Colorectal cancer screening use among insured adults: Is out-of-pocket cost a barrier to routine screening?

Current Trends in the Management of a Complex Polyp: Endoscopy versus Surgery

Many colorectal cancers arise from either adenomatous polyps or sessile serrated lesions. However, due to the implementation of screening guidelines at the age of 45 years and the ability to perform therapeutic endoscopic polyp resections, the incidence and mortality of colorectal cancer has been decreasing in the United States. Polyps can be distinguished not only by pathology, but characterized by their complexity depending on the size, location, and morphology. Historically, polyps that were endoscopically more challenging to resect were referred for surgical resection. However, due to rapid advancement in endoscopic techniques and availability of tools, many of these complex polyps can be safely and effectively resected endoscopically. In this section, we review the different methods and potential challenges associated with endoscopic resection techniques including endoscopic mucosal resection, endoscopic submucosal dissection, or endoscopic full-thickness resection of a complex polyp.

Developing and Implementing a Colorectal Cancer Screening Program in Uganda: Stakeholder Perceived Barriers and Opportunities

INTRODUCTION

Colorectal cancer (CRC) incidence is increasing in Uganda. Despite this, and the disproportionately high burden of early onset and late-stage CRC cases, no CRC screening program exists in Uganda. To guide and inform future CRC prevention efforts, interviews with key stakeholders were undertaken to better understand the perceived barriers and opportunities relevant to the development and implementation of a CRC screening program in Uganda.

METHODS

Semi-structured key informant interviews were conducted with key stakeholders in cancer prevention, screening and policy/programming (n = 11, 6 medically qualified and 5 non-medical), who were recruited across Uganda using maximum variation sampling between March and April 2022. Interviews were audio recorded, transcribed, coded and later analysed using a deductive thematic analysis approach guided by the social ecological model.

RESULTS

Major barriers included lack of government priority for CRC prevention programs, lack of resources/funding for CRC screening (policy level), inadequate screening facilities and equipment, limited training/knowledge of CRC and capacity of the health workforce (health system level), challenges in the delivery of CRC awareness messages (community level), emotions associated with CRC screening and poor awareness of CRC and its symptoms (individual level). Major opportunities included the existence of a draft national cancer control plan (policy level), existence of less costly CRC screening alternatives, less costly primary prevention measures (health system level), existence of community leadership and structures (community level), likely acceptability of the faecal occult blood test and peer support (individual level).

CONCLUSION

There are substantive barriers to CRC screening program development and implementation in Uganda. However, there are signs, like the development of a cancer control plan, that suggest a shift towards strategic planning and allocation of resources at a population level for addressing the issues of cancer prevention and care, including CRC. In the meantime, efforts should prioritise primary prevention interventions such as mass education to promote CRC awareness.

Evaluating the implementation of a multicomponent intervention to improve faecal immunochemical test-based (FIT) colorectal cancer screening in primary care

Screening has proven effective at reducing the incidence and mortality of colorectal cancer (CRC). The faecal immunochemical test (FIT) is recommended for screening people aged 50-74 years at average risk of CRC in Alberta, Canada. This project implemented a multicomponent intervention in real-world, primary care settings in Alberta to improve the FIT participation rate and evaluated the reach, effectiveness and implementation outcomes.The multicomponent intervention comprised of in-clinic FIT kit distribution, patient education and reminder calls, was implemented in four primary care clinics. Reach was measured as the proportion of patients receiving the intervention. Effectiveness was measured by comparing the proportion of patients completing FIT during preintervention and perintervention periods. Implementation was measured by the perceived acceptability, appropriateness and feasibility of providers in implementing the intervention. Data were collected from electronic medical records and validated survey tools.Four clinics implemented the intervention during an 8-month study period (September 2021 to April 2022); 99% of eligible patients received a FIT kit. The baseline FIT completion rate across participating clinics was 62%, which increased by 13 percentage points to 75% during the intervention period. Of the 75% who completed the FIT, 56% did without a reminder call, whereas 19% did so after receiving one or more reminders. More than 90% of providers perceived the intervention implementation as acceptable, feasible and appropriate.The multicomponent FIT intervention was perceived as acceptable, feasible, and appropriate and improved the FIT screening rates in pilot clinics. An implementation guidance document has been developed and tested to communicate the implementation process for use by other primary care clinics and aid in the spread of the intervention across Alberta. Implementing this intervention in routine practice can help decrease the incidence and mortality of CRC.

Evolving Dynamics of Colorectal Cancer in High Socio-Demographic Regions

BACKGROUND

Colorectal cancer (CRC) poses a significant global health challenge, with evolving demographic trends emphasizing the need for accurate forecasting models. Existing forecasting models lack comprehensive coverage. By integrating machine learning algorithms, this study aims to provide more accurate and precise predictions, filling critical gaps in understanding CRC incidence, death, and disability-adjusted life year (DALY) rate trends, especially in high socio-demographic index (SDI) regions. Specific emphasis is placed on exploring age-, sex-, and country-specific variations in CRC trends.

MATERIALS AND METHODS

An ensemble forecasting algorithm integrating Simple Linear Regression, Exponential Smoothing, and Autoregressive Integrated Moving Average, capable of handling a short time series was developed and validated, utilizing a dataset encompassing age-, sex-, and country-specific CRC incidence, mortality, and DALY rates.

RESULTS

Our forecasting models reveal rising trends in CRC burden in the 15-49 years age group (young-onset) and decreasing trends in CRC burden in the 50-74 years age group (late-onset) in high SDI regions with sex-specific variations in incidence, mortality, and DALY rates. Some inflection points for demographic shifts in CRC disease burden, particularly death rates, were identified as early as within the next 5 years. We predict a shift in CRC burden towards females, particularly in older adults.

CONCLUSION

A novel multifactor model was developed for comparing the incidence, mortality, and DALY rates of young- and late-onset CRC in high SDI regions. The rising incidence of young-onset CRC in high SDI regions underscores the need for proactive health strategies. By refining predictive models, adjusting screening guidelines to target younger, high-risk populations, and investing in public awareness and research, we can facilitate early detection and improve outcomes. This study addresses a significant gap in CRC forecasting and provides a robust framework for anticipating demographic shifts in CRC burden, making it an indispensable tool for healthcare planning.

Willingness to be tested for a secondary cause of hypertension: a survey of the Australian general community

BACKGROUND

Primary aldosteronism (PA) represents the most common and potentially curable cause of secondary hypertension. However, PA is not commonly screened for, and up to 34% of patients who screen positive do not complete the full diagnostic process. This suggests that the diagnostic process may pose a barrier to patients and may contribute to the under-diagnosis of PA.

AIMS

To evaluate the willingness of the Australian general public to undergo testing for secondary causes of hypertension and identify enablers or barriers to testing from the patients' perspective.

METHODS

An online survey containing questions on knowledge and attitudes towards hypertension, willingness to be tested and enablers/barriers towards testing was distributed to the Australian community.

RESULTS

Of 520 adult respondents (mean age 50.4 years, SD 27.3 years; 28.8% hypertensive; 56.0% female), the majority of non-hypertensive and hypertensive respondents (82.7% vs 70.0%; P = 0.03) were willing to undergo testing for a secondary cause of hypertension that involved blood and urine tests. Greater knowledge of hypertensive risk modification strategies and complications was predictive of willingness to be tested, whereas age, sex, education level, geographic location, socio-economic status and cardiovascular comorbidities were not. The top three barriers to testing included fear of a serious underlying condition, lack of belief in further testing and increased stress associated with further testing.

CONCLUSION

A high proportion of patients are willing to engage in testing for a secondary cause of hypertension. Education about the risks associated with hypertension and the testing process may overcome several barriers to testing.

Comparative Effectiveness of 2 Interventions to Increase Breast, Cervical, and Colorectal Cancer Screening Among Women in the Rural US: A Randomized Clinical Trial

Importance

Women living in rural areas have lower rates of breast, cervical, and colorectal cancer screening compared with women living in urban settings.

Objective

To assess the comparative effectiveness of (1) a mailed, tailored digital video disc (DVD) intervention; (2) a DVD intervention plus telephonic patient navigation (DVD/PN); and (3) usual care with simultaneously increased adherence to any breast, cervical, and colorectal cancer screening that was not up to date at baseline and to assess cost-effectiveness.

Design, Setting, and Participants

This randomized clinical trial recruited and followed up women from rural Indiana and Ohio (community based) who were not up to date on any or all recommended cancer screenings. Participants were randomly assigned between November 28, 2016, and July 1, 2019, to 1 of 3 study groups (DVD, DVD/PN, or usual care). Statistical analyses were completed between August and December 2021 and between March and September 2022.

Intervention

The DVD interactively assessed and provided messages for health beliefs, including risk of developing the targeted cancers and barriers, benefits, and self-efficacy for obtaining the needed screenings. Patient navigators counseled women on barriers to obtaining screenings. The intervention simultaneously supported obtaining screening for all or any tests outside of guidelines at baseline.

Main Outcomes and Measures

Receipt of any or all needed cancer screenings from baseline through 12 months, including breast, cervical, and colorectal cancer, and cost-effectiveness of the intervention. Binary logistic regression was used to compare the randomized groups on being up to date for all and any screenings at 12 months.

Results

The sample included 963 women aged 50 to 74 years (mean [SD] age, 58.6 [6.3] years). The DVD group had nearly twice the odds of those in the usual care group of obtaining all needed screenings (odds ratio [OR], 1.84; 95% CI, 1.02-3.43; P = .048), and the odds were nearly 6 times greater for DVD/PN vs usual care (OR, 5.69; 95% CI, 3.24-10.5; P < .001). The DVD/PN intervention (but not DVD alone) was significantly more effective than usual care (OR, 4.01; 95% CI, 2.60-6.28; P < .001) for promoting at least 1 (ie, any) of the needed screenings at 12 months. Cost-effectiveness per woman who was up to date was $14 462 in the DVD group and $10 638 in the DVD/PN group.

Conclusions and Relevance

In this randomized clinical trial of rural women who were not up to date with at least 1 of the recommended cancer screenings (breast, cervical, or colorectal), an intervention designed to simultaneously increase adherence to any or all of the 3 cancer screening tests was more effective than usual care, available at relatively modest costs, and able to be remotely delivered, demonstrating great potential for implementing an evidence-based intervention in remote areas of the midwestern US.

Trial Registration

ClinicalTrials.gov Identifier: NCT02795104.

Trends and Factors Associated with Fecal Occult Blood Test Utilization among Hispanic Adults in Puerto Rico and the United States: BRFSS 2012-2020

Identifying factors associated with colorectal cancer screening utilization is important to guide colorectal cancer prevention and control programs. We evaluated trends and factors associated with previous-year fecal occult blood test (FOBT) use among Hispanic adults living in Puerto Rico and the U.S. mainland. Using data from the Behavioral Risk Factor Surveillance System (2012-2020), trends in FOBT use were analyzed using joinpoint regression to estimate annual percentage change (APC). Logistic regression stratified by location identified factors associated with FOBT use. FOBT was more common among Hispanic adults ages 50 to 75 years living in Puerto Rico than in the U.S. mainland [Puerto Rico: 20.5%[2012] to 45.6%[2020], APC = 11.4%; U.S. mainland: 9.9%[2012] to 16.7%[2020], APC = 5.9%]. Factors inversely associated with FOBT use were similar in Puerto Rico and the U.S. mainland, including lack of health insurance, not having a personal doctor, having a checkup >12 months ago, and not being able to see a doctor due to cost, as were factors associated with higher FOBT use, including older age, retirement, or having two or more chronic diseases. Among Hispanics living in the U.S. mainland, lack of exercise and less education were inversely associated with FOBT. Factors related to poor access to healthcare were associated with lower use of FOBT among Hispanics. Efforts to improve colorectal cancer screening in Hispanics are necessary to address health disparities across the colorectal cancer care continuum.

PREVENTION RELEVANCE

Colorectal cancer screening reduces cancer incidence and mortality. All screening modalities, including less invasive FOBT tests, are underutilized, especially in non-White and low-income populations. Evaluation of trends and factors associated with the increase in the use of colorectal cancer screening can inform programs to address the lack of screening among racial minorities.

Knowledge, Attitudes, and Beliefs About Colorectal Cancer Screening in Puerto Rico

The purpose of this study was to describe the psychosocial factors influencing participation in colorectal cancer screening (CRCS) among Puerto Rican men and women. We conducted seven focus groups in metropolitan and rural areas of Puerto Rico (PR) with men and women (using gender specific groups) aged 50 to 80 years (n = 51) who were non-adherent to CRC guidelines. The focus group guide included questions related to colorectal cancer (CRC) and CRC screening knowledge, attitudes, and beliefs. We analyzed data using a modified grounded theory approach to identify emergent themes. Focus groups revealed seven major themes that represented barriers to CRCS: (1) lack of CRC knowledge, (2) lack of knowledge about colorectal cancer screening tests as well as the required preparation, (3) embarrassment, (4) low perceived benefit of CRCS and sense of fatalism, (5) transportation (mostly among participants in rural areas), (6) lack of time, and (7) financial burden. All participants understood the benefits of CRCS once the procedure was explained. Additionally, participants reported a lack of provider recommendation for CRCS. In this group of Puerto Rican participants who were non-adherent to CRCS, there were misconceptions about CRC, screening tests available, and preparation and testing procedures. Participants' low levels of knowledge and negative attitudes concerning CRCS and low reported provider recommendation were important deterrents to screening. These findings suggest the need for educational efforts to increase knowledge and attitudes about CRCS and improved patient-provider communication to reduce missed opportunities to recommend.

Patient Cost Exposure And Use Of Preventive Care Among ACA-Compliant Individual Plans

The Affordable Care Act (ACA) mandated coverage of common preventive services with zero patient cost sharing. However, patients may still experience high same-day costs when receiving these "zero-dollar" preventive services. Our analysis of on- and off-exchange individual-market health plans during 2016-18 revealed that 21-61 percent of enrollees experienced same-day cost exposure greater than $0 when accessing ACA-mandated free preventive services.

Increasing breast, cervical, and colorectal cancer screening among rural women: Baseline characteristics of a randomized control trial

BACKGROUND

Rural women suffer disproportionately from breast, cervical, and colorectal cancer mortality compared to those in urban areas. Screening behaviors for these three cancers share many similar beliefs and barriers. Unfortunately, published interventions have not attempted to simultaneously bring women up to date with screening for three cancers (breast, cervical, and colorectal) even though multiple behavior change interventions are effective. The aim of this randomized controlled study was to compare the effectiveness of a mailed interactive and tailored DVD vs. DVD plus telephonic patient navigation (DVD + PN) vs. Usual Care (UC) to increase the percentage of rural women (aged 50-74) up to date for breast, cervical, and colorectal cancer screening.

METHODS

Nine hundred eighty-three participants needing one, two, or three cancer screening tests were consented and randomized to one of three groups. Prior to randomization, women were assessed for baseline characteristics including sociodemographics, health status, and cancer screening test beliefs. Screening status was assessed by medical record review.

RESULTS

At baseline, the average age of participants was 58.6 years. Nineteen percent of the sample was not up to date with screenings for all three cancers. Colorectal cancer had the highest percentage of women (69%) who were not up to date with screening followed by cervical (57%) and then breast cancer (41%). Sixty percent of women reported receiving a reminder for mammography; 30%, for cervical cancer screening; 15% for colonoscopy; and 6% for FOBT/FIT.

DISCUSSION

Increasing adherence to colorectal cancer screening may be the most urgent need among all screening tests. This clinical trial is registered at clinicaltrials.gov with identifier NCT02795104.

Unseen Threats of Chronic Diseases among the Middle-Aged: Examining the Feasibility of Well-Defined Healthcare Vouchers in Encouraging Uptake of General Checkups

Background: The ageing population and the emergence of chronic diseases continue to pose immense challenges to the healthcare system. This study aims to explore how likely middle-aged citizens could be encouraged to attend health checkups by well-defined healthcare vouchers, and to explore potential factors associated with the uptake of health checkups. Methods: A cross-sectional survey with self-administered structured questionnaires was conducted among Hong Kong residents aged 45-59. The questionnaire consisted of 25 items, including attitudes toward healthcare vouchers and checkups, utilisation patterns of healthcare services, and socio-demographics. Results: We received 278 responses between June and September 2021. Among the study participants, 62.6% (174) attended regular checkups currently, and a total of 252 (90.6%) indicated that it was likely for them to undertake health checkups with well-defined vouchers. This proportion showed an increase of 44.8% after introducing vouchers (78 of 174) when compared with the proportion currently attending regular health checkups. Multiple logistic regression analysis revealed that the perceived barrier of health checkup uptake included financial cost (AOR 0.367, 95% CI 0.162-0.832, p = 0.016), whilst the government's recommendation (AOR 1.685, 95% CI 1.052-2.698, p = 0.030) and full support by the employer-purchased insurance (AOR 2.395, 95% CI 1.036-5.523, p = 0.041) were positively associated with uptakes. Conclusions: Financial cost is a significant barrier to health promotion and disease prevention. Well-defined vouchers, as a demand-side financial tool, were widely accepted by our participants as incentives to undergo health checkups. Our findings indicate that the voucher scheme could be extended to individuals aged 45-59 for health checkups by easing the financial barrier, and show the importance of involving government recommendations and employer-purchased insurance.

Endoscopic Management of Complex Colorectal Polyps: Current Insights and Future Trends

Most colorectal cancers arise from adenomatous polyps and sessile serrated lesions. Screening colonoscopy and therapeutic polypectomy can potentially reduce colorectal cancer burden by early detection and removal of these polyps, thus decreasing colorectal cancer incidence and mortality. Most endoscopists are skilled in detecting and removing the vast majority of polyps endoscopically during a routine colonoscopy. Polyps can be considered “complex” based on size, location, morphology, underlying scar tissue, which are not amenable to removal by conventional endoscopic polypectomy techniques. They are technically more challenging to resect and carry an increased risk of complications. Most of these polyps were used to be managed by surgical intervention in the past. Rapid advancement in endoscopic resection techniques has led to a decreasing role of surgery in managing these complex polyps. These endoscopic resection techniques do require an expert in the field and advanced equipment to perform the procedure. In this review, we discuss various advanced endoscopic techniques for the management of complex polyps.

Epidemiologic disparities in colon cancer screening and adherence during the COVID-19 pandemic: a retrospective cohort analysis

BACKGROUND

Colorectal cancer (CRC) is the second-leading cause of death in the USA. CRC screening remains underutilized, especially in underinsured populations. Screening has been heavily disrupted during the COVID-19 pandemic.

PURPOSE

The goal is to explore the impact of the pandemic on ethnic and gender disparities in CRC screening.

METHODS

Patients were identified 1 year before and after COVID-19 precautions began, using March 1, 2020, as the inflection point. The primary inclusion criterion was an ordered colonoscopy. The outcome of interest was a colonoscopy performed. Differences by year and race were assessed using chi-square analysis. A cohort of 1549 patients (899 in pre-COVID; 650 in post-COVID) between age 45 and 75 for whom a colonoscopy was ordered was selected from EHR at a large institution.

RESULTS

There was a 51% reduction in screening colonoscopies performed. White patients had a decrease of 49%, and African Americans had a 55% reduction. Stool testing increased from 47% prior to the pandemic to 94% during the pandemic representing a greater than 100% increase in stool testing uptake.

CONCLUSION

The true impact of COVID-19 on colorectal cancer is yet to be uncovered as future mortality estimates from CRC are ongoing. Due to the widespread closure of endoscopy centers and delay in screening, we believe that the pandemic worsened the screening disparities most prevalent among minority populations. Our study points to the drastic reduction of screening for all races, especially for African Americans.

The impact of COVID-19 pandemic on insurance demand: the case of China

The COVID-19 has been a worldwide pandemic and it needs for studies related to effect on people's demand for insurance during the pandemic which is an important way to transfer risk. However, there is a lack of research linking COVID-19 and people's demand for insurance. The objective of this paper is to investigate the impact of COVID-19 pandemic on issuance demand, using data covering 241 cities on confirmed COVID-19 cases and insurance company revenue in China. The empirical results show that more confirmed COVID-19 cases are associated with greater per capita insurance revenue and the results are robust when considering endogeneity concern. Economically, the per capita insurance revenue increases by 0.896 Yuan for each more confirmed case. In terms of insurance type, the greatest increased insurance revenue is for life insurance, followed by health insurance. We further consider the heterogeneity of regions and find that the impact of COVID-19 on insurance revenue only exists in regions with worse medical treatment conditions or higher medical burden.

A Promotor-Led Pilot Study to Increase Colorectal Cancer Screening in Latinos: The Juntos Contra El Cáncer Program

Background. Latinos have lower colorectal cancer (CRC) screening rates compared to other racial/ethnic groups in the United States, despite an overall increase in CRC screening over the past 10 years. To address this disparity, we implemented a promotor-led intervention to increase CRC screening test adherence in community-based settings, connecting community members with a partnering federally qualified health center. Purpose. To evaluate the Juntos Contra el Cáncer/Together Against Cancer (JUNTOS) intervention, by assessing pre-post changes in (1) CRC screening test adherence and (2) CRC knowledge and perceived barriers to CRC screening. We also assessed the feasibility and acceptability of program activities. Method. JUNTOS was a group-based intervention, delivered by promotores (community health workers), to promote CRC screening test adherence among Latino adults. The intervention consisted of a culturally tailored 2½-hour interactive workshop followed by an appointment scheduling assistance from a promotor. Workshop participants were Latino adults (males and females) aged 50 to 75 years who were not up-to-date with CRC screening guidelines. We conducted interviews before and 6 to 9 months after the workshop to assess program outcomes. Results. Of the 177 participants included, 118 reported completing the CRC screening test (66.7%) by 6 to 9 months postintervention. We observed baseline to 6- to 9-month increase in CRC knowledge and lower perceived barriers to obtaining CRC screening. Furthermore, the intervention was found to be feasible and acceptable. Conclusion. Results suggest that JUNTOS can be feasibly implemented in partnership with a federally qualified health center. The current study supports group-based CRC interventions in community and clinic settings.

Impact of Race and Socioeconomics Disparities on Survival in Young-Onset Colorectal Adenocarcinoma-A SEER Registry Analysis

INTRODUCTION

We aimed to assess the impact of socio-economic determinants of health (SEDH) on survival disparities within and between the ethnic groups of young-onset (<50 years age) colorectal adenocarcinoma patients.

PATIENTS AND METHODS

Surveillance, epidemiology, and end results (SEER) registry was used to identify colorectal adenocarcinoma patients aged between 25-49 years from 2012 and 2016. Survival analysis was performed using the Kaplan-Meir method. Cox proportional hazards model was used to determine the hazard effect of SEDH. American community survey (ACS) data 2012-2016 were used to analyze the impact of high school education, immigration status, poverty, household income, employment, marital status, and insurance type.

RESULTS

A total of 17,145 young-onset colorectal adenocarcinoma patients were studied. Hispanic (H) = 2874, Non-Hispanic American Indian/Alaskan Native (NHAIAN) = 164, Non-Hispanic Asian Pacific Islander (NHAPI) = 1676, Non-Hispanic black (NHB) = 2305, Non-Hispanic white (NHW) = 10,126. Overall cancer-specific survival was, at 5 years, 69 m. NHB (65.58 m) and NHAIAN (65.67 m) experienced worse survival compared with NHW (70.11 m), NHAPI (68.7), and H (68.31). High school education conferred improved cancer-specific survival significantly with NHAPI, NHB, and NHW but not with H and NHAIAN. Poverty lowered and high school education improved cancer-specific survival (CSS) in NHB, NHW, and NHAPI. Unemployment was associated with lowered CSS in H and NAPI. Lower income below the median negatively impacted survival among H, NHAPI NHB, and NHW. Recent immigration within the last 12 months lowered CSS survival in NHW. Commercial health insurance compared with government insurance conferred improved CSS in all groups.

CONCLUSIONS

Survival disparities were found among all races with young-onset colorectal adenocarcinoma. The pattern of SEDH influencing survival was unique to each race. Overall higher income levels, high school education, private insurance, and marital status appeared to be independent factors conferring favorable survival found on multivariate analysis.

Colorectal cancer screening in African Americans: are we following the guidelines?

PURPOSE

The age at onset, incidence, and mortality rate of colorectal cancer varies among racial groups being highest in African Americans. This increased risk led to the recommendation to begin screening at the age of 45 years. Whether the recommendation for screening of African Americans at an earlier age was implemented is unknown.

METHODS

We used data from the Cancer Control Supplement of National Health Interview Survey (NHIS) conducted in the years 2005, 2010, and 2015 to analyze demographic data and use of colorectal screening (colonoscopy, stool heme testing, sigmoidoscopy, computed tomographic colonography) among the US population between the ages of 45-49 years.

RESULTS

Data on colorectal screening was available from 6740 individuals; 16.5% were African Americans. Screening test use among African Americans in 2005, 2010, and 2015 was similar to use in Whites (i.e., 15.4% (95% CI 11.4-19.4), 28.4% (95% CI 19.3-30.4) and 20.2% (95% CI 14.8-25.5) vs. 16.9% (95% CI 15.1-18.6), 19.3% (95% CI 16.9-21.7), and 21.4% (95% CI 18.6-24.2) in 2005, 2010 and 2015, respectively. Observed screening test use rates may largely be accounted for by diagnostic exams.

CONCLUSION

The recommendation for earlier colorectal screening of African Americans has not yet resulted in increased test utilization. These results emphasize the need for multidisciplinary actions to inform and implement public health policy.

Gastrointestinal Endoscopy in the Era of COVID-19

Coronavirus disease 2019 (COVID-19) is caused by severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2), which led to a worldwide pandemic that started in early 2020. Healthcare systems across the world encountered an unprecedented surge of COVID-19 patients resulting in more than half a million deaths globally. COVID-19 has affected multiple sub-specialties and procedure-related fields, including gastroenterology. Gastrointestinal (GI) endoscopy centers are specialized units where thousands of endoscopies are performed annually. A significant proportion of these procedures are affected due to the national and regional lockdowns across the globe. To adapt to this rapidly evolving situation, endoscopy centers have undergone significant changes and have taken unprecedented precautions to avoid the transmission of the virus. However, endoscopy centers are going through financial strain due to a reduction in the number of procedures from lockdowns and fear of virus transmission. Theoretically, endoscopies could add to the disease transmission as SARS-CoV-2 has shown to be present in the GI secretions. Multiple precautions such as mandatory use of face masks, safe distancing, use of barriers between the endoscopists and patients, negative pressure rooms, extended use of personal protective equipment, and volume reduction have been taken to decrease the risk of disease transmission by these centers. Moreover, pre-endoscopy COVID-19 testing has now become the norm. In this review, we highlight the significant changes assumed by the endoscopy center. Furthermore, we discuss cost-related concerns of pre-endoscopy COVID-19 testing, the downtime and delays related to the procedures, and effects of rescheduling. As the pandemic progresses through multiple phases, endoscopy centers should use a dynamic approach to adapt and strive to provide the best patient care.

Precision Approaches in the Management of Colorectal Cancer: Current Evidence and Latest Advancements Towards Individualizing the Treatment

The genetic and molecular underpinnings of metastatic colorectal cancer have been studied for decades, and the applicability of these findings in clinical decision making continues to evolve. Advancements in translating molecular studies have provided a basis for tailoring chemotherapeutic regimens in metastatic colorectal cancer (mCRC) treatment, which have informed multiple practice guidelines. Various genetic and molecular pathways have been identified as clinically significant in the pathogenesis of metastatic colorectal cancer. These include rat sarcoma (RAS), epithelial growth factor receptor (EGFR), vascular endothelial growth factor VEGF, microsatellite instability, mismatch repair, and v-raf murine sarcoma viral oncogene homolog b1 (BRAF) with established clinical implications. RAS mutations and deficiencies in the mismatch repair pathway guide decisions regarding the administration of anti-EGFR-based therapies and immunotherapy, respectively. Furthermore, there are several emerging pathways and therapeutic modalities that have not entered mainstream use in mCRC treatment and are ripe for further investigation. The well-established data in the arena of targeted therapies provide evidence-based support for the use or avoidance of various therapeutic regimens in mCRC treatment, while the emerging pathways and platforms offer a glimpse into the future of transforming a precision approach into a personalized treatment.

Scope of Artificial Intelligence in Screening and Diagnosis of Colorectal Cancer

Globally, colorectal cancer is the third most diagnosed malignancy. It causes significant mortality and morbidity, which can be reduced by early diagnosis with an effective screening test. Integrating artificial intelligence (AI) and computer-aided detection (CAD) with screening methods has shown promising colorectal cancer screening results. AI could provide a "second look" for endoscopists to decrease the rate of missed polyps during a colonoscopy. It can also improve detection and characterization of polyps by integration with colonoscopy and various advanced endoscopic modalities such as magnifying narrow-band imaging, endocytoscopy, confocal endomicroscopy, laser-induced fluorescence spectroscopy, and magnifying chromoendoscopy. This descriptive review discusses various AI and CAD applications in colorectal cancer screening, polyp detection, and characterization.

Effects of the Affordable Care Act on the Receipt of Colonoscopies among the Insured Elderly

Background: The Affordable Care Act (ACA) waived deductibles and eliminated coinsurance for colonoscopies for Medicare beneficiaries beginning in January 1, 2011. This study investigated the effect of the ACA’s directive to remove the financial barriers on the receipt of colonoscopies among the elderly insured, who are predominantly covered by Medicare. Methods: Data from the 2008–2016 Behavioral Risk Factor Surveillance System (BRFSS) were used to examine the receipt of colonoscopies in two years prior to the implementation of the ACA (2008 and 2010) and three years after the change (2012, 2014, and 2016). Multivariate logistic regressions were estimated to examine the change in colonoscopy use before and after the introduction of the ACA, adjusting for patient characteristics and availability of health care providers in the geographic region. Results: Of 349,899 eligible elderly insured in the age group 65 to 75 years, 236,275 (67.2%) had received a colonoscopy in the previous ten years. The receipt of colonoscopies increased from 63.5% in pre-ACA years to 69.2% in the post-ACA years (p < 0.001). Compared with the pre-ACA period, the odds ratio of colonoscopy uptake in post-ACA years was 1.15 (95% CI = 1.08–1.22). Conclusions: A statistically significant increase in colonoscopy use was observed in the post-ACA years. However, achieving the target coverage rate of 80% will require additional interventions to encourage higher levels of screenings.

Economic evaluations of screening strategies for the early detection of colorectal cancer in the average-risk population: A systematic literature review

Background

Colorectal cancer (CRC) screening has proven effective in reducing CRC mortality. This study aimed to systematically review, and evaluate the reporting quality, of the economic evidence regarding CRC screening in average-risk individuals.

Methods

Databases searched included Medline, EMBASE, National Health Service Economic Evaluation, Database of Abstracts of Reviews of Effects, Cost-Effectiveness Analysis registry, EconLit, and Health Technology Assessment database. Eligible studies were cost-effectiveness and cost-utility analyses comparing CRC screening strategies in average-risk individuals, published in English or Spanish, between January 2012 and November 2018. Reporting quality was assessed using the Consolidated Health Economic Evaluation Reporting Standards (CHEERS) checklist.

Results

Of 1,993 publications initially retrieved, 477 were excluded by duplicate review, 1,449 by title/abstract review, and 34 by full-text review. Finally, 33 publications were included in the qualitative synthesis. Most studies were conducted in Europe (36,4%), followed by United States (24,2%) and Asia (24,2%). The main screening modalities considered were fecal immunochemical tests (70%), colonoscopy (67%), guaiac fecal occult blood test (42%) and flexible sigmoidoscopy (30%). In most studies, CRC screening was deemed cost-effective compared to no screening. Sensitivity analyses indicated that cost of CRC screening tests, adherence to screening, screening test sensitivity, and cost of CRC treatment had the greatest impact on cost-effectiveness results across studies. The majority of studies (73%) adequately reported at least 50% of the items included in the CHEERS checklist. Least well reported items included setting, study perspective, discount rate, model choice, and methods to identify effectiveness data or to estimate resource use and costs.

Conclusions

CRC screening is an efficient alternative to no screening. Nevertheless, it is not possible to conclude which strategy should be preferred for population-based screening programs. Although we observed an overall good adherence to CHEERS recommendations, there is still room for improvement in economic evaluations reporting in this field.

The Rise of Colorectal Cancer in Asia: Epidemiology, Screening, and Management

PURPOSE OF REVIEW

Colorectal cancer (CRC) remains the third most commonly diagnosed cancer globally, and its incidence and mortality rates have been on the rise in Asia. In this paper, we summarize the recent trends and screening challenges of CRC in this region.

RECENT FINDINGS

In 2018, Asia had the highest proportions of both incident (51.8%) and mortality (52.4%) CRC cases (all genders and ages) per 100,000 population in the world. In addition, there has been a rising trend of this disease across Asia with some regional geographic variations. This rise in CRC can be attributed to westernized dietary lifestyle, increasing population aging, smoking, physical inactivity, and other risk factors. In curbing the rising trend, Japan, South Korea, Singapore, and Taiwan have launched nationwide population-based screening programs. CRC screening across this region has been found to be effective and cost-effective compared with no screening at all. The emergence of new therapies has caused a reduction in case fatality; however, these new options have had a limited impact on cure rates and long-term survival due to the great disparity in treatment capacity/resources and screening infrastructures among Asian countries with different degrees of economic development. CRC is still rising in Asia, and implementation of screening is necessary for moderate- to high-incidence countries and construction of treatment capacity is the priority task in low-incidence and low-income countries. Unless countries in Asia implement CRC screening, the incidence and mortality rates of this disease will continue to rise especially with the rapidly rising population growth, economic development, westernized lifestyle, and increasing aging.