Social determinants and participation in fecal occult blood test based colorectal cancer screening: A qualitative systematic review and meta-synthesis

ISSUE ADDRESSED

Colorectal cancer (CRC) screening through fecal occult blood testing (FOBT) has saved thousands of lives globally with multiple countries adopting comprehensive population wide screening programs. Participation rates in FOBT based CRC screening for the socially and economically disadvantaged remains low. The aim of this systematic review is to explore empirical evidence that will guide targeted interventions to improve participation rates within priority populations.

METHODS

PubMed, Embase, Scopus, Cinahl and PsycInfo were systematically searched from inception to 22 June 2022. Eligible studies contained qualitative evidence identifying barriers to FOBT based CRC screening for populations impacted by the social determinants of health. An inductive thematic synthesis approach was applied using grounded theory methodology, to explore descriptive themes and interpret these into higher order analytical constructs and theories.

RESULTS

A total of 8,501 publications were identified and screened. A total of 48 studies from 10 countries were eligible for inclusion, representing 2,232 subjects. Coding within included studies resulted in 30 key descriptive themes with a thematic frequency greater than 10%. Coded themes applied to four overarching, interconnected barriers driving inequality for priority populations: social, behavioural, economic and technical/interfaces. SO WHAT?: This study has highlighted the need for stronger patient/provider relationships to mitigate barriers to FOBT screening participation for diverse groups. Findings can assist health professionals and policy makers address the systemic exclusion of priority populations in cancer screening by moving beyond the responsibility of the individual to a focus on addressing the information asymmetry driving low value perceptions.

Recognition and participation of colorectal cancer screening in Turkiye: A systematic review and meta-analysis study

Colorectal cancers (CRCs) have an important share in the prevalence and mortality among all cancers. It was aimed to make a systematic review and meta-analysis of researches about the prevalence of knowing fecal occult blood test (FOBT) and colonoscopy, which are among the CRC screening methods, and the prevalence of having these tests at any time in life. A literature search using five different databases were screened both in Turkish and English language and a total of 1176 studies were reached. Of these, 22 studies were selected to be included in this study. In the evaluation of the researches included in the study, the studies were read in a way to look for answers to PICOS questions. Open Meta-analyst demo program and random effects model was used. The prevalence rate and 95% confidence interval of knowing and having FOBT and colonoscopy were calculated. According to the meta-analysis results, the prevalence of knowing the FOBT among the CRC screening tests was 19.3%, the prevalence of having the FOBT was 13.2%, the prevalence of knowing colonoscopy was 31.7%, and the prevalence of having colonoscopy was 10.0%. As a conclusion prevalence of knowing and having FOBT and colonoscopy was low in risky individuals in Turkiye.

Knowledge, Compliance, and Inequities in Colon Cancer Screening in Spain: An Exploratory Study

In Spain, inequities exist in implementing colorectal cancer (CRC) tests with the target population-adults aged 50 to 69-as part of population-based CRC screening programs. This research aims to further our understanding of the target population's awareness, attitudes, and perceptions of these test-based screening programs. A survey was carried out using an online panel representative of the target population, with a sample collected from 5313 individuals. Data collection took place in June 2022. Descriptive and bivariate analyses were carried out using contingency tables, the Chi-square test, and Cramer's V statistics. The sample was also segmented based on key variables. Finally, the results were analyzed using logistic regression. In the sample population, 62.5% had taken the fecal occult blood test (FOBT), 72.5% reported receiving the invitation letter to participate in the screening program, and 86.8% had prior knowledge of the FOBT. Noncompliance was mainly due to lack of symptoms (40%), non-receipt of invitation letters (39.7%), and forgetfulness or neglect (28.5%). On the contrary, receipt of the letter of invitation (OR 7.35, p < 0.01) and prior knowledge of FOBT (OR 6.32, p < 0.01) were the main variables that increased the probability of test uptake. Other significant variables included frequency of primary care visits (OR 1.71, p < 0.01) and being older (65-69 years old) (OR 1.52, p < 0.01) There is still a pressing need for greater awareness of both CRC risk factors and the benefits of early detection, as well as for overcoming the common misconception that detection should only be sought when symptoms are present.

Evaluating changes to home bowel cancer screening kits: an end-user perspective study

PURPOSE

Many people do not participate in mail-out bowel cancer screening programs due to difficulties using the screening kit. The current study investigated the ways the screening kit could be modified to improve usability.

METHODS

1,109 people evaluated 15 different screening kit modifications. Participants reported on how these kit modifications would affect their screening barriers, their future screening intentions, and how much they would recommend that the modification is made to the current screening kit used the program. All responses were given via an online survey conducted between April and December of 2021.

RESULTS

Seventeen percent of previous NBCSP non-participators indicated that a one-sample test would increase their intention to participate. Recommendation ratings demonstrated higher levels of support for modifications that included providing a barcode naming label (M = 9.06, 95% CI [8.81, 9.31]), having a larger diameter opening of the collection tube (M = 8.42, 95% CI [8.10, 8.74]), and highlighting the expiry date on the kit packaging (M = 8.59, 95% CI [8.29, 8.89]). There were lower levels of support for modifications that reduced the size of the packaging the kit is sent in (M = 6.47, 95% CI [6.09, 6.85]), removed branding from kit packaging (M = 5.98, 95% CI [5.57, 6.39]), and removed the information booklet that comes with the screening kit (M = 5.25, 95% CI [4.78, 5.72]).

CONCLUSION

These findings highlight multiple ways in which bowel cancer screening kits can be changed to increase usability for invitees of national bowel cancer screening programs. Findings have implications for all screening programs that use immunochemical-based bowel cancer screening kits.

Improving colorectal cancer screening - consumer-centred technological interventions to enhance engagement and participation amongst diverse cohorts

The current "Gold Standard" colorectal cancer (CRC) screening approach of faecal occult blood test (FOBT) with follow-up colonoscopy has been shown to significantly improve morbidity and mortality, by enabling the early detection of disease. However, its efficacy is predicated on high levels of population participation in screening. Several international studies have shown continued low rates of screening participation, especially amongst highly vulnerable lower socio-economic cohorts, with minimal improvement using current recruitment strategies. Research suggests that a complex of dynamic factors (patient, clinician, and the broader health system) contribute to low citizen engagement. This paper argues that the challenges of screening participation can be better addressed by (1) developing dynamic multifaceted technological interventions collaboratively across stakeholders using human-centered design; (2) integrating consumer-centred artificial intelligence (AI) technologies to maximise ease of use for CRC screening; and (3) tailored strategies that maximise population screening engagement, especially amongst the most vulnerable.

A True Positive and a False Negative? The Dilemma of Negative Colonoscopy After a Positive Fecal Occult Blood Test

INTRODUCTION

Many colonoscopies following a positive fecal immunochemical test (FIT) will not identify a probable cause for fecal blood, and missed neoplasia is a concern. The study determined whether the absence of neoplasia at a FIT positive diagnostic colonoscopy was due to a missed lesion and whether the initial FIT hemoglobin (f-Hb) concentration could predict missed lesions.

METHODS

This was a retrospective audit of patients who had undergone diagnostic colonoscopy after FIT screening (2 sample ≥ 20 µg Hb/g feces). Probable bleeding lesions including cancer, advanced adenoma, colitis, and angiodysplasia were considered a "positive colonoscopy outcome." For those with a negative outcome, findings at the subsequent colonoscopy were assessed.

RESULTS

There were 1087 good quality colonoscopies within 12 months of a positive FIT. In total, 171 (15.7%) patients had a positive outcome at the diagnostic colonoscopy. Subsequent colonoscopies of negative outcome cases (n = 418, median of 3.1y later) were reviewed; of these, there were 57 (13.6%) cases with a positive outcome. This included CRC in 0.5% (n = 2) and advanced adenoma in 11.7% (n = 49). High f-Hb and having both FIT samples ≥ 20 µg/g feces were associated with a positive outcome at the original diagnostic colonoscopy (p < 0.05). However, f-Hb was not predictive for a positive outcome at the subsequent colonoscopy by either maximum f-Hb (p = 0.768), total f-Hb (p = 0.459), or both FIT samples ≥ 20 µg/g (p = 0.091).

CONCLUSION

A small proportion of "false" positive FIT results had cancer or advanced adenoma found at the subsequent colonoscopy. A missed lesion could not be predicted by the initial FIT f-Hb.

Factors Associated with Colorectal Cancer Screening in Spain: Results of the 2017 National Health Survey

This study aimed to determine the CRC screening coverage of people aged between 50 and 69 years who were living in Spain in 2017 and describe the factors associated with not having had a faecal occult blood test (FOBT). A cross-sectional study was performed using data from the Spanish National Health Survey 2017. We analysed 7568 individuals between the ages of 50 and 69 years. The proportion of respondents between 50 and 69 years old who had had an FOBT was 29.0% (n = 2191). The three autonomous communities with the lowest proportion of respondents who had had an FOBT were Extremadura (8.7%, n = 16), Ceuta-Melilla (10.4%, n = 3), and Andalucia (14.1%, n = 186). The variables associated with not having had an FOBT were being 50-54 years old (PR = 1.09; 95% CI 1.04-1.14), having been born outside of Spain (PR = 1.11; 95% CI 1.06-1.16), not having been vaccinated against the flu (PR = 1.09; 95% CI 1.04-1.15), never having had a colonoscopy (PR = 1.49; 95% CI 1.40-1.59), not having had an ultrasound scan in the last year (PR = 1.09; 95% CI 1.04-1.14), and not having seen a primary care physician in the last month (PR = 1.08; 95% CI 1.04-1.12). The factors associated with not getting an FOBT were young age, having been born outside of Spain, not having been vaccinated against the flu in the last campaign, and not making frequent use of healthcare services.

Mail-out bowel cancer screening: Identifying the behavioural stumbling blocks

OBJECTIVE

To describe the actions taken by recipients of mail-out faecal occult blood test (FOBT) kits and to identify the points at which progress towards kit completion typically stops. Differences according to gender, age, and screening intention were also examined.

METHODS

1599 people completed an online survey identifying the actions they took upon receiving an FOBT kit. Latent class analysis was conducted to identify latent subgroups of participants that reported similar actions. Differences between gender, age, and intention status were assessed using non-invariance testing.

RESULTS

Four latent subgroups of FOBT invitees were identified: those who complete and return their FOBT kit ('completers'); those who bring the kit into their house but go no further ('ignorers'); those who open the package and read the bowel cancer information materials but go no further ('readers'); and those who read the instructions but do not place the kit near the toilet and do not complete their FOBT kit ('leavers'). Non-completers who intended to use the kit were most likely to be in the 'leavers' class, while those who had no intention were most likely to be in the 'readers' class.

CONCLUSIONS

Distinct subgroups of non-responders exist among bowel cancer screening invitees, suggesting different behaviour change interventions are needed to facilitate participation. Some invitees, especially those with high participatory intention, are likely to benefit from prompts to take the kit into the toilet, while others, with little participatory intention, often read the invitation materials presenting an opportunity to intervene with health messages.

Superiority of fecal carcinoembryonic antigen as diagnosis marker for adenomatous polyposis coli and asymptomatic colorectal cancer

BACKGROUND

Non-invasive diagnostic tools of adenomatous polyposis coli (APC) and asymptomatic colorectal cancer (CRC) are urgently needed. Although fecal carcinoembryonic antigen (FCEA) has been documented in some studies, the diagnostic potential for the detection of APC and asymptomatic CRC has not been described yet.

METHODS

This is a retrospective study. The pre-diagnostic serum carcinoembryonic antigen (SCEA) and fecal occult blood test (FOBT) levels were retrospectively analyzed in 212 patients with intestinal diseases group (IDG) and 224 controls. The levels of FCEA across all the studied groups were measured using electronic chemiluminescence immunoassay (ECLIA), and their sensitivity and specificity were used to evaluate their diagnostic potential. The individual diagnostic accuracy of the three indices, as well as their combined diagnostic potential, was compared using the receiver operating characteristic (ROC) curve and chi-square test.

RESULTS

The FCEA had low sensitivity (50%) and high specificity (93.91%) for the diagnosis of IDG, with the area under the curve (AUC) value of 0.781. The AUC of FCEA was higher than that of SCEA for the diagnosis of APC and CRC in the APC, asymptomatic CRC, and APC + CRC-stage I patients. The AUCs of FCEA were 0.708 and 0.691 for the 'double-negative patients' and 'triple-negative patients', respectively. In addition, FCEA could diagnose 45.5% of the 'double-negative' patients, 43.3% of the asymptomatic patients, and 42.9% of the 'triple-negative' patients. The combination of FCEA and FOBT improved the diagnostic value (AUC = 0.916).

CONCLUSION

FCEA has been demonstrated to be a favorable diagnostic marker in intestinal diseases, especially in the APC, asymptomatic CRC, and 'double-negative' or 'triple-negative' CRC patients.

Colonoscopy-Related Mortality in a Fecal Immunochemical Test-Based Colorectal Cancer Screening Program

BACKGROUND & AIMS

Many countries have introduced colorectal cancer (CRC) screening programs with fecal immunochemical tests (FITs), and follow-up colonoscopies for individuals with a positive FIT result. In order to make an informed decision to participate, individuals must be informed about the benefits and harms of FIT-based screening and subsequent colonoscopy. Colonoscopy-related fatal complications in FIT-based screening are understudied. We aimed to estimate the colonoscopy-related mortality in a national FIT-based CRC screening program.

METHODS

Colonoscopy-related mortality within 30 days after colonoscopy was assessed by analysis of data from national endoscopy complication databases in the Netherlands, determining the excess 30-day rate of death in FIT-positive individuals undergoing colonoscopy vs FIT-negative individuals (based on data from the national screening database), and determining the rate of likely colonoscopy-related deaths based on registered causes of death by the Statistics Netherlands.

RESULTS

Between October 2013 and December 2017, 172,797 participants underwent colonoscopy after a positive result from a FIT in the Dutch national CRC screening program; 13,848 participants received a diagnosis of CRC. The reported fatal complication rate was 0.23 per 10,000 FIT-positive participants (or 1 per 43,199; 95% CI, 0.090 - 0.60) undergoing colonoscopy, whereas this was 0.91 per 10,000 FIT-positive participants (or 1 per 10,961; 95% CI, 0.44 - 1.38) according to the excess death rate. Likely colonoscopy-related causes of death were reported in 0.86 per 10,000 FIT-positive participants (or 1 per 11,236; 95% CI, 0.48 - 1.63) who underwent colonoscopy, of which 50% considered cardiovascular events.

CONCLUSIONS

Colonoscopy-related mortality within the Dutch FIT-based CRC screening program was estimated to range from 0.23 to 0.91 per 10,000 FIT-positive participants undergoing colonoscopy. These findings indicate underreporting of fatal complications in registries and a noteworthy incidence of fatal cardiovascular adverse events that requires further investigation. Nevertheless, the harm of FIT-based CRC screening is vastly outweighed by the benefits.

Evaluation of Blood Stool Test Utilization for Colorectal Cancer Screening in Georgia, USA

Colorectal cancer (CRC) is the third most prevalent cancer and the second most common cause of cancer-related deaths in the United States (USA). Early screening has been demonstrated to improve clinical outcomes for CRC. Assessing patterns in CRC screening utilization is important for guiding policy and implementing programs for CRC prevention and control. This study examines the trends and sociodemographic factors associated with blood stool test utilization (BSTU) for CRC screening in Georgia, USA. The Behavioral Risk Factor Surveillance System (BRFSS) data were analyzed for Average Annual Percent Change (AAPC) in BSTU between 1997 and 2014 among adults aged 50+ who have had a blood stool test within the past two years, and logistic regression analysis of the 2016 data was performed to identify the associated sociodemographic factors. In Georgia, an overall decrease was observed in BSTU, from 27.8% in 1997 to 16.1% in 2014 (AAPC = -2.6, p = 0.023). The decrease in BSTU was less pronounced in Georgia than nationally (from 26.1% in 1997 to 12.8% in 2014 (AAPC = -4.5, p < 0.001)). BSTU was significantly associated with black race/ethnicity (Black vs. White (aOR = 1.43, p = 0.015)), older age (≥70 vs. 50-59 (aOR = 1.62, p = 0.006)), having insurance coverage (no vs. yes (aOR = 0.37 p = 0.005)), and lower income (≥USD 50,000 vs. Collapse

Key Words

• FOBT
• Georgia
• USA
• blood stool test
• colorectal cancer
• screening

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MESH Headings Collapse

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Affiliation(s)

Benjamin E. Ansa Institute of Public and Preventive Health, Augusta University, Augusta, GA 30912, USA; (B.D.); (J.A.J.)
Nicollette Lewis Medical College of Georgia, Augusta University, Augusta, GA 30912, USA;
Zachary Hoffman Department of Psychology, Augusta University, Augusta, GA 30912, USA; Transitions of Augusta, Augusta, GA 30912, USA
Biplab Datta Institute of Public and Preventive Health, Augusta University, Augusta, GA 30912, USA; (B.D.); (J.A.J.)
J. Aaron Johnson Institute of Public and Preventive Health, Augusta University, Augusta, GA 30912, USA; (B.D.); (J.A.J.)

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Barriers of colorectal cancer screening test among adults in the Saudi Population: A Cross-Sectional study

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Lack of physician recommendation was commonly reported barrier to CRC screening.

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Barriers to CRC screening were observed more in females.

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Barriers to CRC screening were seen more in those who had not performed CRC screening.

Colorectal cancer (CRC) is the third most common cancer and the second most common cause of cancer death worldwide. CRC can be completely cured if detected at an early stage with screening. However, many barriers to screening have been reported. This study aimed to identify the potential barriers to CRC screening among the Saudi population aged ≥45 years. A cross-sectional study of randomly selected adults (aged ≥45 years) attending primary care clinics at KKUH in Saudi Arabia was conducted. A self-administered questionnaire was used to collect data. A total of 448 participants were included. In general, the most commonly reported barrier to CRC screening was a lack of physician recommendation (77.1%). Moreover, fear of painful colonoscopy procedures and a lack of knowledge regarding the availability of the fecal occult blood test (FOBT) were reported by 51.6% and 57.8% of patients, respectively. Significant gender differences were observed, with females reporting more barriers to CRC screening than males (general barriers [p < 0.001] and colonoscopy-specific barriers [p = 0.003]). Participants who had not undergone any previous CRC screening reported significantly more barriers compared to those who had undergone a previous CRC screening (general barriers [p = 0.015], colonoscopy-specific barriers [p = 0.006], and FOBT specific barriers [p = 0.024]). Because a lack of physician recommendation was the most commonly reported general barrier, we recommend that physicians emphasize the need for CRC screening, particularly to high-risk patients. Extensive campaigns and programs must be launched to raise awareness about the importance of screening for CRC. Additionally, gender-specific strategies need to be formulated to promote CRC screening in females.

Proven Strategies for Increasing Adherence to Colorectal Cancer Screening

Although colorectal cancer (CRC) can be prevented or detected early through screening and surveillance, barriers that lower adherence to screening significantly limit its effectiveness. Therefore, implementation of interventions that address and overcome adherence barriers is critical to efforts to decrease morbidity and mortality from CRC. This article reviews the current available evidence about interventions to increase adherence to CRC screening.

Association between colorectal cancer testing and insurance type: Evidence from the Swiss Health Interview Survey 2012

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Colonoscopy and FOBT are both recommended for colorectal cancer screening.

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Colonoscopy costs much more, so test choice might be linked to insurance type.

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Private insurance and low deductibles were associated with more colonoscopies.

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FOBT, which is cheap, was not associated with private insurance.

Both colonoscopy and fecal occult blood test (FOBT) are commonly used for colorectal cancer (CRC) screening, but colonoscopy costs much more than FOBT. Swiss insurance offers high or low deductibles and choice of basic or private insurance. We hypothesized that high deductibles and basic insurance discourage colonoscopy, but do not change FOBT rates.

We determined the proportion of patients tested for CRC in Switzerland (colonoscopy within 10 years, FOBT within 2 years), and determined associations with health insurance type.

We extracted data on 50–75-year-olds from the Swiss Health Interview Surveys of 2012 to determine colonoscopy and FOBT testing rates (n = 7335). Multivariate logistic regression models estimated prevalence ratios (PRs) of CRC testing associated with health insurance type (deductible and private insurance), adjusted for socio-demographic factors (age, gender, education, income) and self-rated health.

The weighted proportion of individuals tested for CRC within recommended intervals was 39.5%. Testing with colonoscopy was significantly associated with private insurance (PR 1.85, 95% CI: 1.46–2.35) and low deductible (PR 2.00, 95% CI: 1.56–2.57). Testing with FOBT was significantly associated with deductible (PR 1.71, 95%CI:1.09–2.68) but not with private insurance.

About 60% of the Swiss population was not current with CRC testing. After adjusting for covariates, private insurance and low deductible was significantly associated with higher prevalence of CRC testing, indicating that waiving the deductible could increase CRC screening uptake and reduce health inequality.

Long-term risk of colorectal cancer after screen-detected adenoma: Experiences from a Danish gFOBT-positive screening cohort

Fecal occult blood test (FOBT) screening for colorectal cancer (CRC) is implemented in several countries. Approximately half of all FOBT-positive persons have screen-detected adenomas. Despite removal of these, patients with large/multiple adenomas have increased risk of later developing new advanced adenomas and CRC. International guidelines exist for colonoscopic surveillance following adenoma removal. These divide patients into low-, intermediate- and high-risk groups. We followed 711 FOBT-positive patients with screening adenoma identified during population-based CRC screening in two Danish counties in 2005-2006. As reference population, we included 1,240,348 persons in the same age group from the rest of Denmark not included in the screening. We estimated the long-term CRC risk stratified by adenoma findings during screening and compared to the reference group. After 12 years follow-up, the CRC incidence among all adenoma patients was 322 cases per 100,000 person-years (95% confidence interval [CI]: 212-489) ranging from 251 (95% CI: 94-671) to 542 (95% CI: 300-978) cases per 100,000 person-years in the low- and high-risk groups, respectively. In the reference population, the CRC incidence was 244 (95% CI: 242-247) per 100,000. Patients with screen-detected high-risk adenomas after a positive FOBT had an almost doubled risk of CRC compared to the reference population (adjusted hazard ratio [aHR] 1.95, 95% CI: 1.08-3.51), and the incidence in those with no follow-up visits was over 3.6 (aHR 3.64, 95% CI: 1.82-7.29) times the incidence in the reference population. The increased CRC risk could be controlled if high-risk patients underwent follow-up colonoscopy (aHR 0.87, 95% CI: 0.28-2.69).

A Call for a Reconsideration of the Use of Fecal Occult Blood Testing in Emergency Medicine

BACKGROUND

Fecal occult blood testing (FOBT) was developed to detect microscopic bleeding caused by colorectal neoplasms. The role of FOBT in the emergency department (ED) is typically used for 5 different clinical workups: trauma, anemia, syncope, hypotension, and before the administration of systemic anticoagulants or thrombolytics.

OBJECTIVE

We scrutinized the literature to assess the utility of FOBT for its 5 most common applications in the emergent setting.

DISCUSSION

Logic and clinical evidence advocating for FOBT usage in the aforementioned situations are lacking. The test itself requires specific drug and dietary restrictions that are often violated or never met when patients present to the ED with acute pathologies. In addition, the poor sensitivity and specificity of the test in these scenarios dictate that neither a negative nor positive FOBT should change the subsequent clinical workup of patients presenting to the ED.

CONCLUSION

Clinical decision making should seldom be predicated on the results of a FOBT in the ED setting.

Using serum placenta growth factor could improve the sensitivity of colorectal cancer screening in fecal occult blood negative population: A multicenter with independent cohort validation study

Background

Colorectal cancer (CRC) is one of the most common cancers worldwide. Screening for CRC using the fecal occult blood test (FOBT) is feasible and useful for decreasing disease‐related mortality; however, its sensitivity and compliance are unsatisfactory.

Methods

This study examined the efficacy of using serum placenta growth factor (PlGF) for a novel CRC screening strategy. To investigate a potential novel screening tool for CRC, we compared the sensitivity, specificity, positive predictive value, and negative predictive value of the FOBT, serum PlGF, and their combination through an examination of two independent cohorts and validation using the second cohort. All the patients and control group received the colonoscopy and FOBT, the colonoscopy was used as the gold standard for the result.

Results

Serum PlGF levels were significantly increased in CRC patients (16.8 ± 11.4 pg/mL) compared with controls (12.0 ± 11.2 pg/mL). The predictive model that used the serum PlGF level alone was as effective as the FOBT (AUC: 0.60 vs 0.68, P = 0.891), and it had significantly higher sensitivity than the FOBT (0.81 vs 0.39). In addition, we found serum PlGF level has a good value for predicting CRC patients in those FOBT negative populations. Finally, combining serum PlGF level and the FOBT improved the predictive power and demonstrated satisfactory sensitivity (0.71) and specificity (0.71). This result was confirmed and validated in the second independent cohort. Furthermore, no matter the stages (early/advanced) and the location (distal/proximal) of CRC, the efficacy of serum PlGF and the combined model remained quite stable.

Conclusion

Serum PlGF level is a potential alternative screening tool for CRC, especially for those who are reluctant to stool‐based screening methods and who were tested as negative FOBT. In addition, combining serum PlGF level and the FOBT could increase the power of CRC screening.

Latinas' Colorectal Cancer Screening Knowledge, Barriers to Receipt, and Feasibility of Home-Based Fecal Immunochemical Testing

Latinas' high colorectal cancer (CRC) mortality makes them a priority population for CRC screening. CRC screening knowledge, perceived barriers, and feasibility of using the Fecal Immunochemical Test (FIT) was assessed among Latinas in Utah. Participants aged ≥50 (n = 95) were surveyed about knowledge and barriers to CRC screening. 27 participants completed a FIT and evaluation survey. Fisher's exact tests assessed sociodemographic correlates of CRC screening outcomes. Most participants were overdue for CRC screening (n = 81, 85%). Age, acculturation, education, and employment were significantly associated with CRC screening status and/or reasons for being overdue (e.g., not knowing about the test, cost). All participants who received a FIT completed it, felt it was easy to use, and reported they would use it again. Latinas had limited awareness of CRC, CRC screenings, and experienced barriers to CRC screening (e.g., limited access, cost), but were willing to utilize a low-cost home-based FIT.

Impact of The Affordable Care Act's Elimination of Cost-Sharing on the Guideline-Concordant Utilization of Cancer Preventive Screenings in the United States Using Medical Expenditure Panel Survey

Currently available evidence regarding the association of the Affordable Care Act’s (ACA) elimination of cost-sharing and the utilization of cancer screenings is mixed. We determined whether the ACA’s zero cost-sharing policy affected the guideline-concordant utilization of cancer screenings, comparing adults (≥21 years) from 2009 with 2011–2014 data from the Medical Expenditure Panel Survey. Study participants were categorized as: 21–64 years with any private insurance, ≥65 years with Medicare only, and 21–64 years uninsured, with a separate sample for each type of screening test. Adjusted weighted prevalence and prevalence ratios (PR (95%CI)) were estimated. In 2014 (vs. 2009), privately-insured women reported 2% (0.98 (0.97–0.99)) and 4% (0.96 (0.93–0.99)) reduction in use of Pap tests and mammography, respectively. Privately-insured non-Hispanic Asian women had 16% (0.84 (0.74–0.97)) reduction in mammography in 2014 (vs. 2009). In 2011 (vs. 2009), privately-insured and Medicare-only men reported 9% (1.09 (1.03–1.16)) and 13% (1.13 (1.02–1.25)) increases in colorectal cancer (CRC) screenings, respectively. Privately-insured women reported a 6–7% rise in 2013–2014 (vs. 2009), and Hispanic Medicare beneficiaries also reported 40–44%, a significant rise in 2011–2014 (vs. 2009), in the utilization of CRC screenings. While the guideline-concordant utilization of Pap tests and mammography declined in the post-ACA period, the elimination of cost-sharing appeared to have positively affected CRC screenings of privately-insured males, females, and Hispanic Medicare-only beneficiaries. Greater awareness about the zero cost-sharing policy may help in increasing the uptake of cancer screenings.

Clinical Practice Guideline on Screening for Colorectal Cancer in Individuals With a Family History of Nonhereditary Colorectal Cancer or Adenoma: The Canadian Association of Gastroenterology Banff Consensus

BACKGROUND & AIMS

A family history (FH) of colorectal cancer (CRC) increases the risk of developing CRC. These consensus recommendations developed by the Canadian Association of Gastroenterology and endorsed by the American Gastroenterological Association, aim to provide guidance on screening these high-risk individuals.

METHODS

Multiple parallel systematic review streams, informed by 10 literature searches, assembled evidence on 5 principal questions around the effect of an FH of CRC or adenomas on the risk of CRC, the age to initiate screening, and the optimal tests and testing intervals. The GRADE (Grading of Recommendation Assessment, Development and Evaluation) approach was used to develop the recommendations.

RESULTS

Based on the evidence, the Consensus Group was able to strongly recommend CRC screening for all individuals with an FH of CRC or documented adenoma. However, because most of the evidence was very-low quality, the majority of the remaining statements were conditional ("we suggest"). Colonoscopy is suggested (recommended in individuals with ≥2 first-degree relatives [FDRs]), with fecal immunochemical test as an alternative. The elevated risk associated with an FH of ≥1 FDRs with CRC or documented advanced adenoma suggests initiating screening at a younger age (eg, 40-50 years or 10 years younger than age of diagnosis of FDR). In addition, a shorter interval of every 5 years between screening tests was suggested for individuals with ≥2 FDRs, and every 5-10 years for those with FH of 1 FDR with CRC or documented advanced adenoma compared to average-risk individuals. Choosing screening parameters for an individual patient should consider the age of the affected FDR and local resources. It is suggested that individuals with an FH of ≥1 second-degree relatives only, or of nonadvanced adenoma or polyp of unknown histology, be screened according to average-risk guidelines.

CONCLUSIONS

The increased risk of CRC associated with an FH of CRC or advanced adenoma warrants more intense screening for CRC. Well-designed prospective studies are needed in order to make definitive evidence-based recommendations about the age to commence screening and appropriate interval between screening tests.

Screening Women Aged 50-59 for CRC Using Fecal Occult Blood Test Produces Outcomes Similar to Men Undergoing Screening Colonoscopy

BACKGROUND

Average-risk women aged 50-59 years have a lower incidence and mortality of colorectal cancer relative to age-matched men, calling into question the benefit of screening colonoscopy in this age group.

AIMS

We aimed to determine whether FOBT is an effective initial screening test in 50-59-year-old women.

METHODS

We conducted a cross-sectional study using a computerized endoscopic report generator. We identified 320,906 individuals who had average-risk screening colonoscopy and 32,369 who had colonoscopy for positive FOBT. The primary outcome was the positive predictive value (PPV) of FOBT for large polyp(s) greater than 9 mm, as a surrogate for advanced neoplasia.

RESULTS

Among patients aged 50-59 years undergoing screening colonoscopy, men were more likely than women to have large polyps (6.3 vs 4.2%, p < 0.0001). Black women undergoing screening colonoscopy had higher rates of large polyps compared to non-Black women. The PPV in FOBT-positive men aged 50-54 (11.5%) and 55-59 (14.4%) was higher than in women aged 50-54 (6.1%) and 55-59 (5.4%). Despite this lower PPV, women aged 50-54 with a positive FOBT had a similar rate of large polyps as 50-54-year-old men undergoing screening colonoscopy (6.1 vs 6.3%, p = 0.626).

CONCLUSIONS

CRC screening with FOBT identifies 50-59-year-old men and women with a higher risk of large polyps. Since younger women have a lower risk of large polyps than men, screening with FOBT in 50-59-year-old non-Black women could be an effective screening strategy, with outcomes similar to the use of screening colonoscopy in 50-59-year-old men.

Risk of Oral and Upper Gastrointestinal Cancers in Persons With Positive Results From a Fecal Immunochemical Test in a Colorectal Cancer Screening Program

BACKGROUND & AIMS

European guidelines recommend screening for colorectal cancer (CRC) using the fecal immunochemical test (FIT), with follow-up colonoscopies for individuals with positive test results. However, more than half of participants with positive results from the FIT are not found to have advanced neoplasia in the colonoscopy examination. Fecal occult blood might also come from the upper gastrointestinal (GI) tract, so perhaps we should consider esophagogastroduodenoscopy (EGD), to detect upper GI cancers. We aimed to determine how many individuals are found to have oral or upper GI cancers (oral cavity, throat, esophageal, gastric, or small bowel cancer) within 3 years after a positive or negative result from a FIT in a CRC screening program.

METHODS

We performed a retrospective analysis of data from a pilot study of 3 rounds of biennial FIT-based screening for CRC in 2 regions in the west of the Netherlands, from 2006 through October 2012. Participants who developed oral or upper GI cancers were identified through linkage with the National Cancer Registry. We classified these cancers into 3 groups: those that developed in individuals with a positive result from a FIT but negative findings from colonoscopy (no advanced neoplasia), those that developed in individuals with a positive result from a FIT and a positive finding from colonoscopy (advanced neoplasia), and those that developed in individuals with negative results from a FIT. We compared oral and upper GI cancer incidence among groups.

RESULTS

Among 16,165 screening participants, linkage identified 52 persons who developed an oral or upper GI cancer within 3 years after a FIT. We found no significant difference in incidence values between individuals with a positive vs a negative FIT result: 8 cancers developed in individuals with a positive result from a FIT (0.37%; 95% CI, 0.19-0.76) and 44 developed in individuals with a negative result from a FIT (0.31%; 95% CI, 0.23-0.42) (P = .65). Of the 8 individuals with a positive result from a FIT and an oral or upper GI cancer, 6 were diagnosed after negative findings from colonoscopy and 2 after positive findings from colonoscopy. We found that only 0.14% of all persons with a positive result from a FIT were diagnosed with a gastric or esophageal cancer within 3 years.

CONCLUSION

In a study of individuals in the Netherlands undergoing screening for CRC by FIT, we found fewer than 1% of patients with a positive result from the FIT to receive a diagnosis of upper GI cancers within 3 years. Routine EGD investigation of individuals with positive results from a FIT and negative findings from colonoscopy is therefore not recommended. TrialRegister.nl, Number: NTR5385.

Factors influencing participation in colorectal cancer screening programs in Spain

To analyze the sociodemographic and organizational factors influencing participation in population-based colorectal cancer screening programs (CRCSP) in Spain, a retrospective study was conducted in a cohort of people invited to participate in the first 3 screening rounds of 6 CRCSP from 2000 to 2012. Mixed logistic regression models were used to analyze the relationship between sociodemographic and organizational factors, such as the type of fecal occult blood test (FOBT) used and the FOBT delivery type. The analysis was performed separately in groups (Initial screening-first invitation, Subsequent invitation for previous never-responders, Subsequent invitation-regular, Subsequent invitation-irregular intervals). The results showed that, in the Initial screening-first invitation group, participation was higher in women than in men in all age groups (OR 1.05 in persons aged 50-59years and OR 1.12 in those aged 60-69years). Participation was also higher when no action was required to receive the FOBT kit, independently of the type of screening (Initial screening-first invitation [OR 2.24], Subsequent invitation for previous never-responders [OR 2.14], Subsequent invitation-regular [OR 2.03], Subsequent invitation-irregular intervals [OR 9.38]) and when quantitative rather than qualitative immunological FOBT (FIT) was offered (Initial screening-first invitation [OR 0.70], Subsequent invitation for previous never-responders [OR 0.12], Subsequent invitation-regular [OR 0.20]) or guaiac testing (Initial screening-first invitation [OR 0.81], Subsequent invitation for previous never-responders [OR 0.88], Subsequent invitation-regular [OR 0.73]). In conclusion, the results of this study show that screening participation could be enhanced by inclusion of the FOBT kit with the screening invitation and the use of the quantitative FIT.

Investigating Factors Associated with FOBT Screening for Colorectal Cancer Based on the Components of Health Belief Model and Social Support

Introduction:

This study aimed to investigate the factors associated with FOBT screening for colorectal cancer based on the components of Health Belief Model and social support in Fasa City, Fars Province, Iran.

Materials and Methods:

This was a cross-sectional study carried out on 240 subjects in people of Fasa city who had 50 years old and above. The subjects in this study were assigned to two groups of 120 patients. The first group included people over 50 years, who referred to the diagnostic laboratories for doing FOBT, but the second group included people aged 50 years and above who did not refer to a laboratory for doing FOBT and were assessed by questionnaires at home. Data were collected through a questionnaire based on health belief model and perceived social support.

Results:

The referring group included 61.3 percent women and 38.7 percent men, with a mean age of 65.24 ± 8.01. The non-referring group included 59.7 percent women and 40.3 percent men, with a mean age of 64.21 ±7.53 (p=0.24). In the referring group, 64.2 percent had undergone FOBT in the past year, while in the non-referring group only 12.72percent had done so (p=0.001). The results showed that the referring group obtained higher scores on awareness about CRC and ways to prevent it, and on HBM Model constructs, and social support compared to the non-referring group (p<0.001). In addition, the referring group reported significantly lower Perceived Barriers compared to the non-referring group (p<0.001).

Conclusion:

The results showed significant differences between the two groups in terms of HBM components and perceived social support for doing FOBT. Therefore, theory-based educational interventions can be used to increase individuals’ Perceived Severity, Perceived Susceptibility, and Perceived Benefits and reduce their Perceived Barriers in order to empower and encourage people to perform FOBT.

Power of screening tests for colorectal cancer enhanced by high levels of M2-PK in addition to FOBT

Colorectal cancer (CRC) is a multistep process that involves adenoma-carcinoma sequence. CRC can be prevented by routine screening, which can detect precancerous lesions. The aim of this study is to clarify whether faecal occult blood test (i-FOBT), tumor M2 pyruvate kinase (t-M2-PK), and endocannabinoid system molecules (cannabinoid receptors type 1-CB1, type 2-CB2, and fatty acid amide hydrolase-FAAH) might represent better diagnostic tools, alone or in combination, for an early diagnosis of CRC. An immunochemical FOB test (i-FOBT) and quantitative ELISA stool test for t-M2-PK were performed in 127 consecutive patients during a 12 month period. Endocannabinoid system molecules and t-M2-PK expression were detected by immunostaining in healthy tissues and normal mucosa surrounding adenomatous and cancerous colon lesions. i-FOBT and t-M2-PK combination leads to a better diagnostic accuracy for pre-neoplastic and neoplastic colon lesions. T-M2-PK quantification in stool samples and in biopsy samples (immunostaining) correlates with tumourigenesis stages. CB1 and CB2 are well expressed in healthy tissues, and their expression decreases in the presence of advanced stages of carcinogenesis and disappears in CRC. FAAH signal is well expressed in normal mucosa and low-risk adenoma, and increased in high-risk adenoma and carcinoma adjacent tissues. This study shows that high levels of t-M2-PK in addition to FOBT enhance the power of a CRC screening test. Endocannabinoid system molecule expression correlates with colon carcinogenesis stages. Developing future faecal tests for their quantification must be undertaken to obtain a more accurate early non-invasive diagnosis for CRC.

General practitioners' perceptions of population based bowel screening and their influence on practice: a qualitative study

Background

Although largely preventable, Australia has one of the highest rates of bowel cancer in the world. General Practitioners (GPs) have an important role to play in prevention and early detection of bowel cancer, however in Australia this is yet to be optimised and participation remains low. This study sought to understand how GPs’ perceptions of bowel screening influence their attitudes to, and promotion of the faecal occult blood test (FOBT), to identify opportunities to enhance their role.

Methods

Interviews were conducted with 31 GPs from metropolitan and regional New South Wales (NSW), Australia. Discussions canvassed GPs’ perceptions of their role in bowel screening and the national screening program; perceptions of screening tests; practices regarding discussing screening with patients; and views on opportunities to enhance their role. Transcripts were coded using Nvivo and thematically analysed.

Results

The study revealed GPs’ perceptions of screening did not always align with broader public health definitions of ‘population screening’. While many GPs reportedly understood the purpose of population screening, notions of the role of asymptomatic screening for bowel cancer prevention were more limited. Descriptions of screening centred on two major uses: the use of a screening ‘process’ to identify individual patients at higher risk; and the use of screening ‘tools’, including the FOBT, to aid diagnosis. While the FOBT was perceived as useful for identifying patients requiring follow up, GPs expressed concerns about its reliability. Colonoscopy by comparison, was considered by many as the gold standard for both screening and diagnosis. This perception reflects a conceptualisation of the screening process and associated tools as an individualised method for risk assessment and diagnosis, rather than a public health strategy for prevention of bowel cancer.

Conclusion

The results show that GPs’ perceptions of screening do not always align with broader public health definitions of ‘population screening’. Furthermore, the way GPs understood screening was shown to impact their clinical practice, influencing their preferences for, and use of ‘screening’ tools such as FOBT. The findings suggest emphasising the preventative opportunity of FOBT screening would be beneficial, as would formally engaging GPs in the promotion of bowel screening.

FIT: A meta-analysis on colorectal cancer screening test

BACKGROUND

After lung and prostate cancers, colorectal cancer (CRC) is the third most common cancer in men and the second most common cancer in women after breast cancer worldwide. Every year, more than one million people are diagnosed with colorectal cancer worldwide and half of these patients die from this disease, making it the fourth leading cause of death in the world. This systematic review aimed to assess the effectiveness of the two colorectal diagnostic tests of FOBT (fecal occult blood test) and FIT (fecal immunochemical test)) in terms of technical performance.

METHODS

To retrieve the relevant evidence, appropriate medical databases such as Cochrane library, NHSEED, Scopus and Google scholar were searched from February 2013 to July 2014, using free-texts and Mesh. In this study, inclusion/exclusion criteria of the papers, randomized controlled trials, economic evaluations, systematic reviews, meta-analyses and meta-syntheses of the effectiveness of FIT versus FOBT tests in moderate-risk populations (age: 50 to 70 years), which had reported the least of such outcomes as sensitivity, specificity and clinical outcomes were reviewed. The analyses of the effectiveness outcomes were performed in the form of meta-analysis.

RESULTS

Five papers were eligible to be included in the final phase of the study for synthesis. FIT showed a better performance in participation and positivity rate. Moreover, in terms of false positive and negative rate, FIT showed fewer rates compared to FOBT (RR:-4.06; 95% CI (-7.89-0.24), and NN-scope (Number need to scope) (2.2% vs. 1.6%), and NN-screen (Number need to screen) (84% vs. 31-49% in different cut off levels) showed significant differences in FOBT vs. FIT, respectively.

CONCLUSION

In the five included studies (3, 11-14), the acceptability of FIT was more than FOBT. However, in our meta-analysis, no difference was found between the two tests. FIT was significant in positivity rate and had a better performance in participation rate, and a fewer false negative numbers compared to FOBT.

SEPT9: A Specific Circulating Biomarker for Colorectal Cancer

SEPT9 gene methylation has been implicated as a biomarker for colorectal cancer (CRC) for more than 10 years and has been used clinically for more than 6 years. Studies have proven it to be an accurate, reliable, fast, and convenient method for CRC. In this chapter, we will first provide the background on the role of septin9 protein and the theoretical basis of the SEPT9 gene methylation assay. We will then focus on the performance of SEPT9 gene methylation assay for CRC early detection and screening by analyzing the data obtained in clinical trials and comparing its performance with other methods or markers. Finally, we will discuss the future applications of the assay in monitoring cancer recurrence, evaluating surgery, chemotherapy, and predicting long-term survival. We hope this chapter can provide a full overview of the theoretical basis, development, validation, and clinical applications of the SEPT9 assay for both basic science researchers and clinical practitioners.

Participation rates for organized colorectal cancer screening programmes: an international comparison

OBJECTIVE

Participation, an indicator of screening programme acceptance and effectiveness, varies widely in clinical trials and population-based colorectal cancer (CRC) screening programmes. We aimed to assess whether CRC screening participation rates can be compared across organized guaiac fecal occult blood test (G-FOBT)/fecal immunochemical test (FIT)-based programmes, and what factors influence these rates.

METHODS

Programme representatives from countries participating in the International Cancer Screening Network were surveyed to describe their G-FOBT/FIT-based CRC screening programmes, how screening participation is defined and measured, and to provide participation data for their most recent completed screening round.

RESULTS

Information was obtained from 15 programmes in 12 countries. Programmes varied in size, reach, maturity, target age groups, exclusions, type of test kit, method of providing test kits and use, and frequency of reminders. Coverage by invitation ranged from 30-100%, coverage by the screening programme from 7-67.7%, overall uptake/participation rate from 7-67.7%, and first invitation participation from 7-64.3%. Participation rates generally increased with age and were higher among women than men and for subsequent compared with first invitation participation.

CONCLUSION

Comparisons among CRC screening programmes should be made cautiously, given differences in organization, target populations, and interpretation of indicators. More meaningful comparisons are possible if rates are calculated across a uniform age range, by gender, and separately for people invited for the first time vs. previously.

Use of Biomarkers in Screening for Cancer

Screening for premalignant lesions or early invasive disease has the potential to reduce mortality from cancer. Because of their ease of measurement, several biomarkers have been evaluated or are currently undergoing evaluation as screening tests for early malignancy. These include the use of AFP in screening for hepatocellular cancer in high-risk subjects, CA 125 in combination with transvaginal ultrasound (TVU) in screening for epithelial ovarian cancer, PSA in screening for prostate cancer, faecal occult blood testing (FOBT) in screening for colorectal cancer (CRC) and vanillymandelic acid and homovanillic acid in screening for neuroblastoma in newborn infants, Of these biomarkers, only the use of FOBT in screening for CRC has unequivocally been shown to reduce mortality from cancer. Although 2 large randomized prospective trials have evaluated PSA as a screening test for prostate cancer, it is still unclear whether the benefits outweigh the harms in this setting. Although biomarkers have many attractive features as cancer screening tests, lack of sensitivity and specificity, when combined with the low prevalence of specific cancer types in asymptomatic subjects, limit their application for the early detection of malignancy.

Five-year experience of organized colorectal cancer screening in a Swedish population - increased compliance with age, female gender, and subsequent screening round

OBJECTIVE

To evaluate compliance by age, gender, and screening round in the population based Stockholm/Gotland colorectal cancer screening programme.

METHODS

All individuals aged between 60 and 69 living in the counties of Stockholm and Gotland (Sweden) have, since 2008, successively been included in a colorectal cancer screening programme using biennial faecal occult blood tests (Hemoccult®). Personal invitations including test kits have been sent to home addresses, and individuals with a positive test result have been called to a defined clinic for an assessment colonoscopy. Descriptive statistics have been used to evaluate different aspects of compliance.

RESULTS

Over the five-year period 2008-2012, more than 200,000 individuals from nine different birth cohorts have been invited, with a compliance rate of approximately 60%, which increased by age, female gender, and subsequent screening round. In total, 4,300 individuals (2.1%) with positive tests were referred to assessment colonoscopy, where 213 colorectal cancers were diagnosed. The compliance with the follow-up colonoscopies varied by year, and ranged from 85.6-92.4%.

CONCLUSION

The strong organization of the programme contributed to a high compliance rate, that increased by screening round. The lower participation rate among men and among individuals at younger ages needs further attention.

Tests and investigations for colorectal cancer screening

Worldwide, colorectal (CRC) is the third most common form of cancer, after lung and breast cancer, and the fourth most common cause of cancer death, although in developed countries CRC incidence is higher and it accounts for an even higher proportion of cancer deaths. Successful treatment of early-stage CRC confers substantial survival advantage, and there is now overwhelming evidence that screening average-risk individuals for CRC reduces the incidence and disease-specific mortality. In spite of considerable research for new biomarkers for CRC, the detection of blood in faeces remains the most effective screening tool. The best evidence to date for population-based CRC screening comes from randomised-controlled trials that used a guaiac-based faecal occult blood test (gFOBt) as the first-line screening modality, whereby test-positive individuals are referred for follow-up investigations, usually colonoscopy. A major innovation in the last ten years or so has been the development of other more analytically sensitive and specific screening techniques for blood in faeces. The faecal immunochemical test for haemoglobin (FIT) confers substantial benefits over gFOBt in terms of analytical sensitivity, specificity and practicality and FIT are now recommended for CRC screening by the European guidelines for quality assurance in colorectal cancer screening and diagnosis. The challenge internationally is to develop high quality CRC screening programmes for which uptake is high. This is especially important for developing countries witnessing an increase in the incidence of CRC as populations adopt more westernised lifestyles. This review describes the tests available for CRC screening and how they are being used worldwide. The reader will gain an understanding of developments in CRC screening and issues that arise in choosing the most appropriate screening test (or tests) for organised population-based screening internationally and optimising the performance of the chosen test (or tests). Whilst a wide range of literature has been cited, this is not a systematic review. The authors provide FOBT CRC screening for a population of 14.6 million in the south of England and the senior author (SPH) was the lead author of the European guidelines for quality assurance in colorectal cancer screening and diagnosis and leads the World Endoscopy Organization Colorectal Cancer Committee's Expert Working Group on 'FIT for Screening'.

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSION

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

PRACTICE IMPLICATIONS

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

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

BACKGROUND & AIMS

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Health benefits and cost-effectiveness of a hybrid screening strategy for colorectal cancer

BACKGROUND & AIMS

Colorectal cancer (CRC) screening guidelines recommend screening schedules for each single type of test except for concurrent sigmoidoscopy and fecal occult blood test (FOBT). We investigated the cost-effectiveness of a hybrid screening strategy that was based on a fecal immunological test (FIT) and colonoscopy.

METHODS

We conducted a cost-effectiveness analysis by using the Archimedes Model to evaluate the effects of different CRC screening strategies on health outcomes and costs related to CRC in a population that represents members of Kaiser Permanente Northern California. The Archimedes Model is a large-scale simulation of human physiology, diseases, interventions, and health care systems. The CRC submodel in the Archimedes Model was derived from public databases, published epidemiologic studies, and clinical trials.

RESULTS

A hybrid screening strategy led to substantial reductions in CRC incidence and mortality, gains in quality-adjusted life years (QALYs), and reductions in costs, comparable with those of the best single-test strategies. Screening by annual FIT of patients 50-65 years old and then a single colonoscopy when they were 66 years old (FIT/COLOx1) reduced CRC incidence by 72% and gained 110 QALYs for every 1000 people during a period of 30 years, compared with no screening. Compared with annual FIT, FIT/COLOx1 gained 1400 QALYs/100,000 persons at an incremental cost of $9700/QALY gained and required 55% fewer FITs. Compared with FIT/COLOx1, colonoscopy at 10-year intervals gained 500 QALYs/100,000 at an incremental cost of $35,100/QALY gained but required 37% more colonoscopies. Over the ranges of parameters examined, the cost-effectiveness of hybrid screening strategies was slightly more sensitive to the adherence rate with colonoscopy than the adherence rate with yearly FIT. Uncertainties associated with estimates of FIT performance within a program setting and sensitivities for flat and right-sided lesions are expected to have significant impacts on the cost-effectiveness results.

CONCLUSIONS

In our simulation model, a strategy of annual or biennial FIT, beginning when patients are 50 years old, with a single colonoscopy when they are 66 years old, delivers clinical and economic outcomes similar to those of CRC screening by single-modality strategies, with a favorable impact on resources demand.

Prospective cohort study of compliance with faecal immunochemical tests for colorectal cancer screening in Hong Kong

OBJECTIVE

This study aims to examine the rate and determinants of faecal immunochemical test (FIT) compliance over a four-year period among asymptomatic participants in a colorectal cancer (CRC) screening programme in Hong Kong.

METHOD

Self-referred screening participants aged between 50 and 70 years who chose FIT for annual screening were followed up for four years (2008-2012). All participants were reminded up to three times yearly for FIT retrieval within two months of the expected screening date. The proportions of screening participants who failed to adhere to annual FIT tests in 1, 2, 3 and 4-years, respectively, after the initial screening uptake were evaluated. The factors associated with non-compliance with FITs in any year were assessed by a binary logistic regression analysis.

RESULTS

From 5700 consecutive screening participants, the compliance rates to FIT were 95.1%, 79.9%, 66.2% and 68.4% at years one to four, respectively. The proportions of people missing one, two and three tests were 6.2%, 19.6% and 2.1%, respectively. From multivariate regression analysis, male subjects, younger participants, smokers and those with positive family history of CRC were more likely to be non-compliant.

CONCLUSION

Participants identified as at higher risk for screening non-compliance should be especially considered for individual reminders to enhance screening effectiveness.

Clinical features of colorectal cancer detected by the national cancer screening program

PURPOSE

Since 2004, the National Cancer Screening Program of Korea has included colorectal cancer screening based on primary screening with the fecal occult blood test (FOBT). We report on the clinical features of colorectal cancer detected by the National Cancer Screening Program.

METHODS

We retrospectively analyzed 577 patients who underwent elective surgery for colorectal cancer at the Seoul National University Hospital between January 2008 and December 2009. We compared the clinical features of colorectal cancers detected by the National Cancer Screening Program (NCSP group) with those of the control group in terms of age, gender, preoperative symptom, location of the tumor, surgical technique and tumor-node-metastasis (TNM) stage.

RESULTS

Age, gender, location of the tumor and operation types were not different between the two groups. The proportion of asymptomatic patients was significantly higher in the NCSP group than it was in the control group (86.5% vs. 20.0%; P < 0.001). The proportion of less invasive lesions (T1 or T2) was significantly higher in the NCSP group (46.3% vs. 27.7%; P = 0.002). The pathologic stages of the colorectal cancers in the NCSP group were I, 40.3%; II, 17.9%; III, 40.3% and IV, 1.5% whereas in the control group, they were I, 20.8%; II, 32.9%; III, 34.9% and IV, 11.4%. The proportion of stage I cancer was significantly higher in the NCSP group than in the control group (40.3% vs. 20.8%; P = 0.006).

CONCLUSION

Our study demonstrates the FOBT in the NCSP is effective in early detection of colorectal cancer.