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Adegbulugbe AA, Farah E, Ruan Y, Yong JHE, Cheung WY, Brenner DR. The projected health and economic impact of increased colorectal cancer screening participation among Canadians by income quintile. Can J Public Health 2024:10.17269/s41997-024-00868-8. [PMID: 38502494 DOI: 10.17269/s41997-024-00868-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/16/2023] [Accepted: 02/09/2024] [Indexed: 03/21/2024]
Abstract
OBJECTIVES Disparities in colorectal cancer (CRC) screening uptake by socioeconomic status have been observed in Canada. We used the OncoSim-Colorectal model to evaluate the health and economic outcomes associated with increasing the participation rates of CRC screening programs to 60% among Canadians in different income quintiles. METHODS Baseline CRC screening participation rates were obtained from the 2017 Canadian Community Health Survey. The survey participants were categorized into income quintiles using their reported household income and 2016 Canadian Census income quintile thresholds. Within each quintile, the participation rate was the proportion of respondents aged 50-74 who reported having had a fecal test in the past two years. Using the OncoSim-Colorectal model, we simulated an increase in CRC screening uptake to 60% across income quintiles to assess the effects on CRC incidence, mortality, and associated economic costs from 2024 to 2073. RESULTS Increasing CRC screening participation rates to 60% across all income quintiles would prevent 69,100 CRC cases and 36,600 CRC deaths over 50 years. The improvement of clinical outcomes would also translate to increased person-years and health-adjusted person-years. The largest impact was observed in the lowest income group, with 22,200 cases and 11,700 deaths prevented over 50 years. Increased participation could lead to higher screening costs ($121 million CAD more per year) and lower treatments costs ($95 million CAD less per year), averaged over the period 2024-2073. CONCLUSION Increased screening participation will improve clinical outcomes across all income groups while alleviating associated treatment costs. The benefits of increased participation will be strongest among the lowest income quintile.
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Affiliation(s)
- Abisola A Adegbulugbe
- Department of Oncology, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
- Department of Community Health Sciences, University of Calgary, Calgary, AB, Canada
| | - Eliya Farah
- Department of Oncology, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
- Department of Community Health Sciences, University of Calgary, Calgary, AB, Canada
| | - Yibing Ruan
- Department of Cancer Epidemiology and Prevention Research, Alberta Health Services, Calgary, AB, Canada
| | - Jean H E Yong
- Canadian Partnership Against Cancer, Toronto, ON, Canada
| | - Winson Y Cheung
- Department of Oncology, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
- Department of Community Health Sciences, University of Calgary, Calgary, AB, Canada
- Department of Cancer Epidemiology and Prevention Research, Alberta Health Services, Calgary, AB, Canada
| | - Darren R Brenner
- Department of Oncology, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada.
- Department of Cancer Epidemiology and Prevention Research, Alberta Health Services, Calgary, AB, Canada.
- Forzani & MacPhail Colon Cancer Screening Centre, Alberta Health Services, Calgary, AB, Canada.
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2
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Luo Z, Dong X, Wang C, Cao W, Zheng Y, Wu Z, Xu Y, Zhao L, Wang F, Li J, Ren J, Shi J, Chen W, Li N. Association Between Socioeconomic Status and Adherence to Fecal Occult Blood Tests in Colorectal Cancer Screening Programs: Systematic Review and Meta-Analysis of Observational Studies. JMIR Public Health Surveill 2023; 9:e48150. [PMID: 37906212 PMCID: PMC10646673 DOI: 10.2196/48150] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2023] [Revised: 07/21/2023] [Accepted: 07/31/2023] [Indexed: 11/02/2023] Open
Abstract
BACKGROUND Screening adherence is important in reducing colorectal cancer (CRC) incidence and mortality. Disparity in CRC screening adherence was observed in populations of different socioeconomic status (SES), but the direction and strength of the association remained unclear. OBJECTIVE We aimed to systematically review all the observational studies that have analyzed the association between SES and adherence to organized CRC screening based on fecal occult blood tests. METHODS We systematically reviewed the studies in PubMed, Embase, and Web of Science and reference lists of relevant reviews from the inception of the database up until June 7, 2023. Individual SES, neighborhood SES, and small-area SES were included, while any SES aggregated by geographic areas larger than neighbors were excluded. Studies assessing SES with any index or score combining indicators of income, education, deprivation, poverty, occupation, employment, marital status, cohabitation, and others were included. A random effect model meta-analysis was carried out for pooled odds ratios (ORs) and relative risks for adherence related to SES. RESULTS Overall, 10 studies, with a total of 3,542,379 participants and an overall adherence rate of 64.9%, were included. Compared with low SES, high SES was associated with higher adherence (unadjusted OR 1.73, 95% CI 1.42-2.10; adjusted OR 1.53, 95% CI 1.28-1.82). In the subgroup of nonindividual-level SES, the adjusted association was significant (OR 1.57, 95% CI 1.26-1.95). However, the adjusted association was insignificant in the subgroup of individual-level SES (OR 1.46, 95% CI 0.98-2.17). As for subgroups of the year of print, not only was the unadjusted association significantly stronger in the subgroup of early studies (OR 1.97, 95% CI 1.59-2.44) than in the subgroup of late studies (OR 1.43, 95% CI 1.31-1.56), but also the adjusted one was significantly stronger in the early group (OR 1.86, 95% CI 1.43-2.42) than in the late group (OR 1.26, 95% CI 1.14-1.39), which was consistent and robust. Despite being statistically insignificant, the strength of the association seemed lower in studies that did not adjust for race and ethnicity (OR 1.31, 95% CI 1.21-1.43) than the overall estimate (OR 1.53, 95% CI 1.28-1.82). CONCLUSIONS The higher-SES population had higher adherence to fecal occult blood test-based organized CRC screening. Neighborhood SES, or small-area SES, was more competent than individual SES to be used to assess the association between SES and adherence. The disparity in adherence between the high SES and the low SES narrowed along with the development of interventions and the improvement of organized programs. Race and ethnicity were probably important confounding factors for the association.
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Affiliation(s)
- Zilin Luo
- Office of Cancer Screening, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
- Chinese Academy of Medical Sciences Key Laboratory for National Cancer Big Data Analysis and Implement, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Xuesi Dong
- Office of Cancer Screening, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
- Chinese Academy of Medical Sciences Key Laboratory for National Cancer Big Data Analysis and Implement, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Chenran Wang
- Office of Cancer Screening, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
- Chinese Academy of Medical Sciences Key Laboratory for National Cancer Big Data Analysis and Implement, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Wei Cao
- Office of Cancer Screening, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
- Chinese Academy of Medical Sciences Key Laboratory for National Cancer Big Data Analysis and Implement, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Yadi Zheng
- Office of Cancer Screening, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
- Chinese Academy of Medical Sciences Key Laboratory for National Cancer Big Data Analysis and Implement, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Zheng Wu
- Office of Cancer Screening, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
- Chinese Academy of Medical Sciences Key Laboratory for National Cancer Big Data Analysis and Implement, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Yongjie Xu
- Office of Cancer Screening, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
- Chinese Academy of Medical Sciences Key Laboratory for National Cancer Big Data Analysis and Implement, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Liang Zhao
- Office of Cancer Screening, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
- Chinese Academy of Medical Sciences Key Laboratory for National Cancer Big Data Analysis and Implement, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Fei Wang
- Office of Cancer Screening, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
- Chinese Academy of Medical Sciences Key Laboratory for National Cancer Big Data Analysis and Implement, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Jibin Li
- Office of Cancer Screening, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Jiansong Ren
- Office of Cancer Screening, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
- Chinese Academy of Medical Sciences Key Laboratory for National Cancer Big Data Analysis and Implement, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Jufang Shi
- Office of Cancer Screening, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
- Chinese Academy of Medical Sciences Key Laboratory for National Cancer Big Data Analysis and Implement, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Wanqing Chen
- Office of Cancer Screening, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
- Chinese Academy of Medical Sciences Key Laboratory for National Cancer Big Data Analysis and Implement, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Ni Li
- Office of Cancer Screening, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
- Chinese Academy of Medical Sciences Key Laboratory for National Cancer Big Data Analysis and Implement, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
- Department of Epidemiology and Biostatistics, Jiangsu Key Lab of Cancer Biomarkers, Prevention and Treatment, Collaborative Innovation Center for Cancer Personalized Medicine, School of Public Health, Nanjing Medical University, Nanjing, China
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Drastal M, Shaw K, Hyman N, Green M, Baumgart CQ, Diaz D. Colorectal Cancer Screening Decisions From Student-Led Telemedicine Initiative During COVID-19. PRiMER 2023; 7:253936. [PMID: 36845846 PMCID: PMC9957458 DOI: 10.22454/primer.2023.253936] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
Background and Objectives With the onset of the COVID-19 pandemic, there has been a significant decrease in colorectal cancer (CRC) screening leading to delayed diagnoses and increased cancer deaths. To mitigate these burgeoning gaps in care, we developed a medical student-led service learning project aimed at improving rates of colorectal cancer screening at the Farrell Health Center (FHC), a primary care practice within the Ambulatory Care Network (ACN) at New York-Presbyterian Hospital. Methods A cohort of 973 FHC patients aged 50-75 years were identified as possibly overdue for screening. Student volunteers reviewed patient charts to confirm screening eligibility and then contacted patients to offer colonoscopy or stool DNA test. Following the patient outreach intervention, medical student volunteers completed a questionnaire to assess the educational value for the service-learning experience. Results Fifty-three percent of identified patients were due for CRC screening; 67.8% of eligible patients were reached by volunteers. Among the patients reached, 47.0% were referred for CRC screening. No statistical significance was observed between likelihood of CRC screening acceptance and patient age or sex; 87% of medical student volunteers felt that the service-learning project was a valuable educational experience. Conclusion The student-led patient telehealth outreach program is an effective model for identifying and referring patients overdue for CRC screening and an enriching educational experience for preclinical medical students. The structure provides a valuable framework to address gaps in health care maintenance.
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Affiliation(s)
| | - Kaitlin Shaw
- Columbia University Irving Medical Center, New York, NY
| | | | - Matthew Green
- Columbia University Mailman School of Public Health, New York, NY
| | | | - Daniela Diaz
- Columbia University Irving Medical Center, New York, NY
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Hassanlouei B, Ostovar A, Motevalian SA, Ghanbari Motlagh A, Moradi Y, Salehi M, Asadi Lari M. Colorectal Cancer Screening Program Results in Iran. Med J Islam Repub Iran 2022; 36:118. [PMID: 36447540 PMCID: PMC9700411 DOI: 10.47176/mjiri.36.118] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2022] [Indexed: 01/25/2023] Open
Abstract
Background: Colorectal cancer (CRC) accounts for a large proportion of the global burden of cancer and is the fourth leading cause of cancer-related mortality worldwide. Fecal Immunochemical Testing (FIT) can be used for CRC screening programs due to its high accuracy and compliance. The present study reports the preliminary results of the CRC screening program in Iran among all people aged 50 to 69 years. Methods: This cross-sectional study was carried out on 2,669,625 participants referred to health centers in Iran for CRC screening programs in 2018 and 2019. The data required for this study was taken from the CRC screening program. Relevant information for all individuals aged 50 to 69 referred to the health system that was called for colorectal cancer screening was extracted from the Integrated Electronic Health Records (SIB) database. Finally, the standards indices were calculated for all provinces. Gender, history of inflammatory bowel disease (IBD) (Crohn's disease or ulcerative colitis), history of colon cancer or adenoma in a first-degree family (father, mother, siblings or children), history of colon cancer in a second-degree family if occurred under the age of fifty (aunt, uncle, grandparents), lower gastrointestinal bleeding in a prior month, constipation in the prior month (with or without diarrhea, abdominal pain and feeling of fullness in the colon after defecation), more than ten percent weight loss in the last six months and FIT were assessed. Results: Among a total number of over 2.6 million, 56.3% were female, and the number of people evaluated by health care providers for CRC screening programs in 2018 and 2019 were 1,365,248 (14.23%) and 1,304,377 (12.89%), respectively. The number of people with positive FIT evaluated for the CRC screening program in 2018 and 2019 was 33,299 (3.09%) and 33,583 (2.57%), respectively. Bushehr province (0.59%) and Isfahan province (7.35%) had the lowest and highest positive FIT rate in 2018, respectively. Also, the correlation between the above-mentioned variables and the number of people with a positive FIT across gender was statistically significant (p<0.05). The study of the relationship between the number of positive FIT cases and the variables examined by Behvarz and community health worker showed that the number of people with a family history of colon cancer in second-degree relatives under the age of 50 and also the number of people with an individual history of inflammatory bowel disease had a significant association with the number of positive FIT cases (p<0.05) (β=-0.718, 95% CI; -2.557-14.992, β=0.388, 95% CI; 0.322-16.737, respectively). The relationship between the number of positive FIT cases and effective variables was not statistically significant (p>0.05). Conclusion: Positive cases should be referred for further evaluation and colonoscopy. Before performing a screening program, the conditions for performing colonoscopy for these people must be assessed and prepared. The FIT for CRC screening program can be easily promoted in Iran.
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Affiliation(s)
- Babak Hassanlouei
- Department of Epidemiology, School of Public Health, Iran University of Medical Sciences, Tehran, Iran
| | - Afshin Ostovar
- Osteoporosis Research Center, Endocrinology and Metabolism Clinical Sciences Institute, Tehran University of Medical Sciences, Tehran, Iran
| | - Seyed Abbas Motevalian
- Department of Epidemiology, School of Public Health, Iran University of Medical Sciences, Tehran, Iran
| | - Ali Ghanbari Motlagh
- Department of Radiotherapy, Faculty of Medicine, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Yousef Moradi
- Social Determinants of Health Research Center, Research Institute for Health Development, Kurdistan University of Medical Sciences, Sanandaj, Iran
| | - Masoud Salehi
- Health Management and Economics Research Center and Department of Biostatistics, School of Public Health, Iran University of Medical Sciences, Tehran, Iran
| | - Mohsen Asadi Lari
- Department of Epidemiology, School of Public Health, Iran University of Medical Sciences, Tehran, Iran,Corresponding author: Dr Mohsen Asadi Lari,
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van der Meulen MP, Toes-Zoutendijk E, Spaander MCW, Dekker E, Bonfrer JMG, van Vuuren AJ, Kuipers EJ, van Kemenade FJ, van Velthuysen MF, Thomeer MGJ, van Veldhuizen H, de Koning HJ, Lansdorp-Vogelaar I, van Leerdam ME. Socioeconomic differences in participation and diagnostic yield within the Dutch national colorectal cancer screening programme with faecal immunochemical testing. PLoS One 2022; 17:e0264067. [PMID: 35176116 PMCID: PMC8853540 DOI: 10.1371/journal.pone.0264067] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2021] [Accepted: 02/02/2022] [Indexed: 12/22/2022] Open
Abstract
Background CRC mortality rates are higher for individuals with a lower socioeconomic status (SES). Screening could influence health inequalities. We therefore aimed to investigate SES differences in participation and diagnostic yield of FIT screening. Methods All invitees in 2014 and 2015 in the Dutch national CRC screening programme were included in the analyses. We used area SES as a measure for SES and divided invitees into quintiles, with Quintile 1 being the highest SES. Logistic regression analysis was used to compare the participation rate, positivity rate, colonoscopy uptake, positive predictive value (PPV) and detection rate across the SES groups. Results Participation to FIT screening was significantly lower for Quintile 5 (67.0%) compared to the other Quintiles (73.0% to 75.1%; adjusted OR quintile 5 versus quintile 1: 0.73, 95%CI: 0.72–0.74), as well as colonoscopy uptake after a positive FIT (adjusted OR 0.73, 95%CI: 0.69–0.77). The detection rate per FIT participant for advanced neoplasia gradually increased from 3.3% in Quintile 1 to 4.0% in Quintile 5 (adjusted OR 1.20%, 95%CI 1.16–1.24). As a result of lower participation, the yield per invitee was similar for Quintile 5 (2.04%) and Quintile 1 (2.00%), both being lower than Quintiles 2 to 4 (2.20%-2.28%). Conclusions Screening has the potential to reduce health inequalities in CRC mortality, because of a higher detection in participants with a lower SES. However, in the Dutch screening programme, this is currently offset by the lower participation in this group.
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Affiliation(s)
| | - Esther Toes-Zoutendijk
- Department of Public Health, Erasmus MC University Medical Center, Rotterdam, The Netherlands
- * E-mail:
| | - Manon C. W. Spaander
- Department of Gastroenterology and Hepatology, Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | - Evelien Dekker
- Department of Gastroenterology and Hepatology, Academic Medical Center, Academic University Medical Centers, Amsterdam, The Netherlands
| | - Johannes M. G. Bonfrer
- Department of Clinical Chemistry, Netherlands Cancer Institute–Antoni van Leeuwenhoek Hospital, Amsterdam, The Netherlands
| | - Anneke J. van Vuuren
- Department of Pathology, Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | - Ernst J. Kuipers
- Department of Gastroenterology and Hepatology, Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | | | - M. F. van Velthuysen
- Department of Pathology, Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | - Maarten G. J. Thomeer
- Department of Radiology, Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | - Harriët van Veldhuizen
- Department of Quality Improvement, Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | - Harry J. de Koning
- Department of Public Health, Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | - Iris Lansdorp-Vogelaar
- Department of Public Health, Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | - Monique E. van Leerdam
- Department of Gastroenterology and Hepatology, Netherlands Cancer Institute–Antoni van Leeuwenhoek Hospital, Amsterdam, The Netherlands
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Lofters AK, Baker NA, Corrado AM, Schuler A, Rau A, Baxter NN, Leung FH, Weyman K, Kiran T. Care in the Community: Opportunities to improve cancer screening uptake for people living with low income. Prev Med Rep 2022; 24:101622. [PMID: 34976677 PMCID: PMC8684029 DOI: 10.1016/j.pmedr.2021.101622] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2021] [Revised: 08/11/2021] [Accepted: 10/23/2021] [Indexed: 11/16/2022] Open
Abstract
Despite organized provincial cancer screening programs, people living with low income consistently have lower rates of screening in Ontario, Canada than their more socioeconomically advantaged peers. We previously published results of a two-phase, exploratory qualitative study involving both interviews and focus groups whose objective was to integrate knowledge of people living with low income on how to improve primary care strategies aimed at increasing cancer screening uptake. In the current paper, we report previously unpublished findings from that study that identify how taking a community outreach approach in primary care may lead to increased cancer screening uptake among people living with low income. Participants told us that they saw value in a community outreach approach to cancer screening. They recommended specific actionable approaches, in particular, mobile community-based screening and community information sessions, and recommended taking an ethno-specific lens depending on the communities being targeted. Participants expressed a desire for primary care providers to go out into the community to learn more about the whole patient, such as could be achieved with home visits, but they simultaneously believed that this may be challenging in urban settings and in the context of perceived physician shortages. Models of primary care that provide support to an entire local community and provide some of their services directly in that community may have a meaningful impact on cancer screening for socially marginalized groups.
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Affiliation(s)
- Aisha K Lofters
- Peter Gilgan Centre for Women's Cancers, Women's College Hospital, Toronto, ON M5S 2B1, Canada.,MAP Centre for Urban Health Solutions, Li Ka Shing Knowledge Institute, St. Michael's Hospital, 30 Bond Street, Toronto, ON M5B 1W8, Canada.,Department of Family and Community Medicine, University of Toronto, 500 University Avenue, Toronto, ON M5G 1V7, Canada.,ICES, 2075 Bayview Avenue, Toronto, ON M4N 3M5, Canada.,Dalla Lana School of Public Health, 155 College Street, Health Science Building 6th floor, Toronto, ON M5T 3M7, Canada.,Ontario Health (Cancer Care Ontario), 620 University Avenue, Toronto, ON M5G 2L7, Canada
| | - Natalie Alex Baker
- Dalla Lana School of Public Health, 155 College Street, Health Science Building 6th floor, Toronto, ON M5T 3M7, Canada.,Applied Health Research Centre, Li Ka Shing Knowledge Institute, St. Michael's Hospital, 30 Bond Street, Toronto, ON M5B 1W8, Canada
| | - Ann Marie Corrado
- Peter Gilgan Centre for Women's Cancers, Women's College Hospital, Toronto, ON M5S 2B1, Canada
| | - Andree Schuler
- MAP Centre for Urban Health Solutions, Li Ka Shing Knowledge Institute, St. Michael's Hospital, 30 Bond Street, Toronto, ON M5B 1W8, Canada.,Department of Family and Community Medicine, St. Michael's Hospital, 30 Bond Street, Toronto, ON M5B 1W8, Canada
| | - Allison Rau
- Applied Health Research Centre, Li Ka Shing Knowledge Institute, St. Michael's Hospital, 30 Bond Street, Toronto, ON M5B 1W8, Canada
| | - Nancy N Baxter
- Melbourne School of Population and Global Health, University of Melbourne, Australia.,Department of Surgery, University of Toronto, Toronto, ON M5B 1W8, Canada.,Institute of Health Policy, Management and Evaluation, 155 College Street, Health Science Building 6th floor, Toronto, ON M5T 3M6, Canada
| | - Fok-Han Leung
- Department of Family and Community Medicine, University of Toronto, 500 University Avenue, Toronto, ON M5G 1V7, Canada.,Department of Family and Community Medicine, St. Michael's Hospital, 30 Bond Street, Toronto, ON M5B 1W8, Canada
| | - Karen Weyman
- Department of Family and Community Medicine, University of Toronto, 500 University Avenue, Toronto, ON M5G 1V7, Canada.,Department of Family and Community Medicine, St. Michael's Hospital, 30 Bond Street, Toronto, ON M5B 1W8, Canada
| | - Tara Kiran
- MAP Centre for Urban Health Solutions, Li Ka Shing Knowledge Institute, St. Michael's Hospital, 30 Bond Street, Toronto, ON M5B 1W8, Canada.,Department of Family and Community Medicine, University of Toronto, 500 University Avenue, Toronto, ON M5G 1V7, Canada.,ICES, 2075 Bayview Avenue, Toronto, ON M4N 3M5, Canada.,Department of Family and Community Medicine, St. Michael's Hospital, 30 Bond Street, Toronto, ON M5B 1W8, Canada.,Institute of Health Policy, Management and Evaluation, 155 College Street, Health Science Building 6th floor, Toronto, ON M5T 3M6, Canada
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7
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Hajizadeh M, Charles M, Johnston GM, Urquhart R. Socioeconomic inequalities in colorectal cancer incidence in Canada: trends over two decades. Cancer Causes Control 2021; 33:193-204. [PMID: 34779993 DOI: 10.1007/s10552-021-01518-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2021] [Accepted: 11/02/2021] [Indexed: 11/28/2022]
Abstract
PURPOSE Colorectal cancer is the third most commonly diagnosed cancer in Canada. This study aimed to measure and examine trends in socioeconomic inequalities in the incidence of colorectal cancer in Canada. METHODS This study is a time trend ecological study based on Canadian Census Division level data constructed from the Canadian Cancer Registry, Canadian Census of Population, and National Household Survey. We assessed trends in income and education inequalities in colorectal cancer incidence in Canada from 1992 to 2010. The age-standardized Concentration index ([Formula: see text]), which measures inequality across all socioeconomic groups, was used to quantify socioeconomic inequalities in colorectal cancer incidence in Canada. RESULTS The average crude colorectal cancer incidence was found to be 61.52 per 100,000 population over the study period, with males having a higher incidence rate than females (males: 66.98; females: 56.25 per 100,000 population). The crude incidence increased over time and varied by province. The age-standardized C indicated a higher concentration of colorectal cancer incidence among lower income and less-educated neighborhoods in Canada. Income and education inequalities increased over time among males. CONCLUSION The concentration of colorectal cancer incidence in low socioeconomic neighborhoods in Canada has implications for primary prevention and screening.
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Affiliation(s)
- Mohammad Hajizadeh
- School of Health Administration, Faculty of Health, Dalhousie University, Sir Charles Tupper Medical Building, 5850 College Street, 2nd Floor, Halifax, NS, B3H 4R2, Canada.
| | - Marie Charles
- Faculty of Medicine, Dalhousie University, Halifax, Canada
| | - Grace M Johnston
- Cancer Care Program, Nova Scotia Health, School of Health Administration, Dalhousie University, Halifax, Canada
| | - Robin Urquhart
- Department of Community Health and Epidemiology, Faculty of Medicine, Dalhousie University, Halifax, Canada
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8
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Tran TN, Van Hal G, Peeters M, Jidkova S, De Schutter H, Hoeck S. Population-Based Data Reveal Factors Associated with Organised and Non-Organised Colorectal Cancer Screening: An Important Step towards Improving Coverage. Int J Environ Res Public Health 2021; 18:8373. [PMID: 34444122 DOI: 10.3390/ijerph18168373] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/23/2021] [Revised: 08/02/2021] [Accepted: 08/05/2021] [Indexed: 02/05/2023]
Abstract
We investigated factors associated with organised and non-organised colorectal cancer screening using faecal occult blood tests, based on data from 308 municipalities in Flanders (6.6 million residents, 57% of Belgium) during 2015-2017. Logistic regression with generalized estimating equations was used to assess the associations between municipal characteristics and organised and non-organised screening coverages. Factors associated negatively with both organised and non-organised screening: percentage of people aged 70-74 in the target population [OR (odds ratios) = 0.98, 95%CI (confidence interval): 0.97-0.99 and OR = 0.98, 95%CI: 0.96-0.999, respectively]; negatively with organised screening: average income [OR = 0.97, 95%CI: 0.96-0.98], percentage of people with a non-Belgian/Dutch nationality [OR = 0.962, 95%CI: 0.957-0.967]; positively with organised screening: percentages of men in the target population [OR = 1.13, 95%CI: 1.11-1.14], jobseekers [OR = 1.12, 95%CI: 1.09-1.15] and people with at least one general practitioner (GP) visit in the last year [OR = 1.04, 95%CI: 1.03-1.05]; positively with non-organised screening: number of patients per GP [OR = 1.021, 95%CI: 1.016-1.026], percentage of people with a global medical dossier handled by a preferred GP [OR = 1.025, 95%CI: 1.018-1.031]. This study helps to identify the hard-to-reach subpopulations in CRC screening, and highlights the important role of GPs in the process of promoting screening among non-participants and encouraging non-organised participants to switch to organised screening.
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Decker KM, Lambert P, Nugent Z, Biswanger N, Samadder J, Singh H. Time Trends in the Diagnosis of Colorectal Cancer With Obstruction, Perforation, and Emergency Admission After the Introduction of Population-Based Organized Screening. JAMA Netw Open 2020; 3:e205741. [PMID: 32453385 PMCID: PMC7251446 DOI: 10.1001/jamanetworkopen.2020.5741] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
IMPORTANCE Up to 30% of patients with a diagnosis of colorectal cancer (CRC) present as an emergency (an intestinal obstruction, perforation, or emergency hospital admission) (OPE). There are limited data about the association of organized, population-based colorectal cancer screening with the rate of emergency presentations. OBJECTIVE To examine the association of CRC screening with OPE at cancer diagnosis and time trends in the rate of OPE after the start of organized CRC screening using a highly sensitive fecal occult blood test. DESIGN, SETTING, AND PARTICIPANTS A historical cohort study was conducted among 1861 individuals 52 to 74 years of age with a diagnosis of CRC from January 1, 2007, to December 31, 2015, who lived in Winnipeg, Manitoba, a province with universal health care and an organized CRC screening program. Statistical analysis was performed from January 22, 2019, to February 26, 2020. EXPOSURES Variables included prior CRC screening, era of diagnosis, cancer stage at diagnosis, tumor site in the colon, area level mean household income, primary care continuity of care, and comorbidity. MAIN OUTCOMES AND MEASURES The primary outcomes were defined as an OPE. Logistic regression was used to evaluate factors associated with OPE at CRC diagnosis. Trends over time were calculated using Joinpoint Regression. RESULTS From 2007 to 2015, 1861 individuals 52 to 74 years of age (1133 men; median age, 65.1 years [interquartile range, 60.0-70.3 years]) received a diagnosis of CRC in Winnipeg. Most individuals had good continuity of care and moderate comorbidities. Overall, 345 individuals (18.5%) had an OPE. The rate of emergency hospital admissions decreased significantly from 2007 (the start of the organized, province-wide CRC screening program) to 2015 (annual change, -7.1%; 95% CI, -11.3% to -2.8%; P = .01). There was no change in the rate of obstructions or perforations or stage IV CRCs. Individuals who were up to date for CRC screening were significantly less likely to receive a diagnosis of an OPE (odds ratio, 0.38; 95% CI, 0.28-0.50; P < .001). The results were similar after adding emergency department visits and stage IV CRC at diagnosis to the outcome. CONCLUSIONS AND RELEVANCE This study suggests that the rate of emergency hospital admissions decreased over time for individuals who underwent CRC screening, but there was no change in the rate of obstructions and perforations. Individuals who were up to date for CRC screening were less likely to have a CRC diagnosis with an OPE.
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Affiliation(s)
- Kathleen M. Decker
- Department of Community Health Sciences, University of Manitoba, Winnipeg, Manitoba
- Research Institute in Oncology and Hematology, CancerCare Manitoba, Winnipeg, Manitoba
- Epidemiology and Cancer Registry, CancerCare Manitoba, Winnipeg, Manitoba
| | - Pascal Lambert
- Epidemiology and Cancer Registry, CancerCare Manitoba, Winnipeg, Manitoba
| | - Zoann Nugent
- Epidemiology and Cancer Registry, CancerCare Manitoba, Winnipeg, Manitoba
- Department of Internal Medicine, University of Manitoba, Winnipeg, Manitoba
| | - Natalie Biswanger
- Epidemiology and Cancer Registry, CancerCare Manitoba, Winnipeg, Manitoba
| | - Jewel Samadder
- Division of Gastroenterology and Hepatology, Department of Medicine, Mayo Clinic, Phoenix, Arizona
- Department of Medicine, University of Utah, Salt Lake City
| | - Harminder Singh
- Department of Community Health Sciences, University of Manitoba, Winnipeg, Manitoba
- Research Institute in Oncology and Hematology, CancerCare Manitoba, Winnipeg, Manitoba
- Department of Internal Medicine, University of Manitoba, Winnipeg, Manitoba
- Medical Oncology and Hematology, CancerCare Manitoba, Winnipeg, Manitoba
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Decker K, Moineddin R, Kendell C, Urquhart R, Biswanger N, Groome P, McBride ML, Winget M, Whitehead M, Grunfeld E. Changes in primary care provider utilization by phase of care for women diagnosed with breast cancer: a CanIMPACT longitudinal cohort study. BMC Fam Pract 2019; 20:161. [PMID: 31752693 PMCID: PMC6873454 DOI: 10.1186/s12875-019-1052-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 07/18/2019] [Accepted: 11/15/2019] [Indexed: 12/14/2022]
Abstract
BACKGROUND Primary care providers (PCPs) have always played an important role in cancer diagnosis. There is increasing awareness of the importance of their role during treatment and survivorship. We examined changes in PCP utilization from pre-diagnosis to survival for women diagnosed with breast cancer, factors associated with being a high user of primary care, and variation across four Canadian provinces. METHODS The cohorts included women 18+ years of age diagnosed with stage I-III invasive breast cancer in years 2007-2012 in British Columbia (BC), Manitoba (MB), Ontario (ON), and Nova Scotia (NS) who had surgery plus adjuvant chemotherapy and were alive 30+ months after diagnosis (N = 19,589). We compared the rate of PCP visits in each province across phases of care (pre-diagnosis, diagnosis, treatment, and survival years 1 to 4). RESULTS PCP use was greatest during treatment and decreased with each successive survival year in all provinces. The unadjusted difference in PCP use between treatment and pre-diagnosis was most pronounced in BC where PCP use was six times higher during treatment than pre-diagnosis. Factors associated with being a high user of primary care during treatment included comorbidity and being a high user of care pre-diagnosis in all provinces. These factors were also associated with being a higher user of care during diagnosis and survival. CONCLUSIONS Contrary to the traditional view that PCPs focus primarily on cancer prevention and early detection, we found that PCPs are involved in the care of women diagnosed with breast cancer across all phases of care.
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Affiliation(s)
- K. Decker
- CancerCare Manitoba, 675 McDermot Avenue, Winnipeg, Manitoba R0E 0V9 Canada
- University of Manitoba, 750 Bannatyne Avenue, Winnipeg, Manitoba R3E 0W2 Canada
| | - R. Moineddin
- University of Toronto, 500 University Avenue, Toronto, Ontario M5G 1V7 Canada
| | - C. Kendell
- Dalhousie University, 1276 South Park Street, Halifax, Nova Scotia B3H 2Y9 Canada
- Nova Scotia Health Authority, 1276 South Park Street, Halifax, Nova Scotia B3H 2Y9 Canada
| | - R. Urquhart
- Dalhousie University, 1276 South Park Street, Halifax, Nova Scotia B3H 2Y9 Canada
| | - N. Biswanger
- CancerCare Manitoba, 675 McDermot Avenue, Winnipeg, Manitoba R0E 0V9 Canada
| | - P. Groome
- Queen’s University, 62 Fifth Field Company Lane, Kingston, Ontario K7L 3N6 Canada
| | - M. L. McBride
- BC Cancer Agency, 686 West Broadway, Suite 500, Vancouver, British Columbia V5Z 1G1 Canada
| | - M. Winget
- Stanford University, 1265 Welch Road, Stanford, California, 94305 USA
| | - M. Whitehead
- Queen’s University, 62 Fifth Field Company Lane, Kingston, Ontario K7L 3N6 Canada
| | - E. Grunfeld
- University of Toronto, 500 University Avenue, Toronto, Ontario M5G 1V7 Canada
- Ontario Institute for Cancer Research, 661 University Avenue, Suite 510, Toronto, Ontario M5G 0A3 Canada
| | - for the Canadian Team to Improve Community-Based Cancer Care Along the Continuum (CanIMPACT)
- CancerCare Manitoba, 675 McDermot Avenue, Winnipeg, Manitoba R0E 0V9 Canada
- University of Manitoba, 750 Bannatyne Avenue, Winnipeg, Manitoba R3E 0W2 Canada
- University of Toronto, 500 University Avenue, Toronto, Ontario M5G 1V7 Canada
- Dalhousie University, 1276 South Park Street, Halifax, Nova Scotia B3H 2Y9 Canada
- Nova Scotia Health Authority, 1276 South Park Street, Halifax, Nova Scotia B3H 2Y9 Canada
- Queen’s University, 62 Fifth Field Company Lane, Kingston, Ontario K7L 3N6 Canada
- BC Cancer Agency, 686 West Broadway, Suite 500, Vancouver, British Columbia V5Z 1G1 Canada
- Stanford University, 1265 Welch Road, Stanford, California, 94305 USA
- Ontario Institute for Cancer Research, 661 University Avenue, Suite 510, Toronto, Ontario M5G 0A3 Canada
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James PD, Rabeneck L, Yun L, Paszat L, Baxter NN, Govindarajan A, Antonova L, Tinmouth JM. Repeated faecal occult blood testing is associated with decreased advanced colorectal cancer risk: A population-based study. J Med Screen 2017; 25:141-148. [PMID: 28862521 DOI: 10.1177/0969141317718860] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
OBJECTIVE To evaluate the association between repeated faecal occult blood testing and advanced colorectal cancer risk at population level in Canada. METHODS A retrospective cohort study of all Ontario residents aged 56-74 diagnosed with colorectal cancer from 1 April 2007 to 31 March 2010, identified using health administrative data. The primary outcome was stage IV colorectal cancer, and primary exposure was faecal occult blood testing use within five years prior to colorectal cancer diagnosis. Patients were categorized into four mutually exclusive groups based on their exposure to faecal occult blood testing in the five years prior to colorectal cancer diagnosis: none, pre-diagnostic, repeated, and sporadic. Logistic regression was utilized to adjust for confounders. RESULTS Of 7753 patients (median age 66, interquartile range 61-70, 62% male) identified, 1694 (22%) presented with stage I, 2056 (27%) with stage II, 2428 (31%) with stage III, and 1575 (20%) with stage IV colorectal cancer. There were 4092 (53%) with no record of prior faecal occult blood testing, 1485 (19%) classified as pre-diagnostic, 1693 (22%) as sporadic, and 483 (6%) as repeated faecal occult blood testing. After adjusting for confounders, patients who had repeated faecal occult blood testing were significantly less likely to present with stage IV colorectal cancer at diagnosis (Odds ratio 0.46, 95% Confidence Interval 0.34-0.62) than those with no prior faecal occult blood testing. CONCLUSIONS Repeated faecal occult blood testing is associated with a decreased risk of advanced colorectal cancer. Our findings support the use of organized screening programmes that employ repeated faecal occult blood testing to improve colorectal cancer outcomes at population level.
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Affiliation(s)
- Paul D James
- 1 The Ottawa Health Research Institute and Department of Medicine, University of Ottawa, Ottawa, Canada.,2 Department of Medicine, University of Toronto, Toronto, Ontario, Canada.,3 Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada
| | - Linda Rabeneck
- 2 Department of Medicine, University of Toronto, Toronto, Ontario, Canada.,3 Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada.,4 Prevention and Cancer Control, Cancer Care Ontario, Toronto, Ontario, Canada.,7 Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada.,8 Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
| | - Lingsong Yun
- 3 Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada
| | - Lawrence Paszat
- 2 Department of Medicine, University of Toronto, Toronto, Ontario, Canada.,3 Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada
| | - Nancy N Baxter
- 2 Department of Medicine, University of Toronto, Toronto, Ontario, Canada.,3 Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada.,4 Prevention and Cancer Control, Cancer Care Ontario, Toronto, Ontario, Canada.,5 Department of Surgery, University of Toronto, Toronto, Ontario, Canada.,6 Li Ka Shing Research Institute, St. Michael's Hospital, Toronto, Ontario, Canada
| | - Anand Govindarajan
- 3 Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada.,5 Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Lilia Antonova
- 1 The Ottawa Health Research Institute and Department of Medicine, University of Ottawa, Ottawa, Canada
| | - Jill M Tinmouth
- 2 Department of Medicine, University of Toronto, Toronto, Ontario, Canada.,3 Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada.,4 Prevention and Cancer Control, Cancer Care Ontario, Toronto, Ontario, Canada.,9 Sunnybrook Research Institute, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
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Lofters AK, Schuler A, Slater M, Baxter NN, Persaud N, Pinto AD, Kucharski E, Davie S, Nisenbaum R, Kiran T. Using self-reported data on the social determinants of health in primary care to identify cancer screening disparities: opportunities and challenges. BMC Fam Pract 2017; 18:31. [PMID: 28241787 PMCID: PMC5330155 DOI: 10.1186/s12875-017-0599-z] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/06/2016] [Accepted: 02/09/2017] [Indexed: 12/13/2022]
Abstract
Background Data on the social determinants of health can help primary care practices target improvement efforts, yet relevant data are rarely available. Our family practice located in Toronto, Ontario routinely collects patient-level sociodemographic data via a pilot-tested survey developed by a multi-organizational steering committee. We sought to use these data to assess the relationship between the social determinants and colorectal, cervical and breast cancer screening, and to describe the opportunities and challenges of using data on social determinants from a self-administered patient survey. Methods Patients of the family practice eligible for at least one of the three cancer screening types, based on age and screening guidelines as of June 30, 2015 and who had answered at least one question on a socio-demographic survey were included in the study. We linked self-reported data from the sociodemographic survey conducted in the waiting room with patients’ electronic medical record data and cancer screening records. We created an individual-level income variable (low-income cut-off) that defined a poverty threshold and took household size into account. The sociodemographic characteristics of patients who were overdue for screening were compared to those who were up-to-date for screening for each cancer type using chi-squared tests. Results We analysed data for 5766 patients for whom we had survey data. Survey participants had significantly higher screening rates (72.9, 78.7, 74.4% for colorectal, cervical and breast cancer screening respectively) than the 13, 036 patients for whom we did not have survey data (59.2, 65.3, 58.9% respectively). Foreign-born patients were significantly more likely to be up-to-date on colorectal screening than their Canadian-born peers but showed no significant differences in breast or cervical cancer screening. We found a significant association between the low-income cut-off variable and cancer screening; neighbourhood income quintile was not significantly associated with cancer screening. Housing status was also significantly associated with colorectal, cervical and breast cancer screening. There was a large amount of missing data for the low-income cut-off variable, approximately 25% across the three cohorts. Conclusion While we were able to show that neighbourhood income might under-estimate income-related disparities in screening, individual-level income was also the most challenging variable to collect. Future work in this area should target the income disparity in cancer screening and simultaneously explore how best to collect measures of poverty. Electronic supplementary material The online version of this article (doi:10.1186/s12875-017-0599-z) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- A K Lofters
- Department of Family & Community Medicine, St. Michael's Hospital, 30 Bond Street, Toronto, ON, M5B 1W8, Canada. .,Department of Family & Community Medicine, University of Toronto, 500 University Avenue, 5th Floor, Toronto, ON, M5G 1V7, Canada. .,Centre for Urban Health Solutions, Li Ka Shing Knowledge Institute, St. Michael's Hospital, 30 Bond Street, Toronto, ON, M5B 1W8, Canada. .,Dalla Lana School of Public Health, University of Toronto, Health Sciences Building, 155 College Street, 6th Floor, Toronto, ON, M5T 3M7, Canada. .,Institute for Clinical Evaluative Sciences, 2075 Bayview Avenue, Toronto, Ontario, M4N 3M5, Canada.
| | - A Schuler
- Department of Family & Community Medicine, St. Michael's Hospital, 30 Bond Street, Toronto, ON, M5B 1W8, Canada.,Centre for Urban Health Solutions, Li Ka Shing Knowledge Institute, St. Michael's Hospital, 30 Bond Street, Toronto, ON, M5B 1W8, Canada
| | - M Slater
- Department of Family & Community Medicine, St. Michael's Hospital, 30 Bond Street, Toronto, ON, M5B 1W8, Canada
| | - N N Baxter
- Dalla Lana School of Public Health, University of Toronto, Health Sciences Building, 155 College Street, 6th Floor, Toronto, ON, M5T 3M7, Canada.,Department of Surgery, Li Ka Shing Knowledge Institute, St. Michael's Hospital, 30 Bond Street, Toronto, ON, M5B 1W8, Canada
| | - N Persaud
- Department of Family & Community Medicine, St. Michael's Hospital, 30 Bond Street, Toronto, ON, M5B 1W8, Canada.,Department of Family & Community Medicine, University of Toronto, 500 University Avenue, 5th Floor, Toronto, ON, M5G 1V7, Canada.,Centre for Urban Health Solutions, Li Ka Shing Knowledge Institute, St. Michael's Hospital, 30 Bond Street, Toronto, ON, M5B 1W8, Canada
| | - A D Pinto
- Department of Family & Community Medicine, St. Michael's Hospital, 30 Bond Street, Toronto, ON, M5B 1W8, Canada.,Department of Family & Community Medicine, University of Toronto, 500 University Avenue, 5th Floor, Toronto, ON, M5G 1V7, Canada.,Centre for Urban Health Solutions, Li Ka Shing Knowledge Institute, St. Michael's Hospital, 30 Bond Street, Toronto, ON, M5B 1W8, Canada.,Dalla Lana School of Public Health, University of Toronto, Health Sciences Building, 155 College Street, 6th Floor, Toronto, ON, M5T 3M7, Canada
| | - E Kucharski
- Cancer Care Ontario, 620 University Avenue, Toronto, ON, M5G 2L7, Canada
| | - S Davie
- Department of Family & Community Medicine, St. Michael's Hospital, 30 Bond Street, Toronto, ON, M5B 1W8, Canada
| | - R Nisenbaum
- Centre for Urban Health Solutions, Li Ka Shing Knowledge Institute, St. Michael's Hospital, 30 Bond Street, Toronto, ON, M5B 1W8, Canada.,Dalla Lana School of Public Health, University of Toronto, Health Sciences Building, 155 College Street, 6th Floor, Toronto, ON, M5T 3M7, Canada
| | - T Kiran
- Department of Family & Community Medicine, St. Michael's Hospital, 30 Bond Street, Toronto, ON, M5B 1W8, Canada.,Department of Family & Community Medicine, University of Toronto, 500 University Avenue, 5th Floor, Toronto, ON, M5G 1V7, Canada.,Centre for Urban Health Solutions, Li Ka Shing Knowledge Institute, St. Michael's Hospital, 30 Bond Street, Toronto, ON, M5B 1W8, Canada.,Institute for Clinical Evaluative Sciences, 2075 Bayview Avenue, Toronto, Ontario, M4N 3M5, Canada
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