Multi-component interventions and change in screening rates in primary care clinics in the Colorectal Cancer Control Program

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Evidence-based interventions (EBIs) in clinics increase colorectal cancer screening.

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Even more effective are multi-component interventions (MCIs) vs a single strategy.

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We examined the effectiveness of MCIs in CDC’s Colorectal Cancer Control Program.

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Combination of 3–4 EBIs or 2–3 strategies led to significant increase in screening.

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Some MCIs led up to 7.2 percentage points annual increases.

Colorectal cancer (CRC) screening has been shown to decrease CRC mortality. Implementation of evidence-based interventions (EBIs) increases CRC screening. The purpose of this analysis is to determine which combinations of EBIs or strategies led to increases in clinic-level screening rates among clinics participating in CDC’s Colorectal Cancer Control Program (CRCCP). Data were collected from CRCCP clinics between 2015 and 2018 and the analysis was conducted in 2020. The outcome variable was the annual change in clinic level CRC screening rate in percentage points. We used first difference (FD) estimator of linear panel data regression model to estimate the associations of outcome with independent variables, which include different combinations of EBIs and intervention strategies. The study sample included 486 unique clinics with 1156 clinic years of total observations. The average baseline screening rate was 41 % with average annual increase of 4.6 percentage points. Only two out of six combinations of any two EBIs were associated with increases in screening rate (largest was 6.5 percentage points, P < 0.001). Any combinations involving three EBIs or all four EBIs were significantly associated with the outcome with largest increase of 7.2 percentage points (P < 0.001). All interventions involving 2–3 strategies led to increases in rate with largest increase associated with the combination of increasing community demand and access (6.1 percentage points, P < 0.001). Clinics implementing combinations of these EBIs, particularly those including three or more EBIs, often were more likely to have impact on screening rate change than those implementing none.

Vital Signs: Colorectal Cancer Screening Test Use - United States, 2018

BACKGROUND

Colorectal cancer (CRC) is the second leading cause of cancer death in the United States of cancers that affect both men and women. Despite strong evidence that screening for CRC reduces incidence and mortality, CRC screening prevalence is below the national target. This report describes current CRC screening prevalence by age, various demographic factors, and state.

METHODS

Data from the 2018 Behavioral Risk Factor Surveillance System survey were analyzed to estimate the percentages of adults aged 50-75 years who reported CRC screening consistent with the United States Preventive Services Task Force recommendation.

RESULTS

In 2018, 68.8% of adults were up to date with CRC screening. The percentage up to date was 79.2% among respondents aged 65-75 years and 63.3% among those aged 50-64 years. CRC screening prevalence was lowest among persons aged 50-54 years (50.0%) and increased with age. Among respondents aged 50-64 years, CRC screening prevalence was lowest among persons without health insurance (32.6%) and highest among those with reported annual household income of ≥$75,000 (70.8%). Among respondents aged 65-75 years, CRC screening prevalence was lowest among those without a regular health care provider (45.6%), and highest among those with reported annual household income ≥$75,000 (87.1%). Among states, CRC screening prevalence was highest in Massachusetts (76.5%) and lowest in Wyoming (57.8%).

DISCUSSION

CRC screening prevalence is lower among adults aged 50-64 years, although most reported having a health care provider and health insurance. Concerted efforts are needed to inform persons aged <50 years about the benefit of screening so that screening can start at age 50 years.

A conceptual framework and metrics for evaluating multicomponent interventions to increase colorectal cancer screening within an organized screening program

BACKGROUND

Multicomponent, evidence-based interventions are viewed increasingly as essential for increasing the use of colorectal cancer (CRC) screening to meet national targets. Multicomponent interventions involve complex care pathways and interactions across multiple levels, including the individual, health system, and community.

METHODS

The authors developed a framework and identified metrics and data elements to evaluate the implementation processes, effectiveness, and cost effectiveness of multicomponent interventions used in the Centers for Disease Control and Prevention's Colorectal Cancer Control Program.

RESULTS

Process measures to evaluate the implementation of interventions to increase community and patient demand for CRC screening, increase patient access, and increase provider delivery of services are presented. In addition, performance measures are identified to assess implementation processes along the continuum of care for screening, diagnosis, and treatment. Series of intermediate and long-term outcome and cost measures also are presented to evaluate the impact of the interventions.

CONCLUSIONS

Understanding the effectiveness of multicomponent, evidence-based interventions and identifying successful approaches that can be replicated in other settings are essential to increase screening and reduce CRC burden. The use of common framework, data elements, and evaluation methods will allow the performance of comparative assessments of the interventions implemented across CRCCP sites to identify best practices for increasing colorectal screening, particularly among underserved populations, to reduce disparities in CRC incidence and mortality.

Economic assessment of patient navigation to colonoscopy-based colorectal cancer screening in the real-world setting at the University of Chicago Medical Center

BACKGROUND

This report details the cost effectiveness of a non-nurse patient navigation (PN) program that was implemented at the University of Chicago Medical Center to increase colonoscopy-based colorectal cancer (CRC) screening.

METHODS

The authors investigated the impact of the PN intervention by collecting process measures. Individuals who received navigation were compared with a historic cohort of non-navigated patients. In addition, a previously validated data-collection instrument was tailored and used to collect all costs related to developing, implementing, and administering the program; and the incremental cost per patient successfully navigated (the cost of the intervention divided by the change in the number who complete screening) was calculated.

RESULTS

The screening colonoscopy completion rate was 85.1% among those who were selected to receive PN compared with 74.3% when no navigation was implemented. With navigation, the proportion of no-shows was 8.2% compared with 15.4% of a historic cohort of non-navigated patients. Because the perceived risk of noncompletion was greater among those who received PN (previous no-show or cancellation, poor bowel preparation) than that in the historic cohort, a scenario analysis was performed. Assuming no-show rates between 0% and 50% and using a navigated rate of 85%, the total incremental program cost per patient successfully navigated ranged from $148 to $359, whereas the incremental intervention-only implementation cost ranged from $88 to $215.

CONCLUSIONS

The current findings indicate that non-nurse PN can increase colonoscopy completion, and this can be achieved at a minimal incremental cost for an insured population at an urban academic medical center.

Rectal cancer survival in the United States by race and stage, 2001 to 2009: Findings from the CONCORD-2 study

BACKGROUND

In the first CONCORD study, 5-year survival for patients with diagnosed with rectal cancer between 1990 and 1994 was <60%, with large racial disparities noted in the majority of participating states. We have updated these findings to 2009 by examining population-based survival by stage of disease at the time of diagnosis, race, and calendar period.

METHODS

Data from the CONCORD-2 study were used to compare survival among individuals aged 15 to 99 years who were diagnosed in 37 states encompassing up to 80% of the US population. We estimated net survival up to 5 years after diagnosis correcting for background mortality with state-specific and race-specific life table. Survival estimates were age-standardized with the International Cancer Survival Standard weights. We present survival estimates by race (all, black, and white) for 2001 through 2003 and 2004 through 2009 to account for changes in collecting the data for Surveillance, Epidemiology, and End Results Summary Stage 2000.

RESULTS

There was a small increase in 1-year, 3-year, and 5-year net survival between 2001-2003 (84.6%, 70.7%, and 63.2%, respectively), and 2004-2009 (85.1%, 71.5%, and 64.1%, respectively). Black individuals were found to have lower 1-year, 3-year, and 5-year survival than white individuals in both periods; the absolute difference in survival between black and white individuals declined only for 5-year survival. Black patients had lower 5-year survival than whites at each stage at the time of diagnosis in both time periods.

CONCLUSIONS

There was little improvement noted in net survival for patients with rectal cancer, with persistent disparities noted between black and white individuals. Additional investigation is needed to identify and implement effective interventions to ensure the consistent and equitable use of high-quality screening, diagnosis, and treatment to improve survival for patients with rectal cancer. Cancer 2017;123:5037-58. Published 2017. This article is a U.S. Government work and is in the public domain in the USA.

A Comparison of Fecal Immunochemical and High-Sensitivity Guaiac Tests for Colorectal Cancer Screening

OBJECTIVES

Annual testing using either a high-sensitivity guaiac fecal occult blood test (HS-gFOBT) or a fecal immunochemical test (FIT) is recommended for screening average-risk people for colorectal cancer. We compared the performance characteristics of the HS-gFOBT Hemoccult II SENSA and two FITs (InSure FIT and OC FIT-CHEK) for detecting advanced colorectal neoplasia.

METHODS

The study included 1,006 asymptomatic patients, aged 50-75 years, who were scheduled to receive a screening colonoscopy at gastroenterology practices in the Minneapolis and Indianapolis metropolitan areas. Each participant was asked to complete all three stool tests before their colonoscopy. Each test's performance characteristics were evaluated using the screening colonoscopic results as the reference standard.

RESULTS

Sensitivity for detecting advanced colorectal neoplasia was highest for InSure FIT (26.3%, 95% confidence interval (CI) 15.9-40.7), followed by OC FIT-CHEK (15.1%, 95% CI 6.7-26.1) and Hemoccult II SENSA (7.4%, 95% CI 1.9-17.0). InSure FIT was statistically significantly more sensitive than both OC FIT-CHEK (absolute difference in sensitivity=11.2%, 95% CI 0.4-24.2) and Hemoccult II SENSA (difference in sensitivity=18.9%, 95% CI 10.2-32.6). Specificities were relatively high for all tests (between 96.8% and 98.6%).

CONCLUSIONS

Our results suggest that some FITs are more sensitive than the HS-gFOBT Hemoccult II SENSA, but these results need to be confirmed in larger asymptomatic populations. Comparisons between the FITs examined in this study and other FITs are needed to determine the best tests for population screening.

Colorectal cancer screening: Estimated future colonoscopy need and current volume and capacity

BACKGROUND

In 2014, a national campaign was launched to increase colorectal cancer (CRC) screening rates in the United States to 80% by 2018; it is unknown whether there is sufficient colonoscopy capacity to reach this goal. This study estimated the number of colonoscopies needed to screen 80% of the eligible population with fecal immunochemical testing (FIT) or colonoscopy and determined whether there was sufficient colonoscopy capacity to meet the need.

METHODS

The Microsimulation Screening Analysis-Colon model was used to simulate CRC screening test use in the United States (2014-2040); the implementation of a national screening program in 2014 with FIT or colonoscopy with 80% participation was assumed. The 2012 Survey of Endoscopic Capacity (SECAP) estimated the number of colonoscopies that were performed and the number that could be performed.

RESULTS

If a national screening program started in 2014, by 2024, approximately 47 million FIT procedures and 5.1 million colonoscopies would be needed annually to screen the eligible population with a program using FIT as the primary screening test; approximately 11 to 13 million colonoscopies would be needed annually to screen the eligible population with a colonoscopy-only screening program. According to the SECAP survey, an estimated 15 million colonoscopies were performed in 2012, and an additional 10.5 million colonoscopies could be performed.

CONCLUSIONS

The estimated colonoscopy capacity is sufficient to screen 80% of the eligible US population with FIT, colonoscopy, or a mix of tests. Future analyses should take into account the geographic distribution of colonoscopy capacity. Cancer 2016;122:2479-86. © 2016 American Cancer Society.

Use of Evidence-Based Interventions to Address Disparities in Colorectal Cancer Screening

Colorectal cancer (CRC) is the second leading cause of cancer death among cancers that affect both men and women. Despite strong evidence of their effectiveness, CRC screening tests are underused. Racial/ethnic minority groups, persons without insurance, those with lower educational attainment, and those with lower household income levels have lower rates of CRC screening. Since 2009, CDC's Colorectal Cancer Control Program (CRCCP) has supported state health departments and tribal organizations in implementing evidence-based interventions (EBIs) to increase use of CRC screening tests among their populations. This report highlights the successful implementation of EBIs to address disparities by two CRCCP grantees: the Alaska Native Tribal Health Consortium (ANTHC) and Washington State's Breast, Cervical, and Colon Health Program (BCCHP). ANTHC partnered with regional tribal health organizations in the Alaska Tribal Health System to implement provider and client reminders and use patient navigators to increase CRC screening rates among Alaska Native populations. BCCHP identified patient care coordinators in each clinic who coordinated staff training on CRC screening and integrated client and provider reminder systems. In both the Alaska and Washington programs, instituting provider reminder systems, client reminder systems, or both was facilitated by use of electronic health record systems. Using multicomponent interventions in a single clinical site or facility can support more organized screening programs and potentially result in greater increases in screening rates than relying on a single strategy. Organized screening systems have an explicit policy for screening, a defined target population, a team responsible for implementation of the screening program, and a quality assurance structure. Although CRC screening rates in the United States have increased steadily over the past decade, this increase has not been seen equally across all populations. Increasing the use of EBIs, such as those described in this report, in health care clinics and systems that serve populations with lower CRC screening rates could substantially increase CRC screening rates.

Moving forward: using the experience of the CDCs' Colorectal Cancer Screening Demonstration Program to guide future colorectal cancer programming efforts

BACKGROUND

The Centers for Disease Control and Prevention (CDC) established and supported a 4-year Colorectal Cancer Screening Demonstration Program (CRCSDP) from 2005 to 2009 for low-income, under- or uninsured men and women aged 50-64 at 5 sites in the United States.

METHODS

A multiple methods evaluation was conducted including 1) a longitudinal, comparative case study of program implementation, 2) the collection and analysis of client-level screening and diagnostic services outcome data, and 3) the collection and analysis of program- and patient-level cost data.

RESULTS

Several themes emerged from the results reported in the series of articles in this Supplement. These included the benefit of building on an existing infrastructure, strengths and weakness of both the 2 most frequently used screening tests (colonoscopy and fecal occult blood tests), variability in costs of maintaining this screening program, and the importance of measuring the quality of screening tests. Population-level evaluation questions could not be answered because of the small size of the participating population and the limited time frame of the evaluation. The comprehensive evaluation of the program determined overall feasibility of this effort.

CONCLUSIONS

Critical lessons learned through the implementation and evaluation of the CDC's CRCSDP led to the development of a larger population-based program, the CDC's Colorectal Cancer Control Program (CRCCP).

Colorectal cancer incidence and screening - United States, 2008 and 2010

Colorectal cancer (CRC) is the second leading cause of cancer-related deaths in the United States among cancers that affect both men and women. Screening for CRC reduces incidence and mortality. In 2008, the U.S. Preventive Services Task Force (USPSTF) recommended that persons aged 50-75 years at average risk for CRC be screened for the disease by using one or more of the following methods: fecal occult blood testing (FOBT) every year, sigmoidoscopy every 5 years (with high-sensitivity FOBT every 3 years), or colonoscopy every 10 years.

National evidence on the use of shared decision making in prostate-specific antigen screening

PURPOSE

Recent clinical practice guidelines on prostate cancer screening using the prostate-specific antigen (PSA) test (PSA screening) have recommended that clinicians practice shared decision making-a process involving clinician-patient discussion of the pros, cons, and uncertainties of screening. We undertook a study to determine the prevalence of shared decision making in both PSA screening and nonscreening, as well as patient characteristics associated with shared decision making.

METHODS

A nationally representative sample of 3,427 men aged 50 to 74 years participating in the 2010 National Health Interview Survey responded to questions on the extent of shared decision making (past physician-patient discussion of advantages, disadvantages, and scientific uncertainty associated with PSA screening), PSA screening intensity (tests in past 5 years), and sociodemographic and health-related characteristics.

RESULTS

Nearly two-thirds (64.3%) of men reported no past physician-patient discussion of advantages, disadvantages, or scientific uncertainty (no shared decision making); 27.8% reported discussion of 1 to 2 elements only (partial shared decision making); 8.0% reported discussion of all 3 elements (full shared decision making). Nearly one-half (44.2%) reported no PSA screening, 27.8% reported low-intensity (less-than-annual) screening, and 25.1% reported high-intensity (nearly annual) screening. Absence of shared decision making was more prevalent in men who were not screened; 88% (95% CI, 86.2%-90.1%) of nonscreened men reported no shared decision making compared with 39% (95% CI, 35.0%-43.3%) of men undergoing high-intensity screening. Extent of shared decision making was associated with black race, Hispanic ethnicity, higher education, health insurance, and physician recommendation. Screening intensity was associated with older age, higher education, usual source of medical care, and physician recommendation, as well as with partial vs no or full shared decision making.

CONCLUSIONS

Most US men report little shared decision making in PSA screening, and the lack of shared decision making is more prevalent in nonscreened than in screened men. Screening intensity is greatest with partial shared decision making, and different elements of shared decision making are associated with distinct patient characteristics. Shared decision making needs to be improved in decisions for and against PSA screening.

Prevalence of colorectal cancer screening among adults--Behavioral Risk Factor Surveillance System, United States, 2010

Among cancers that affect both men and women, colorectal cancer is the second leading cause of cancer death. In 2007 (the most recent year for which data are available), >142,000 persons received a diagnosis for colorectal cancer and >53,000 persons died. Screening for colorectal cancer has been demonstrated to be effective in reducing the incidence of and mortality from the disease. In 2008, the U.S. Preventive Services Task Force (USPSTF) recommended that persons aged 50-75 years at average risk for colorectal cancer be screened by using one or more of the following methods: high-sensitivity fecal occult blood testing (FOBT) every year, sigmoidoscopy every 5 years with FOBT every 3 years, or colonoscopy every 10 years.

Breast cancer screening among adult women--Behavioral Risk Factor Surveillance System, United States, 2010

Breast cancer continues to have a substantial impact on the health of women in the United States. It is the most commonly diagnosed cancer (excluding skin cancers) among women, with more than 210,000 new cases diagnosed in 2008 (the most recent year for which data are available). Incidence rates are highest among white women at 122.6 per 100,000, followed by blacks at 118 per 100,000, Hispanics at 92.8, Asian/Pacific Islanders at 87.9, and American Indian/Alaskan Natives at 65.6. Although deaths from breast cancer have been declining in recent years, it has remained the second leading cause of cancer deaths for women since the late 1980s with >40,000 deaths reported in 2008. Although white women are more likely to receive a diagnosis of breast cancer, black women are more likely to die from breast cancer than women of any other racial/ethnic group. In addition, studies have demonstrated that nonwhite minority women tend to have a more advanced stage of disease at the time of diagnosis. Breast cancer also occurs more often among women aged ≥50 years, those with first-degree family members with breast cancer, and those who have certain genetic mutations. Understanding who is at risk for breast cancer helps inform guidelines for who should get screened for breast cancer.

Association between smoking status, and free, total and percent free prostate specific antigen

PURPOSE

There are scant data available on the relationship between smoking and total prostate specific antigen, free prostate specific antigen and percent-free prostate specific antigen. Given the high prevalence of smoking and the frequency of prostate specific antigen screening, it is important to determine any association between smoking and prostate specific antigen values using nationally representative data.

MATERIALS AND METHODS

Included in the final study population were 3,820 men 40 years old or older who participated in the 2001-2006 NHANES (National Health and Nutrition Examination Survey) and met the eligibility criteria for prostate specific antigen testing. The distributions of total, free and percent free prostate specific antigen were estimated by sociodemographic and clinical characteristics. Multivariate linear regression models were fit to determine the adjusted relationship between smoking and total and percent free prostate specific antigen while simultaneously controlling for these characteristics.

RESULTS

For all ages combined the median total and free prostate specific antigen levels were 0.90 (0.81-0.90) and 0.26 (0.25-0.28) ng/ml, respectively. Multivariate linear regression analysis showed that total prostate specific antigen was 7.9% and 12.2% lower among current and former smokers, respectively, than among never smokers. High body mass index and diabetes were also statistically significantly associated with a lower total prostate specific antigen. Approximately a third of the men had a percent free prostate specific antigen less than 25%. Current smokers had a significantly lower percent free prostate specific antigen than former smokers.

CONCLUSIONS

Our finding that smoking is inversely associated with total prostate specific antigen may have potential implications for the interpretation of prostate specific antigen levels in men who are current or former smokers. Given the high prevalence of smoking, obesity and diabetes, additional research on the combined effect of these health risk factors is warranted.

Implementing screening for Lynch syndrome among patients with newly diagnosed colorectal cancer: summary of a public health/clinical collaborative meeting

Lynch syndrome is the most common cause of inherited colorectal cancer, accounting for approximately 3% of all colorectal cancer cases in the United States. In 2009, an evidence-based review process conducted by the independent Evaluation of Genomic Applications in Practice and Prevention Working Group resulted in a recommendation to offer genetic testing for Lynch syndrome to all individuals with newly diagnosed colorectal cancer, with the intent of reducing morbidity and mortality in family members. To explore issues surrounding implementation of this recommendation, the Centers for Disease Control and Prevention convened a multidisciplinary working group meeting in September 2010. This article reviews background information regarding screening for Lynch syndrome and summarizes existing clinical paradigms, potential implementation strategies, and conclusions which emerged from the meeting. It was recognized that widespread implementation will present substantial challenges, and additional data from pilot studies will be needed. However, evidence of feasibility and population health benefits and the advantages of considering a public health approach were acknowledged. Lynch syndrome can potentially serve as a model to facilitate the development and implementation of population-level programs for evidence-based genomic medicine applications involving follow-up testing of at-risk relatives. Such endeavors will require multilevel and multidisciplinary approaches building on collaborative public health and clinical partnerships.

Use of the prostate-specific antigen test among men aged 75 years or older in the United States: 2006 Behavioral Risk Factor Surveillance System

INTRODUCTION

In 2008, the US Preventive Services Task Force (USPSTF) updated prostate cancer screening guidelines to recommend against screening for prostate cancer in men aged 75 years or older. We describe the prevalence of prostate-specific antigen (PSA) testing in this population and identify factors that may be correlated with the use of this test.

METHODS

Data came from the 2006 Behavioral Risk Factor Surveillance System. We assessed the status of PSA testing in the past year among 9,033 US men aged 76 or older who had no history of prostate cancer. We conducted descriptive and multiple logistic regression analyses to assess associations of PSA testing with certain sociodemographic and psychosocial factors.

RESULTS

Overall, 60% of men aged 76 or older reported having a PSA test in the past year. Men who had health insurance, were satisfied with life, or always had emotional support were significantly more likely to report having a PSA test in the past year. However, men who had no routine health checkup; were divorced, widowed, or separated; or had less than a high school education were significantly less likely to report having had a PSA test.

CONCLUSION

PSA testing is common among men aged 75 or older in the United States. Certain sociodemographic and psychosocial factors were associated with receipt of this test. This study may not only provide baseline data to evaluate acceptance and implementation of the USPSTF screening guidelines but may also help physicians and public health providers better understand these sociodemographic and psychosocial factors in this population.

Understanding the burden of human papillomavirus-associated anal cancers in the US

BACKGROUND

Anal cancer is an uncommon malignancy in the US; up to 93% of anal cancers are associated with human papillomavirus.

METHODS

Cases diagnosed between 1998 and 2003 from 39 population-based cancer registries were analyzed. The following anal cancer histologies were included in the analysis: squamous cell, adenocarcinoma, and small cell/neuroendocrine carcinomas. Incidence rates were age-adjusted to the 2000 US standard population.

RESULTS

From 1998 through 2003, the annual age-adjusted invasive anal cancer incidence rate was 1.5 per 100,000 persons. Squamous cell carcinoma (SCC) was the most common histology overall, accounting for 18,105 of 21,395 (84.6%) cases of anal cancer. Women had a higher rate of SCC (1.5 per 100,000) than men (1.0). Whites and blacks had the highest incidence rate (1.3), whereas Asians/Pacific Islanders (API) had the lowest rate (0.3). Incidence rates of anal SCC increased 2.6% per year on average. The majority of SCC cases were diagnosed at the in situ or localized stage (58.1%). API were more likely to be diagnosed with regional or distant stage disease than were other racial/ethnic groups (27.5% and 11.8%, respectively). Males had lower 5-year relative survival than females for all stages of disease.

CONCLUSIONS

Rates of anal SCC varied by sex, race, and ethnicity. A higher proportion of API were diagnosed at regional/distant stage. Men had lower 5-year survival rates than women. Continued surveillance and additional research are needed to assess the potential impact of the HPV vaccine on the anal cancer burden in the US.

Erythrocyte vitamin B12 activity in healthy Indian lactovegetarians

Plasma and erythrocyte vitamin B12 was measured in apparently healthy Indian lactovegetarians and compared with the healthy non-vegetarians from the same population. Comparison of the mean values for routine haematological parameters revealed no significant difference in various dietetic groups. The plasma vitamin B12 levels were distinctly lower in the lactovegetarians than in the non-vegetarians. However, the mean erythrocyte vitamin B12 levels in different dietetic groups showed no significant difference.