can be used to generate evidence to inform precision screening strategies. Attendees concluded that the strength of evidence for efficacy and effectiveness of precision strategies varies by cancer site, that no one research strategy or methodology would be able or appropriate to address the many knowledge gaps in precision screening, and that issues surrounding implementation must be researched as well. Additional discussion needs to occur to identify the high priority research areas in precision cancer screening for pertinent organs and to gather the necessary evidence to determine whether further implementation of precision cancer screening strategies in the general population would be feasible and beneficial. Cancer Epidemiol Biomarkers Prev; 25(11); 1449-55. ©2016 AACR.