Colorectal cancer screening with flexible sigmoidoscopy—participants' experiences and technical feasibility

Participants' satisfaction with colorectal cancer screening programs: A systematic review

INTRODUCTION

Since satisfaction with cancer screening experience can increase adherence to programs and contribute to reduce morbidity and mortality, its assessment is crucial for programs´ effectiveness. Our aim was to conduct a systematic review about satisfaction of participants with organized colorectal cancer screening.

METHODS

We searched relevant scientific databases (MEDLINE, EMBASE, PsycINFO, and CINAHL) from inception to May 2022. We selected cross-sectional studies and clinical trials reporting a quantitative survey-based measure of satisfaction towards CRC screening.

RESULTS

A total of 15 studies were included, being published from 1992 to 2019 for an overall number of 21 surveys. Of those, 16 (76%) investigated satisfaction with screening tests (fecal occult blood test, fecal immunochemical test, sigmoidoscopy, colonoscopy, computed tomographic colonography), 4 (19%) with colonoscopy as assessment test after suspicious findings, and 2 (10%) with both the screening and assessment phase. None of the included surveys used a validated questionnaire. Most surveys reported a high level of satisfaction for both screening and further assessment phases. Temporary pain, discomfort, embarrassment, and anxiety while waiting for results were the commonest negative aspects perceived, with some variability across studies and considered procedures.

CONCLUSIONS

Satisfaction with the information and communication about screening was generally good, but some authors reported participants' sub-optimal understanding of informative material. Satisfaction with CRC screening is generally high, but its evaluation is performed using non-validated instruments, which limits the interpretation of results and prevents comparability of the current body of evidence.

Interval cancers in a guaiac-based colorectal cancer screening programme: Consequences on sensitivity

Objective

To evaluate interval cancers in the population-based colorectal cancer screening programme of Stockholm/Gotland, Sweden.

Methods

From 2008, individuals aged 60–69 were invited to colorectal cancer screening using biennial guaiac-based faecal occult blood test (Hemoccult®). Interval cancers, defined as colorectal cancer among participants not diagnosed by the screening programme but registered in the Swedish cancer register, were evaluated by cross-checking the screening histories for all cancers in the region 2008–2012.

Results

Of 203,848 individuals from nine different birth cohorts who participated (∼60%), 4530 (2.2%) tested positive. All invited individuals were followed up for 24 months after invitation. The cancer register reported 557 colorectal cancer, 219 (39.3%) screen-detected cancers and 338 (60.7%) interval cancers, generating both test- and episode sensitivities of approximately 40% and an interval cancer-rate of 17.1/10,000 tests. Among individuals with positive tests without colorectal cancer diagnosed at work-up colonoscopy, 37 interval cancers (10.9%) occurred. There was statistically significant lower sensitivity in women, ranging 22.4–32.2%, compared with 43.2–52.0% in men. Age-group and tumour location were not strongly correlated to screen-detected cancer rates. The programme sensitivity increased by year (20.3–25.0%), with successively more colorectal cancers diagnosed within the expanding programme (11.6–16.2%).

Conclusion

Interval cancer is a quality indicator of a screening programme. As the interval cancer-rate determined in a well-organized population-based screening programme was actually higher than the screen-detected cancer rate, a change to a more sensitive screening test is indicated. The lower screen-detected cancers among women, and compliance and quality of work-up colonoscopies also need attention.

Rigid or flexible sigmoidoscopy in colorectal clinics? Appraisal through a systematic review and meta-analysis

AIM

Rigid sigmoidoscopy is sometimes performed at first presentation in colorectal clinics. We assessed the feasibility of flexible sigmoidoscopy in similar situations by comparing it with rigid sigmoidoscopy as a first investigative tool.

METHODS

The Medline, Embase, and Cochrane databases were searched for randomized and non-randomized clinical trials comparing the usefulness of rigid and flexible sigmoidoscopy. The risk difference (RD) and weighted mean difference (WMD) were calculated for the cancers/abnormalities detected and discomfort associated with the procedure, respectively. The standard mean difference (SMD) was calculated for the depth of examination and duration of the procedure.

RESULTS

Flexible sigmoidoscopy had a significantly higher rate of detection of cancers and total abnormalities (RD of 0.020 and 0.138 and 95% confidence interval [CI] of 0.006-0.034 and 0.077-0.200, respectively), and rigid sigmoidoscopy caused significantly more patient discomfort (WMD of 0.981 and 95% CI of 0.693-1.269). Flexible sigmoidoscopy provided significantly greater depth of examination (SMD of 3.175, 95% CI of 2.397-3.954), and rigid sigmoidoscopy required less time (SMD of -1.601, 95% CI of -2.728 to -0.474).

CONCLUSIONS

Flexible sigmoidoscopy is a better investigative tool in colorectal clinics than the rigid sigmoidoscopy. Implementation of this idea can help in early diagnosis at first presentation and can certainly expedite the management of colorectal malignancies.

Factors Associated with Colorectal Cancer Screening Among Cambodians, Vietnamese, Koreans and Chinese Living in the United States

The purpose of this community-based participatory study was to identify factors associated with colorectal cancer (CRC) screening compliance and non-compliance among Cambodians, Vietnamese, Koreans and Chinese men and women 50 years and older living in the United States. A cross-sectional design was used in the study. The completed sample included 815 Asian Americans which included Cambodians (N=215), Vietnamese (N=195), Koreans (N=94) and Chinese (N=311). A 95-item questionnaire was developed and pilot tested for content validity and reliability. An in-person data collection approach was utilized and participants were given choice in responding in English or their native language. Of the 815 participants, 79.1% (N=645) reported never-screened, 7.9% (N=64), non-compliance, and 13.0% (N=106) compliance. Education was significantly associated with never-screened for CRC for Vietnamese and Chinese; employment status for Cambodians and Koreans; lack of health insurance for Cambodians, Korean and Chinese; English fluency and years lived in the U.S. for Vietnamese, Koreans, and Chinese. Less acculturated Asian Americans were more likely to be never screened, but differentially across ethnic subgroups. Barriers to screening included lack of knowledge, language, transportation, and time. Increased culturally-targeted public awareness and education programs are needed to improve CRC screening and compliance among high risk Asian American ethnic subgroups.

Listening to music does not reduce pain during sigmoidoscopy

OBJECTIVE

Up to 40% of the sigmoidoscopies are considered painful by patients. Nonpharmacological intervention would be attractive, as sedation and analgesia carry the risk of side-effects and increase procedure-related costs. Music might have the potential of pain reduction, but its effect during sigmoidoscopy has not been established yet. To study whether listening to music reduces experienced pain during sigmoidoscopy.

METHODS

Consecutive patients, above 18 years of age, undergoing sigmoidoscopy without sedation or analgesia and who gave their informed consent were included in this study. Patients in the music group listened to their preferred music (classical, jazz, English or Dutch Popular) during the sigmoidoscopy. The control group received care as usual. The outcome measures were pain intensity during sigmoidoscopy (measured with a 100-mm-long visual analogue scale) and the proportion of patients with at least moderate pain during sigmoidoscopy (pain intensity score of 50 mm or higher).

RESULTS

The music groups consisted of 153 patients, the control group of 154 patients. The mean pain intensity + or - standard deviation was 36 + or - 27 mm in the music group and 40 + or - 29 in the control group (P=0.27) during sigmoidoscopy. The proportion of patients with at least moderate pain during sigmoidoscopy was 29 and 37% in the respective groups (P=0.12).

CONCLUSION

Listening to music by patients did not reduce pain intensity during sigmoidoscopy. As a consequence, music during sigmoidoscopy is not recommended for this purpose.

Colonoscopy training for nurse endoscopists: a feasibility study

BACKGROUND

Screening by using colonoscopy is recommended in many countries to reduce the risk of death from colorectal cancer. Given the limited supply of medical endoscopists, nurse endoscopists may represent an economic alternative.

OBJECTIVE

To develop a colonoscopy training program for nurse endoscopists and to evaluate the feasibility of this program.

DESIGN

Two nurse endoscopists and 1 first-year GI fellow were enrolled in a colonoscopy training protocol, including computer-simulator training, flexible sigmoidoscopies, and colonoscopies under direct supervision.

SETTING

A single-center prospective study.

PATIENTS

The first 150 complete colonoscopies of each trainee endoscopist were evaluated and compared with 150 colonoscopies performed by an experienced endoscopist.

MAIN OUTCOME MEASUREMENTS

Objective criteria for competency were diagnostic accuracy, cecal-intubation rate, cecal-intubation time, the need for assistance, and complications. Subjective criteria included patient satisfaction, pain, and discomfort scores.

RESULTS

The nurse endoscopists' unassisted cecal-intubation rate was 80% for the first 25 procedures, gradually increasing in subsequent cases to 96% for the last 25 procedures. The mean cecal-intubation time at the end of the training period was 10 minutes. Cecal-intubation rates and times were comparable between the nurse trainees and the fellow. The patients reported low degrees of pain and discomfort, and high satisfaction scores, irrespective of the type of endoscopist. Diagnostic accuracy of the trainees was good. The complication rate was 0.3%.

LIMITATION

Nonrandomized design.

CONCLUSIONS

This pilot study suggests that nurses can be trained to perform colonoscopy in an effective manner, with results similar to a GI fellow. The learning curve indicated that 150 procedures are required before independent examinations are attempted.

A 9-year follow-up study of participants and nonparticipants in sigmoidoscopy screening: importance of self-selection

BACKGROUND

Self-selection may compromise cost-effectiveness of screening programs. We hypothesized that nonparticipants have generally higher morbidity and mortality than participants.

METHODS

A Swedish population-based random sample of 1,986 subjects ages 59 to 61 years was invited to sigmoidoscopy screening and followed up for 9 years by means of multiple record linkages to health and population registers. Gender-adjusted cancer incidence rate ratio (IRR) and overall and disease group-specific and mortality rate ratio (MRR) with 95% confidence intervals (95% CI) were estimated for nonparticipants relative to participants. Cancer and mortality rates were also estimated relative to the age-matched, gender-matched, and calendar period-matched Swedish population using standardized incidence ratios and standardized mortality ratios.

RESULTS

Thirty-nine percent participated. The incidence of colorectal cancer (IRR, 2.2; 95% CI, 0.8-5.9), other gastrointestinal cancer (IRR, 2.7; 95% CI, 0.6-12.8), lung cancer (IRR, 2.2; 95% CI, 0.8-5.9), and smoking-related cancer overall (IRR, 1.4; 95% CI, 0.7-2.5) tended to be increased among nonparticipants relative to participants. Standardized incidence ratios for most of the studied cancers tended to be >1.0 among nonparticipants and <1.0 among participants. Mortality from all causes (MRR, 2.4; 95% CI, 1.7-3.4), neoplastic diseases (MRR, 1.9; 95% CI, 1.1-3.5), gastrointestinal cancer (MRR, 4.7; 95% CI, 1.1-20.7), and circulatory diseases (MRR, 2.3; 95% CI, 1.2-4.2) was significantly higher among nonparticipants than among participants. Standardized mortality ratio for the studied outcomes tended to be increased among nonparticipants and was generally decreased among participants.

CONCLUSION

Individuals who might benefit most from screening are overrepresented among nonparticipants. This self-selection may attenuate the cost-effectiveness of screening programs on a population level.

Factors associated with intentions to adhere to colorectal cancer screening follow-up exams

Background

To increase adherence rate to recommendations for follow-up after abnormal colorectal cancer (CRC) screening results, factors that inhibit and facilitate follow-up must be identified. The purpose of this study was to identify the factors associated with intention to adhere to CRC screening follow-up exams.

Methods

During a 4-week period in October 2003, this survey was conducted with 426 subjects participating in a community-based CRC screening program in Nagano, Japan. Study measures included intention to adhere to recommendation for clinical follow-up in the event of an abnormal fecal occult blood test (FOBT) result, perceived susceptibility and severity of CRC, perceived benefits and barriers related to undergoing follow-up examination, social support, knowledge of CRC risk factors, health status, previous CRC screening, personality and social demographic characteristics. Univariate and multivariate logistic regression analyses on intention to adhere to recommendations for follow-up were performed.

Results

Among the 288 individuals analyzed, approximately 74.7% indicated that they would definitely adhere to recommendations for follow-up. After controlling for age, gender, marital status, education, economic status, trait anxiety, bowel symptoms, family history of CRC, and previous screening FOBT, analyses revealed that lower levels of perceived barriers, higher levers of perceived benefits and knowledge of CRC risk factors were significantly associated with high intention respectively.

Conclusion

The results of this study suggest that future interventions should focus on reducing modifiable barriers by clarifying misperceptions about follow-up, promoting the acceptance of complete diagnostic evaluations, addressing psychological distress, and making follow-up testing more convenient and accessible. Moreover, educating the public regarding the risk factors of CRC and increasing understanding of the benefits of follow-up is also important.