Factors Affecting Adherence in a Pragmatic Trial of Annual Fecal Immunochemical Testing for Colorectal Cancer

Follow-up Colorectal Cancer Screening After Negative-Result and Positive-Result Multitarget Stool DNA Tests: A Population-Based Study in Southeast Minnesota

Objective

To provide contemporary data on subsequent screening after negative-result multitarget stool DNA (mt-sDNA) tests and follow-up colonoscopy after positive-result mt-sDNA tests.

Patients and Methods

Negative-result mt-sDNA tests (for patients aged 50-72 years) and positive-result mt-sDNA tests (for patients aged 50-75 years) were identified among average risk patients from a 9-county region in Southeast Minnesota from January 1, 2016 to December 31, 2022. Competing risks models of time to subsequent colorectal cancer (CRC) screening were modeled separately for the negative mt-sDNA and positive mt-sDNA cohorts. Multistate Cox proportional hazards models compared rates of CRC screening modality by patient demographic characteristics.

Results

At 3.5 years after a negative-result mt-sDNA test (n=18,739 tests), 55.0% (95% CI, 53.9%-56.3%) of patients were rescreened, which increased to 81.0% (95% CI, 80.0%-82.1%) at 5 years. Most tests were repeat mt-sDNA tests (48.3% at 3.5 years; 95% CI, 47.2%-49.5%). Rescreening with any modality was more likely with older age and among females and less likely among Black persons, Asian persons, and those with other or mixed race. After a positive-result mt-sDNA test (n=2863 tests), 80.9% (95% CI, 79.6%-82.6%) and 84.4% (95% CI, 83.2%-86.0%) of patients completed follow-up colonoscopy by 6 months and 1 year, respectively. Those of other or mixed race had lower rates of follow-up colonoscopy compared with White persons.

Conclusion

Although rates of overall rescreening after a negative-result mt-sDNA test and follow-up colonoscopy after positive-result mt-sDNA tests were high, racial disparities were apparent. Targeted interventions are needed to improve equity in CRC screening adherence and follow-up care across diverse patient populations.

Mailed Outreach and Patient Navigation for Colorectal Cancer Screening Among Rural Medicaid Enrollees: A Cluster Randomized Clinical Trial

Importance

Approximately 60 million adults live in rural regions of the US, which historically have low rates of colorectal cancer (CRC) screening and follow-up. Rural residents enrolled in Medicaid have particularly low CRC screening and follow-up rates.

Objective

To determine the effectiveness and implementation of a collaborative Medicaid health plan-clinic program of mailed fecal immunochemical test (FIT) outreach and patient navigation to colonoscopy following an abnormal FIT result when implemented in rural clinics as part of standard care.

Design, Setting, and Participants

This cluster randomized clinical trial was conducted at 28 rural clinic units in Oregon affiliated with 3 Medicaid health plans. The clinics were randomized to the intervention (n = 14) or to usual care (n = 14). Participants were Medicaid enrollees (aged 50-75 years) due for CRC screening. The intervention was delivered from May 11, 2021, through June 4, 2022, and analyses were performed from June 2023 through September 2024.

Intervention

The stepwise intervention involved (1) mailed FIT outreach and (2) patient navigation to colonoscopy following an abnormal FIT result. Implementation support included practice facilitation, training, collaborative learning, and patient tracking tools.

Main Outcomes and Measures

The primary effectiveness outcome was completion of any CRC screening within 6 months of eligibility determination. An additional effectiveness outcome was follow-up colonoscopy completion within 6 months of an abnormal FIT result. Implementation was measured as (1) the proportion of intervention-eligible enrollees who were mailed an FIT and who were sent an advance notification or reminder and (2) the proportion with an abnormal FIT result who were offered patient navigation.

Results

This study included 5614 Medicaid enrollees (2613 in intervention clinics and 3001 in usual care clinics). Enrollees had a mean (SD) age of 58.2 (5.5) years; most (4940 [88.0%]) were aged 50 to 64 years. A total of 2948 enrollees (52.5%) were female, 325 (6.2%) were Hispanic and 3774 (67.2%) were White, and 4457 (79.4%) lived in rural regions. Compared with Medicaid enrollees in usual care clinics, enrollees in intervention clinics had a higher adjusted 6-month proportion of any CRC screening completion (11.8% vs 4.5%; difference, 7.3 [95% CI, 5.3-9.2] percentage points). Implementation was 100% (all 1489 intervention-eligible enrollees) for mailed FIT outreach, 88.5% for advance notification, 78.1% for reminders, and 57.9% for patient navigation.

Conclusions and Relevance

In this cluster randomized clinical trial of rural clinics, mailed FIT outreach and patient navigation boosted participation in CRC screening among Medicaid enrollees. More efforts are needed to address low participation in both FIT testing and follow-up colonoscopy.

Trial Registration

ClinicalTrials.gov Identifier: NCT04890054.

Participation and Yield in Multiple Rounds of Colorectal Cancer Screening Based on Fecal Immunochemical Test: A Systematic Review and Meta-Analysis

INTRODUCTION

The evidence on the cumulative participation and yield in multiple rounds of colorectal cancer (CRC) screening based on fecal immunochemical test is sparse. We aimed to assess the trends in participation and detection for advanced colorectal neoplasm under different screening intervals in multiround fecal immunochemical testing-based CRC screening by synthesizing the current available evidence.

METHODS

PubMed, Embase, and Cochrane were retrieved from January 1, 2002, to April 16, 2024, for potential eligible studies, and then, we synthesized participation and advanced colorectal neoplasm detection rates for each screening round, along with their respective 95% confidence intervals (CIs).

RESULTS

Nineteen studies involving a total of 2,296,071 individuals were included. As screening rounds increased, participation exhibited a gradual consistent increase, reaching 78.45% and 74.97% for annual and biennial screening strategies. For annual screening, the cumulative detection rates for 3 rounds were 1.38% (95% CI: 1.18%-1.63%), 1.95% (95% CI: 1.72%-2.21%), and 2.50% (95% CI: 2.29%-2.72%), respectively. For biennial screening, the cumulative detection rates for 4 rounds were 2.22% (95% CI: 1.22%-3.22%), 3.44% (95% CI: 2.06%-4.82%), 4.26% (95% CI: 2.70%-5.83%), and 5.10% (95% CI: 3.28%-7.29%), respectively. Notably, the per-round detection rate of advanced colorectal neoplasms declined yet as the screening progressed.

DISCUSSION

In population-based CRC screening programs, the participation exhibited a slow upward trend for both screening strategies, but the incremental benefits in CRC detection gradually diminished. Tailored strategies, such as extending intervals for individuals with multiple negative fecal immunochemical testing results, might optimize effectiveness and cost-efficiency in population-based CRC screening.

Predictors of Colorectal Cancer Screening and Screening Modalities among Patients seen at Federally Qualified Health Centers Funded by the United States Health Resources and Services Administration

Introduction

Federally qualified health centers provide primary care services to millions of low-income patients in the United States who face challenges accessing colorectal cancer (CRC) screening. We aimed to understand how patient-level factors influence CRC screening participation and screening modality choice in this setting.

Methods

We examined data from the 2022 Health Center Patient Survey, 2021 Uniform Data System, and Area Health Resource File. We performed generalized multilevel logistic regression and multinomial regression to measure associations between our independent variables and receipt of any CRC screening and of screening modalities.

Results

Among 1584 patients ages 50-75, most (56 %) reported having CRC screening, including 33 % with endoscopic screening only, 16 % with stool-based screening only, and 7 % with multiple modalities. Selected factors associated with any CRC screening included having five or more health center visits in the past year (aOR = 1.66, 95 %CI = 1.07-2.56), being insured (Medicaid aOR = 2.25, 95 %CI = 1.44-3.54; other insurance aOR = 2.69, 95 %CI = 1.51-4.82), living within 30  minutes of the health center (aOR = 1.93, 95 %CI = 1.15-3.25), having multiple comorbidities (aOR = 1.72, 95 %CI = 1.13-2.63), using telehealth (aOR = 1.52, 95 %CI = 1.02-2.27), and having a flu shot last year (aOR = 1.77, 95 %CI = 1.29-2.45). We observed that patients who are non-Hispanic Black (aOR = 3.52, 95 %CI = 1.28-9.68) and who do not speak English well or at all (aOR = 5.54, 95 %CI = 1.64-18.75) reported having multiple modalities.

Conclusion

Federally qualified health center patients reported endoscopic CRC screening more commonly than stool-based screening, and barriers to access such as distance to the health center and English proficiency were impactful. Increasing CRC screening in low-income populations requires improving access and promoting opportunities for less invasive screening.

Development of Luminescent Biosensors for Calprotectin

Calprotectin, a metal ion-binding protein complex, plays a crucial role in the innate immune system and has gained prominence as a biomarker for various intestinal and systemic inflammatory and infectious diseases, including inflammatory bowel disease (IBD) and tuberculosis (TB). Current clinical testing methods rely on enzyme-linked immunosorbent assays (ELISAs), limiting accessibility and convenience. In this study, we introduce the Fab-Enabled Split-luciferase Calprotectin Assay (FESCA), a novel quantitative method for calprotectin measurement. FESCA utilizes two new fragment antigen binding proteins (Fabs), CP16 and CP17, that bind to different epitopes of the calprotectin complex. These Fabs are fused with split NanoLuc luciferase fragments, enabling the reconstitution of active luciferase upon binding to calprotectin either in solution or in varied immobilized assay formats. FESCA's output luminescence can be measured with standard laboratory equipment as well as consumer-grade cell phone cameras. FESCA can detect physiologically relevant calprotectin levels across various sample types, including serum, plasma, and whole blood. Notably, FESCA can detect abnormally elevated native calprotectin from TB patients. In summary, FESCA presents a convenient, low-cost, and quantitative method for assessing calprotectin levels in various biological samples, with the potential to improve the diagnosis and monitoring of inflammatory diseases, especially in at-home or point-of-care settings.

Data Challenges in Identifying Patients Due for Colorectal Cancer Screening in Rural Clinics

INTRODUCTION

Colorectal cancer (CRC) incidence and mortality are disproportionately high among rural residents despite the availability of effective screening methods. Outreach activities can improve CRC screening rates but rely on accurate identification of patients due for screening. We report on data challenges in rural clinics and Medicaid health plans in Oregon in identifying patients eligible for CRC screening, in a large project implementing mailed fecal immunochemical tests (FIT) and patient navigation.

METHODS

We analyzed data from clinic intake surveys and administrative claims. Clinics were asked to identify total population numbers relevant to CRC screening and follow-up. Health plans also identified enrollees eligible for CRC screening in Spring, 2021. Clinic staff validated patient lists for eligibility using their electronic health records (EHR).

RESULTS

EHR features varied across the 29 participating and 28 responding clinics. Among the 28 responding clinics, 21 were able to report their Medicaid population (75%), 19 reported the number of patients aged 50 to 75 (68%) and the number screened for CRC in the last year (68%). Only 8 (29%) were able to report screening details such as number screened by FIT and 9 were able to report on patients with an abnormal FIT or colonoscopy completed after FIT (32%). Health plans had challenges properly identifying where enrollees received care and had missing data for race and ethnicity (range 22 to 34% unknown race, <1% to 24% unknown ethnicity).

DISCUSSION

Most participating rural primary care clinics and Medicaid health plans experienced challenges identifying the population due for a CRC screening outreach program. Better EHR functionality and data reporting capabilities could help rural clinics apply population-based strategies and ultimately attenuate disparities in cancer screening and follow-up.

Colorectal cancer screening in a safety-net health system: The intersectional impact of race, ethnicity, language, and mental health

Though rates of colorectal cancer (CRC) screening continue to improve with increased advocacy and awareness, there are numerous disparities that continue to be defined within different health systems and populations. We aimed to define associations between patients' socio-demographic characteristics and CRC screening in a well-resourced safety-net health system. A retrospective review was performed from 2018 to 2019 of patients between 50 and 75-years-old who had a primary care visit within the last two years. Numerous patient characteristics were extracted from the medical record, including self-reported race, self-reported ethnicity, insurance, preferred language, severe mental health diagnoses (SMHD), and substance use disorder (SUD). Multivariate logistic regression assessed characteristics associated with CRC screening. Of 22,145 included patients, 16,065 (72.5%) underwent CRC screening. <40% of the population was White or of North American/European ethnicity and 38% had limited English proficiency. Hispanic patients had the highest screening rate while White patients had the lowest among races (78.1% vs 68.5%, respectively). White patients had higher rates of SMHD and SUD (p < 0.001). In multivariable analysis, most other races (Black, Asian, and Hispanic), ethnicities, and languages had significantly higher odds of screening, ranging from 20% to 55% higher, when White, North American/European, English-speakers are used as reference. In a well-resourced safety-net health system, patients who were non-White, non-North American/European, and non-English-speaking, had higher odds of CRC screening. This data from a unique health system may better guide screening outreach and implementation strategies in historically under-resourced communities, leading to strategies for equitable colorectal cancer screening.

Review article: obesity and colorectal cancer

BACKGROUND

Obesity is a growing global public health problem. More than half the European and North American population is overweight or obese. Colon and rectum cancers are still the second leading cause of cancer death worldwide, and epidemiological data support an association between obesity and colorectal cancers (CRCs).

AIM

To review the literature on CRC epidemiology in obese subjects, assessing the effects of obesity, including childhood or maternal obesity, on CRC, diagnosis, management, and prognosis, and discussing targeted prophylactic measures.

METHOD

We searched PubMed for obesity/overweight/metabolic syndrome and CRC. Other key words included 'staging', 'screening', 'treatment', 'weight loss', 'bariatric surgery' and 'chemotherapy'.

RESULTS

In Europe, about 11% of CRCs are attributed to overweight and obesity. Epidemiological data suggest that obesity is associated with a 30%-70% increased risk of colon cancer in men, the association being less consistent in women. Visceral fat or abdominal obesity seems to be of greater concern than subcutaneous fat obesity, and any 1 kg/m² increase in body mass index confers more risk (hazard ratio 1.03). Obesity might increase the likelihood of recurrence or mortality of the primary cancer and may affect initial management, including accurate staging. The risk maybe confounded by different factors, including lower adherence to organised CRC screening programmes. It is unclear whether bariatric surgery helps reduce rectal cancer risk.

CONCLUSIONS

Despite a growing body of evidence linking obesity to CRC, many questions remain unanswered, including whether we should screen patients with obesity earlier or propose prophylactic bariatric surgery for certain patients with obesity.

Colorectal Neoplasia Detection in Individuals With Positive Multitarget Stool DNA Tests: Data From the New Hampshire Colonoscopy Registry

BACKGROUND

The US Preventive Services Task Force (USPSTF) includes multitarget stool DNA (mt-sDNA) testing as a colorectal cancer (CRC) screening option in average-risk individuals, but data on colonoscopy outcomes after positive mt-sDNA tests in community settings are needed.

AIM

The aim of this study was to investigate colonoscopy outcomes and quality following positive mt-sDNA in the population-based New Hampshire Colonoscopy Registry.

METHODS

We compared colonoscopy outcomes and quality between age-matched, sex-matched, and risk-matched patients from 30 endoscopy practices with and without a preceding positive mt-sDNA test. Main outcomes were colonoscopy findings of CRC, advanced noncancerous neoplasia, nonadvanced neoplasia, or normal examination. Quality measures included withdrawal time, bowel preparation quality, examination completion, and percentage of average-risk individuals with normal colonoscopies receiving a USPSTF-recommended 10 year rescreening interval.

RESULTS

Individuals with positive mt-sDNA tests (N=306, average age 67.0 y; 61.8% female) were significantly more likely than colonoscopy-only patients (N=918, 66.2 y; 61.8% female) to have CRC (1.3% vs. 0.4%) or advanced noncancerous neoplasia (27.1% vs. 8.2%) (P<0.0001). Neoplasia was found in 68.0% of patients having colonoscopy after a positive mt-sDNA test, (positive predictive value, was 68.0%), versus 42.3% of patients with colonoscopy only (P<0.0001). No significant differences in colonoscopy quality measures were observed between cohorts.

CONCLUSIONS

Colonoscopy after a positive mt-sDNA test was more frequently associated with CRC and colorectal neoplasia than colonoscopy alone. Positive mt-sDNA tests can enrich the proportion of colonoscopies with clinically relevant findings. Follow-up recommendations suggest that endoscopists do not inappropriately shorten rescreening intervals in mt-sDNA-positive patients with normal colonoscopy. These findings support the clinical utility of mt-sDNA for CRC screening in community practice.

Source matters: a survey of cost variation for fecal immunochemical tests in primary care

Background

Colorectal cancer (CRC) screening can improve health outcomes, but screening rates remain low across the US. Mailed fecal immunochemical tests (FIT) are an effective way to increase CRC screening rates, but is still underutilized. In particular, cost of FIT has not been explored in relation to practice characteristics, FIT selection, and screening outreach approaches.

Methods

We administered a cross-sectional survey drawing from prior validated measures to 252 primary care practices to assess characteristics and context that could affect the implementation of direct mail fecal testing programs, including the cost, source of test, and types of FIT used. We analyzed the range of costs for the tests, and identified practice and test procurement factors. We examined the distributions of practice characteristics for FIT use and costs answers using the non-parametric Wilcoxon rank-sum test. We used Pearson’s chi-squared test of association and interpreted a low p-value (e.g. < 0.05) as evidence of association between a given practice characteristic and knowing the cost of FIT or fecal occult blood test (FOBT).

Results

Among the 84 viable practice survey responses, more than 10 different types of FIT/FOBTs were in use; 76% of practices used one of the five most common FIT types. Only 40 practices (48%) provided information on FIT costs. Thirteen (32%) of these practices received the tests for free while 27 (68%) paid for their tests; median reported cost of a FIT was $3.04, with a range from $0.83 to $6.41 per test. Costs were not statistically significantly different by FIT type. However, practices who received FITs from manufacturer’s vendors were more likely to know the cost (p = 0.0002) and, if known, report a higher cost (p = 0.0002).

Conclusions

Our findings indicate that most practices without lab or health system supplied FITs are spending more to procure tests. Cost of FIT may impact the willingness of practices to distribute FITs through population outreach strategies, such as mailed FIT. Differences in the ability to obtain FIT tests in a cost-effective manner could have consequences for implementation of outreach programs that address colorectal cancer screening disparities in primary care practices.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-022-07576-4.

Patient Adherence to Fecal Calprotectin Testing Is Low Compared to Other Commonly Ordered Tests in Patients With Inflammatory Bowel Disease

Background

Limited data exist on adherence to fecal calprotectin (FCP) testing in patients with inflammatory bowel disease.

Methods

Completion rates for patients who had at least one FCP test ordered (n = 3082) and a subgroup with C-reactive protein, complete blood count, and Clostridium difficile tests also ordered (n = 1563) were analyzed.

Results

More patients completed blood than stool tests, with FCP having the poorest adherence of all tests analyzed. Older patients had higher FCP completion rates. No differences were noted in completion rates across age, gender, or ethnicity for blood tests.

Conclusions

Further studies are needed to develop strategies that improve the uptake of FCP.

What's the "secret sauce"? How implementation variation affects the success of colorectal cancer screening outreach

BACKGROUND

Mailed fecal immunochemical testing (FIT) programs can improve colorectal cancer (CRC) screening rates, but health systems vary how they implement (i.e., adapt) these programs for their organizations. A health insurance plan implemented a mailed FIT program (named BeneFIT), and participating health systems could adapt the program. This multi-method study explored which program adaptations might have resulted in higher screening rates.

METHODS

First, we conducted a descriptive analysis of CRC screening rates by key health system characteristics and program adaptations. Second, we generated an overall model by fitting a weighted regression line to our data. Third, we applied Configurational Comparative Methods (CCMs) to determine how combinations of conditions were linked to higher screening rates. The main outcome measure was CRC screening rates.

RESULTS

Seventeen health systems took part in at least 1 year of BeneFIT. The overall screening completion rate was 20% (4-28%) in year 1 and 25% (12-35%) in year 2 of the program. Health systems that used two or more adaptations had higher screening rates, and no single adaptation clearly led to higher screening rates. In year 1, small systems, with just one clinic, that used phone reminders (n = 2) met the implementation success threshold (≥ 19% screening rate) while systems with > 1 clinic were successful when offering a patient incentive (n = 4), scrubbing mailing lists (n = 4), or allowing mailed FIT returns with no other adaptations (n = 1). In year 2, larger systems with 2-4 clinics were successful with a phone reminder (n = 4) or a patient incentive (n = 3). Of the 10 systems that implemented BeneFIT in both years, seven improved their CRC screening rates in year 2.

CONCLUSIONS

Health systems can choose among many adaptations and successfully implement a health plan's mailed FIT program. Different combinations of adaptations led to success with health system size emerging as an important contextual factor.

Noninvasive strategies for colorectal cancer screening: opportunities and limitations

PURPOSE OF REVIEW

In the United States, only 67% of patients are up to date with colorectal cancer (CRC) screening. While colonoscopy is highly sensitive and specific for CRC and precursor lesion detection and removal, it is invasive, expensive and resource heavy. Hence, there is an unfulfilled need for multiple modality CRC screening that can improve current CRC screening rates and may be resource effective strategies when used in conjunction with a colonoscopy program. Our review highlights the complementary, often underutilized, noninvasive CRC screening methods with a focus on performance, risks, benefits, and recent updates.

RECENT FINDINGS

Studies demonstrate that fecal immunochemical testing (FIT) is superior to guaiac-based fecal occult blood tests for CRC screening. Studies show superiority of multitarget stool DNA test to FIT in sensitivity, though with concern for decreased specificity in setting of one-time tests. Technical advances continue to improve accuracy of colon capsule endoscopy. There are ongoing studies to characterize often difficult-to-detect high-risk lesions in computed tomography colonography. Septin 9 continues to have suboptimal accuracy for CRC screening, but has been shown to be associated with more advanced, invasive CRC stages.

SUMMARY

There are ongoing advances in noninvasive screening modalities for CRC; these should be considered as alternatives to colonoscopy in specific patient populations.

Fecal Immunologic Test Results and Diagnostic Colonoscopy in a Mexican Population at Average Risk for Colorectal Cancer

Colorectal cancer is preventable and treatable by screening and early detection. Fecal immunochemical tests (FIT) for average risk individuals is an effective strategy for screening. Incidence and mortality in Mexico is increasing and large-scale screening programs do not yet exist. The aim of this study was to evaluate the feasibility of FIT-based colorectal cancer screening program in Mexico City. For more than 15 months, average risk individuals in Mexico City were invited to participate at Mexico's Instituto Nacional de Cancerologia (INCan, Mexico City, Mexico). Participants received an FIT kit for stool collection, results ≥20 ng/mL were referred for high quality colonoscopy. Participants' results were classified according to the most advanced clinical finding as: adenocarcinoma, high-risk adenomas, low-risk adenomas, serrated lesions, hyperplastic polyps, and no polyps. Sequential analyses were performed to assess the positive predictive value (PPV) of FIT. A total of 810 participants were eligible, 737 (91.0%) returned the FIT and 112 (15.2%) had an abnormal result. Of these participants, 87 (77.7%) completed colonoscopy. Clinical findings of participants included: seven (8.1%) adenocarcinomas, 18 (20.7%) high-risk adenomas, 23 (26.4%) low-risk adenomas, one (1.2%) serrated lesions, 14 (16.1%) hyperplasic polyps, and 24 (27.6%) no polyps. The PPV of FIT using the ≥20 ng/mL was 8.1% for cancer and 20.7% for high-risk adenomas. In conclusion, colorectal cancer screening with FIT is feasible at INCan in Mexico City, where resources are available. Further studies are needed to determine feasibility of colorectal cancer screening in other settings, as well as optimal hemoglobin detection cut-off points to maximize the population benefits of colorectal cancer screening with FIT in Mexico.

Mailed fecal immunochemical test outreach for colorectal cancer screening: Summary of a Centers for Disease Control and Prevention-sponsored Summit

Uptake of colorectal cancer screening remains suboptimal. Mailed fecal immunochemical testing (FIT) offers promise for increasing screening rates, but optimal strategies for implementation have not been well synthesized. In June 2019, the Centers for Disease Control and Prevention convened a meeting of subject matter experts and stakeholders to answer key questions regarding mailed FIT implementation in the United States. Points of agreement included: 1) primers, such as texts, telephone calls, and printed mailings before mailed FIT, appear to contribute to effectiveness; 2) invitation letters should be brief and easy to read, and the signatory should be tailored based on setting; 3) instructions for FIT completion should be simple and address challenges that may lead to failed laboratory processing, such as notation of collection date; 4) reminders delivered to initial noncompleters should be used to increase the FIT return rate; 5) data infrastructure should identify eligible patients and track each step in the outreach process, from primer delivery through abnormal FIT follow-up; 6) protocols and procedures such as navigation should be in place to promote colonoscopy after abnormal FIT; 7) a high-quality, 1-sample FIT should be used; 8) sustainability requires a program champion and organizational support for the work, including sufficient funding and external policies (such as quality reporting requirements) to drive commitment to program investment; and 9) the cost effectiveness of mailed FIT has been established. Participants concluded that mailed FIT is an effective and efficient strategy with great potential for increasing colorectal cancer screening in diverse health care settings if more widely implemented.

Proven Strategies for Increasing Adherence to Colorectal Cancer Screening

Although colorectal cancer (CRC) can be prevented or detected early through screening and surveillance, barriers that lower adherence to screening significantly limit its effectiveness. Therefore, implementation of interventions that address and overcome adherence barriers is critical to efforts to decrease morbidity and mortality from CRC. This article reviews the current available evidence about interventions to increase adherence to CRC screening.

Stool-Based Tests for Colorectal Cancer Screening: Performance Benchmarks Lead to High Expected Efficacy

PURPOSE OF REVIEW

Participation goals for colorectal cancer (CRC) screening in the USA have not been met. Non-invasive screening strategies may improve CRC screening participation. We highlight recent literature on stool-based screening performance and expectations for emerging non-invasive screening tests.

RECENT FINDINGS

Stool-based CRC screening detects screen-relevant colorectal neoplasia and outperforms a currently available plasma assay. Though modestly sensitive for CRC, adherence to annual fecal immunochemical testing (FIT) is sub-optimal. Multi-target stool DNA (MT-sDNA) has greater adherence, superior sensitivity for screen-relevant lesions (including those in the proximal colon and sessile serrated architecture), and equivalent specificity to FIT over a 3-year period. Stool-based CRC screening tests are anticipated to reduce the incidence and mortality of CRC through detection of early-stage cancers and high-risk polyps. These endpoints in performance will need to be met by emerging blood sample-based tests in order have meaningful impact in clinical practice.

Adherence to national guidelines for colorectal cancer screening in Israel: Comprehensive multi-year assessment based on electronic medical records

OBJECTIVES

To assess time trends in colorectal cancer screening uptake, time-to-colonoscopy completion following a positive fecal occult blood test and associated patient factors, and the extent and predictors of longitudinal screening adherence in Israel.

SETTING

Nation-wide population-based study using data collected from four health maintenance organizations for the Quality Indicators in Community Healthcare Program.

METHODS

Screening uptake for the eligible population (aged 50-74) was recorded 2003-2018 using aggregate data. For a subcohort (2008-2012, N = 1,342,617), time-to-colonoscopy following a positive fecal occult blood test and longitudinal adherence to screening guidelines were measured using individual-level data, and associated factors assessed in multivariate models.

RESULTS

The annual proportion screened rose for both sexes from 11 to 65%, increasing five-fold for age group 60-74 and >six-fold for 50-59 year olds, respectively. From 2008 to 2012, 67,314 adults had a positive fecal occult blood test, of whom 71% eventually performed a colonoscopy after a median interval of 122 (95% confidence interval 110.2-113.7) days. Factors associated with time-to-colonoscopy included age, socioeconomic status, and comorbidities. Only 25.5% of the population demonstrated full longitudinal screening adherence, mainly attributable to colonoscopy in the past 10 years rather than annual fecal occult blood test performance (83% versus 17%, respectively). Smoking, diabetes, lower socioeconomic status, cardiovascular disease, and hypertension were associated with decreased adherence. Performance of other cancer screening tests and frequent primary care visits were strongly associated with adherence.

CONCLUSIONS

Despite substantial improvement in colorectal cancer screening uptake on a population level, individual-level data uncovered gaps in colonoscopy completion after a positive fecal occult blood test and in longitudinal adherence to screening, which should be addressed using focused interventions.

Vital Signs: Colorectal Cancer Screening Test Use - United States, 2018

BACKGROUND

Colorectal cancer (CRC) is the second leading cause of cancer death in the United States of cancers that affect both men and women. Despite strong evidence that screening for CRC reduces incidence and mortality, CRC screening prevalence is below the national target. This report describes current CRC screening prevalence by age, various demographic factors, and state.

METHODS

Data from the 2018 Behavioral Risk Factor Surveillance System survey were analyzed to estimate the percentages of adults aged 50-75 years who reported CRC screening consistent with the United States Preventive Services Task Force recommendation.

RESULTS

In 2018, 68.8% of adults were up to date with CRC screening. The percentage up to date was 79.2% among respondents aged 65-75 years and 63.3% among those aged 50-64 years. CRC screening prevalence was lowest among persons aged 50-54 years (50.0%) and increased with age. Among respondents aged 50-64 years, CRC screening prevalence was lowest among persons without health insurance (32.6%) and highest among those with reported annual household income of ≥$75,000 (70.8%). Among respondents aged 65-75 years, CRC screening prevalence was lowest among those without a regular health care provider (45.6%), and highest among those with reported annual household income ≥$75,000 (87.1%). Among states, CRC screening prevalence was highest in Massachusetts (76.5%) and lowest in Wyoming (57.8%).

DISCUSSION

CRC screening prevalence is lower among adults aged 50-64 years, although most reported having a health care provider and health insurance. Concerted efforts are needed to inform persons aged <50 years about the benefit of screening so that screening can start at age 50 years.

Cross-sectional adherence with the multi-target stool DNA test for colorectal cancer screening: Real-world data from a large cohort of older adults

Objective

To determine cross-sectional adherence with the multi-target stool DNA test used for colorectal cancer screening in a large, fully insured Medicare population.

Methods

All patients aged 65–85 with a valid multi-target stool DNA test order from 1 September 2016 to 31 August 2017 identified from the Exact Sciences Laboratories (Madison, WI; sole-source national multi-target stool DNA test provider) database were evaluated for test adherence. Cross-sectional adherence, defined as multi-target stool DNA test completion within 365 days from order date, was analyzed overall and by time to adherence, as well as by available patient (age, sex, test order date, Medicare coverage type) and provider (specialty, year of first multi-target stool DNA test order, multi-target stool DNA test order frequency, and practice location) factors.

Results

Among 368,494 Medicare beneficiaries (64% female), overall cross-sectional adherence was 71%. Cumulative adherence rates increased more rapidly at 30 (44%) and 60 (65%) days, followed by more gradual increases at 90 (67%), 180 (70%), and 365 (71%) days. By provider specialty, primary care clinicians represented a higher percentage of multi-target stool DNA orders than gastroenterologists (88% vs. 6%), but had a lower associated patient adherence rate (71% vs. 78%).

Conclusions

In this large, national sample of Medicare insured older adults, nearly three-quarters of patients adhered with a multi-target stool DNA order for colorectal cancer screening. These real-world data should inform further clinical and population health applications, reimbursement model simulations, and guideline-endorsed colorectal cancer screening strategies adherence.