Evolving perspectives on stool testing for colorectal cancer: a qualitative systematic review

What factors influence the uptake of bowel, breast and cervical cancer screening? An overview of international research

BACKGROUND

For cancer screening programmes to be effective in early detection it is important that those invited can access screening services and understand the benefits of participation. A better understanding of the factors that matter to potential participants of cancer screening programmes can assist in developing strategies to increase current uptake.

METHODS

We conducted an overview of systematic reviews to answer the question: What factors influence the uptake of cancer screening services (breast, bowel and cervical) in high-income countries? A thematic approach supported by tabular summaries and qualitative heat maps was used to categorize factors, described as 'barriers' or 'facilitators'.

RESULTS

A total of 41 systematic reviews met the criteria for inclusion. The barrier with the greatest number of 'hot spots' across all three screening programmes was a fear of the unknown regarding a possible diagnosis of cancer or abnormal screening results, followed closely by a general lack of knowledge surrounding cancer screening programmes. The greatest collective facilitator to uptake was recommendation by a healthcare provider to attend screening.

CONCLUSION

Across all factors 'trust' and 'building trusted relationships' can be seen as integral to the success of cancer screening programmes and must be reflective of collaborative efforts to mitigate barriers and enhance facilitators to uptake. There is future scope to consider interventions that (i) increase demand for screening services, (ii) reduce barriers to uptake of services and/or (iii) are relevant to the healthcare system and those providing services.

Qualitative Analysis of Colorectal Cancer Screening for African American and Hispanic Populations in Nebraska: an Application of the PRECEDE Framework

Nationally and in Nebraska, African Americans (AA) and Hispanics have lower colorectal cancer (CRC) screening rates compared to non-Hispanic Whites. We aimed to obtain perspectives from AA and Hispanic cancer survivors and caregivers in Nebraska about CRC screening to improve outreach efforts. Data from four virtual focus groups (AA female, AA male, Hispanic rural, and Hispanic urban) conducted between April-August 2021 were analyzed using a directed content approach based on the Predisposing, Reinforcing, and Enabling Constructs in Educational Diagnosis and Evaluation (PRECEDE) model. Most of the 19 participants were female (84%) and survivors (58%). Across groups, awareness of colonoscopy was high, but awareness of fecal testing needed to be higher, with confusion about different types of fecal tests. Predisposing factors were trust in the health system; awareness of CRC screening; machismo; fear of cancer; embarrassment with screening methods; and negative perceptions of CRC screening. Enabling factors included provider recommendations, healthcare access, and insurance. Reinforcing factors included prioritizing personal health and having a support system. Suggestions to improve screening included increasing healthcare access (free or low-cost care), increasing provider diversity, health education using various methods and media, and enhancing grassroots health promotion efforts. Lack of awareness, accessibility issues, attitudes and perceptions of CRC and CRC screening, trust, and cultural and linguistic concerns are major issues that need to be addressed to reduce CRC screening disparities among AA and Hispanic adults.

Can we do better? A qualitative study in the East of England investigating patient experience and acceptability of using the faecal immunochemical test in primary care

OBJECTIVES

The faecal immunochemical test (FIT) is increasingly used in UK primary care to triage patients presenting with symptoms and at different levels of colorectal cancer risk. Evidence is scarce on patients' views of using FIT in this context. We aimed to explore patients' care experience and acceptability of using FIT in primary care.

DESIGN

A qualitative semi-structured interview study. Interviews were conducted via Zoom between April and October 2020. Transcribed recordings were analysed using framework analysis.

SETTING

East of England general practices.

PARTICIPANTS

Consenting patients (aged ≥40 years) who presented in primary care with possible symptoms of colorectal cancer, and for whom a FIT was requested, were recruited to the FIT-East study. Participants were purposively sampled for this qualitative substudy based on age, gender and FIT result.

RESULTS

44 participants were interviewed with a mean age 61 years, and 25 (57%) being men: 8 (18%) received a positive FIT result. Three themes and seven subthemes were identified. Participants' familiarity with similar tests and perceived risk of cancer influenced test experience and acceptability. All participants were happy to do the FIT themselves and to recommend it to others. Most participants reported that the test was straightforward, although some considered it may be a challenge to others. However, test explanation by healthcare professionals was often limited. Furthermore, while some participants received their results quickly, many did not receive them at all with the common assumption that 'no news is good news'. For those with a negative result and persisting symptoms, there was uncertainty about any next steps.

CONCLUSIONS

While FIT is acceptable to patients, elements of communication with patients by the healthcare system show potential for improvement. We suggest possible ways to improve the FIT experience, particularly regarding communication about the test and its results.

Perceived barriers and benefits in the participation in faecal occult blood test colorectal cancer screening programme

BACKGROUND

Colorectal cancer is the second cancer-related cause of death in the world. Tumour stage at diagnosis is the principal prognosis factor of survival. However, the participation in the programme is around 50%. The aim of the study was to identify the benefits and barriers perceived by the population when participating in a colorectal cancer screening programme with faecal occult blood test.

METHODS

We carried out a cases-controls study with 408 participants. We analyzed epidemiological and social variables associated with lifestyle and behavioural factors based in the Health Belief Model. We conducted a descriptive analysis, and identified variables associated to adherence by a logistic regression.

RESULTS

Variables independently associated with the participation in a colorectal cancer screening programme were age (OR 1.06; 95% CI: 1.01-1.11), having a stable partner (OR 1.96; 95% CI: 1.20-3.18), the level of education (OR 1.59; 95% CI: 1.02-2.47) and two of the barriers to participate in the faecal occult blood test screening: "you don't know how to do one" (OR=0.46; 95% CI: 0.23-0.93) and "it is not that important right now" (OR=0.43; 95% CI: 0.24-0.78).

CONCLUSION

The existing barriers for screening with faecal occult blood test are the best factor predicting. This is relevant when designing the intervention programmes, as they should focus on reducing perceived barriers to increase the participation in colorectal cancer screening, thereby reducing colorectal cancer mortality.

Moving beyond the initial colonoscopy: a call for action

INTRODUCTION

The evolution of colorectal screening has made headway with continual efforts globally to increase screening rates for colonoscopy-naïve patients. However, little has been done to encourage repeat colonoscopies after the initial scope despite recommendations to repeat colonoscopy every 10 years, with the uptake rates of repeat colonoscopy remaining abysmal at 22%.

METHODS

Previously, a qualitative systematic review evaluated the barriers and facilitators patients faced in their decisions to undergo colonoscopy, analyzing articles from Medline, Embase, CINAHL, PsycINFO and Web of Science. Key findings from articles which highlighted factors influencing patients' decisions to return for repeat colonoscopies were summarized.

RESULTS

Three articles were identified in the search. Facilitators for repeat colonoscopy included patients' assurance garnered from fostered trust in the patient-provider relationship, their intrinsic motivations from fear of cancer and an innate appreciation for the significance of obtaining repeated colonoscopies. Procedural factors such as the option for procedural visualization, its comprehensiveness and the utilization of anesthesia were also crucial motivators. Barriers that patients highlighted comprised of cumbersome bowel preparation and potential complications.

DISCUSSION

Recently, minimal research has been conducted on the sentiments of healthcare providers and patients regarding repeat colonoscopy. The lack of emphasis from healthcare institutions on encouraging patients to repeat colonoscopy after 10 years prevents effective colorectal cancer screening. To proficiently alleviate the burden of colorectal cancer, patient counseling has to shift beyond explaining colonoscopy risks and complications to promoting regular follow-up scopes. This article thus calls for more studies to focus on evaluating the uptake of repeat colonoscopies.

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.