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

Combining fecal immunochemical testing and questionnaire-based risk assessment in selecting participants for colonoscopy screening in the Chinese National Colorectal Cancer Screening Programs: A population-based cohort study

BACKGROUND

Screening reduces colorectal cancer (CRC) burden by allowing early resection of precancerous and cancerous lesions. An adequate selection of high-risk individuals and a high uptake rate for colonoscopy screening are critical to identifying people more likely to benefit from screening and allocating healthcare resources properly. We evaluated whether combining a questionnaire-based interview for risk factors with fecal immunochemical test (FIT) outcomes for high-risk assessment is more efficient and economical than a questionnaire-based interview-only strategy.

METHODS AND FINDINGS

In this multicenter, population-based, prospective cohort study, we enrolled community residents aged 40 to 74 years in 29 provinces across China. From 2016 to 2020, a total of 1,526,824 eligible participants were consecutively enrolled in the Cancer Screening Program in Urban China (CanSPUC) cohort, and 940,605 were enrolled in the Whole Life Cycle of Cancer Screening Program (WHOLE) cohort, with follow-up to December 31, 2022. The mean ages were 56.89 and 58.61 years in CanSPUC and WHOLE, respectively. In the WHOLE cohort, high-risk individuals were identified by combining questionnaire-based interviews to collect data on risk factors (demographics, diet history, family history of CRC, etc.) with FIT outcomes (RF-FIT strategy), whereas in the CanSPUC cohort, high-risk individuals were identified using only interview-based data on risk factors (RF strategy). The primary outcomes were participation rate and yield (detection rate of advanced neoplasm, early-stage detection rate of CRCs [stage I/II], screening yield per 10,000 invitees), which were reported for the entire population and for different gender and age groups. The secondary outcome was the cost per case detected. In total, 71,967 (7.65%) and 281,985 (18.47%) individuals were identified as high-risk and were invited to undergo colonoscopy in the RF-FIT group and RF group, respectively. The colonoscopy participation rate in the RF-FIT group was 26.50% (19,071 of 71,967) and in the RF group was 19.54% (55,106 of 281,985; chi-squared test, p < 0.001). A total of 102 (0.53%) CRCs and 2,074 (10.88%) advanced adenomas were detected by the RF-FIT, versus 90 (0.16%) and 3,593 (6.52%) by the RF strategy (chi-squared test, both p < 0.001). The early-stage detection rate using the RF-FIT strategy was significantly higher than that by the RF strategy (67.05% versus 47.95%, Fisher's exact test, p = 0.016). The cost per CRC detected was $24,849 by the RF-FIT strategy versus $55,846 by the RF strategy. A limitation of the study was lack of balance between groups with regard to family history of CRC (3.5% versus 0.7%).

CONCLUSIONS

Colonoscopy participation and screening yield were better with the RF-FIT strategy. The association with CRC incidence and mortality reduction should be evaluated after long-term follow-up.

Colorectal Cancer Screening for Persons With a Positive Family History—Evaluation of the FARKOR Program for the Secondary Prevention of Colorectal Cancer in Persons Aged 25 to 50

BACKGROUND

Persons with a positive family history of colorectal cancer (CRC) are more likely than others to develop CRC and are also younger at the onset of the disease. Nonetheless, the German Federal Joint Committee (G-BA, Gemeinsamer Bundes - ausschuss) recommends screening all persons aged 50 and above regardless of their family history. FARKOR was a project supported by the Innovation Fund of the G-BA to study the feasibility, efficacy, and safety of a risk-adapted early detection program for CRC among persons aged 25 to 50 without any specific past medical history.

METHODS

Physicians in private practice in Bavaria documented their activities relating to FARKOR online. The FARKOR process comprised a declaration of consent, a simplified family history for CRC, an optional, more comprehensive family history, a counseling session for participatory decision-making on further measures, and various modalities of screening (an immunological fecal occult blood test [iFOBT], colonoscopy, or no screening). Related physician activities outside the FARKOR process were assessed by record linkage between study data and data of the patients' health insurance carriers.

RESULTS

The simplified family history was documented in 25 847 persons and positive for CRC in 5769 (22.3%). 3232 persons had a more comprehensive family history, among whom 2054 (63.6%) participated in screening measures. 1595 underwent colonoscopy; 278 persons who had already undergone colonoscopy in the preceding five years were excluded from the analysis. Colonoscopy revealed adenoma in 232 persons (17,6 %), advanced adenoma in 78 (5.9%) and carcinoma in 4 (0.3%). There were no serious complications.

CONCLUSION

The detection rates in this study corresponded to those of persons aged 55 to 59 in the current early detection program. Despite numerous problems in the performance of the study (inconsistencies in documentation, external performance of screening measures on program participants), the results support the feasibility of a risk-adapted early detection program in the young target population with a family history of CRC.

A comprehensive systematic review of colorectal cancer screening clinical practices guidelines and consensus statements

High-quality clinical practice guidelines (CPGs) and consensus statements (CSs) are essential for evidence-based medicine. The purpose of this systematic review was to appraise the quality and reporting of colorectal cancer (CRC) screening CPGs and CSs. After prospective registration (Prospero no: CRD42021286156), a systematic review searched CRC guidances in duplicate without language restrictions in ten databases, 20 society websites, and grey literature from 2018 to 2021. We appraised quality with AGREE II (% of maximum score) and reporting with RIGHT (% of total 35 items) tools. Twenty-four CPGs and 5 CSs were analysed. The median overall quality and reporting were 54.0% (IQR 45.7-75.0) and 42.0% (IQR 31.4-68.6). The applicability had low quality (AGREE II score <50%) in 83% of guidances (24/29). Recommendations and conflict of interest were low-reported (RIGHT score <50%) in 62% guidances (18/29) and 69% (20/29). CPGs that deployed systematic reviews had better quality and reporting than CSs (AGREE: 68.5% vs. 35.5%; p = 0.001; RIGHT: 74.6% vs. 41.4%; p  =  0.001). In summary, CRC screening CPGs and CSs achieved low quality and reporting. It is necessary a revision and an improvement of the current guidances. Their development should apply a robust methodology using proper guideline development tools to obtain high-quality evidence-based documents.

Systematic review of shared decision-making in guidelines about colorectal cancer screening

INTRODUCTION

We aimed to systematically evaluate quality of shared decision-making (SDM) in colorectal cancer (CRC) screening clinical practice guidelines (CPGs) and consensus statements (CSs).

METHODS

Search for CRC screening guidances was from 2010 to November 2021 in EMBASE, Web of Science, MEDLINE, Scopus and CDSR, and the World Wide Web. Three independent reviewers and an arbitrator rated the quality of each guidance using a SDM quality assessment tool (maximum score: 31). Reviewer agreement was 0.88.

RESULTS

SDM appeared in 41/83 (49.4%) CPGs and 9/19 (47.4%) CSs. None met all the quality criteria, and 51.0% (52/102) failed to meet any quality items. Overall compliance was low (mean 1.63, IQR 0-2). Quality was better in guidances published after 2015 (mean 1, IQR 0-3 vs. mean 0.5, IQR 0-1.5; p = 0.048) and when the term SDM was specifically reported (mean 4.5, IQR 2.5-4.5 vs. mean 0.5, IQR 0-1.5; p < 0.001). CPGs underpinned by systematic reviews showed better SDM quality than consensus (mean 1, IQR 0-3 vs. mean 0, IQR 0-2, p = 0.040).

CONCLUSION

SDM quality was suboptimal and mentioned in less than half of the guidances, and recommendations were scarce. Guideline developers should incorporate evidence-based SDM recommendations in guidances to underpin the translation of evidence into practice.

Cost-effectiveness of risk-tailored screening strategy for colorectal cancer: A systematic review

BACKGROUND AND AIM

Though one-size-fits-all age-based screening for colorectal cancer (CRC) is effective in reducing the incidence and mortality, the evidence regarding on personized screening based on individual risk factors has been growing. The study aimed to perform a systematic review to synthesize economic evidence of risk-tailored CRC screening strategies.

METHODS

This systematic review was conducted in EMBASE, Web of Science, PubMed, Cochrane Library, Econlit, and National Institute for Health Research Economic Evaluation Database from inception to June 30, 2021. We calculated the incremental cost-effectiveness ratio (ICER) of cost per life year or quality-adjusted life year gained for the risk-tailored screening compared with no screening or uniform screening. A strategy was cost-effective with less cost and equal or more effectiveness than the comparator along with lower ICER than the willingness-to-pay threshold.

RESULTS

Our review finally comprised seven studies. Five studies reported the results of comparisons of risk-tailored CRC screening with no screening, and supported that risk-tailored screening was cost-effective. All of seven studies reported the ICERs of risk-tailored screening and age-based screening. Disparities in the discrimination of risk-prediction tool, accuracy of adopted techniques, uptake rate of screening and cost estimation impacted the cost-effectiveness.

CONCLUSIONS

Studies on the economic evaluation of risk-tailored CRC screening are limited, and current evidence is not sufficient to support the replacement of risk-tailored screening for traditional age-based screening.