Preventing Colorectal Cancer: Pathway to Achieving an 80% Screening Goal in the United States: Overview and Proceedings of a Population Health Advisory Board

Influence of Political Ideology on Colorectal Cancer Screening Among Adults in the United States

BACKGROUND

Political ideologies have emerged as one of the risk factors driving healthcare decisions, including colorectal cancer screening in US adults. Previous links between conservative viewpoints and lower awareness of preventive health services have been established. We aimed to evaluate how differences in political ideology affect CRC screening practices using a nationally representative sample of US adults.

METHODS

Using data from the 2020 Health Information National Trends Survey (HINTS), we compared compliance with CRC screening guidelines between conservative, moderate, and liberal political groups. Survey-weighted multivariable logistic regression models were employed to ascertain the relationship between political ideology and CRC screening.

RESULTS

Of the 3368 respondents, 71.0% (95% CI: 67.8, 74.0) were screened for CRC. A total of 1026 (30.5%) were liberal, 1148 (34.1%) were moderate, and 1194 (35.4%) were conservative. Out of the conservatives (78.8%) were non-Hispanic Whites compared to moderates (61.4%) and liberals (64.0%). There was no significant difference in age, level of education, or income group by political ideology. In adjusted models, there was no significant difference in CRC screening by political ideology.

CONCLUSION

Contrary to previous ties, we found no significant differences in compliance with CRC screening guidelines among these groups, concluding that CRC screening remains a significant health concern for all individuals, irrespective of political ideologies.

Multilevel analysis of social determinants of advanced stage colorectal cancer diagnosis

The advanced stage at diagnosis of colorectal cancer (CRC) may be related to individual factors, socioeconomic conditions, and healthcare service availability. The objective of the study was to analyze the prevalence of advanced stage CRC at the time of diagnosis and its association with individual, contextual, socioeconomic, and healthcare service indicators. An observational, cross-sectional study was conducted, analyzing cases of malignant neoplasms of the colon and rectum in individuals of both sexes, aged between 18 and 99 years, diagnosed between 2010 and 2019 in Brazil (n = 69,047). Data were collected from the Hospital Cancer Registry (HCR), Atlas of Human Development in Brazil, and from the National Registry of Health Institutions (NRHI). A Multilevel Poisson Regression model with random intercept was used. The prevalence of advanced stage CRC at diagnosis was 65.6%. Advanced stage was associated with older age groups prevalence ratio (PR) 4.40 and younger age groups (PR 1.84), low Human Development Index (HDI) (PR 1.22), and low density of family health strategy teams (PR 1.10). The study highlights the unequal distribution of social determinants of health in the diagnosis CRC in Brazil, revealing the need to evaluate and redirect public policies aimed at improving early detection and prevention of CRC in the country.

Investigating the role of county-level colorectal cancer screening rates on stage at diagnosis of colorectal cancer in rural Georgia

BACKGROUND

To examine the impact of county-level colorectal cancer (CRC) screening rates on stage at diagnosis of CRC and identify factors associated with stage at diagnosis across different levels of screening rates in rural Georgia.

METHODS

We performed a retrospective analysis utilizing data from 2004 to 2010 Surveillance, Epidemiology, and End Results Program. The 2013 United States Department of Agriculture rural-urban continuum codes were used to identify rural Georgia counties. The 2004-2010 National Cancer Institute small area estimates for screening behaviors were applied to link county-level CRC screening rates. Descriptive statistics and multinominal logistic regressions were performed.

RESULTS

Among 4,839 CRC patients, most patients diagnosed with localized CRC lived in low screening areas; however, many diagnosed with regionalized and distant CRC lived in high screening areas (p-value = 0.009). In multivariable analysis, rural patients living in high screening areas were 1.2-fold more likely to be diagnosed at a regionalized and distant stage of CRC (both p-value < 0.05). When examining the factors associated with stage at presentation, Black patients who lived in low screening areas were 36% more likely to be diagnosed with distant diseases compared to White patients (95% CI, 1.08-1.71). Among those living in high screening areas, patients with right-sided CRC were 38% more likely to have regionalized disease (95% CI, 1.09-1.74).

CONCLUSION

Patients living in high screening areas were more likely to have a later stage of CRC in rural Georgia.

IMPACT

Allocating CRC screening/treatment resources and improving CRC risk awareness should be prioritized for rural patients in Georgia.

County-level colorectal cancer screening rates on colorectal cancer survival in the state of Georgia: Does county-level rurality matter?

PURPOSE

Investigating CRC screening rates and rurality at the county-level may explain disparities in CRC survival in Georgia. Although a few studies examined the relationship of CRC screening rates, rurality, and/or CRC outcomes, they either used an ecological study design or focused on the larger population.

METHODS

We conducted a retrospective analysis utilizing data from the 2004-2010 Surveillance, Epidemiology, and End Results Program. The 2013 United States Department of Agriculture rural-urban continuum codes and 2004-2010 National Cancer Institute small-area estimates for screening behaviors were used to identify county-level rurality and CRC screening rates. Kaplan-Meier method and Cox proportional hazard regression were performed.

RESULTS

Among 22,160 CRC patients, 5-year CRC survival rates were lower among CRC patients living in low screening areas in comparison with intermediate/high areas (69.1% vs. 71.6% /71.3%; p-value = 0.030). Patients living in rural high-screening areas also had lower survival rates compared to non-rural areas (68.2% vs. 71.8%; p-value = 0.009). Our multivariable analysis demonstrated that patients living in intermediate (HR, 0.91; 95% CI, 0.85-0.98) and high-screening (HR, 0.92; 95% CI, 0.85-0.99) areas were at 8%-9% reduced risk of CRC death. Further, non-rural CRC patients living in intermediate and high CRC screening areas were 9% (HR, 0.91; 95% CI, 0.83-0.99) and 10% (HR, 0.90; 95% CI, 0.82-0.99) less likely to die from CRC.

CONCLUSIONS

Lower 5-year survival rates were observed in low screening and rural high-screening areas. Living in intermediate/high CRC screening areas was negatively associated with the risk of CRC death. Particularly, non-rural patients living in intermediate/high-screening areas were 8%-9% less likely to die from CRC. Targeted CRC screening resources should be prioritized for low screening and rural communities.

Population impact and cost-effectiveness of artificial intelligence-based diabetic retinopathy screening in people living with diabetes in Australia: a cost effectiveness analysis

Background

We aimed to evaluate the cost-effectiveness of an artificial intelligence-(AI) based diabetic retinopathy (DR) screening system in the primary care setting for both non-Indigenous and Indigenous people living with diabetes in Australia.

Methods

We performed a cost-effectiveness analysis between January 01, 2022 and August 01, 2023. A decision-analytic Markov model was constructed to simulate DR progression in a population of 1,197,818 non-Indigenous and 65,160 Indigenous Australians living with diabetes aged ≥20 years over 40 years. From a healthcare provider's perspective, we compared current practice to three primary care AI-based screening scenarios-(A) substitution of current manual grading, (B) scaling up to patient acceptance level, and (C) achieving universal screening. Study results were presented as incremental cost-effectiveness ratio (ICER), benefit-cost ratio (BCR), and net monetary benefits (NMB). A Willingness-to-pay (WTP) threshold of AU$50,000 per quality-adjusted life year (QALY) and a discount rate of 3.5% were adopted in this study.

Findings

With the status quo, the non-Indigenous diabetic population was projected to develop 96,269 blindness cases, resulting in AU$13,039.6 m spending on DR screening and treatment during 2020-2060. In comparison, all three intervention scenarios were effective and cost-saving. In particular, if a universal screening program was to be implemented (Scenario C), it would prevent 38,347 blindness cases, gain 172,090 QALYs and save AU$595.8 m, leading to a BCR of 3.96 and NMB of AU$9,200 m. Similar findings were also reported in the Indigenous population. With the status quo, 3,396 Indigenous individuals would develop blindness, which would cost the health system AU$796.0 m during 2020-2060. All three intervention scenarios were cost-saving for the Indigenous population. Notably, universal AI-based DR screening (Scenario C) would prevent 1,211 blindness cases and gain 9,800 QALYs in the Indigenous population, leading to a saving of AU$19.2 m with a BCR of 1.62 and NMB of AU$509 m.

Interpretation

Our findings suggest that implementing AI-based DR screening in primary care is highly effective and cost-saving in both Indigenous and non-Indigenous populations.

Funding

This project received grant funding from the Australian Government: the National Critical Research Infrastructure Initiative, Medical Research Future Fund (MRFAI00035) and the NHMRC Investigator Grant (APP1175405). The contents of the published material are solely the responsibility of the Administering Institution, a participating institution or individual authors and do not reflect the views of the NHMRC. This work was supported by the Global STEM Professorship Scheme (P0046113), the Fundamental Research Funds of the State Key Laboratory of Ophthalmology, Project of Investigation on Health Status of Employees in Financial Industry in Guangzhou, China (Z012014075). The Centre for Eye Research Australia receives Operational Infrastructure Support from the Victorian State Government. W.H. is supported by the Melbourne Research Scholarship established by the University of Melbourne. The funding source had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

Opportunities and Challenges in Screening for Colorectal Cancer

Colorectal cancer (CRC) is a leading cause of mortality in the United States. Outcomes are greatly improved if CRC is detected early; hence, screening is currently recommended for adults aged 45 years and older at average risk for the disease. Despite this recommendation and the availability of accurate screening tests, the CRC screening rates are below those recommended. The goal of this study was to identify temporal trends (from 2015 to 2019) in CRC screening rates and the utilization of screening tests recommended for CRC detection among average-risk individuals within the St Elizabeth Healthcare system in Kentucky, United States. The primary population of interest was patients aged 50-75 years (the CRC screening was recommended for this age group at the time of the study). Deidentified data were sourced from patients' electronic health records, and the results showed that screening rates increased significantly from 26% in 2015 to 49% in 2019 (<0.0001). The incidence of any screening test also increased significantly from 2015 to 2019, for those who were due for screening (P < 0.05) and for the entire cohort (P < 0.1). The use of multitarget stool DNA (mt-sDNA) increased 40-fold over the study timeframe (P < 0.05). These study results confirm that CRC screening rates remain suboptimal, although incidence and adherence improved significantly in those aged 50-75 years from 2015 to 2019. The growing adoption and availability of mt-sDNA may be correlated with an increase in overall screening in this average-risk population.

Improving colorectal cancer screening - consumer-centred technological interventions to enhance engagement and participation amongst diverse cohorts

The current "Gold Standard" colorectal cancer (CRC) screening approach of faecal occult blood test (FOBT) with follow-up colonoscopy has been shown to significantly improve morbidity and mortality, by enabling the early detection of disease. However, its efficacy is predicated on high levels of population participation in screening. Several international studies have shown continued low rates of screening participation, especially amongst highly vulnerable lower socio-economic cohorts, with minimal improvement using current recruitment strategies. Research suggests that a complex of dynamic factors (patient, clinician, and the broader health system) contribute to low citizen engagement. This paper argues that the challenges of screening participation can be better addressed by (1) developing dynamic multifaceted technological interventions collaboratively across stakeholders using human-centered design; (2) integrating consumer-centred artificial intelligence (AI) technologies to maximise ease of use for CRC screening; and (3) tailored strategies that maximise population screening engagement, especially amongst the most vulnerable.