Participants' characteristics in a French colorectal cancer mass screening campaign

Randomized controlled dissemination study of community-to-clinic navigation to promote CRC screening: Study design and implications

INTRODUCTION

Regular screening facilitates early diagnosis of colorectal cancer (CRC) and reduction of CRC morbidity and mortality. Screening rates for minorities and low-income populations remain suboptimal. Provider referral for CRC screening is one of the strongest predictors of adherence, but referrals are unlikely among those who have no clinic home (common among poor and minority populations).

METHODS/STUDY DESIGN

This group randomized controlled study will test the effectiveness of an evidence based tailored messaging intervention in a community-to-clinic navigation context compared to no navigation. Multicultural, underinsured individuals from community sites will be randomized (by site) to receive CRC screening education only, or education plus navigation. In Phase I, those randomized to education plus navigation will be guided to make a clinic appointment to receive a provider referral for CRC screening. Patients attending clinic appointments will continue to receive navigation until screened (Phase II) regardless of initial arm assignment. We hypothesize that those receiving education plus navigation will be more likely to attend clinic appointments (H1) and show higher rates of screening (H2) compared to those receiving education only. Phase I group assignment will be used as a control variable in analysis of screening follow-through in Phase II. Costs per screening achieved will be evaluated for each condition and the RE-AIM framework will be used to examine dissemination results.

CONCLUSION

The novelty of our study design is the translational dissemination model that will allow us to assess the real-world application of an efficacious intervention previously tested in a randomized controlled trial.

Psychosocial risk profiles among black male Veterans Administration patients non-adherent with colorectal cancer screening

OBJECTIVE

This study identifies unique psychosocial characteristics among African American men that put the men at risk for non-adherence to colorectal cancer (CRC) screening (colonoscopy, sigmoidoscopy, and fecal occult blood tests (FOBT)). Subgroups sharing similar psychosocial characteristics may be targeted with specific intervention strategies aimed at increasing participation in screening, which could lead to increased early detection and decreased morbidity and mortality.

METHODS

The male African American veterans in our sample (n = 260) had a mean age of 57.3 (SD = 7.3) years. Our study employs latent class analysis, a quantitative-based, audience segmentation method to identify homogeneous subgroups of African American men with similar psychosocial characteristics related to CRC screening, potentially in need of different health information and intervention strategies. Latent class regression was used to examine the relationships among latent class structure and demographic characteristics.

RESULTS

There were four psychosocial risk classes across the three screening tests. A significant subset of men had psychosocial characteristics indicative of willingness to be screened for each test (colonscopy = 21.8%, sigmoidoscopy = 31.5%, and FOBT = 10.8%), although they were currently non-adherent. Men who received a past screening test, had greater than a high school education, or were married were more likely to be represented in a latent class indicative of being prepared for getting colonoscopy or sigmoidoscopy. Sociodemographic variables were unrelated to FOBT latent class structure.

CONCLUSIONS

Segmenting our sample of male African American veterans based on psychosocial risk characteristics can inform the development of more precisely targeted interventions for African American men who are non-adherent for CRC screening.

Guaiac versus immunochemical tests: faecal occult blood test screening for colorectal cancer in a rural community

OBJECTIVE

To describe patient participation and clinical performance in a colorectal cancer (CRC) screening program utilising faecal occult blood test (FOBT).

METHODS

A community-based intervention was conducted in a small, rural community in north Queensland, 2000/01. One of two FOBT kits--guaiac (Hemoccult-II) or immunochemical (!nform)--was assigned by general practice and mailed to participants (3,358 patients aged 50-74 years listed with the local practices).

RESULTS

Overall participation in FOBT screening was 36.3%. Participation was higher with the immunochemical kit than the guaiac kit (OR=1.9, 95% CI 1.6-2.2). Women were more likely to comply with testing than men (OR=1.4, 95% CI 1.2-1.7), and people in their 60s were less likely to participate than those 70-74 years (OR=0.8, 95% CI 0.6-0.9). The positivity rate was higher for the immunochemical (9.5%) than the guaiac (3.9%) test (chi2=9.2, p=0.002), with positive predictive values for cancer or adenoma of advanced pathology of 37.8% (95% CI 28.1-48.6) for !nform and 40.0% (95% CI 16.8-68.7) for Hemoccult-II. Colonoscopy follow-up was 94.8% with a medical complication rate of 2-3%.

CONCLUSIONS

An immunochemical FOBT enhanced participation. Higher positivity rates for this kit did not translate into higher false-positive rates, and both test types resulted in a high yield of neoplasia.

IMPLICATIONS

In addition to type of FOBT, the ultimate success of a population-based screening program for CRC using FOBT will depend on appropriate education of health professionals and the public as well as significant investment in medical infrastructure for colonoscopy follow-up.

Would general practitioners support a population-based colorectal cancer screening programme of faecal-occult blood testing?

BACKGROUND

The success of a population-based screening for colorectal cancer (CRC) is determined to a large extent by general practitioner (GP) attitudes, beliefs and support. The extent to which GPs support population-based CRC screening remains unclear.

AIMS

To assess the knowledge, attitudes and practices of GPs in relation to CRC screening, and to identify the determinants of GP support for population-based faecal-occult blood testing (FOBT).

METHODS

A cross-sectional postal survey was conducted with a random sample of 692 GPs in Queensland, -Australia. We assessed GP knowledge, attitudes and practices concerning CRC screening in relation to their stance on population-based FOBT screening.

RESULTS

Although the response rate was low (41%), participants were representative of Queensland GPs in general. Of 284 participating GPs, 143 (50.5%) indicated that they would support a population-based FOBT screening programme, 42 (14.8%) would not and 98 (34.6%) were unsure. Belief in FOBT test efficacy (P <0.001), possession of CRC guidelines (P <0.05) and belief in earlier stage detection (P <0.05) were major determinants of support for population-based FOBT screening. No significant association was observed for doctor's sex, location of practice, age, year completed medical training, membership of a Division of General Practice, number of weekly consultations, number of patients investigated for CRC per month, size of practice, own family history of CRC, interest in further information on CRC screening or treatment, and current use of FOBT with asymptomatic patients aged > or =40 years.

CONCLUSIONS

GP support for FOBT population-based screening appears to have increased over recent years. The knowledge and attitudes/beliefs of GPs are key determinants of their support.

A randomized trial of direct mailing of fecal occult blood tests to increase colorectal cancer screening

BACKGROUND

Although colorectal cancer screening by using a fecal occult blood test (FOBT), flexible sigmoidoscopy, colonoscopy, or barium enema x-ray reduces the incidence of and death from colorectal cancer, the rate of colorectal cancer screening in the general population is low. We conducted a randomized trial consisting of direct mailing of FOBT kits to increase colorectal cancer screening among residents of Wright County, Minnesota, a community in which colorectal cancer screening was promoted.

METHODS

At baseline, we mailed a questionnaire about colorectal cancer screening to a random sample of Wright County residents aged 50 years or older who were randomly selected from the Minnesota State Driver's License and Identification Card database (estimated N = 1451). The sample was randomly allocated into three equal subgroups: one group (control) received only the questionnaire, one group received FOBT kits by direct mail with reminders, and one group received FOBT kits by direct mail without reminders. Study participants were sent a follow-up questionnaire 1 year after baseline. We used the responses to the questionnaires to estimate the 1-year change in self-reported screening rates in each group and the differences in the changes among the groups, along with the associated bootstrap 95% confidence intervals (CIs).

RESULTS

At baseline, the estimated response rate was 86.5%, self-reported adherence to FOBT guidelines was 21.5%, and overall adherence to any colorectal cancer screening test guidelines was 55.8%. The 1-year rate changes in absolute percentage for self-reported adherence to FOBT use were 1.5% (95% CI = -2.9% to 5.9%) for the control group, 16.9% (95% CI = 11.5% to 22.3%) for the direct-mail-FOBT-with-no-reminders group, and 23.2% (95% CI = 17.2% to 29.3%) for the direct-mail-FOBT-with-reminders group. The 1-year rate changes for self-reported adherence to any colorectal cancer screening test were 7.8% (95% CI = 3.2% to 12.0%) for the control group, 13.2% (95% CI = 8.4% to 18.2%) for the direct-mail-FOBT-with-no-reminders group, and 14.1% (95% CI = 9.1% to 19.1%) for the direct-mail-FOBT-with-reminders group.

CONCLUSION

Direct mailing of FOBT kits combined with follow-up reminders promotes more rapid increases in the use of FOBT and nearly doubles the increase in overall rate of adherence to colorectal cancer screening guidelines in a general population compared with a community-wide screening promotion and awareness campaign.

Beliefs associated with fecal occult blood test and colonoscopy use at a worksite colon cancer screening program

Colorectal cancer (CRC) is the second leading cause of cancer death in the United States. Although regular screening can decrease morbidity and mortality from CRC, screening rates nationwide are very low. This descriptive study assessed beliefs associated with fecal occult blood test and colonoscopy use among participants of a worksite colon cancer screening program. Randomly selected employees, aged 40 and older, were mailed a survey on CRC screening-related beliefs. Instruments were tested for reliability and validity. Results indicated that fecal occult blood test use was significantly associated with being female, Caucasian, having low perceived barriers, and provider recommendation. Colonoscopy use was significantly associated with higher knowledge, lower barriers, higher benefits, higher self-efficacy, and provider recommendation. Findings may be used to develop interventions designed to improve CRC screening rates.

Screening for colorectal cancer using the faecal occult blood test: a critical literature review

Colorectal cancer (CRC) is a major health problem whose outcome is crucially dependent on the stage of disease at the time of diagnosis. Consequently, early detection of CRC by mass population screening is the subject of much international research and debate. A critical literature review was undertaken to determine the effectiveness of faecal occult blood (FOB) testing in CRC screening. Four issues were addressed: an appraisal of available FOB tests, their impact on CRC mortality, the appropriate screening interval and the factors influencing public compliance with FOB screening. A computerized literature search was conducted, supplemented by cross-referencing and hand searching. Forty studies which fulfilled pre-defined inclusion and exclusion criteria were appraised. A thorough assessment of methodology, combined with an applied hierarchy of evidence, resulted in the selection of 22 studies for review. The evidence from this review is that no single (currently used) FOB test provides optimal screening performance, that biennial FOB screening reduces CRC mortality by between 6-18%, that there is a small advantage in annual screening and that better dissemination of information can improve compliance rates. An appreciation of the current evidence and issues surrounding CRC screening is important to nurses in their capacity as health promoters and educators. Definitive answers to many important questions regarding FOB screening for CRC do not currently exist. Before the concept of a national screening programme could be supported, further research is needed, the key elements of which must include the assessment of more sensitive and specific FOB tests and the promotion of population compliance.

Participation in faecal occult blood screening for colorectal cancer in a well defined French population: results of five screening rounds from 1988 to 1996

OBJECTIVE

To evaluate the influence on compliance of demographic variables and of the way of proposing a faecal occult blood test in a colorectal cancer mass screening programme.

SETTING

Well defined population in Burgundy (France).

METHODS

From 1988 to 1996 five screening rounds were conducted in people aged 45 to 74 on entering the study. The screening test was provided free of charge by primary care physicians over a four month period, then mailed to non-consultants, followed by a potential reminder letter. The whole population was invited to participate in each screening campaign.

RESULTS

During the five successive rounds, compliance was 52.8%, 54.0%, 57.3%, 58.3%, and 56.2%. It was higher in women than in men, in those initially aged 50 to 69 than in the extreme age groups, and in urban than in rural areas. Overall, 68.7% of the invited population completed at least one screening test and 37.2% completed the five rounds. Among those who participated once in a screening campaign, between 79.6% and 87.6% participated in the succeeding ones. Compliance was higher when the test was proposed by GPs (varying between 85.2% and 94.0% according to the screening campaign) than when it was sent by post (varying between 26.0% and 33.7%).

CONCLUSION

In France, a participation rate of over 50% can be achieved in colorectal cancer screening by means of a faecal occult blood test. To achieve this, primary care physicians have to play an active part in the programme and the test must be mailed to non-consultants.

Participation in colorectal cancer screening: a review

The purpose of this review is to evaluate the published literature on adherence to colorectal cancer (CRC) screening with fecal occult blood testing (FOBT) and sigmoidoscopy. Specifically, the review addresses the following: 1) prevalence of FOBT and sigmoidoscopy; 2) interventions to increase adherence to FOBT and sigmoidoscopy; 3) correlates or predictors of adherence to FOBT and sigmoidoscopy; and 4) reasons for nonadherence. Other objectives are to put the literature on CRC screening adherence in the context of recently reported findings from experimental interventions to change prevention and early detection behaviors and to suggest directions for future research on CRC screening adherence. CRC screening offers the potential both for primary and for secondary prevention. Data from the 1992 National Health Interview Survey show that 26% of the population more than 49 years of age report FOBT within the past 3 years and 33% report ever having had sigmoidoscopy. The Year 2000 goals set forth in Healthy People 2000 are for 50% of the population more than 49 years of age to report FOBT within the past 2 years and for 40% to report that they ever had sigmoidoscopy. Thus, systematic efforts to increase CRC screening are warranted. To date, attempts to promote CRC screening have used both a public health model that targets entire communities, e.g., mass media campaigns, and a medical model that targets individuals, e.g., general practice patients. Most of these efforts, however, did not include systematic evaluation of strategies to increase adherence. The data on FOBT show that the median adherence rate to programmatic offers of FOBT is between 40% and 50%, depending on the type of population offered the test, e.g., patients or employees. Approximately, 50% of those initially offered testing in unselected populations will respond to minimal prompts or interventions. A salient issue for FOBT, however, is whether or not the behavior can be sustained over time. Fewer studies examined adherence to sigmoidoscopy. Adherence was highest in relatives of CRC cases and in employer-sponsored programs offered to workers at increased risk of CRC. At present, we know very little about the determinants of CRC screening behaviors, particularly as they relate to rescreening.