Screening participation in individuals with a family history of colorectal cancer: a review

Understanding perceptions of the public and key stakeholders toward a localised cancer screening promotion campaign

The aim of this study was to explore perceptions of members of the public and key stakeholders of a localised campaign to increase engagement with cervical cancer screening. Whilst numerous interventions have been trialled to increase engagement with cancer screening, the evidence for their effectiveness is somewhat mixed. In addition, few studies have explored the perceptions of members of the public targeted by such campaigns nor the perceptions of healthcare professionals who may be involved in delivering such campaigns in the United Kingdom. Members of the public who had potentially been exposed to the campaign in the North-East of England were approached to take part in individual interviews whilst stakeholders were invited to take part in a focus group. A total of 25 participants (13 members of the public, 12 stakeholders) took part. All interviews were audio recorded, transcribed verbatim and analysed using applied thematic analysis. Four themes were identified, two of which were cross-cutting (barriers to screening and factors promoting screening), with one theme identified as specific to the public interviews (knowledge of and attitudes toward awareness campaigns) and one theme specific to the focus group (keeping campaigns relevant. Awareness of the localised campaign was limited; however, when made aware, participants were mostly positive towards the approach, although mixed responses were noted in relation to financial incentives. Members of the public and stakeholders identified some common barriers to screening although differed in their perceptions of promotional factors. This study highlights the importance of multiple strategies to promote cervical screening as one size fits all approach may limit engagement.

Individuals With a Family History of Colorectal Cancer Warrant Tailored Interventions to Address Patient-Reported Barriers to Screening

INTRODUCTION

Population health interventions to increase colorectal cancer (CRC) screening rates often exclude individuals with a family history of CRC, and interventions to increase screening in this high-risk group are rare. We aimed to determine the screening rate and barriers and facilitators to screening in this population to inform interventions to increase screening participation.

METHODS

We performed a retrospective chart review and cross-sectional survey of patients excluded from mailed fecal immunochemical test (FIT) outreach because of a family history of CRC in a large health system. We used χ 2 , Fisher exact, and Student t tests to compare demographic and clinical characteristics of patients overdue and not overdue for screening. We then administered a survey (mailed and telephone) to overdue patients to assess barriers and facilitators to screening.

RESULTS

There were 296 patients excluded from mailed FIT outreach, and 233 patients had a confirmed family history of CRC. Screening participation was low (21.9%), and there were no significant demographic or clinical differences between those overdue and not overdue for screening. There were 79 survey participants. Major patient-reported barriers to screening colonoscopy were patient forgetfulness (35.9%), fear of pain during colonoscopy (17.7%), and hesitancy about bowel preparation (29.4%). To facilitate screening colonoscopy, patients recommended reminders (56.3%), education about familial risk (50%), and colonoscopy education (35.9%).

DISCUSSION

Patients with a family history of CRC who are excluded from mailed FIT outreach have low screening rates and report multiple mutable barriers to screening. They warrant targeted efforts to increase screening participation.

Exploration of Malaysian Stakeholders View on Barriers to and Facilitators of Colorectal Cancer Screening Among Older Population

According to the Malaysian National Cancer Registry (MNCR), more than 70% of colorectal cancer (CRC) cases in Malaysia are presented in the advanced stages of the disease, leading to poor survival rates while taxing the health care system. This study aims to explore the barriers to and facilitators of CRC screening uptake in the perspectives of the general population, health care providers, and policymakers. In-depth, semi-structured interviews were conducted with 25 purposively sampled respondents comprising general population above the age of 40, health care providers, and policymakers. Commonly reported barriers to CRC screening included psychological, poor knowledge and awareness, lack of physicians' recommendation, and inadequate implementation of CRC-related campaigns at systemic level. Facilitating factors for CRC screening included family support and family history of CRC. A comprehensive understanding of barriers and facilitators is relevant for designing an effective intervention and policy to increase CRC screening rates in Malaysia.

Compliance of Blood Relatives of Colorectal Cancer Patients to Colorectal Screening Guidelines

BACKGROUND

There is a wide range of options for colorectal cancer (CRC) screening in the average-risk population. However, screening tests for CRC vary regarding the degree of supporting evidence. Colonoscopy, Satisfaction, and Safety Questionnaire based on patients' experience (CSSQP).

AIM OF THE STUDY

To study the compliance of blood relatives of patients with colorectal cancer to colorectal cancer screening.

SUBJECT AND METHODS

This cross-sectional study included 134 participants of blood relatives of CRC patients undergoing colonoscopy following primary care or secondary care referrals, after exclusion of those who refused to take part, and subjects already having or had cancer elsewhere. This work was conducted in Internal Medicine Department, Zagazig University Hospitals. All participants in this study completed a questionnaire, which comprised a pre-procedure questionnaire that included name, age, residence, history of smoking, history of bleeding problems, history of colonoscopy, and family history of colon cancer.

RESULTS

The age of the studied cases ranged from 19 to 66 years with a mean of 44.08 years. Regarding the sex distribution, 53% were male. Most of the study group were married (84.3%). More than half of the studied group were educated (57.2%). The most frequent occupations were professional (29.1%). Of the studied cases, 60.4% had enough income and 47.8% were smokers. The study group had no history of other malignancy or previous colonoscopy. All the studied cases refused colonoscopy for screening, but 91% of them accepted CRC genetic tests and all of them accepted any other tests like stool analysis or CT scan. Regarding advising others to do a colonoscopy, 66.4% advised cases with symptoms to do a colonoscopy. Finally, 82.8% of the studied group preferred medical treatment if they had symptoms. There was a statistically significant increase in the frequency of acceptance of CRC genetic tests among educated compared to non-educated and among those who had enough income compared to those who did not have enough income.

CONCLUSION

Providing non-invasive screening choices can augment participation in programs for colorectal cancer screening. The success of a screening program depends on having tests with acceptable performance, but also on the willingness of the target population to take part. This study showed that offering non-invasive tests, options significantly increase compliance to colorectal cancer screening.

Developing genetic counselling services in an underdeveloped healthcare setting

Genetic counselling services are well established in North America, Western Europe and Australia. In other regions, genetic counselling services are still emerging. Where this is the case, an in-depth understanding of the main stakeholders’ needs, challenges and opportunities will inform the changes and innovations required to bring genetic counselling closer to the community. The present study explored the needs and challenges of patients, family members and professionals with a view to setting up a cancer genetic counselling service in Romania. In order to get a comprehensive outlook, key stakeholders were interviewed using data source triangulation method. Thirty-four semi-structured interviews were conducted (13 patients, 11 family members and 10 professionals). Thematic analysis was used to explore and identify needs, barriers and opportunities in emerging cancer genetic counselling services. Three major themes were identified: (1) the “Needs” theme mainly focuses on various types of support that participants mentioned wanting: psychosocial, peer and additional support; (2) the “Challenges” theme includes aspects related to limited access to healthcare, lack of integrated services and pressure on the families; (3) the “Hopes” theme highlights the wish for integrated healthcare and an empathic rapport with healthcare providers. Our findings highlighted the main needs, challenges and hopes the patients, family members and professionals have and provides the groundwork for setting up cancer genetic counselling services.

Risk-stratified strategies in population screening for colorectal cancer

Colorectal cancer (CRC) screening has been demonstrated to reduce CRC incidence and mortality. However, besides such benefits, CRC screening is also associated with potential harmful effects. In an ideal world, screening would only be directed to the small proportion of the population that might potentially benefit. Risk‐based screening can be seen as a first step towards this ideal world, by redistributing screening resources from low‐risk to high‐risk individuals. In theory, this should result in scarce resources being used in individuals who benefit most, while intensity of screening is reduced in individuals who benefit less, hence improving the benefit‐harm ratio among all invitees. Available strategies that have been proposed for risk‐based CRC screening include using information on age, sex, prior screening history, lifestyle and/or genetic information. Implementation of risk‐based screening requires careful consideration of reliable risk prediction models, participation with screening and informed decision‐making. While it is important to recognise the limitations of current approaches, available evidence suggests that it might be feasible to start planning the introduction of tailored strategies within screening programmes. Implementing risk‐based screening based on age, sex and prior screening history alone would already represent a substantial improvement over current uniform screening approaches. We propose that it is time that screening programmes start there and continue striving towards more comprehensive approaches embedding primary prevention as an effective approach to lower risk for everyone.

Prevalence of a First-Degree Relative With Colorectal Cancer and Uptake of Screening Among Persons 40 to 54 Years Old

BACKGROUND & AIMS

People with a first-degree relative with colorectal cancer (CRC) are recommended to start CRC screening at age 40. However, there is limited information on how many people in different age groups have a known family history of CRC and how many of them have had a colonoscopy.

METHODS

We set up a multicenter, cross-sectional, population-based study in Germany to determine what proportions of persons in age groups from 40 to 54 years old have a known family history of CRC. We invited 160,000 persons to participate in an online survey from 2015 through 2016. We investigated what proportions of persons in each age group reported a family history of CRC and what proportions of persons underwent a colonoscopy examination using descriptive statistics and multiple logistic regression models.

RESULTS

Of 28,711 responders to the online questionnaire (8428 were age 40-44 years, 9879 were age 45-49 years, and 10,404 were age 50-54 years), 2705 stated that they had a first-degree relative with CRC (9.4%). The prevalence of a first-degree relative with CRC increased with age: 7.5%, 9.6%, and 10.9% for people 40 to 44 years old, 45 to 49 years old, and 50 to 54 years old, respectively. The prevalence of a first-degree relative who received a diagnosis of CRC at age 70 years or older increased steadily with each age group. Although a greater proportion of people with a family history of CRC had undergone a colonoscopy examination (54.5%) than people without a family history of CRC (25.7%; P < .0001), large proportions of people within this risk group were not in compliance with the guidelines (54.8%, 47.6%, and 38.6% for ages 40-44 y, 45-49 y, and 50-54 y, respectively).

CONCLUSIONS

One in 10 persons in Germany age 40 to 54 years old has a first-degree relative with CRC. Guidelines recommend initiation of screening at ages 40 to 45 years for people with a family history, yet at this age many people do not have a family history of CRC yet, and almost half of persons 40 to 54 years old with a family history of CRC have not yet received a screening colonoscopy.

An action plan to address the rising burden of colorectal cancer in younger adults

Aim: The National Colorectal Cancer Roundtable convened a national Summit to discuss the causes of early-onset colorectal cancer and clinical challenges to mitigating burden of this disease. Materials & methods: Information presented was synthesized through scientific consensus building to determine priorities for new research and practice change. Results: Research priorities include evaluating role of novel risk factors, understanding natural history and identifying ways to implement evidenced-based practices for identifying and managing at-risk persons. Practice change should focus on adoption of guidelines for collecting family history, screening in young adults at risk, provider and population awareness about risk and symptoms, and universal tumor testing. Conclusion: Successful implementation of strategies to address research and practice change will require collaboration from multiple partners.

Evaluating the effects of a risk-adapted screening program for familial colorectal cancer in individuals between 25 and 50 years of age: study protocol for the prospective population-based intervention study FARKOR

BACKGROUND

Colorectal cancer (CRC) is the second most common malignant disease and the second most common cause of cancer death in Germany. Official CRC screening starts at age 50. As there is evidence that individuals with a family history of CRC have an increased risk of developing CRC before age 50, there are recommendations to start screening for this group earlier. This study aims to evaluate the clinical and economic effects of a risk-adapted screening program for CRC in individuals between 25 and 50 years of age with potentially increased familial CRC risk.

METHODS

FARKOR (Familiäres Risiko für das Kolorektale Karzinom) is a population-based prospective intervention study. All members of cooperating statutory health insurance companies between 25 and 50 years of age living in a model region in Germany (federal state of Bavaria, 3.5 million inhabitants in this age group) can participate in the program between October 2018 and March 2020. Recruitment takes place through physicians and through a public campaign. Additionally, insurances contact recently diagnosed CRC patients in order to encourage their relatives to participate in the program. Physicians assess a participant's familial history of CRC using a short questionnaire. All participants with a family history of CRC are invited to a shared decision making process to decide on further screening options consisting of either undergoing an immunological test for fecal occult blood or colonoscopy. Comprehensive data collection based on self-reported lifestyle information, medical documentation and health administrative databases accompanies the screening program. Longterm benefits, harms and the cost-effectiveness of the risk-adapted CRC screening program will be assessed by decision analytic modeling.

DISCUSSION

The data collected in this study will add important pieces of information that are still missing in the evaluation of the effects and the cost-effectiveness of a risk-adapted CRC screening strategy for individuals under 50 years of age.

TRIAL REGISTRATION

German Clinical Trials Register, DRKS-IDDRKS00015097.

Cost-Effectiveness of Personalized Screening for Colorectal Cancer Based on Polygenic Risk and Family History

BACKGROUND

There is growing evidence for personalizing colorectal cancer screening based on risk factors. We compared the cost-effectiveness of personalized colorectal cancer screening based on polygenic risk and family history to uniform screening.

METHODS

Using the MISCAN-Colon model, we simulated a cohort of 100 million 40-year-olds, offering them uniform or personalized screening. Individuals were categorized based on polygenic risk and family history of colorectal cancer. We varied screening strategies by start age, interval and test and estimated costs, and quality-adjusted life years (QALY). In our analysis, we (i) assessed the cost-effectiveness of uniform screening; (ii) developed personalized screening scenarios based on optimal screening strategies by risk group; and (iii) compared the cost-effectiveness of both.

RESULTS

At a willingness-to-pay threshold of $50,000/QALY, the optimal uniform screening scenario was annual fecal immunochemical testing (FIT) from ages 50 to 74 years, whereas for personalized screening the optimal screening scenario consisted of annual and biennial FIT screening except for those at highest risk who were offered 5-yearly colonoscopy from age 50 years. Although these scenarios gained the same number of QALYs (17,887), personalized screening was not cost-effective, costing an additional $428,953 due to costs associated with determining risk (assumed to be $240 per person). Personalized screening was cost-effective when these costs were less than ∼$48.

CONCLUSIONS

Uniform colorectal cancer screening currently appears more cost-effective than personalized screening based on polygenic risk and family history. However, cost-effectiveness is highly dependent on the cost of determining risk.

IMPACT

Personalized screening could become increasingly viable as costs for determining risk decrease.

Invitation to Screening Colonoscopy in the Population at Familial Risk for Colorectal Cancer

BACKGROUND

Screening colonoscopy can lower the incidence of colorectal cancer (CRC), yet participation rates are low even in groups at high risk. The goal of this study was to double the rate of participation in screening colonoscopy among persons at familial risk and then to determine the frequency of neoplasia in this risk group.

METHODS

In a nationwide, cluster-randomized, multicenter study, first-degree relatives (FDR) of patients with CRC across Germany received written informational materials concerning the familial risk of CRC, along with an invitation to undergo colonoscopy. Participants in the intervention group were additionally counseled by nurses over the telephone. The primary endpoint of the study was colonoscopy uptake within 30 days.

RESULTS

The participants' mean age was 50.8 years. The colonoscopy uptake rates were 99/125 (79%) in the intervention group and 97/136 (71%) in the control group (RR = 1.11; 95% confidence interval [0.97; 1.28]). A polypectomy was performed in 72 of 196 asymptomatic persons (37%). In 13 cases (7%), an advanced neoplasia was detected; two of these persons had colon cancer (stages T0 and T1). 42% of the participants expressed barriers against colonoscopy. 22 reported mild side effects; there were no serious side effects.

CONCLUSION

Additional counseling by nurses over the telephone does not increase the participation rate. Approaching patients who have CRC is an opportunity to increase the participation of their first-degree relatives in screening colonoscopy. The frequency of neoplasia that was found in this study underscores the need to screen relatives even before they reach the usual age threshold for screening.

Willingness to Pay for Colorectal Cancer Screening and Effect of Copayment in Southern Thailand

Background:

The incidence rate of colorectal cancer in Thailand is increasing. Hence, the nationwide screening programme with copayment is being considered. There are two proposed screening alternatives: annual fecal immunochemical test (FIT) and once-in-10-year colonoscopy. A copayment for FIT is 60 Thai baht (THB) per test (≈ 1.7 USD); a copayment for colonoscopy is 2,300 THB per test (≈ 65.5 USD).

Methods:

The willingness to pay (WTP) technique, which is theoretically founded on a cost-benefit analysis, was used to assess an effect of copayment on the uptake. Subjects were patients aged 50-69 years without cancer or screening experience. WTP for the proposed tests was elicited.

Results:

Nearly two thirds of subjects were willing to pay for FIT. Less than half of subjects were willing to pay for colonoscopy. Among them, median WTP for both tests was greater than the proposed copayments. In a probit model, knowing CRC patient and presence of companion were associated with non-zero WTP for FIT. Presence of companion, female, and family history of cancer were associated with non-zero WTP for colonoscopy. After adjustment for starting price in the linear model, marital status, drinking behavior, and risk attitude were associated with WTP. None of factors was significant for colonoscopy. Uptake decreased as levels of copayment increased. At proposed copayments, the uptake rates of 59.8% and 21.6% were estimated for colonoscopy and FIT respectively. The demand for FIT was price inelastic; the demand for colonoscopy was price elastic. Estimates of optimal copayment were 62.1 THB for FIT and 460.2 THB for colonoscopy. At the optimal copayment, uptake rates would be 59.8% for FIT and 42.3% for colonoscopy.

Conclusion(s):

More subjects were willing to pay for FIT than for colonoscopy (59.0% versus 46.5%). The estimated uptake rates were 59.8% and 21.6% for colonoscopy and FIT at the proposed copayments.

Community-based survey of knowledge of, attitudes to and practice of colorectal cancer screening in Hong Kong

OBJECTIVE

We aimed to investigate the knowledge, attitudes and practice of colorectal cancer (CRC) and screening in the community to complement the introduction of population-based CRC screening in Hong Kong SAR, China.

METHODS

Clients attending the Family Planning Association of Hong Kong clinics from March to June 2016 were randomly invited to participate in this questionnaire survey.

RESULTS

Knowledge of CRC and screening for it was still deficient in the community. Respondents scored less than half on their knowledge of the symptoms and screening methods of CRC as well as on the local screening policy. Fewer than 30% knew that CRC can be asymptomatic and they had insufficient knowledge of primary lifestyle prevention of CRC. However, most (86.0%) would like to participate in CRC screening. The cost and trouble involved were the two main reasons given for not wanting to do so. Only 14.0% of the whole sample and 27.0% of those aged 50 years or above had undergone CRC screening irrespective of screening method. One-fifth of those who had been screened had some abnormality, with a cancer detection rate of 2.2%. Employment, income, knowledge and perception of risk were major determinants of their decision to undergo screening.

CONCLUSIONS

To reduce the morbidity and mortality of CRC significantly, average risk and high-risk groups should be encouraged to come forward for screening even if they are asymptomatic. Educating the population, simplifying the screening procedure and offering financial support by the government are keys to success.

A cross-sectional survey assessing factors associated with reading cancer screening information: previous screening behaviour, demographics and decision-making style

Background

There is broad agreement that cancer screening invitees should know the risks and benefits of testing before deciding whether to participate. In organised screening programmes, a primary method of relaying this information is via leaflets provided at the time of invitation. Little is known about why individuals do not engage with this information. This study assessed factors associated with reading information leaflets provided by the three cancer screening programmes in England.

Methods

A cross-sectional survey asked screening-eligible members of the general population in England about the following predictor variables: uptake of previous screening invitations, demographic characteristics, and ‘decision-making styles’ (i.e. the extent to which participants tended to make decisions in a way that was avoidant, rational, intuitive, spontaneous, or dependent). The primary outcome measures were the amount of the leaflet that participants reported having read at their most recent invitation, for any of the three programmes for which they were eligible. Associations between these outcomes and predictor variables were assessed using binary or ordinal logistic regression.

Results

After exclusions, data from 275, 309, and 556 participants were analysed in relation to the breast, cervical, and bowel screening programmes, respectively. Notable relationships included associations between regularity of screening uptake and reading (more of) the information leaflets for all programmes (e.g. odds ratio: 0.16 for participants who never/very rarely attended breast screening vs. those who always attended previously; p = .009). Higher rational decision-making scores were associated with reading more of the cervical and bowel screening leaflets (OR: 1.13, p < .0005 and OR: 1.11, p = .045, respectively). Information engagement was also higher for White British participants compared with other ethnic groups for breast (OR: 3.28, p = .008) and bowel (OR: 2.58, p = .015) information; an opposite relationship was observed for older participants (OR: 0.96, p = .048; OR: 0.92, p = .029).

Conclusions

Interventions that increase screening uptake may also increase subsequent engagement with information. Future research could investigate how to improve engagement at initial invitations. There may also be scope to reduce barriers to accessing non-English information and alternative communication strategies may benefit participants who are less inclined to weigh up advantages and disadvantages as part of their decision-making.

Cancer risk awareness and screening uptake in individuals at higher risk for colon cancer: a cross-sectional study

OBJECTIVE

We aimed to measure cancer knowledge and feasibility of a screening colonoscopy among a cohort of individuals at higher risk of colon cancer.

METHODS

This study was conducted as part of an ongoing screening cohort, in which first degree relatives (FDRs) of patients with colon cancer are invited to participate in a free of charge screening colonoscopy. We enrolled 1017 FDRs in the study between 2013 and 2014 measuring their data on demographics, cancer knowledge and colonoscopy uptake. A p value of <0.05 was considered statistically significant.

RESULTS

The relative's mean age was 48.7 years. Only about 28% of FDRs were aware of their increased risk for cancer, near 35.0% had ever heard about colonoscopy with 22% aware of the correct age to start screening. Comparing cancer knowledge of FDRs at high risk versus those at moderate risk, we recorded non-significant differences (p>0.05). Almost two-thirds of FDRs expressed willingness to undergo a colonoscopy and 49.2% completed the procedure, of which 12.8% had advanced neoplasm.

CONCLUSIONS

Our data indicated that remarkable numbers of FDRs were not still informed of their cancer risk or never received a physician recommendation for screening. The desirable uptake at first invitation, which would be higher over successive invitations, supports the feasibility of a family-based recruitment approach for early screening. This has promising implications to introduce targeted screening colonoscopy into the healthcare system in Iran and other developing nations.

Understanding the contribution of family history to colorectal cancer risk and its clinical implications: A state-of-the-science review

Persons with a family history (FH) of colorectal cancer (CRC) or adenomas that are not due to known hereditary syndromes have an increased risk for CRC. An understanding of these risks, screening recommendations, and screening behaviors can inform strategies for reducing the CRC burden in these families. A comprehensive review of the literature published within the past 10 years has been performed to assess what is known about cancer risk, screening guidelines, adherence and barriers to screening, and effective interventions in persons with an FH of CRC and to identify FH tools used to identify these individuals and inform care. Existing data show that having 1 affected first-degree relative (FDR) increases the CRC risk 2-fold, and the risk increases with multiple affected FDRs and a younger age at diagnosis. There is variability in screening recommendations across consensus guidelines. Screening adherence is <50% and is lower in persons under the age of 50 years. A provider's recommendation, multiple affected relatives, and family encouragement facilitate screening; insufficient collection of FH, low knowledge of guidelines, and poor family communication are important barriers. Effective interventions incorporate strategies for overcoming barriers, but these have not been broadly tested in clinical settings. Four strategies for reducing CRC in persons with familial risk are suggested: 1) improving the collection and utilization of the FH of cancer, 2) establishing a consensus for screening guidelines by FH, 3) enhancing provider-patient knowledge of guidelines and communication about CRC risk, and 4) encouraging survivors to promote screening within their families and partnering with existing screening programs to expand their reach to high-risk groups. Cancer 2016. © 2016 American Cancer Society. Cancer 2016;122:2633-2645. © 2016 American Cancer Society.

Family history and the risk of colorectal cancer: The importance of patients' history of colonoscopy

Registry-based studies on the risk of colorectal cancer (CRC) for persons with a family history (FH) typically did not control for important covariates, such as history of colonoscopy. We aimed to quantify the association between FH and CRC risk, carefully accounting for potential confounders. We conducted a population-based case-control study in Germany. A total of 4,313 patients with a first diagnosis of CRC (cases) and 3,153 controls recruited from 2003 to 2014 were included. We used multiple logistic regression analyses to assess the association between FH and risk of CRC with odds ratios (OR) and the resulting 95% confidence intervals (95% CI). A total of 582 cases (13.5%) and 321 (10.2%) controls reported a history of CRC in a first-degree relative, which was associated with a 41% increase in risk of CRC (OR: 1.41, 95% CI 1.22-1.63) after adjustment for sex and age. The OR substantially increased to 1.73 (95% CI, 1.48-2.03) after comprehensive adjustment including previous colonoscopies. Irrespective of their FH status, persons with history of colonoscopies had a lower CRC risk compared with persons without previous colonoscopies and without family history (OR: 0.25, 95% CI, 0.22-0.28 for persons without FH and OR 0.45, 95% CI, 0.36-0.56 for persons with FH). In an era of widespread use of colonoscopy, adjusting for previous colonoscopy is therefore crucial for deriving valid estimates of FH-related CRC risk. Colonoscopy reduces the risk of CRC among those with FH far below levels of people with no FH and no colonoscopy.

Screening behaviors, health beliefs, and related factors of first-degree relatives of colorectal cancer patients with ongoing treatment in Turkey

BACKGROUND

Colorectal cancer (CRC) is one of the most common cancers. Family history is an important risk factor; first-degree relatives (FDRs) are most at risk. Studies are needed to determine the screening behavior of FDRs and factors affecting their health behaviors.

OBJECTIVE

The purpose of this study was to investigate the screening behaviors, health beliefs, and related factors of FDRs (parent, sibling, or child) of CRC patients undergoing treatment.

METHODS

A cross-sectional design was used with 400 FDRs of patients undergoing treatment at 2 hospitals in Turkey. Data were collected using the Colorectal Cancer Risk Questionnaire and the Turkish Colorectal Cancer Health Belief Model Scale.

RESULTS

A slight majority of the participants were male (51.3%), with a mean of age 37.7 years. The rate of having at least 1 colonoscopy in FDRs was 22.2%. First-degree relatives reported high perceived confidence-benefits scores on average (mean, 48.4 ± 5.2) and high perceived barrier scores on average (mean, 15.5 ± 3.8). Health motivation of FDRs was the strongest predictor of their having a colonoscopy (odds ratio, 7.50; 95% confidence interval, 3.40-16.5).

CONCLUSIONS

First-degree relatives have a low rate of having a colonoscopy but are more likely to have had this procedure if they have strong health motivation.

IMPLICATIONS FOR PRACTICE

Nurses working with CRC patients must develop strategies to increase FDRs' knowledge of, awareness of, and motivation for CRC screening tests. Risk counseling of FDRs during the treatment period might increase screening rates.

Cancer Screening Patterns and Concerns in Caregivers of Patients Undergoing Radiation Therapy

PURPOSE

Evolving cancer screening guidelines can confuse the public. Caregivers of patients undergoing radiation oncology may represent a promising outreach target for disseminating and clarifying screening information. We aimed to: (1) determine the incidence of cancer screening in this cohort, and (2) identify barriers to and deficiencies in screening.

METHODS

We distributed a 21-item survey on cancer screening history and related concerns to caregivers ≥ 18 years old at one urban and two suburban radiation oncology centers. Reported screening habits were compared with American Cancer Society/American Urological Association guidelines for breast, cervical, colon, and prostate cancer. Statistical analysis included Pearson χ(2) tests.

RESULTS

A total of 209 caregivers (median age, 55.5 years; 146 women) were surveyed. Although 92% had primary care physicians (PCPs), only 58% reported being informed about recommended screening intervals. Participants ≤ 49 years old were less likely to report PCP discussion of cancer screening than older participants (41% and 66%, respectively; P = .006). Ninety-eight respondents (47%) had one or more screening concern(s). Among screening-eligible caregivers, 23 (18%) reported not undergoing regular colonoscopies. Fourteen women (13%) did not have Papanicolaou smears at recommended intervals, and 21 (18%) did not have annual mammograms. Six men (21%) did not undergo annual prostate screening. Decreased recommended screening with colonoscopy and mammography correlated with younger age.

CONCLUSION

This survey of relatively unexplored caregivers identified cancer screening deficiencies and concerns that might be addressed by targeted interventions. With approximately 60% of patients with cancer receiving radiation therapy, advice in the radiation oncology setting could positively affect cancer screening behaviors in caregivers.

Colorectal cancer screening in the familial risk population: Is colonoscopy still the strategy of choice?

First-degree relatives of patients with colorectal cancer (CRC) are at high risk of this disease. For this reason, medical organizations and clinical guidelines recommend more intensive screening and surveillance for such first-degree relatives than for the average-risk population. Colonoscopy has been the cornerstone of CRC screening in this setting. Although colonoscopy is the most sensitive technique for the detection of neoplastic lesions (especially non-advanced adenomas), its role is less clear for CRC. In addition, screening colonoscopy has several limitations that may affect the success of a screening campaign, such as poor participant acceptance, the need for skilled endoscopists, participant access to screening colonoscopy, overburdened endoscopy units, potential complications, and procedure-related costs. In addition, recent evidence has cast doubt on the advantage of colonoscopy over other strategies for the detection of advanced neoplastic lesions. Despite being less sensitive in general, other screening methods frequently recommended in the average-risk population may be more acceptable and thus help increase CRC screening uptake. This review discusses recent evidence on the risk of CRC in first-degree relatives, the advantages and disadvantages of each screening technique, participation rates depending on the technique, patient preferences, and barriers to screening.

Randomized trial to increase colorectal cancer screening in an ethnically diverse sample of first-degree relatives

BACKGROUND

Ethnic minorities, especially African Americans and Latinos, bear a disproportionate burden of colorectal cancer (CRC), as reflected in incidence, cancer stage, and mortality statistics. In all ethnic groups, first-degree relatives (FDRs) of CRC cases are at an elevated disease risk. However, underuse of CRC screening persists and is particularly evident among minority groups. The current study tested a stepped intervention to increase CRC screening among an ethnically diverse sample of FDRs of CRC cases.

METHODS

A statewide cancer registry was used to recruit CRC cases and through them their FDRs. Relatives who were not current on CRC screening were randomized to intervention or usual-care control arms. The stepped intervention consisted of ethnically targeted and individually tailored print materials followed by telephone counseling for those unscreened at 6 months.

RESULTS

The study sample of 1280 individuals consisted of 403 Latino, 284 African American, 242 Asian, and 351 white FDRs. Statistically significant effects were observed for the cumulative print plus telephone intervention at 12 months (26% in the intervention vs 18% in the control group) and the print intervention alone at 6 months (15% in the intervention vs 10% in the control group). The effect of the print intervention alone versus the cumulative interventions was not statistically significantly different. Stratified analyses indicated that the intervention was effective among white, Latino, and Asian individuals, but not among African-Americans.

CONCLUSIONS

Overall, the intervention was effective in increasing screening rates. Oversampling racial/ethnic minorities allowed for the examination of effects within subgroups, revealing no effect among African American individuals. This finding illustrates the importance of including sufficient numbers of participants from diverse ethnic subgroups in intervention research to enable such stratified analyses.

Practical opportunities to improve early detection and prevention of colorectal cancer (CRC) in members of high-risk families

Colorectal cancer (CRC) incidence and mortality are steadily declining and CRC screening rates are increasing in the United States. Although this a very good news, several definable groups still have very low screening rates including younger (under age 50) members of high-risk CRC families. This opinion piece describes five strategies that could be incorporated into routine practice to improve identification and guideline-based screening in members of high-risk families. Routine incorporation of a simple family history screening tool and outreach to high-risk family members could substantially improve guideline-based screening in this population. Identification of CRCs and advanced adenomas in the endoscopy suite defines another group of high-risk families for similar outreach. Lynch syndrome families can be identified by testing CRCs and selected adenomas for microsatellite instability or loss of DNA repair protein expression. Finally, selective addition of aspirin to surveillance endoscopy can decrease the risk of new adenomas and CRCs. The rationale for these strategies as well as mechanisms for their implementation and evaluation in clinical practice is described.

Intention to undergo colonoscopy screening among relatives of colorectal cancer cases: a theory-based model

BACKGROUND

It is recommended that persons having familial risk of colorectal cancer begin regular colonoscopy screening at an earlier age than those in the general population. However, many individuals at increased risk do not adhere to these screening recommendations.

PURPOSE

The goal of this study was to examine cognitive, affective, social, and behavioral motivators of colonoscopy intention among individuals at increased risk of familial colorectal cancer.

METHODS

Relatives of colorectal cancer cases (N = 481) eligible for colonoscopy screening completed a survey assessing constructs from several theoretical frameworks including fear appeal theories.

RESULTS

Structural equation modeling indicated that perceived colorectal cancer risk, past colonoscopy, fear of colorectal cancer, support from family and friends, and health-care provider recommendation were determinants of colonoscopy intention.

CONCLUSIONS

Future interventions to promote colonoscopy in this increased risk population should target the factors we identified as motivators. (ClinicalTrials.gov number NCT01274143).

The evolution of colorectal cancer genetics-Part 1: from discovery to practice

Colorectal cancer (CRC) is an increasing burden on our society. Identifying those who are at the greatest risk and improving triage for treatment will have the greatest impact on healthcare. CRC is a prime paradigm for cancer genetics: the majority of disease results from stages of progression lending itself to prevention by early detection of the pre-disease (neoplastic) state. Approximately 10% represent well defined hereditary cancer syndromes. Hereditary CRC has the added benefit that many are slow growing and family members are armed with the knowledge of potential risk of associated carcinomas and empowerment to reduce the disease burden. This knowledge provides the indication for early endoscopic and/or surgical intervention for prevention or treatment of an entire family cohort. The molecular basis of CRC allows enhanced characterization of carcinomas, leading to targeted therapies.

Familial colorectal cancer: a review

Familial colorectal cancer constitutes a heterogeneous group of patients in whom the underlying molecular mechanism is still unknown. Predisposition to a such neoplasms in this setting seems to be due to common low-penetrance genetic components, but the role of genetic testing in clinical practice has to be determined. Although screening guidelines in this moderate-risk population are empiric, data obtained in epidemiologic, meta-analyses and cohort studies and, more recently, the increased risk of advanced adenomas in first degree relatives who underwent screening colonoscopy support the need to include these individuals in specific screening programs. However, data to determine what test to use, how often to use and which organizational strategy to implement are needed. At present, screening uptake in this population is less than optimal; offering the opportunity to access to screening and improving screening uptake is a first significant step.

Screening participation for people at increased risk of colorectal cancer due to family history: a systematic review and meta-analysis

We conducted a systematic review and a meta-analysis of observational studies to identify and summarise the level of colorectal cancer (CRC) screening participation for people at increased risk due to family history of the disease. Medline, Cinhal, Embase and PsychInfo databases were comprehensively searched between January 1995 and May 2012 to identify relevant articles. To be included, studies had to report on screening for people who had at least one first-degree relative with CRC and no previous personal diagnosis of the disease. Pooled screening participation levels were calculated for each screening modality. Seventeen studies, accounting for a total of 13,269 subjects with a family history of CRC met the inclusion criteria. Seven studies, including a total of 6,901 subjects had a pooled faecal occult blood testing screening participation (at least once) of 25 % (95 % CI 12-38). Five studies including a total of 5,091 subjects had a pooled sigmoidoscopy-based screening participation (at least once) of 16 % (95 % CI 7-27). Seven studies including a total of 9,965 subjects had pooled participation colonoscopy-based screening (at least once) of 40 % (95 % CI 26-54). There was a significant level of screening heterogeneity between studies. This review identified a substantial underuse of CRC screening for people at increased risk of developing the disease. It highlights the potential opportunity that exists for increasing screening participation among this segment of the population and the need to adjust the current CRC screening policies towards that objective.

Agreement between self-reported and registered colorectal cancer screening: a meta-analysis

This random-effects meta-analysis investigates the accuracy of self-reported colorectal cancer screening history as a function of screening mode (colonoscopy, flexible sigmoidoscopy, faecal occult blood testing - FOBT, double-contrast barium enema - DCBE) and survey mode (written, telephone, face-to-face). Summary estimates of sensitivity, specificity, positive predictive value (PPV) and area under the receiver operating characteristic curve (AUC) were calculated. Medical record data were used as reference. We included 23 studies comprising 11,592 subjects. Colonoscopy yielded higher AUC [0.948, 95% confidence interval (CI) = 0.918, 0.968] than flexible sigmoidoscopy (0.883, 95% CI = 0.849, 0.911) and FOBT (0.869, 95% CI = 0.833, 0.898). Colonoscopy showed the highest sensitivity (0.888, 95% CI = 0.835, 0.931), whereas specificity was comparable between screening modes (ranging from 0.802 for FOBT to 0.904 for DCBE). AUC was not significantly different between survey modes. Prevalence of screening history correlated positively with sensitivity and negatively with specificity, possibly because of errors in the medical records. In conclusion, the accuracy of self-reported cancer screening is generally moderate, and higher for colonoscopy than for sigmoidoscopy and FOBT.

Public awareness of colorectal cancer screening: knowledge, attitudes, and interventions for increasing screening uptake

Colorectal cancer ranks as one of the most incidental and death malignancies worldwide. Colorectal cancer screening has proven its benefit in terms of incidence and mortality reduction in randomized controlled trials. In fact, it has been recommended by medical organizations either in average-risk or family-risk populations. Success of a screening campaign highly depends on how compliant the target population is. Several factors influence colorectal cancer screening uptake including sociodemographics, provider and healthcare system factors, and psychosocial factors. Awareness of the target population of colorectal cancer and screening is crucial in order to increase screening participation rates. Knowledge about this disease and its prevention has been used across studies as a measurement of public awareness. Some studies found a positive relationship between knowledge about colorectal cancer, risk perception, and attitudes (perceived benefits and barriers against screening) and willingness to participate in a colorectal cancer screening campaign. The mentioned factors are modifiable and therefore susceptible of intervention. In fact, interventional studies focused on average-risk population have tried to increase colorectal cancer screening uptake by improving public knowledge and modifying attitudes. In the present paper, we reviewed the factors impacting adherence to colorectal cancer screening and interventions targeting participants for increasing screening uptake.

A randomized trial to increase colonoscopy screening in members of high-risk families in the colorectal cancer family registry and cancer genetics network

BACKGROUND

Individuals with a strong family history of colorectal cancer have significant risk for colorectal cancer, although adherence to colonoscopy screening in these groups remains low. This study assessed whether a tailored telephone counseling intervention can increase adherence to colonoscopy in members of high-risk families in a randomized, controlled trial.

METHODS

Eligible participants were recruited from two national cancer registries if they had a first-degree relative with colorectal cancer under age 60 or multiple affected family members, which included families that met the Amsterdam criteria for hereditary non-polyposis colon cancer (HNPCC), and if they were due for colonoscopy within 24 months. Participants were randomized to receive a tailored telephone intervention grounded in behavioral theory or a mailed packet with general information about screening. Colonoscopy status was assessed through follow-up surveys and endoscopy reports. Cox proportional hazards models were used to assess intervention effect.

RESULTS

Of the 632 participants (ages 25-80), 60% were female, the majority were White, non-Hispanic, educated, and had health insurance. Colonoscopy adherence increased 11 percentage points in the tailored telephone intervention group, compared with no significant change in the mailed group. The telephone intervention was associated with a 32% increase in screening adherence compared with the mailed intervention (HR, 1.32; P = 0.01).

CONCLUSIONS

A tailored telephone intervention can effectively increase colonoscopy adherence in high-risk persons. This intervention has the potential for broad dissemination to healthcare organizations or other high-risk populations.

IMPACT

Increasing adherence to colonoscopy among persons with increased colorectal cancer risk could effectively reduce incidence and mortality from this disease.

How is the increased risk of colorectal cancer in first-degree relatives of patients communicated?

OBJECTIVES

Compared with the general population, first-degree relatives (FDRs) of colorectal cancer (CRC) patients have a two-fold to four-fold higher risk of developing CRC. Little data is available regarding communication between doctors and CRC patients about risk to FDRs. We aimed to evaluate CRC patients' knowledge of FDRs' increased CRC risk, and FDRs' knowledge of this risk and adherence to CRC screening.

MATERIALS AND METHODS

In this retrospective, single-center, population-based observational study, patients aged 18-80 years who underwent surgery for CRC between January 2005 and May 2010 were asked to complete a questionnaire. A questionnaire sent to the patients' FDRs (siblings and children) asked whether they had been advised to undergo any CRC screening examination, whether they had done so, and if so, when initiated and by whom. Main outcome measurements were: CRC patients' and their FDRs' information status regarding the FDRs' increased CRC risk and screening status.

RESULTS

Of 343 index patients (390 contacted, 47 deceased/moved), 134 replied to the survey (39.1% response rate). Among index patients, 82.1% (110/134) were informed about FDRs' increased CRC risk. This information was provided mainly by gastroenterologists and general practitioners (65.7 and 28.4%, respectively). Among FDRs, 85.1% (143/168) were informed about their increased CRC risk, but 69% did not undergo a screening colonoscopy. Among the FDRs more than 50 years of age, 40.8% did not undergo a screening colonoscopy.

CONCLUSION

In Switzerland, CRC patients and their FDRs are well informed about FDRs' increased CRC risk. However, the majority of FDRs do not undergo the recommended CRC screening.

Determinants of adherence to screening by colonoscopy in individuals with a family history of colorectal cancer

OBJECTIVE

Although first-degree relatives (FDRs) of colorectal cancer (CRC) patients, as a high-risk population, have the most to gain from colonoscopy screening, their adherence is suboptimal. Thus, an assessment of the determinants of adherence to screening is of potential importance.

METHODS

A cross-sectional study was conducted among 318 FDRs of 164 CRC patients treated at Tel-Aviv Sourasky Medical Center. Interviews were conducted with a questionnaire using I-Change Model.

RESULTS

Adherence to interval colonoscopy was low with only 73 FDRs (23.0%). Greater adherence was associated with socio-demographic variables (older age, siblings, having spouse, higher level of education and income) and behavioral variables (healthier lifestyle, utilization of preventive health services). Family physicians and kin were identified as the most influential figures on uptake. Intention, affective barriers, positive attitudes, social support, cues to action, age, and health maintenance were the strongest determinants of participation in CRC screening.

CONCLUSION

Adherence to colonoscopy is determined by multiple variables. Medical staff can play a key role in increasing adherence to colonoscopy.

PRACTICE IMPLICATIONS

Future interventions should focus on fostering positive attitudes, overcoming barriers, enhancing social support and providing a medical recommendation. Special efforts should be invested in young FDRs, those of low socio-economic status and those who underutilize preventive medicine.

Racial and ethnic variations in the effects of family history of colorectal cancer on screening compliance

BACKGROUND & AIMS

Individuals with a family history of colorectal cancer (CRC) have a higher risk of developing CRC than the general population, and studies have shown that they are more likely to undergo CRC screening. We assessed the overall and race- and ethnicity-specific effects of a family history of CRC on screening.

METHODS

We analyzed data from the 2009 California Health Interview Survey to estimate overall and race- and ethnicity-specific odds ratios (ORs) for the association between family history of CRC and CRC screening.

RESULTS

The unweighted and weighted sample sizes were 23,837 and 8,851,003, respectively. Individuals with a family history of CRC were more likely to participate in any form of screening (OR, 2.3; 95% confidence limit [CL], 1.7, 3.1) and in colonoscopy screening (OR, 2.7; 95% CL, 2.2, 3.4) than those without a family history, but this association varied among racial and ethnic groups. The magnitude of the association between family history and colonoscopy screening was highest among Asians (OR, 6.1; 95% CL, 3.1, 11.9), lowest among Hispanics (OR, 1.4; 95% CL, 0.67, 2.8), and comparable between non-Hispanic whites (OR, 3.1; 95% CL, 2.6, 3.8) and non-Hispanic blacks (OR 2.6; 95% CL, 1.2, 5.7) (P for interaction < .001).

CONCLUSIONS

The effects of family history of CRC on participation in screening vary among racial and ethnic groups, and have the lowest effects on Hispanics, compared with other groups. Consequently, interventions to promote CRC screening among Hispanics with a family history should be considered.

Gynecologic cancer screening and communication with health care providers in women with Lynch syndrome

We evaluated knowledge of gynecologic cancer screening recommendations, screening behaviors, and communication with providers among women with Lynch syndrome (LS). Women aged ≥25 years who were at risk for LS-associated cancers completed a semi-structured interview and a questionnaire. Of 74 participants (mean age 40 years), 61% knew the appropriate age to begin screening, 75-80% correctly identified the recommended screening frequency, and 84% reported no previous screening endometrial biopsy. Women initiated discussions with their providers about their LS cancer risks, but many used nonspecific terms or relied on family history. Most were not offered high-risk screening options. While many women were aware of risk-appropriate LS screening guidelines, adherence was suboptimal. Improving communication between women and their providers regarding LS-related gynecologic cancer risk and screening options may help improve adherence.

Screening patterns in patients with a family history of colorectal cancer often do not adhere to national guidelines

BACKGROUND

Currently, there are no data on adherence to guidelines for colorectal cancer (CRC) screening in patients with a family history.

AIM

We conducted a retrospective study to assess if such patients were being appropriately screened according to American Gastroenterological Association (AGA) guidelines.

METHODS

Two independent reviewers performed a comprehensive medical record review of family and CRC screening history on 362 adults with a family history of CRC in a first-degree relative who had recently undergone screening colonoscopy. The endpoint was appropriate initiation of screening and endoscopist-recommended subsequent screening intervals, as compared to AGA guideline recommendations.

RESULTS

Of 362 subjects, only 146 (40.3 %) were screened appropriately; 213 (58.9 %) had late initiation of screening (i.e., screening was started ≥5 years later than the age recommended by guidelines) and three (0.8 %) had premature initiation (i.e., screening was started ≥1 year too early). Of cases involving delayed screening initiation, 126 were not under primary care at the time when screening was supposed to have started, while most of the remaining received either no or incorrect screening recommendations from their primary care provider. Of 270 subjects with no neoplasia found on initial screening, 112 (41.5 %) had endoscopist-recommended subsequent screening intervals that were ≥2 years shorter than that recommended by guidelines. Results were similar if American Society of Gastrointestinal Endoscopy or American College of Gastroenterology guidelines were used.

CONCLUSIONS

Patients with a family history often suffer from late initiation of screening and overly short endoscopist-recommended subsequent intervals for colonoscopy. Further education of patients and providers on screening recommendations may be helpful.

Screening participation predictors for people at familial risk of colorectal cancer: a systematic review

CONTEXT

People with a family history of colorectal cancer (CRC) are at increased risk of developing the disease. Information on the screening practices of this segment of the population is scarce.

EVIDENCE ACQUISITION

A systematic review was conducted of observational studies to identify factors associated with CRC screening participation for people at increased risk due to family history of the disease.MEDLINE, Cinahl Information Sevices, Embase, and PsycINFO databases were searched comprehensively between January 1995 and May 2012 to identify relevant articles. To be included, studies had to report on screening for people who had at least one first-degree relative with CRC, have described the study design, and reported on at least two predictors of adherence to CRC screening using a multivariate analysis.

EVIDENCE SYNTHESIS

The search identified a total of 4986 articles, of which ten met the review's inclusion criteria. There were important inconsistencies among studies in the factors that were associated with screening. Receiving recommendations from clinicians was the most consistent predictor identified across studies. The review also revealed a consistent pattern of association with predictors related to familial aspects of CRC, such as strength of family history, and relationship to the affected relative. Among the psychological constructs, "social influence" emerged as the most consistent predictor of screening participation.

CONCLUSIONS

This review provides evidence that clinicians, as well as use of family history and social networks, offer the most promising avenues to promoting and improving screening participation by individuals at increased risk of colorectal cancer.

Individual- and provider-level factors associated with colorectal cancer screening in accordance with guideline recommendation: a community-level perspective across varying levels of risk

BACKGROUND

Participation rates in colorectal cancer screening (CRC) are low. Relatively little is known about screening uptake across varying levels of risk and across population groups. The purpose of the current study was to identify factors associated with (i) ever receiving colorectal cancer (CRC) testing; (ii) risk-appropriate CRC screening in accordance with guidelines; and (iii) recent colonoscopy screening.

METHODS

1592 at-risk persons (aged 56-88 years) were randomly selected from the Hunter Community Study (HCS), Australia. Participants self-reported family history of CRC was used to quantify risk in accordance with national screening guidelines.

RESULTS

1117 participants returned a questionnaire; 760 respondents were eligible for screening and analysis. Ever receiving CRC testing was significantly more likely for persons: aged 65-74 years; who had discussed with a doctor their family history of CRC or had ever received screening advice. For respondents "at or slightly above average risk", guideline-appropriate screening was significantly more likely for persons: aged 65-74 years; with higher household income; and who had ever received screening advice. For respondents at "moderately or potentially high risk", guideline-appropriate screening was significantly more likely for persons: with private health insurance and who had discussed their family history of CRC with a doctor. Colonoscopy screening was significantly more likely for persons: who had ever smoked; discussed their family history of CRC with a doctor; or had ever received screening advice.

CONCLUSIONS

The level of risk-appropriate screening varied across populations groups. Interventions that target population groups less likely to engage in CRC screening are pivotal for decreasing screening inequalities.

A population-based cross-sectional study of colorectal cancer screening practices of first-degree relatives of colorectal cancer patients

Background

The aim of this study was to determine the proportions and predictors of first-degree relatives (FDRs) of colorectal cancer (CRC) patients (i) ever receiving any CRC testing and (ii) receiving CRC screening in accordance with CRC screening guidelines.

Methods

Colorectal cancer patients and their FDRs were recruited through the population-based Victorian Cancer Registry, Victoria, Australia. Seven hundred and seven FDRs completed telephone interviews. Of these, 405 FDRs were deemed asymptomatic and eligible for analysis.

Results

Sixty-nine percent of FDRs had ever received any CRC testing. First-degree relatives of older age, those with private health insurance, siblings and FDRs who had ever been asked about family history of CRC by a doctor were significantly more likely than their counterparts to have ever received CRC testing. Twenty-five percent of FDRs “at or slightly above average risk” were adherent to CRC screening guidelines. For this group, adherence to guideline-recommended screening was significantly more likely to occur for male FDRs and those with a higher level of education. For persons at “moderately increased risk” and “potentially high risk”, 47% and 49% respectively adhered to CRC screening guidelines. For this group, guideline-recommended screening was significantly more likely to occur for FDRs who were living in metropolitan areas, siblings, those married or partnered and those ever asked about family history of CRC.

Conclusions

A significant level of non-compliance with screening guidelines was evident among FDRs. Improved CRC screening in accordance with guidelines and effective systematic interventions to increase screening rates among population groups experiencing inequality are needed.

Trial Registration

Australian and New Zealand Clinical Trial Registry: ACTRN12609000628246

Patients undergoing colorectal cancer screening underestimate their cancer risk and delay presentation for screening

BACKGROUND

Colorectal cancer (CRC) is the third most common cancer in Canada. Screening guidelines recommend that first-time screening should occur at 50 years of age for average-risk individuals and at 40 years of age for those with a family history of CRC.

OBJECTIVE

To examine whether persons with a positive CRC family history were achieving screening at 40 years of age and whether average-risk persons were achieving screening at 50 years of age.

METHODS

The present study was a cross-sectional analysis of subjects who entered a colon cancer screening program and were undergoing CRC screening for the first time.

RESULTS

A total of 778 individuals were enrolled in the present study: 340 (174 males) with no family history of CRC, and 438 (189 males) with a positive family history of CRC. For the group with a positive family history, the mean (± SD) age for primary screening was 54.4 ± 8.5 years, compared with 58.2 ± 6.4 years for the group with no family history. On average, those with a positive family history initiated screening 3.8 years (95% CI 2.8 to 4.8; P<0.05) earlier than those without. Adenoma polyp detection rate for the positive family history group was 20.8% (n=91) compared with 23.5 % (n=80) for the group with no family history.

CONCLUSIONS

Individuals with a positive CRC family history are initiating screening approximately four years earlier than those without a family history; nevertheless, both groups are undergoing screening well past current guideline recommendations.

The Family Health Promotion Project (FHPP): design and baseline data from a randomized trial to increase colonoscopy screening in high risk families

Colorectal cancer (CRC) is a significant cause of mortality and morbidity in the United States, much of which could be prevented through adequate screening. Consensus guidelines recommend that high-risk groups initiate screening earlier with colonoscopy and more frequently than average risk persons. However, a large proportion of high risk individuals do not receive regular colonoscopic screening. The Family Health Promotion Project (FHPP) is a randomized-controlled trial to test the effectiveness of a telephone-based counseling intervention to increase adherence to risk-appropriate colonoscopy screening in high risk individuals. Unaffected members of CRC families from two national cancer family registries were enrolled (n=632) and randomized to receive either a single session telephone counseling intervention using Motivational Interviewing techniques or a minimal mail-out intervention. The primary endpoint, rate of colonoscopy screening, was assessed at 6, 12 and 24 months post-enrollment. In this paper, we describe the research design and telephone counseling intervention of the FHPP trial, and report baseline data obtained from the two high risk cohorts recruited into this trial. Results obtained at baseline confirm the need for interventions to promote colonoscopy screening among these high risk individuals, as well as highlighting several key opportunities for intervention, including increasing knowledge about risk-appropriate screening guidelines, and providing both tailored risk information and barriers counseling.

Colorectal cancer screening in first-degree relatives of colorectal cancer: participation, knowledge, and barriers against screening

BACKGROUND

Family history is one of the most important risk factors for developing colorectal cancer (CRC), and medical organizations recommend CRC screening in this population. However, the use of CRC screening is still low in our country.

OBJECTIVE

To investigate the use of CRC screening, knowledge about CRC and screening tests, and factors related to screening in a family-risk population.

METHODS

A total of 334 family-risk participants answered a questionnaire to assess the use of CRC screening tests, knowledge about CRC, risk perception, and barriers against screening.

RESULTS

In total, 22% of participants had undergone at least one of the recommended tests for CRC screening. Furthermore, indication for screening was found in only 8% of participants. Use of CRC screening tests was significantly lower than mammography for breast cancer detection in women (20 vs. 82%, P<0.001) and use of serum prostate-specific antigen for prostate cancer detection in men (27 vs. 46%, P<0.001). Most participants (59%) knew that being elderly was a risk factor and only about half (47%) had knowledge about any of the recommended examinations. Only in about half of the cases (47%) was subjective risk perception higher than in the general population. In the logistic regression analysis, having more than one affected relative (odds ratio= 2.63, 95% confidence interval: 1.05-6.68; P=0.03) and a high subjective perception of risk (odds ratio= 2.87, 95% confidence interval: 1.10-7.46; P=0.03) were independent predictors for CRC screening.

CONCLUSION

Less than 25% of the family-risk population has undergone a CRC screening test. Family history and subjective risk perception of CRC are the strongest predictors of CRC screening.

Screening practices of unaffected people at familial risk of colorectal cancer

Our objective was to determine screening practices of unaffected people in the general population at moderately increased and potentially high risk of colorectal cancer (CRC) because of their family history of the disease. A total of 1,627 participants in the Australasian Colorectal Cancer Family Registry study were classified into two CRC risk categories, according to the strength of their family history of the disease. We calculated the proportion of participants that adhered to national CRC screening guidelines by age group and for each familial risk category. We carried out a multinomial logistic regression analysis to evaluate the associations between screening and sociodemographic factors. Of the 1,236 participants at moderately increased risk of CRC, 70 (6%) reported having undergone guideline-defined "appropriate" screening, 251 (20%) reported some, but less than appropriate screening, and 915 (74%) reported never having had any CRC screening test. Of the 392 participants at potentially high risk of CRC, three (1%) reported appropriate screening, 140 (36%) reported some, but less than appropriate screening, and 249 (64%) reported never having had any CRC screening test. On average, those of middle age, higher education, and who had resided in Australia longer were more likely to have had screening for CRC. The uptake of recommended screening by unaffected people at the highest familial risk of developing CRC is extremely low. Guidelines for CRC screening are not being implemented in the population. More research is needed to identify the reasons so as to enable development of strategies to improve participation in screening.

Lynch syndrome: barriers to and facilitators of screening and disease management

Background

Lynch syndrome is a hereditary cancer with confirmed carriers at high risk for colorectal (CRC) and extracolonic cancers. The purpose of the current study was to develop a greater understanding of the factors influencing decisions about disease management post-genetic testing.

Methods

The study used a grounded theory approach to data collection and analysis as part of a multiphase project examining the psychosocial and behavioral impact of predictive DNA testing for Lynch syndrome. Individual and small group interviews were conducted with individuals from 10 families with the MSH2 intron 5 splice site mutation or exon 8 deletion. The data from confirmed carriers (n = 23) were subjected to re-analysis to identify key barriers to and/or facilitators of screening and disease management.

Results

Thematic analysis identified personal, health care provider and health care system factors as dominant barriers to and/or facilitators of managing Lynch syndrome. Person-centered factors reflect risk perceptions and decision-making, and enduring screening/disease management. The perceived knowledge and clinical management skills of health care providers also influenced participation in recommended protocols. The health care system barriers/facilitators are defined in terms of continuity of care and coordination of services among providers.

Conclusions

Individuals with Lynch syndrome often encounter multiple barriers to and facilitators of disease management that go beyond the individual to the provider and health care system levels. The current organization and implementation of health care services are inadequate. A coordinated system of local services capable of providing integrated, efficient health care and follow-up, populated by providers with knowledge of hereditary cancer, is necessary to maintain optimal health.

Changes in risk perceptions in relation to self-reported colorectal cancer screening among first-degree relatives of colorectal cancer cases enrolled in a randomized trial

OBJECTIVE

This secondary data analysis was conducted to evaluate the applicability of the Risk Reappraisal Hypothesis, which has been proposed to explain the influence of performing a health behavior on perceived risk. Data were collected in the context of a randomized trial, which found that an individually tailored, multicomponent intervention was successful in increasing colorectal cancer (CRC) screening among first-degree relatives of CRC cases.

METHOD

The ethnically diverse study sample (N = 841; 29% Latino, 21% African American, 20% Asian) consisted of adult siblings and children (40-80 years) of CRC cases, identified through the California Cancer Registry. Data were collected at baseline and at 6- and 12-month follow-up. Changes in self-reported risk perception (perceived likelihood of developing CRC) were examined over the study period in relation to study condition and screening status.

RESULTS

Greater increases in perceived risk were observed among intervention versus control-group participants over the study period, but increases were limited to intervention participants who had not been screened. We also examined trajectories of perceived risk in relation to timing of screening receipt (e.g., before 6 months, 6-12 months, never). Continued upward shifts in risk were observed during the study period among intervention participants not screened during the study. In contrast, participants screened by 6 months displayed a reduction or leveling off in perceived risk between 6- and 12-month follow-up.

CONCLUSION

Results provide support for the applicability of the Risk Reappraisal Hypothesis within a high-risk sample enrolled in a CRC screening promotion trial. Future research is needed to explore the impact of short-term risk reductions on future CRC screening behavior.

Determinants of participation in colonoscopic screening by siblings of colorectal cancer patients in France

Background

Targeted colonosocopic screening is recommended for first-degree relatives of colorectal cancer patients diagnosed before the age of 60 and offers the possibility of reducing morbidity and mortality, but participation remains too low. The objective of this study was to determine in a French population the factors that affect siblings' participation in screening, notably those relating to the individuals, their medical care, their family and their social network.

Methods

A cross sectional survey was conducted in siblings of index patients having undergone surgery for colorectal cancer between 1999 and 2002 in two French counties. Siblings were contacted during 2007 and 2008 through the index patient. The factors affecting participation in colonoscopic screening were studied by logistic regression taking into account family cluster effect.

Results

172 siblings of 74 index cases were included. The declared rate of undergoing at least one colonoscopy among siblings was 66%; 95%CI 59-73%. Five variables were independently associated with colonoscopic screening: perceiving fewer barriers to screening (OR = 3.2; 95%CI 1.2-8.5), having received the recommendation to undergo screening from a physician (OR = 4.9; 1.7-13.7), perceiving centres practising colonoscopy as more accessible (OR = 3.2, 1.3-7.8), having discussed screening with all siblings (OR = 3.9; 1.6-9.6) and being a member of an association (OR = 2.6; 1.0-6.6).

Conclusions

The factors independently associated with participation in CRC screening by an individual at increased risk belonged to each of four dimensions relating to his individual psychosocial characteristics, to his relationship with a physician, within the family and social environment. The relevance of these results to clinical practice may help to improve compliance to recommendations in a global preventive strategy including all stages of the information pathway from the physician to the index patient and his relatives.

Colon cancer screening practices and disclosure after receipt of positive or inconclusive genetic test results for hereditary nonpolyposis colorectal cancer

BACKGROUND

Patients who receive conclusive genetic test results for hereditary nonpolyposis colorectal cancer (HNPCC) tend to adopt appropriate colorectal cancer screening behaviors and disclose their test results. However, little is known about the disclosure processes or screening behaviors of individuals who receive inconclusive genetic test results. This study compared endoscopy use and disclosure between individuals with positive and inconclusive genetic test results, within a year after results were received.

METHODS

Individuals with a personal history of cancer and suspected of having HNPCC participated in genetics education and counseling, underwent HNPCC testing, and received genetic test results (GCT) within a prospective cohort study. Demographic, psychosocial, and behavioral data were obtained from questionnaires and interviews completed before and after GCT.

RESULTS

Index cases with inconclusive genetic test results were less likely to screen within 12 months. Index cases who disclosed test results to children within 6 months were more likely to screen within 12 months, controlling for mutation status. Index cases with inconclusive genetic test results were less likely to share results with a healthcare provider within 6 months. Index cases who disclosed genetic test results to healthcare providers within 6 months were more likely to have endoscopy within 12 months.

CONCLUSIONS

Genetic test results and disclosure significantly affected colon cancer screening at 12-month follow-up. Interventions to improve adherence to colorectal cancer screening should consider increased education of those receiving inconclusive results and encourage disclosure to healthcare providers and family members.

Communication, encouragement, and cancer screening in families with and without mutations for hereditary nonpolyposis colorectal cancer: a pilot study

PURPOSE

Known and suspected mutation carriers for hereditary nonpolyposis colorectal cancer are advised to have colonoscopies every 1 to 2 years to detect colorectal cancer. Little is known about colonoscopy completion in families suspected of having hereditary nonpolyposis colorectal cancer but without identified mutations.

METHODS

This study examined the effect of communication and encouragement on colonoscopy in families with and without known mutations. Twenty-three respondents from 11 families with indeterminate genetic test results were matched with 23 respondents from 11 families with mutation-positive results. Hierarchical modeling examined the effects of relational characteristics on time since last colonoscopy in index cases and their first-degree relatives.

RESULTS

Nearly one fifth of respondents were not screening appropriately. Time since last screening did not differ according to family mutation status. However, respondents who communicated about risk and received encouragement to screen from a greater proportion of named family members, and those who had a greater proportion of named family members involved in both communication and encouragement were significantly more likely to have a shorter time interval since last colonoscopy.

CONCLUSION

Identifying patterns of interaction within at-risk families, regardless of gene mutation status, may be one avenue for promoting screening adherence.