The influence of multi-morbidities on colorectal cancer screening recommendations and completion

Factors influencing participation in colorectal cancer screening among average-risk populations: A descriptive-analytical study in a developing country

INTRODUCTION

Colorectal cancer (CRC) is a leading cause of cancer-related deaths globally, with early detection significantly improving treatment outcomes. Understanding the factors influencing the decision to participate in colorectal cancer screening programs can help design interventions to improve these programs.

METHOD

This study investigates factors influencing CRC screening participation among average-risk individuals aged 50-70 years in Isfahan province, utilizing data from the comprehensive E-health information system. Employing Andersen's Behavioral Model, the study examines predisposing, enabling, and need-for-care factors. A logistic regression model was used to identify significant predictors of screening participation.

RESULTS

The analysis in this study includes 808,978 average-risk individuals in Isfahan, with a mean age of 56.67 years (SD = 7.17). Results indicate that younger age, male gender, marital status, health insurance coverage, flexible work time pattern, Iranian nationality, and high-risk lifestyles positively influence the probability of participation. The predictor screening analysis reveals that lifestyle, chronic disease, and education are the top three factors influencing participation, with lifestyle being the most dominant predictor.

CONCLUSION

Participation in colorectal cancer screening is influenced by numerous factors. Therefore, it is recommended that all important factors determining individuals' participation in colorectal cancer diagnosis be considered and that individuals' lifestyles be adjusted to encourage effective participation in colorectal cancer screening. Understanding these factors can guide targeted interventions to enhance CRC screening uptake and early detection.

A machine learning-based prediction model for colorectal liver metastasis

Colorectal liver metastasis (CRLM) is a primary factor contributing to poor prognosis and metastasis in colorectal cancer (CRC) patients. This study aims to develop and validate a machine learning (ML)-based risk prediction model using conventional clinical data to forecast the occurrence of CRLM. This retrospective study analyzed the clinical data of 865 CRC patients between January 2018 and September 2024. Patients were categorized into non-CRLM and CRLM groups. The least absolute shrinkage and selection operator regression was employed to identify key clinical variables, and five ML algorithms were utilized to develop prediction models. The optimal model was selected based on performance metrics including the receiver operating characteristic curve, precision-recall curve, decision curve analysis, and calibration curve, which collectively evaluated both the predictive accuracy and clinical utility of the model. Among the five ML algorithms evaluated, Random forest demonstrated the best performance. Leveraging the Random forest algorithm, we developed the CRLM-Lab6 prediction model, which incorporates six features: LDH, CA199, ALT, CEA, TBIL, and AGR. This model exhibits robust predictive performance, achieving an area under the curve of 0.94, a sensitivity of 0.88, and a specificity of 0.93. To enhance its practical utility, the model has been integrated into an accessible web application. This study developed a novel risk prediction model by integrating ML algorithms with conventional laboratory test data to evaluate the likelihood of CRLM occurrence. The model demonstrates excellent predictive performance and has significant clinical application potential.

Cervical cancer screening rates in females living with HIV at three healthcare settings in the United States, 2010-2019

PURPOSE

Females living with human immunodeficiency virus (FLWHIV) are at increased risk of cervical cancer and U.S. guidelines, first published in 2009 and updated since then, recommend more frequent screening in this population. We examined screening rates among FLWHIV in the U.S. during 2010-2019.

METHODS

This cohort study included 18-89-year-old FLWHIV during 2010-2019 at three U.S. healthcare settings. Sociodemographics, comorbidities, and cervical cancer screening tests were ascertained from administrative and clinical databases. We reported cervical cancer screening rates overall and by modality. Generalized estimating equations with Poisson distribution were used to estimate screening rate ratios (SRRs) and 95% confidence intervals (CIs) for the associations between screening rates and calendar year, age, race and ethnicity, and comorbidity.

RESULTS

Among 3,556 FLWHIV, a total of 7,704 cervical cancer screening tests were received over 18,605 person-years during 2010-2019 (screening rate = 41.4 per 100 person-years). Relatively lower screening rates were associated with later calendar years (SRR = 0.71 [95% CI 0.68-0.75] for 2017-2019 versus 2010-2013), older age (SRR = 0.82 [95% CI 0.74-0.89] for 50-65-year-olds versus 18-29-year-olds), non-Hispanic white race versus non-Hispanic Black race (SRR = 0.89 [95% CI 0.81-0.98]) and greater comorbidity burden (SRR = 0.89 [95% CI 0.82-0.98] for ≥ 9 versus 0-6 comorbidity score).

CONCLUSION

The decrease in cervical cancer screening rates during 2010-2019 in this large cohort of FLWHIV may be explained at least partly by guideline changes during the study period recommending longer screening intervals. Our findings of relatively lower screening rates in FLWHIV who were non-Hispanic white, older, and with greater comorbidity burden should be confirmed in other U.S.

SETTINGS

Perceptions of the Impact of Comorbidity on the Bowel Cancer Screening Programme: Qualitative Study With Bowel Screening Participants and Staff

INTRODUCTION

The impact of multiple health conditions on bowel cancer screening is currently unknown. We explored the impact of multiple health conditions on bowel cancer screening perceptions, experience and clinical management decisions following a positive stool test.

METHODS

Semi-structured qualitative interviews were conducted remotely with Bowel Screening Wales staff (n = 16) stratified by regional location and role and with screening participants (n = 19) stratified by age, gender and comorbidity. Interview topics were guided by the Common-Sense Model.

RESULTS

Screening participants, regardless of comorbidity status, placed great emphasis on the importance of early detection of cancer and completing the bowel screening process. Screening staff emphasised comorbidities in the clinical decision-making process; however, screening participants had low awareness of the impact that comorbidities can have on bowel screening. Participants describe how the presence of multiple health conditions can mask potential bowel symptoms and influence beliefs about follow-up.

CONCLUSION

Bowel screening staff try to individualise the service to meet participant needs. The potential mismatch in screening staff and participant awareness and expectations of the bowel screening and diagnostic process needs to be addressed. Clearer and more regular communication with screening participants could support the screening process, particularly for those with significant coexisting health conditions or facing time delays. The possible masking effects and misattribution of symptoms because of comorbidities highlight an opportunity for education and raising awareness for screening participants and a potential area of focus for discussions in clinical consultations and staff training.

PATIENT AND PUBLIC CONTRIBUTION

Project funding included costs for patients and public contributors to be compensated for their contributions to the project, in line with current standards. A patient and public contributor was involved in the design of the study, including protocol development, and the interpretation of key findings and implications for patients, which are subsequently reflected within the manuscript.

Optimization of colorectal cancer screening strategies: New insights

In this editorial, we discuss the article by Agatsuma et al. We concentrate specifically on the current routinely used screening tests recommended by society guidelines and delve into the significance of early diagnosis of colorectal cancer (CRC) and its substantial impact on both incidence and mortality rates. Screening is highly recommended, and an early diagnosis stands out as the most crucial predictor of survival for CRC patients. Therefore, it is essential to identify and address the barriers hindering adherence to screening measures, as these barriers can vary among different populations. Furthermore, we focus on screening strategy optimization by selecting high-risk groups. Patients with comorbidities who regularly visit hospitals have been diagnosed at an early stage, showing no significant difference compared to patients undergoing regular screening. This finding highlights the importance of extending screening measures to include patients with comorbidities who do not routinely visit the hospital.

Effectiveness of colonoscopy, immune fecal occult blood testing, and risk-graded screening strategies in colorectal cancer screening

BACKGROUND

Colorectal cancer (CRC) is one of the most common malignant tumors, and early screening is crucial to improving the survival rate of patients. The combination of colonoscopy and immune fecal occult blood detection has garnered significant attention as a novel method for CRC screening. Colonoscopy and fecal occult blood tests, when combined, can improve screening accuracy and early detection rates, thereby facilitating early intervention and treatment. However, certain risks and costs accompany it, making the establishment of a risk classification model crucial for accurate classification and management of screened subjects.

AIM

To evaluate the feasibility and effectiveness of colonoscopy, immune fecal occult blood test (FIT), and risk-graded screening strategies in CRC screening.

METHODS

Based on the randomized controlled trial of CRC screening in the population conducted by our hospital May 2020 to May 2023, participants who met the requirements were randomly assigned to a colonoscopy group, an FIT group, or a graded screening group at a ratio of 1:2:2 (after risk assessment, the high-risk group received colonoscopy, the low-risk group received an FIT test, and the FIT-positive group received colonoscopy). The three groups received CRC screening with different protocols, among which the colonoscopy group only received baseline screening, and the FIT group and the graded screening group received annual follow-up screening based on baseline screening. The primary outcome was the detection rate of advanced tumors, including CRC and advanced adenoma. The population participation rate, advanced tumor detection rate, and colonoscopy load of the three screening programs were compared.

RESULTS

A total of 19373 subjects who met the inclusion and exclusion criteria were enrolled, including 8082 males (41.7%) and 11291 females (58.3%). The mean age was 60.05 ± 6.5 years. Among them, 3883 patients were enrolled in the colonoscopy group, 7793 in the FIT group, and 7697 in the graded screening group. Two rounds of follow-up screening were completed in the FIT group and the graded screening group. The graded screening group (89.2%) and the colonoscopy group (42.3%) had the lowest overall screening participation rates, while the FIT group had the highest (99.3%). The results of the intentional analysis showed that the detection rate of advanced tumors in the colonoscopy group was greater than that of the FIT group [2.76% vs 2.17%, odds ratio (OR) = 1.30, 95% confidence interval (CI): 1.01-1.65, P = 0.037]. There was no significant difference in the detection rate of advanced tumors between the colonoscopy group and the graded screening group (2.76% vs 2.35%, OR = 1.9, 95%CI: 0.93-1.51, P = 0.156), as well as between the graded screening group and the FIT group (2.35% vs 2.17%, OR = 1.09%, 95%CI: 0.88-1.34, P = 0.440). The number of colonoscopy examinations required for each patient with advanced tumors was used as an index to evaluate the colonoscopy load during population screening. The graded screening group had the highest colonoscopy load (15.4 times), followed by the colonoscopy group (10.2 times), and the FIT group had the lowest (7.8 times).

CONCLUSION

A hierarchical screening strategy based on CRC risk assessment is feasible for screening for CRC in the population. It can be used as an effective supplement to traditional colonoscopy and FIT screening programs.

Prediction and analysis of albumin-bilirubin score combined with liver function index and carcinoembryonic antigen on liver metastasis of colorectal cancer

BACKGROUND

Colorectal cancer (CRC) is a common malignant tumor, and liver metastasis is one of the main recurrence and metastasis modes that seriously affect patients' survival rate and quality of life. Indicators such as albumin bilirubin (ALBI) score, liver function index, and carcinoembryonic antigen (CEA) have shown some potential in the prediction of liver metastasis but have not been fully explored.

AIM

To evaluate its predictive value for liver metastasis of CRC by conducting the combined analysis of ALBI, liver function index, and CEA, and to provide a more accurate liver metastasis risk assessment tool for clinical treatment guidance.

METHODS

This study retrospectively analyzed the clinical data of patients with CRC who received surgical treatment in our hospital from January 2018 to July 2023 and were followed up for 24 months. According to the follow-up results, the enrolled patients were divided into a liver metastasis group and a nonliver metastasis group and randomly divided into a modeling group and a verification group at a ratio of 2:1. The risk factors for liver metastasis in patients with CRC were analyzed, a prediction model was constructed by least absolute shrinkage and selection operator (LASSO) logistic regression, internal validation was performed by the bootstrap method, the reliability of the prediction model was evaluated by subject-work characteristic curves, calibration curves, and clinical decision curves, and a column graph was drawn to show the prediction results.

RESULTS

Of 130 patients were enrolled in the modeling group and 65 patients were enrolled in the verification group out of the 195 patients with CRC who fulfilled the inclusion and exclusion criteria. Through LASSO regression variable screening and logistic regression analysis. The ALBI score, alanine aminotransferase (ALT), and CEA were found to be independent predictors of liver metastases in CRC patients [odds ratio (OR) = 8.062, 95% confidence interval (CI): 2.545-25.540], (OR = 1.037, 95%CI: 1.004-1.071) and (OR = 1.025, 95%CI: 1.008-1.043). The area under the receiver operating characteristic curve (AUC) for the combined prediction of CRLM in the modeling group was 0.921, with a sensitivity of 78.0% and a specificity of 95.0%. The H-index was 0.921, and the H-L fit curve had χ2 = 0.851, a P value of 0.654, and a slope of the calibration curve approaching 1. This indicates that the model is extremely accurate, and the clinical decision curve demonstrates that it can be applied effectively in the real world. We conducted internal verification of one thousand resamplings of the modeling group data using the bootstrap method. The AUC was 0.913, while the accuracy was 0.869 and the kappa consistency was 0.709. The combination prediction of liver metastasis in patients with CRC in the verification group had an AUC of 0.918, sensitivity of 85.0%, specificity of 95.6%, C-index of 0.918, and an H-L fitting curve with χ 2 = 0.586, P = 0.746.

CONCLUSION

The ALBI score, ALT level, and CEA level have a certain value in predicting liver metastasis in patients with CRC. These three criteria exhibit a high level of efficacy in forecasting liver metastases in patients diagnosed with CRC. The risk prediction model developed in this work shows great potential for practical application.

Cardiovascular Health and Colorectal Cancer Screening in Black Men: A Cross-Sectional Analysis

African American/Black (henceforth Black) men face disproportionate risks of morbidity and mortality from both cardiovascular disease (CVD) and colorectal cancer (CRC). The American Heart Association's Life's Simple 7 (LS7) tool was designed to examine predictors of CVD with included behaviors also linked to CRC risk (i.e., smoking status, weight, diet, and physical activity). However, no studies have combined LS7 assessment alongside CRC screening history, which serves as a proxy for assessing CRC risk, in Black men. In this study, Black men aged 45-75 participating in annual community wellness events were screened for 6 of 7 LS7 measures (excluding diet, LS6) and self-reported CRC screening. Analyses conducted using R 4.0.5. revealed that Black men (N = 680), with an average age of 57.3 years (SD = 7.5), reported poor (39.7%), intermediate (34.6%), or ideal (25.7%) LS6 scores with higher scores corresponding to lower risk for CVD. However, for every 1-point increase in LS6 scores (0-6), there was a 26% lower odds of reported CRC screening (p = .001). In the fully adjusted model, men with 4+ ideal LS6 behaviors had a 60% lower odds of self-reported CRC screening compared to those with two ideal LS6 behaviors (p < .001). These findings underscore the need for culturally relevant interventions for Black men across all levels of cardiovascular health (CVH) to increase CRC screening uptake.

Multi-morbidity and its association with common cancer diagnoses: a UK Biobank prospective study

BACKGROUND

Whilst multi-morbidity is known to be a concern in people with cancer, very little is known about the risk of cancer in multi-morbid patients. This study aims to investigate the risk of being diagnosed with lung, colorectal, breast and prostate cancer associated with multi-morbidity.

METHODS

We investigated the association between multi-morbidity and subsequent risk of cancer diagnosis in UK Biobank. Cox models were used to estimate the relative risks of each cancer of interest in multi-morbid participants, using the Cambridge Multimorbidity Score. The extent to which reverse causation, residual confounding and ascertainment bias may have impacted on the findings was robustly investigated.

RESULTS

Of the 436,990 participants included in the study who were cancer-free at baseline, 21.6% (99,965) were multi-morbid (≥ 2 diseases). Over a median follow-up time of 10.9 [IQR 10.0-11.7] years, 9,019 prostate, 7,994 breast, 5,241 colorectal, and 3,591 lung cancers were diagnosed. After exclusion of the first year of follow-up, there was no clear association between multi-morbidity and risk of colorectal, prostate or breast cancer diagnosis. Those with ≥ 4 diseases at recruitment had double the risk of a subsequent lung cancer diagnosis compared to those with no diseases (HR 2.00 [95% CI 1.70-2.35] p for trend < 0.001). These findings were robust to sensitivity analyses aimed at reducing the impact of reverse causation, residual confounding from known cancer risk factors and ascertainment bias.

CONCLUSIONS

Individuals with multi-morbidity are at an increased risk of lung cancer diagnosis. While this association did not appear to be due to common sources of bias in observational studies, further research is needed to understand what underlies this association.

The prevalence of comorbidity in the lung cancer screening population: A systematic review and meta-analysis

OBJECTIVE

Comorbidity is associated with adverse outcomes for all lung cancer patients, but its burden is less understood in the context of screening. This review synthesises the prevalence of comorbidities among lung cancer screening (LCS) candidates and summarises the clinical recommendations for screening comorbid individuals.

METHODS

We searched MEDLINE, EMBASE, EBM Reviews, and CINAHL databases from January 1990 to February 2021. We included LCS studies that reported a prevalence of comorbidity, as a prevalence of a particular condition, or as a summary score. We also summarised LCS clinical guidelines that addressed comorbidity or frailty for LCS as a secondary objective for this review. Meta-analysis was used with inverse-variance weights obtained from a random-effects model to estimate the prevalence of selected comorbidities.

RESULTS

We included 69 studies in the review; seven reported comorbidity summary scores, two reported performance status, 48 reported individual comorbidities, and 12 were clinical guideline papers. The meta-analysis of individual comorbidities resulted in an estimated prevalence of 35.2% for hypertension, 23.5% for history of chronic obstructive pulmonary disease (COPD) (10.7% for severe COPD), 16.6% for ischaemic heart disease (IHD), 13.1% for peripheral vascular disease (PVD), 12.9% for asthma, 12.5% for diabetes, 4.5% for bronchiectasis, 2.2% for stroke, and 0.5% for pulmonary fibrosis.

CONCLUSIONS

Comorbidities were highly prevalent in LCS populations and likely to be more prevalent than in other cancer screening programmes. Further research on the burden of comorbid disease and its impact on screening uptake and outcomes is needed. Identifying individuals with frailty and comorbidities who might not benefit from screening should become a priority in LCS research.

Commencing colorectal cancer screening at age 45 years in U.S. racial groups

Screening for colorectal cancer (CRC) is cost-effective for reducing its mortality among the average-risk population. In the US, CRC incidence and mortality differ among racial/ethnic groups, with non-Hispanic Blacks (NHB) and American Indian/Alaska Natives showing highest incidence and mortality and earlier presentation. Since 2005, some professional societies have recommended CRC screening for NHB to commence at 45 years or earlier; this was not implemented due to lack of recommendation from key groups that influence insurance payment coverage. In 2017 the highly influential U.S. Multi-Society Task Force for Colorectal Cancer recommended screening to commence at 45 years for NHB; this recommendation was supplanted by data showing an increase in early-onset CRCs in non-Hispanic Whites approaching the under-50-year rates observed for NHB. Subsequently the American Cancer Society and the USPSTF recommended that the entire average-risk population move to commence CRC screening at 45 years. Implementing screening in 45–49-year-olds has its challenges as younger groups compared with older groups participate less in preventive care. The US had made extensive progress pre-COVID-19 in closing the disparity gap for CRC screening in NHB above age 50 years; implementing screening at younger ages will take ingenuity, foresight, and creative strategy to reach a broader-aged population while preventing widening the screening disparity gap. Approaches such as navigation for non-invasive and minimally invasive CRC screening tests, removal of financial barriers such as co-pays, and complete follow up to abnormal non-invasive screening tests will need to become the norm for broad implementation and success across all racial/ethnic groups.

Rate and associated factors of refusal to perform immunochemical Faecal Occult Blood Test (iFOBT) among semi-urban communities

The uptake of the immunochemical faecal occult blood test (iFOBT) in many countries with an opportunistic colorectal cancer (CRC) screening programme remains suboptimal. This study aimed to determine the rate, associated factors and reasons of refusal to perform the iFOBT test offered under an opportunistic CRC screening programme in semi-urban communities. This cross-sectional study was conducted among the average-risk individuals living in semi-urban areas, who sought care from public primary care centres across Kedah state, Malaysia. The information regarding the sociodemographic and clinical characteristics of individuals who were offered the iFOBT between January and April 2019, along with their willingness to perform the test, was gathered. The factors associated with the refusal were further explored using the logistic regression analysis. The individuals offered the iFOBT (n = 920) were mainly female (52.4%) and had a mean age of 58.7±10.6 years. The refusal rate of the iFOBT was 32.2%. Patients who did not have hypertension (adjusted OR: 3.33; 95% CI: 2.44, 4.54), did not have CRC symptoms (adjusted OR: 3.15; 95% CI:1.26, 7.89), had the test offered by either medical assistants (adjusted OR: 2.44; 95% CI: 1.71, 3.49) or nurses (adjusted OR: 2.41; 95% CI 1.65, 3.51), did not have diabetes (adjusted OR: 1.99; 95% CI: 1.42, 2.77),and were not active smokers (adjusted OR: 1.74; 95% CI: 1.22, 2.47), were more likely to refuse the iFOBT. The common reasons of refusing the test included "feeling not ready for the test" (21.6%) and "feeling healthy" (14.9%). The iFOBT was refused by one-third of the average-risk individuals from semi-urban communities. The associated factors and reasons of refusal found in this study could guide policymakers in developing targeted interventions to boost the uptake of CRC screening in Malaysia.