Participation in colorectal cancer screening: a review

Screening practices of Australian men and women categorized as "at or slightly above average risk" of colorectal cancer

PURPOSE

Australia has one of the highest incidences of colorectal cancer (CRC) in the world. In 2006, the federal government introduced a screening program consisting of a one-off fecal occult blood test offered to people turning 50, 55, or 65 years. We conducted a population-based study to estimate CRC screening practices existing outside the current program.

METHODS

A total of 1887 unaffected subjects categorized "at or slightly above average risk" of CRC were selected from the Australasian Colorectal Cancer Family Registry. We calculated the proportions of participants that reported appropriate, under- and over-screening according to national guidelines. We performed a logistic regression analysis to evaluate associations between over-screening and a set of socio-demographic factors.

RESULTS

Of 532 participants at average risk of CRC, eligible for screening, 4 (0.75 %) reported appropriate screening, 479 (90 %) reported never having been screened, 18 (3 %) reported some but less than appropriate screening, and 31 (6 %) reported over-screening. Of 412 participants aged 50 years or over, slightly above average risk of CRC, 1 participant (0.25 %) reported appropriate screening, 316 (77 %) reported no screening, and 11 (3 %) reported some but less than appropriate screening. Among participants under age 50 years, 2 % of those at average risk and 10 % of those slightly above average risk reported over-screening. Middle-aged people, those with a family history of CRC and those with a university degree, were more likely to be over-screened.

CONCLUSION

Overall, the level of CRC screening participation was low and the vast majority of screening tests undertaken were inappropriate in terms of timing, modality, or frequency.

Identifying barriers to colonoscopy screening for nonadherent African American participants in a patient navigation intervention

African Americans have a higher rate of colorectal cancer (CRC) mortality than other racial/ethnic groups. This disparity is alarming given that CRC is largely preventable through the use of endoscopy (screening colonoscopy or sigmoidoscopy), yet rates of CRC screening among African Americans is suboptimal. Only 48.9% of African Americans are screened for CRC through endoscopy or fecal occult blood testing. As such, researchers have focused their efforts on the prevention of CRC through patient navigation (PN) services for colonoscopy screening. Although PN has been successful in increasing colonoscopy screening rates, screening rates of navigated participants could still be improved. Thus, the purpose of this exploratory study was to understand why patients, who received PN services, did not complete a colonoscopy. Sixteen participants were interviewed to identify salient themes related to noncompletion of the colonoscopy procedure. Major themes identified included the following: a lack of knowledge about CRC; fear/anxiety about the procedure, including unknown expectations, fear of pain, and fear of cancer diagnosis; inadequate physician communication about CRC and the colonoscopy exam; and believing that cancer leads to death. Participants felt that greater communication and explanation from their physician might help allay their fears. Our findings also suggest that a universal approach to PN, even within culturally targeted interventions, may not be appropriate for all individuals. Future interventions should consider gender-specific navigation and combining PN with nonmedical interventions to address other identified barriers.

Computer-delivered tailored intervention improves colon cancer screening knowledge and health beliefs of African-Americans

We conducted a randomized controlled trial among African-American patients attending a primary-care provider visit to compare efficacy of a computer-delivered tailored intervention to increase colorectal cancer (CRC) screening (n = 273) with non-tailored print material-an American Cancer Society brochure on CRC screening (n = 283). Health Belief Model constructs were used to develop tailored messages and examined as outcomes. Analysis of covariance models were used to compare changes between CRC knowledge and health belief scores at baseline and 1 week post-intervention. At 1 week, patients who received the computer-delivered tailored intervention had greater changes in CRC knowledge scores (P < 0.001), perceived CRC risk scores (P = 0.005), FOBT barriers scores (P = 0.034) and colonoscopy benefit scores (P < 0.001). Findings show that computer-delivered tailored interventions are an effective adjunct to the clinical encounter that can improve knowledge and health beliefs about CRC screening, necessary precursors to behavior change.

Saliva and plasma TIMP-1 in patients with colorectal cancer: a prospective study

BACKGROUND AND AIMS

A prospective cross-sectional study was designed to test if total levels of TIMP-1 in saliva and plasma correlated with the diagnosis of colorectal cancer (CRC) in a population with symptoms consistent with this disease.

MATERIALS AND METHODS

Stimulated whole saliva and blood samples were collected from 161 individuals referred to colonoscopy with symptoms associated with CRC. The results of the examination, as well as previous and/or current other diseases were recorded. In a blinded study, the authors used an in-house TIMP-1 ELISA previously validated for use in saliva and plasma to determine total levels of TIMP-1.

RESULTS

Fifty-six of the patients (35%) were diagnosed with CRC. Plasma TIMP-1 levels were significantly elevated in CRC patients compared with patients with other, non-malignant diseases and individuals without disease. Significant differences in saliva TIMP-1 levels between CRC patients and individuals without CRC could not be demonstrated. In addition, no correlation was found between levels of TIMP-1 in plasma and saliva.

CONCLUSION

Total levels of TIMP-1 in saliva do not reflect the presence of CRC, and TIMP-1 saliva measurements thus cannot substitute plasma TIMP-1 measurements in detection of CRC.

Patients undergoing colorectal cancer screening underestimate their cancer risk and delay presentation for screening

BACKGROUND

Colorectal cancer (CRC) is the third most common cancer in Canada. Screening guidelines recommend that first-time screening should occur at 50 years of age for average-risk individuals and at 40 years of age for those with a family history of CRC.

OBJECTIVE

To examine whether persons with a positive CRC family history were achieving screening at 40 years of age and whether average-risk persons were achieving screening at 50 years of age.

METHODS

The present study was a cross-sectional analysis of subjects who entered a colon cancer screening program and were undergoing CRC screening for the first time.

RESULTS

A total of 778 individuals were enrolled in the present study: 340 (174 males) with no family history of CRC, and 438 (189 males) with a positive family history of CRC. For the group with a positive family history, the mean (± SD) age for primary screening was 54.4 ± 8.5 years, compared with 58.2 ± 6.4 years for the group with no family history. On average, those with a positive family history initiated screening 3.8 years (95% CI 2.8 to 4.8; P<0.05) earlier than those without. Adenoma polyp detection rate for the positive family history group was 20.8% (n=91) compared with 23.5 % (n=80) for the group with no family history.

CONCLUSIONS

Individuals with a positive CRC family history are initiating screening approximately four years earlier than those without a family history; nevertheless, both groups are undergoing screening well past current guideline recommendations.

Patient-provider discussions about colorectal cancer screening: who initiates elements of informed decision making?

BACKGROUND

Colorectal cancer (CRC) screening rates remain low among low-income minority populations.

OBJECTIVE

To evaluate informed decision making (IDM) elements about CRC screening among low-income minority patients.

DESIGN

Observational data were collected as part of a patient-level randomized controlled trial to improve CRC screening rates. Medical visits (November 2007 to May 2010) were audio-taped and coded for IDM elements about CRC screening. Near the end of the study one provider refused recording of patients' visits (33 of 270 patients). Among all patients in the trial, agreement to be audio taped was 43.5 % (103/237). Evaluable patient (n = 100) visits were assessed for CRC screening discussion occurrence, IDM elements, and who initiated discussion of each IDM element.

PARTICIPANTS

Patients were African American (72.2 %), female (63.7 %), with annual household incomes <$20,000 (60.7 %), without health insurance (57.0 %), and limited health literacy (53.7 %).

KEY RESULTS

Although CRC screening was mentioned during 48 (48 %) visits, no further discussion about screening occurred in 23 visits (19 times mentioned by the participant with no response from providers). During any visit, the maximum number of IDM elements was five; however, only two visits included five elements. The most common IDM element discussed in addition to the nature of the decision was the assessment of the patient's understanding in 16 (33.3 %) of the visits that included a CRC discussion.

CONCLUSIONS

A patient activation intervention initiated CRC screening discussions with health care providers; however, limited IDM occurred about CRC screening during medical visits of minority and low-income patients.

Influence of primary care on breast cancer outcomes among Medicare beneficiaries

PURPOSE

We used the Surveillance Epidemiology and End Results (SEER)-Medicare database to explore the association between primary care and breast cancer outcomes.

METHODS

Using a retrospective cohort study of 105,105 female Medicare beneficiaries with a diagnosis of breast cancer in SEER registries during the years 1994-2005, we examined the total number of office visits to primary care physicians and non-primary care physicians in a 24-month period before cancer diagnosis. For women with invasive cancers, we examined the odds of diagnosis of late-stage disease, according to the American Joint Commission on Cancer (AJCC) (stages III and IV vs stages I and II), and survival (breast cancer specific and all cause) using logistic regression and proportional hazards models, respectively. We also explored whether including noninvasive cancers, such as ductal carcinoma in situ (DCIS), would alter results and whether prior mammography was a potential mediator of associations.

RESULTS

Primary care physician visits were associated with improved breast cancer outcomes, including greater use of mammography, reduced odds of late-stage diagnosis, and lower breast cancer and overall mortality. Prior mammography (and resultant earlier stage diagnosis) mediated these associations in part, but not completely. Similar results were seen for non-primary care physician visits. Results were similar when women with DCIS were included in the analysis.

CONCLUSIONS

Medicare beneficiaries with breast cancer had better outcomes if they made greater use of a primary care physician's ambulatory services. These findings suggest adequate primary medical care may be an important factor in achieving optimal breast cancer outcomes.

Interventions to improve care related to colorectal cancer among racial and ethnic minorities: a systematic review

OBJECTIVE

To systematically review the literature to identify interventions that improve minority health related to colorectal cancer care.

DATA SOURCES

MEDLINE, PsycINFO, CINAHL, and Cochrane databases, from 1950 to 2010.

STUDY ELIGIBILITY CRITERIA, PARTICIPANTS, AND INTERVENTIONS

Interventions in US populations eligible for colorectal cancer screening, and composed of ≥50 % racial/ethnic minorities (or that included a specific sub-analysis by race/ethnicity). All included studies were linked to an identifiable healthcare source. The three authors independently reviewed the abstracts of all the articles and a final list was determined by consensus. All papers were independently reviewed and quality scores were calculated and assigned using the Downs and Black checklist.

RESULTS

Thirty-three studies were included in our final analysis. Patient education involving phone or in-person contact combined with navigation can lead to modest improvements, on the order of 15 percentage points, in colorectal cancer screening rates in minority populations. Provider-directed multi-modal interventions composed of education sessions and reminders, as well as pure educational interventions were found to be effective in raising colorectal cancer screening rates, also on the order of 10 to 15 percentage points. No relevant interventions focusing on post-screening follow up, treatment adherence and survivorship were identified.

LIMITATIONS

This review excluded any intervention studies that were not tied to an identifiable healthcare source. The minority populations in most studies reviewed were predominantly Hispanic and African American, limiting generalizability to other ethnic and minority populations.

CONCLUSIONS AND IMPLICATIONS OF KEY FINDINGS

Tailored patient education combined with patient navigation services, and physician training in communicating with patients of low health literacy, can modestly improve adherence to CRC screening. The onus is now on researchers to continue to evaluate and refine these interventions and begin to expand them to the entire colon cancer care continuum.

Factors associated with participation in colorectal cancer screening in Korea: the Fourth Korean National Health and Nutrition Examination Survey (KNHANES IV)

PURPOSE

Despite the Government's National Cancer Screening Program for colorectal cancer (CRC), the number of individuals participating in screening in Korea is low. Therefore, the aim of this study was to identify associations between relevant risk factors and the uptake of screening in Korea.

METHODS

The Health Interview Survey sub-dataset derived from the Fourth Korean National Health and Nutrition Examination Survey (KNHANES IV) was used to evaluate participation in CRC screening and factors associated with attendance in individuals aged ≥50. Those that completed the questionnaire and not previously diagnosed with CRC were enrolled (8,042 subjects). Multi-dimensional covariates were considered as potential predictors for CRC screening in multivariate analyses.

RESULTS

A total of 33.2% complied with the CRC screening recommendations. The following were associated with participation: age (aged 70 or older [ref], aged 70 or over; odds ratio (OR) 1.81, 95% confidence interval (CI) 1.54-2.14), marital status (OR 1.43, 95%CI 1.23-1.66), urban-dwelling (OR 1.16, 95%CI 1.02-1.32), education level (elementary school or less [ref], high school (OR 1.29, 95%CI 1.09-1.53), university or higher (OR 1.53, 95%CI 1.23-1.91)), household income (fourth quartile [ref], first quartile (OR 1.29, 95%CI 1.07-1.56)), private health insurance (OR 1.38, 95%CI 1.21-1.58), smoking (OR 1.35, 95%CI 1.43-1.60), self-reported depression (OR 0.79, 95%CI 0.68-0.92), and number of chronic diseases (0-3 [ref], ≥4 (OR 1.41, 95%CI 1.22-1.62)).

CONCLUSION

To improve participation in CRC screening, appropriate strategies must be directed toward vulnerable populations, such as those with low socioeconomic status.

Performance of the fecal immunochemical test is not decreased by high ambient temperature in the rapid return system

BACKGROUND

Hemoglobin concentration of fecal immunochemical test may be decreased at high ambient temperature, and fecal samples in FIT may be exposed to high ambient temperature.

AIMS

The aim of this study was to determine whether a high ambient temperature on the day of screening may decrease the performance of FITs in population-based screening.

METHODS

We performed FITs for asymptomatic participants aged 50 years or older. Fecal hemoglobin concentration, the probability of a positive FIT and a detection rate of colorectal neoplasms were compared between low (<10.0 °C) and high (≥25.0 °C) temperature groups.

RESULTS

The FIT results for 8,316 participants were analyzed. The mean log(10) Hb concentration in the low temperature group was significantly higher than those in the high temperature group (0.36 vs. 0.25 ng/ml, p = 0.000). Regression analysis showed that an increase in temperature of 1 °C reduced the probability of a positive FIT by 3.1 %. However, we found no differences between the two groups in the FIT positive rate and detection rate of colorectal neoplasms. In multivariate analysis, high ambient temperature was not a significant risk factor for either the positive FIT result or the detection of colorectal neoplasms.

CONCLUSIONS

Potential instability of fecal hemoglobin at high ambient temperatures should be considered; however, its influence on performance of FIT may be attenuated by the short exposure time of fecal samples to high ambient temperature (i.e., rapid return system).

Clinical end points for developing pharmaceuticals to manage patients with a sporadic or genetic risk of colorectal cancer

To reduce the morbidity and mortality from colorectal cancer (CRC), current clinical practice focuses on screening for early detection and polypectomy as a form of secondary prevention, complemented with surgical interventions when appropriate. No pharmaceutical agent is currently approved for use in clinical practice for the management of patients at risk for CRC. This article will review earlier attempts to develop pharmaceuticals for use in managing patients with a sporadic or genetic risk of CRC. It will also discuss therapeutic end points under evaluation in current efforts to develop drugs for treating CRC risk factors.

Interventions to promote colorectal cancer screening: an integrative review

Behavior change interventions to promote colorectal cancer (CRC) screening have targeted people in community and primary care settings, health care providers, and health systems. Randomized controlled trials provide the strongest evidence of intervention efficacy. The purpose of this integrative review was to evaluate trials of CRC screening interventions published between 1997 and 2007 and to identify knowledge gaps and future directions for research. Thirty-three randomized trials that met inclusion criteria were evaluated using a modified version of the TREND criteria. Significant intervention effects were reported in 6 of 10 trials focused on increasing fecal occult blood testing, 4 of 7 trials focused on sigmoidoscopy or colonoscopy completion, and 9 of 16 trials focused on completion of any screening test. Several effective interventions to promote CRC screening were identified. Future trials need to use theory to guide interventions, examine moderators and mediators, consistently report results, and use comparable outcome measures.

Factors influencing receptivity to future screening options for pancreatic cancer in those with and without pancreatic cancer family history

Background

Pancreatic cancer (PC) is considered the most lethal cancer and approximately 10% of PC is hereditary. The purpose of the study was to assess attitudes of at-risk family members with two or more relatives affected with pancreas cancer (PC) toward PC risk and future screening options.

Methods

At-risk family members and primary care controls were surveyed regarding perceived PC risk, PC worry/concern, attitude toward cancer screening, screening test accuracy, and intentions regarding PC screening via blood testing or more invasive endoscopic ultrasound (EUS).

Results

PC family members reported greater perceived risk of PC than controls (54% vs. 6%, respectively, p < 0.0001). PC family members also reported higher levels of PC worry/concern than controls (p < 0.0001), although 19% of PC family members indicated they were “not at all concerned” about getting PC. PC family members indicated greater acceptance of a false-negative result on a PC screening test relative to controls (12% vs. 8%, p = 0.02). Both groups reported high (>89%) receptivity to the potential PC screening options presented, though receptivity was greater among PC family members as compared to controls (p < 0.0001) for EUS. In multivariable analyses, degree of PC concern (p < 0.0001) was associated with intention to screen for PC by blood test and EUS, while perceived PC risk was associated with likelihood of undergoing EUS only (p < 0.0001).

Conclusions

Receptivity to screening options for PC appears high. Clinicians should address behavioral and genetic risk factors for PC and foster appropriate concern regarding PC risk among at-risk individuals.

Effect of comorbid conditions on adherence to colorectal cancer screening

Potential barriers to colorectal cancer (CRC) screening include preexisting medical conditions (comorbidities), physician recommendation, psychosocial factors, and screening preparedness. This study's purpose was to investigate the impact of comorbid conditions on CRC screening among African Americans. A stage-matched randomized clinical trial was performed. Asymptomatic African Americans over age 50, with a primary care physician, and eligible for CRC screening were recruited at The Mount Sinai Hospital from 2005 to 2008. One hundred sixty-one patients were assessed for referral for, and completion of, CRC screening, comorbid conditions, "readiness to change," and number of physician visits within the observation period. Data was compared to a pretrial index to predict the likely effect of comorbid conditions on CRC screening. One hundred fifty-nine patients completed the study; 108 (68.9%) were referred for and 34 (21.2%) completed CRC screening. No demographic characteristics were associated with CRC screening completion. CRC screening referrals were similar for all patients, regardless of comorbidities or clinical visits. Comorbidities rated as having extreme influence on CRC screening showed a trend toward lower screening rates. There was a significant increase in screening rates among participants in advanced stages of readiness at enrollment. These data suggest that while comorbidities did not predict colonoscopy completion, they may play a role in concert with other factors. This is the only study to assess the effect of screening colonoscopy in an African American primary care setting. We must continue to explore interventions to narrow the disparate gap in screening and mortality rates.

Adherence to follow-up after a positive fecal occult blood test in an organized colorectal cancer screening program in Korea, 2004-2008

BACKGROUND AND AIM

To investigate the participation rates, positivity rates, and follow-up rates from 2004 to 2008 in an organized colorectal cancer (CRC) screening program using a fecal occult blood test (FOBT) in Korea.

METHODS

The study population was men and women aged 50 years or older who were invited to participate in the National Cancer Screening Program for CRC between 1 January 2004 and 31 December 2008. We collected the FOBT results and follow-up information for the FOBT positives.

RESULTS

Participation rates increased steadily each year from 10.5% in 2004 to 21.1% in 2008. Between 2004 and 2008, FOBT positivity rates declined from 8.0% to 6.8%. Among the FOBT-positives, 61.3% of participants underwent either colonoscopy or double contrast barium enema (DCBE) in 2004, and this rate decreased to 38.6% in 2008. Age, health insurance type, and screening history were associated with adherence to follow-up test after a positive FOBT. With regard to follow-up tests, colonoscopy rates increased from 17.9% in 2004 to 27.6% in 2008, while DCBE decreased from 43.4% in 2004 to 11.0% in 2008. Colonoscopy was significantly more likely to be chosen as a follow-up test by men, participants aged 50-59 years, and National Health Insurance beneficiaries.

CONCLUSION

These findings suggest that targeting participants for follow-up, based on age and previous screening history, could be a good way to improve the follow-up rate.

Psychosocial variables associated with colorectal cancer screening in South Australia

BACKGROUND

Population screening reduces mortality from colorectal cancer, yet factors associated with uptake of screening are incompletely understood.

PURPOSE

The purpose of the study was to determine demographic and psychosocial factors associated with participation in faecal occult blood test (FOBT)-based colorectal cancer (CRC) screening in an average risk community programme in Adelaide, South Australia.

METHOD

A questionnaire consistent with the Preventive Health Model was used to determine demographic and psychosocial differences between previous FOBT-based screening participants (n = 413, response rate 93.2%) and non-participants (n = 481, response rate 47.9%). Results were analysed by univariate and multivariate generalised linear modelling, and factors associated with participation were identified.

RESULTS

Factor analysis of psychosocial items revealed an optimal three-factor solution (knowledge, faecal aversion, belief in the value of screening). Following multivariate analyses, two psychosocial and two demographic factors remained as predictors of FOBT screening behaviour: (1) items related to faecal aversion (Aversion), relative risk (RR) = 0.61, CI = 0.55-0.69, (2) perceptions about the value of screening (Value), RR = 1.45, CI = 1.13-1.85, (3) age band 65-69 (Age, five age bands, relative to age 50-54), RR = 1.43, CI = 1.16-1.76 and FOBT type (Test; three tests, Hemoccult, FlexSure, InSure randomly assigned, relative to Hemoccult: FlexSure: RR = 1.41, CI = 1.17-1.71, InSure: RR = 1.76, CI = 1.47-2.11.

CONCLUSIONS

The psychosocial factors associated with non-participation in FOBT-based CRC screening are amenable to interventions designed to improve participation. The small relative risks values associated with each predictor, however, raise the possibility that additional factors are likely to influence screening participation.

Fecal occult blood testing instructions and impact on patient adherence

INTRODUCTION

Although the physician's role with patients is crucial in encouraging FOBT screening, the nature and content of physician-patient discussions about FOBT screening is unclear. As part of a larger study, this paper reports on our analyses of physician beliefs about fecal occult blood testing (FOBT) and strategies they employed to enhance patient adherence. The second aim of this paper is to report on the perceptions of individuals at average risk for colorectal cancer (CRC) in regard to their awareness of the FOBT and their responses to physician recommendations about FOBT screening.

METHODS

The larger study was conducted in urban and rural Manitoba, Canada between 2008 and 2010. We used a qualitative design and conducted semi-structured, audio-recorded interviews with 15 physicians and 27 individuals at average risk for CRC. We included data from 11 family members or friends on their perspectives of FOBT instructions as individuals who were also at average risk for CRC and had their own experiences with CRC screening recommendations.

RESULTS

Despite widespread knowledge of The Canadian Task Force on Preventive Health Care CRC screening guidelines, physician attitudes, behaviors, and instructions were not uniform in promoting patient adherence to FOBT screening. Individuals at average-risk for CRC identified that FOBT instructions were confusing and burdensome, which in turn served as a barrier in their adherence to FOBT screening.

CONCLUSIONS

Variation in FOBT instruction counseling in relation to the recommended age of individuals at average risk for CRC, as well as adequate patient preparation affected patient adherence. We recommend uniform or standardized instructions and counseling by health care providers who administer the FOBT kit to patients to promote adherence to recommended CRC screening.

Effect of tribal language use on colorectal cancer screening among American Indians

American Indians have one of the lowest colorectal cancer (CRC) screening rates for any racial/ethnic group in the U.S., yet reasons for their low screening participation are poorly understood. We examine whether tribal language use is associated with knowledge and use of CRC screening in a community-based sample of American Indians. Using logistic regression to estimate the association between tribal language use and CRC test knowledge and receipt we found participants speaking primarily English were no more aware of CRC screening tests than those speaking primarily a tribal language (OR = 1.16 [0.29, 4.63]). Participants who spoke only a tribal language at home (OR = 1.09 [0.30, 4.00]) and those who spoke both a tribal language and English (OR = 1.74 [0.62, 4.88]) also showed comparable odds of receipt of CRC screening. Study findings failed to support the concept that use of a tribal language is a barrier to CRC screening among American Indians.

Direct mailing of faecal occult blood tests for colorectal cancer screening: a randomized population study from Central Italy

BACKGROUND

Sending faecal occult blood tests (FOBT) by mail has been proposed both as a method to increase participation and a way to reduce staff costs in colorectal cancer screening.

METHODS

Two multicentre randomized controlled trials (ISRCTN10351276) were performed: one randomly assigned 3196 individuals who had previously participated in colorectal screening to receive a FOBT kit at home or a standard invitation; in the second, 4219 people aged 50-69 years who did not respond to a screening invitation were either sent a FOBT or a standard recall letter. The cost per returned kit was calculated in each arm.

RESULTS

Participation was higher with direct FOBT mailing in both trials: relative risk 1.11 (95% CI 1.06-1.17) and 1.36 (95% CI 1.16-1.60) for previous responders and non-responders, respectively. The cost per returned kit for previous responders ranged from 4.24€ to 16.10€, and from 3.29€ to 7.36€ with FOBT mailing and standard invitation, respectively, not including staff costs; for non-responders it ranged from 17.13€ to 46.80€, and from 7.36€ to 18.30€ with FOBT mailing and standard recall, respectively.

CONCLUSIONS

The FOBT mailing strategy modestly increased participation. This method can be used on a population of previous responders to reduce personnel costs and workload. When used as a reminder to non-responders, this method increases costs.

Evaluating the effectiveness of GP endorsement on increasing participation in the NHS Bowel Cancer Screening Programme in England: study protocol for a randomized controlled trial

Background

The success and cost-effectiveness of bowel cancer screening depends on achieving and maintaining high screening uptake rates. The involvement of GPs in screening has been found to improve patient compliance. Therefore, the endorsement of screening by GPs may increase uptake rates amongst non-responders.

Methods/Design

A two-armed randomised controlled trial will evaluate the effectiveness of a GP endorsed reminder in improving patient participation in the NHS Bowel Cancer Screening Programme (NHSBCSP). Up to 30 general practices in the West Midlands with a screening uptake rate of less than 50% will be recruited and patients identified from the patient lists of these practices. Eligible patients will be those aged 60 to 74, who have previously been invited to participate in bowel screening but who have been recorded by the Midlands and North West Bowel Cancer Screening Hub as non-responders. Approximately 4,380 people will be randomised in equal numbers to either the intervention (GP letter and duplicate FOBt kit) or control (no additional contact) arms of the trial.

The primary outcome measure will be the difference in the uptake rate of FOBt screening for bowel cancer between the intervention and control groups at 13 weeks after the GP endorsed reminder and duplicate FOBt kit are sent. Secondary outcome measures will be subgroup analyses of uptake according to gender, age and deprivation quartile, and the validation of methods for collecting GP, NHSBCSP and patient costs associated with the intervention. Qualitative work (30 to 40 semi-structured interviews) will be undertaken with individuals in the intervention arm who return a FOBt kit, to investigate the relative importance of the duplicate FOBt kit, reminder to participate, and GP endorsement of that reminder in contributing to individuals' decisions to participate in screening.

Discussion

Implementing feasible, acceptable and cost-effective strategies to improve screening uptake amongst non-responders to invitations to participate is fundamentally important for the success of screening programmes. If this feasibility study demonstrates a significant increase in uptake of FOBt screening in individuals receiving the intervention, a definitive, appropriately powered future trial will be designed.

Trial registration number

ISRCTN: ISRCTN86784060

Improving adherence to surveillance and screening recommendations for people with colorectal cancer and their first degree relatives: a randomized controlled trial

Background

Colorectal cancer (CRC) is among the leading causes of cancer-related morbidity and mortality worldwide. Despite clinical practice guidelines to guide surveillance care for those who have completed treatment for this disease as well as screening for first degree relatives of people with CRC, the level of uptake of these recommendations remains uncertain. If outcomes for both patients and their families are to be improved, it is important to establish systematic and cost-effective interventions to improve adherence to guideline recommendations for CRC surveillance and screening.

Methods/Design

A randomized controlled trial will be used to test the effectiveness of a print-based intervention to improve adherence to colonoscopy surveillance among people with CRC and adherence to CRC screening recommendations among their first degree relatives (FDRs). People diagnosed with CRC in the past 10 months will be recruited through a population-based cancer registry. Consenting participants will be asked if their first degree relatives might also be willing to participate in the trial. Information on family history of CRC will be obtained from patients at baseline. Patients and their families will be randomized to either minimal ethical care or the print-based intervention. The print-based intervention for FDRs will be tailored to the participant's level of risk of CRC as determined by the self-reported family history assessment. Follow up data on surveillance and screening participation will be collected from patients and their FDRs respectively at 12, 24 and 36 months' post recruitment. The primary analyses will relate to comparing levels of guideline adherence in usual care group versus print-based group in the patient sample and the FDR sample respectively.

Discussion

Results of this study will provide contribute to the evidence base about effective strategies to a) improve adherence to surveillance recommendation for people with CRC; and b) improve adherence to screening recommendation for FDRs of people with CRC. The use of a population-based cancer registry to access the target population may have significant advantages in increasing the reach of the intervention.

Trial registration

This trial is registered with the Australian and New Zealand Clinical Trials Registry Registration Number (ACTRN): ACTRN12609000628246.

Preferência do paciente no rastreamento do câncer colorretal: uma comparação entre colonografia por tomografia computadorizada e colonoscopia

OBJETIVO: Avaliar o grau de aceitação do paciente submetido a colonografia por tomografia computadorizada (CTC) em comparação com a colonoscopia, quando realizadas para rastreamento de doença colorretal. MATERIAIS E MÉTODOS: Cinquenta pacientes com suspeita de doença colorretal foram submetidos a CTC e colonoscopia. Questionários foram aplicados antes e após a realização da CTC e após a colonoscopia. Graduou-se o desconforto esperado e experimentado antes e após a realização da CTC e da colonoscopia, bem como a preferência do paciente por exame. RESULTADOS: Em relação à CTC, antes de iniciar o exame 18% dos pacientes afirmaram esperar pouco desconforto, 78%, desconforto moderado e 4%, muito desconforto. Após a realização do exame, 72% dos pacientes relataram pouco desconforto, 26%, desconforto moderado e apenas um (2%) dos pacientes referiu muito desconforto. Após a realização da colonoscopia, 86% dos pacientes relataram preferência pela CTC. O grau de distensão colônica e a quantidade de fluido residual não influenciaram na preferência dos pacientes. CONCLUSÃO: Os pacientes preferiram a CTC à colonoscopia, não havendo relação estatística com o grau de distensão colônica na CTC e a eficiência do preparo intestinal.

Machine Learning for Automated Polyp Detection in Computed Tomography Colonography

This chapter presents a comprehensive scheme for automated detection of colorectal polyps in computed tomography colonography (CTC) with particular emphasis on robust learning algorithms that differentiate polyps from non-polyp shapes. The authors’ automated CTC scheme introduces two orientation independent features which encode the shape characteristics that aid in classification of polyps and non-polyps with high accuracy, low false positive rate, and low computations making the scheme suitable for colorectal cancer screening initiatives. Experiments using state-of-the-art machine learning algorithms viz., lazy learning, support vector machines, and naïve Bayes classifiers reveal the robustness of the two features in detecting polyps at 100% sensitivity for polyps with diameter greater than 10 mm while attaining total low false positive rates, respectively, of 3.05, 3.47 and 0.71 per CTC dataset at specificities above 99% when tested on 58 CTC datasets. The results were validated using colonoscopy reports provided by expert radiologists.

The influence of sociocultural factors on colonoscopy and FOBT screening adherence among low-income Hispanics

Few studies have examined barriers and facilitators to colorectal cancer (CRC) screening among Hispanics, particularly sociocultural factors that may be relevant. This paper examines the influence of sociocultural factors on adherence to fecal occult blood testing (FOBT) and colonoscopy. A survey was conducted among a sample of 400 low-income Hispanics in East Harlem, New York. Fatalism and health literacy were both significantly associated with colonoscopy screening adherence in bivariate models, though fatalism became non-significant and health literacy became less significant in multivariable models. With respect to adherence to colonoscopy or FOBT, both fatalism and health literacy were associated in bivariate models, though only fatalism remained significant in multivariable models (p=.03; OR: .94; 95% CI: .881-.992). These findings suggest fatalism and health literacy may play a role in shaping CRC screening adherence among low-income Hispanics. Researchers should continue investigating how sociocultural factors influence screening adherence among Hispanics, using larger and more geographically diverse samples.

Aberrant methylation of genes in stool samples as diagnostic biomarkers for colorectal cancer or adenomas: a meta-analysis

BACKGROUND

An increasing number of hypermethylated genes in stool samples have been reported as biomarkers for the detection of colorectal cancer (CRC) or adenomas. We aimed to comprehensively review and compare the evidence for feasibility of using these biomarkers for the detection of colorectal neoplasia.

METHODS

We searched Medline, the Web of Science and OVID for studies that used hypermethylated genes as biomarkers for the detection of CRC or adenomas. A meta-analysis was carried out using the random-effect model with diagnostic odd ratios (DOR) and 95% confidence intervals (CI) as effect measurements.

RESULTS

A total of 19 studies including 2,356 patients were eligible for final analysis. The sensitivity, specificity, positive likelihood ratio, negative likelihood ratio and DOR for the detection of CRC or adenomas were 0.62 (95% CI: 0.51-0.71), 0.89 (95% CI: 0.86-0.92), 5.66 (95% CI: 4.68-6.83), 0.43 (95% CI: 0.34-0.55) and 13.15 (95% CI: 9.82-17.60) respectively. Of these, the sensitivity and specificity for the detection of adenoma were 0.54 (95% CI: 0.39-0.68) and 0.88 (95% CI: 0.83-0.92) respectively.

CONCLUSIONS

Hypermethylated gene panels are not currently accurate enough to be used alone for colorectal neoplasia screening. The discovery and evaluation of additional biomarkers with improved sensitivity and specificity is necessary.

Patient activation increases colorectal cancer screening rates: a randomized trial among low-income minority patients

BACKGROUND

Colorectal cancer (CRC) screening rates remain low among low-income and minority populations. The purpose of this study was to determine whether providing patients with screening information, activating them to ask for a screening test, and telephone barriers counseling improves CRC screening rates compared with providing screening information only.

METHODS

Patients were randomized to CRC screening information plus patient activation and barriers counseling (n = 138) or CRC screening information (n = 132). Barriers counseling was attempted among activated patients if screening was not completed after one month. CRC screening test completion was determined by medical record review at two months after the medical visit. Logistic regression was used to determine whether activated patients were more likely to complete CRC screening, after adjustment for confounding factors (e.g., demographic characteristics and CRC knowledge).

RESULTS

Patients were African American (72.2%), female (63.7%), had annual household incomes less than $20,000 (60.7%), no health insurance (57.0%), and limited health literacy skills (53.7%). In adjusted analyses, more patients randomized to the activation group completed a screening test (19.6% vs. 9.9%; OR = 2.35, 95% CI: 1.14-5.56; P = 0.020). In addition, more activated patients reported discussing screening with their provider (54.4% vs. 27.5%, OR = 3.29, 95% CI: 1.95-5.56; P < 0.001) and had more screening tests ordered (39.1% vs. 17.6%; OR = 3.40, 95% CI: 1.88-6.15; P < 0.001) compared with those in the control group.

CONCLUSION

Patient activation increased CRC screening rates among low-income minority patients.

IMPACT

Innovative strategies are still needed to increase CRC screening discussions, motivate providers to recommend screening to patients, as well as assist patients to complete ordered screening tests.

Telephone reminder call in addition to mailing notification improved the acceptance rate of colonoscopy in patients with a positive fecal immunochemical test

BACKGROUND AND AIMS

Colorectal cancer (CRC) screening with a fecal immunochemical test (FIT) reduces CRC mortality; however, the acceptance rate of a colonoscopy in patients with a positive FIT was not high. The aim of this study was therefore to determine whether a telephone reminder call could increase the acceptance rate of colonoscopy in patients with a positive FIT.

METHODS

We performed FITs for asymptomatic participants aged 50 years or older. For patients with a positive FIT, a colonoscopy was recommended via mailing notification only (control group) or via a telephone reminder call after mailing notification (intervention group). The calls informed patients about the significance of a positive FIT and encouraged a colonoscopy following positive FITs.

RESULTS

The FIT results were positive in 90 of 8,318 patients who received FITs. Fifty patients were advised to receive colonoscopy via mailing notification only, and 40 patients were advised via both a telephone reminder call and a mailing notification. The acceptance rate of colonoscopy was significantly higher in the intervention group than in the control group (p = 0.038). The lesion-detection rate for an advanced neoplasia was also significantly higher in the intervention group than in the control group (p = 0.046). According to multivariate logistic regression analysis, a telephone reminder was a significant determinant of colonoscopy acceptance in patients with a positive FIT (OR 4.33; 95% CI, 1.19-15.75; p = 0.026).

CONCLUSIONS

Telephone reminder calls in addition to mailing notification improved the acceptance rate of colonoscopy in patients with a positive FIT.

Individual-level factors in colorectal cancer screening: a review of the literature on the relation of individual-level health behavior constructs and screening behavior

OBJECTIVE

Compliance with colorectal cancer screening recommendations requires considerable conscious effort on the part of the individual patient, making an individual's decisions about engagement in screening an important contributor to compliance or noncompliance. The objective of this paper was to examine the effectiveness of individual-level behavior theories and their associated constructs in accounting for engagement in colorectal cancer screening behavior.

METHODS

We reviewed the literature examining constructs from formal models of individual-level health behavior as factors associated with compliance with screening for colorectal cancer. All published studies examining one or more constructs from the health belief model, theory of planned behavior, transtheoretical model, or social cognitive theory and their relation to screening behavior or behavioral intentions were included in the analysis.

RESULTS

By and large, results of studies supported the theory-based predictions for the influence of constructs on cancer screening behavior. However, the evidence base for many of these relations, especially for models other than the health belief model, is quite limited.

CONCLUSIONS

Suggestions are made for future research on individual-level determinants of colorectal cancer screening.

Cancer fatalism and poor self-rated health mediate the association between socioeconomic status and uptake of colorectal cancer screening in England

BACKGROUND

Little is known about the psychological predictors of colorectal screening uptake in England and mediators of associations between uptake and socioeconomic status (SES). This study tested the hypotheses that although higher threat and efficacy beliefs, lower cancer fatalism, lower depression, and better self-rated health would predict higher screening uptake, only efficacy beliefs, fatalism, depression, and self-rated health would mediate associations between uptake and SES.

METHODS

Data from 529 adults aged 60 to 69 who had completed a postal survey in 2005-2006 were linked with data on fecal occult blood test (FOBt) uptake recorded at the screening "hub" following its introduction in 2007, resulting in a prospective study.

RESULTS

Screening uptake was 56% and was higher among people with higher SES, better self-rated health, higher self-efficacy beliefs, and lower cancer fatalism in univariate analyses. Path analysis on participants with complete data (n = 515) showed that both better self-rated health and lower cancer fatalism were directly associated with higher uptake of FOBt screening and significantly mediated pathways from SES to uptake. Lower depression only had an indirect effect on uptake through better self-rated health. Efficacy beliefs did not mediate the relationship between SES and uptake.

CONCLUSION

SES differences in uptake of FOBt in England are partially explained by differences in cancer fatalism, self-rated health, and depression.

IMPACT

This is one of only a few studies to examine mediators of the relationship between SES and screening uptake, and future research could test the effectiveness of interventions to reduce fatalistic beliefs to increase equality of uptake.

A randomized controlled trial of a tailored interactive computer-delivered intervention to promote colorectal cancer screening: sometimes more is just the same

BACKGROUND

There have been few studies of tailored interventions to promote colorectal cancer (CRC) screening.

PURPOSE

We conducted a randomized trial of a tailored, interactive intervention to increase CRC screening.

METHODS

Patients 50-70 years completed a baseline survey, were randomized to one of three groups, and attended a wellness exam after being exposed to a tailored intervention about CRC screening (tailored group), a public web site about CRC screening (web site group), or no intervention (survey-only group). The primary outcome was completion of any recommended CRC screening by 6 months.

RESULTS

There was no statistically significant difference in screening by 6 months: 30%, 31%, and 28% of the survey-only, web site, and tailored groups were screened. Exposure to the tailored intervention was associated with increased knowledge and CRC screening self-efficacy at 2 weeks and 6 months. Family history, prior screening, stage of change, and physician recommendation moderated the intervention effects.

CONCLUSIONS

A tailored intervention was not more effective at increasing screening than a public web site or only being surveyed.

Cost-effectiveness of a mailed educational reminder to increase colorectal cancer screening

BACKGROUND

Colorectal cancer (CRC) screening rates are low in many areas and cost-effective interventions to promote CRC screening are needed. Recently in a randomized controlled trial, a mailed educational reminder increased CRC screening rates by 16.2% among U.S. Veterans. The aim of our study was to assess the costs and cost-effectiveness of a mailed educational reminder on fecal occult blood test (FOBT) adherence.

METHODS

In a blinded, randomized, controlled trial, 769 patients were randomly assigned to the usual care group (FOBT alone, n = 382) or the intervention group (FOBT plus a mailed reminder, n = 387). Ten days after picking up the FOBT cards, a 1-page reminder with information related to CRC screening was mailed to the intervention group. Primary outcome was number of returned FOBT cards after 6 months. The costs and incremental cost-effectiveness ratio (ICER) of the intervention were assessed and calculated respectively. Sensitivity analyses were based on varying costs of labor and supplies.

RESULTS

At 6 months after card distribution, 64.6% patients in the intervention group returned FOBT cards compared with 48.4% in the control group (P < 0.001). The total cost of the intervention was $962 or $2.49 per patient, and the ICER was $15 per additional person screened for CRC. Sensitivity analysis based on a 10% cost variation was $13.50 to $16.50 per additional patient screened for CRC.

CONCLUSIONS

A simple mailed educational reminder increases FOBT card return rate at a cost many health care systems can afford. Compared to other patient-directed interventions (telephone, letters from physicians, mailed reminders) for CRC screening, our intervention was more effective and cost-effective.

Initial and continued adherence with bladder cancer screening in an occupationally exposed cohort

OBJECTIVE

To identify significant predictors of initial and repeated adherence with bladder cancer screening in a high-risk occupationally exposed cohort.

METHODS

We analyzed longitudinal (13 years) health survey data and a cross-sectional behavioral health survey from the Drake Health Registry Study. Construct validity of the behavioral health survey scales was evaluated using factor analysis. Initial compliance and repeated adherence were examined in separate logistic regression models.

RESULTS

"Barriers to screening" and "social influence" were associated with initial participation. Lower or no alcohol consumption, comorbidities, worry that screening would find bladder cancer, and ease of arranging schedules were associated with continued adherence.

CONCLUSIONS

Factors affecting adherence with bladder cancer screening change for initial participation and for continued adherence. To enhance overall adherence, specific strategies should be implemented when initiating a screening program and revised accordingly over time.

[Controversial issues in colorectal screening in Hungary: conflict of clinical and public health viewpoints]

In Hungary, mortality rates from colorectal cancer are dramatically high, therefore the reduction by population screening as a public health measure is considered as one of the priorities of National Public Health Program. In the beginning, a human-specific immunological test was applied in the "model programs", as a screening tool, to detect the occult blood in the stool; compliance was 32% in average. However, the objectives of the model programs have not been achieved, because, among other reasons, a debate on the method of choice and the strategy to follow have divided the professional public opinion. In this study the debated issues are critically discussed, being convinced that, at present, population screening seems to be the most promising way to alleviate the burden of colorectal cancer.

To participate or not? Giving voice to gender and socio-economic differences in colorectal cancer screening programmes

This paper examines the influence of gender and socio-economic status (SES) on participation in colorectal cancer (CRC) screening. Qualitative study with eight focus groups comprised of participants and non-participants in a CRC screening programme in Valencia (Spain), structural sample design and discursive analysis by gender, SES and participation. Non-participants and those with lower SES tended to have less knowledge about both the disease and the programme. Reasons for participation varied according to gender: women were motivated because they value the importance of self-care and early detection in order to prevent personal and family suffering while men were encouraged by their partners. Reasons for non-participation were also influenced by gender: women feared the results and considered the test unpleasant whereas men showed carelessness and lack of concern. In population-based programmes, people with lower SES and men are those with the most obstacles to participation due to low health literacy and traditional gender roles respectively. To increase participation in CRC screening programmes based on informed decision making and taking into account social inequalities, information should be more accessible, comprehensible and adapted to gender and SES differences and emphasise the greater vulnerability of men for CRC and the benefits of early detection.

Screening prevalence and incidence of colorectal cancer among American Indian/Alaskan natives in the Indian Health Service

BACKGROUND

Studies on colorectal cancer (CRC) screening and incidence among American Indian/Alaska Natives (AI/AN) are few.

AIMS

Our aim was to determine CRC screening prevalence and to calculate CRC incidence among AI/AN receiving care within the Indian Health Service (IHS).

METHODS

A retrospective cohort study of AI/AN who utilized IHS from 1996 to 2004. AI/AN who were average-risk for CRC and received primary care within IHS were identified by searching the IHS Resource Patient Management System for selected ICD-9/CPT codes (n = 142,051). CRC screening prevalence was calculated and predictors of screening were determined for this group. CRC incidence rates were ascertained for the entire AI/AN population ages 50-80 who received IHS medical care between 1996 and 2004 (n = 283,717).

RESULTS

CRC screening was performed in 4.0% of average-risk AI/AN. CRC screening was more common among women than men (RR = 1.6, 95% CI 1.4-1.7) and among AI/AN living in the Alaska region compared to the Pacific Coast region (RR = 2.5, 95% CI 2.2-2.8) while patients living in the Northern Plains (RR = 0.4, 95% CI 0.3-0.4) were less likely to have been screened. CRC screening was less common among patients with a greater number of primary care visits. The age-adjusted CRC incidence among AI/AN ages 50-80 was 227 cancers per 100,000 person-years.

CONCLUSIONS

CRC was common among AI/AN receiving medical care within IHS. However, CRC screening prevalence was far lower than has been reported for the U.S. population.

Your Body Is the Temple

Colorectal cancer (CRC) is third in cancer incidence and mortality, due in part to lack of awareness and low rates of screening. The purpose of the present study was to evaluate the efficacy of a spiritually based CRC educational intervention delivered by trained Community Health Advisors, in Alabama churches. The aim of the intervention was to increase knowledge and awareness of CRC and early detection, and to eventually increase CRC screening rates. Participants age-eligible for screening ( N = 122) completed baseline, 6-month, and 12-month surveys by telephone. Increases in CRC knowledge, perceived benefits of CRC screening, and awareness of the screening modalities and decreases in perceived barriers to screening suggested that this type of intervention may be promising for CRC control and should be examined further.

Circulating tumour markers can define patients with normal colons, benign polyps, and cancers

Background:

Early diagnosis represents the best opportunity for cure of colorectal cancer. Current screening programmes use faecal occult blood testing for screening, which has limited sensitivity and poor specificity.

Methods:

In this study we looked at a series of previously described diagnostic markers utilising circulating free DNA (cfDNA), with a preparation method allowing small DNA fragments to be isolated. The Circulating free DNA was isolated from samples obtained from 85 patients, including 35 patients without endoscopic abnormality, a group of 26 patients with benign colorectal adenomas, and 24 patients with colorectal carcinomas. In each case, polymerase chain reaction (PCR) was performed for Line1 79 bp, Line1 300 bp, Alu 115 bp, Alu 247 bp, and mitochondrial primers. In addition, carcinoembryonic antigen (CEA) was measured by ELISA. Each marker was analysed between normal, polyp, and cancer populations, and the best performing analysed in combination by logistic regression.

Results:

The best model was able to discriminate normal from populations with adenoma or carcinoma using three DNA markers and CEA, showing an area under the receiver operator characteristic (ROC) curve of 0.855 with a positive predictive value of 81.1% for polyps and cancer diagnosis.

Conclusion:

These circulating markers in combination with other markers offer the prospect of a simple blood test as a possible secondary screen for colorectal cancers and polyps in patients with positive faecal occult blood tests.

Effectiveness of a web-based colorectal cancer screening patient decision aid: a randomized controlled trial in a mixed-literacy population

BACKGROUND

Colorectal cancer (CRC) screening reduces mortality yet remains underutilized. Low health literacy may contribute to this underutilization by interfering with patients' ability to understand and receive preventive health services.

PURPOSE

To determine if a web-based multimedia CRC screening patient decision aid, developed for a mixed-literacy audience, could increase CRC screening.

DESIGN

RCT. Patients aged 50-74 years and overdue for CRC screening were randomized to the web-based decision aid or a control program seen immediately before a scheduled primary care appointment.

SETTING/PARTICIPANTS

A large community-based, university-affiliated internal medicine practice serving a socioeconomically disadvantaged population.

MAIN OUTCOME MEASURES

Patients completed surveys to determine their ability to state a screening test preference and their readiness to receive screening. Charts were abstracted by masked observers to determine if screening tests were ordered and completed.

RESULTS

Between November 2007 and September 2008, a total of 264 patients enrolled in the study. Data collection was completed in 2009, and data analysis was completed in 2010. A majority of participants (mean age=57.8 years) were female (67%), African-American (74%), had annual household incomes of <$20,000 (76%), and had limited health literacy (56%). When compared to control participants, more decision-aid participants had a CRC screening preference (84% vs 55%, p<0.0001) and an increase in readiness to receive screening (52% vs 20%, p=0.0001). More decision-aid participants had CRC screening tests ordered (30% vs 21%) and completed (19% vs 14%), but no statistically significant differences were seen (AOR=1.6, 95% CI=0.97, 2.8, and AOR=1.7, 95% CI=0.88, 3.2, respectively). Similar results were found across literacy levels.

CONCLUSIONS

The web-based decision aid increased patients' ability to form a test preference and their intent to receive screening, regardless of literacy level. Further study should examine ways the decision aid can be combined with additional system changes to increase CRC screening.

Psychosocial determinants of socioeconomic inequalities in cancer screening participation: a conceptual framework

Cancer screening participation shows a strong, graded association with socioeconomic status (SES) not only in countries such as the United States, where insurance status can be a barrier for lower income groups, but also in the United Kingdom, where the National Health Service provides all health care to residents, including screening, for free. Traditionally, the literature on socioeconomic inequalities has focused on upstream factors, but more proximal (downstream) influences on screening participation also need to be examined, particularly those that address the graded nature of the association rather than focusing specifically on underserved groups. This review offers a framework that links some of the components and corollaries of SES (life stress, educational opportunities, illness experience) to known psychosocial determinants of screening uptake (beliefs about the value of early detection, fatalistic beliefs about cancer, self-efficacy). The aim is to explain why individuals from lower SES backgrounds perceive cancer screening tests as more threatening, more difficult to accomplish, and less beneficial. A better understanding of the mechanisms through which lower SES causes negative attitudes toward screening could facilitate the development of intervention strategies to reduce screening inequalities.

Colorectal cancer screening comparing no screening, immunochemical and guaiac fecal occult blood tests: a cost-effectiveness analysis

Comparability of cost-effectiveness of colorectal cancer (CRC) screening strategies is limited if heterogeneous study data are combined. We analyzed prospective empirical data from a randomized-controlled trial to compare cost-effectiveness of screening with either one round of immunochemical fecal occult blood testing (I-FOBT; OC-Sensor®), one round of guaiac FOBT (G-FOBT; Hemoccult-II®) or no screening in Dutch aged 50 to 75 years, completed with cancer registry and literature data, from a third-party payer perspective in a Markov model with first- and second-order Monte Carlo simulation. Costs were measured in Euros (€), effects in life-years gained, and both were discounted with 3%. Uncertainty surrounding important parameters was analyzed. I-FOBT dominated the alternatives: after one round of I-FOBT screening, a hypothetical person would on average gain 0.003 life-years and save the health care system €27 compared with G-FOBT and 0.003 life years and €72 compared with no screening. Overall, in 4,460,265 Dutch aged 50-75 years, after one round I-FOBT screening, 13,400 life-years and €320 million would have been saved compared with no screening. I-FOBT also dominated in sensitivity analyses, varying uncertainty surrounding important effect and cost parameters. CRC screening with I-FOBT dominated G-FOBT and no screening with or without accounting for uncertainty.

Are physicians' recommendations for colorectal cancer screening guideline-consistent?

BACKGROUND

Many older adults in the U.S. do not receive appropriate colorectal cancer (CRC) screening. Although primary care physicians' recommendations to their patients are central to the screening process, little information is available about their recommendations in relation to guidelines for the menu of CRC screening modalities, including fecal occult blood testing (FOBT), flexible sigmoidoscopy (FS), colonoscopy, and double contrast barium enema (DCBE). The objective of this study was to explore potentially modifiable physician and practice factors associated with guideline-consistent recommendations for the menu of CRC screening modalities.

METHODS

We examined data from a nationally representative sample of 1266 physicians in the U.S. surveyed in 2007. The survey included questions about physician and practice characteristics, perceptions about screening, and recommendations for age of initiation and screening interval for FOBT, FS, colonoscopy and DCBE in average risk adults. Physicians' screening recommendations were classified as guideline consistent for all, some, or none of the CRC screening modalities recommended. Analyses used descriptive statistics and polytomous logit regression models.

RESULTS

Few (19.1%; 95% CI:16.9%, 21.5%) physicians made guideline-consistent recommendations across all CRC screening modalities that they recommended. In multivariate analysis, younger physician age, board certification, north central geographic region, single specialty or multi-specialty practice type, fewer patients per week, higher number of recommended modalities, use of electronic medical records, greater influence of patient preferences for screening, and published clinical evidence were associated with guideline-consistent screening recommendations (p < 0.05).

CONCLUSIONS

Physicians' CRC screening recommendations reflect both overuse and underuse, and few made guideline-consistent CRC screening recommendations across all modalities they recommended. Interventions that focus on potentially modifiable physician and practice factors that influence overuse and underuse and address the menu of recommended screening modalities will be important for improving screening practice.

Demographic, social cognitive and social ecological predictors of intention and participation in screening for colorectal cancer

Background

Previous research points to differences between predictors of intention to screen for colorectal cancer (CRC) and screening behavior, and suggests social ecological factors may influence screening behavior. The aim of this study was to compare the social cognitive and social ecological predictors of intention to screen with predictors of participation.

Methods

People aged 50 to 74 years recruited from the electoral roll completed a baseline survey (n = 376) and were subsequently invited to complete an immunochemical faecal occult blood test (iFOBT).

Results

Multivariate analyses revealed five predictors of intention to screen and two predictors of participation. Perceived barriers to CRC screening and perceived benefits of CRC screening were the only predictor of both outcomes. There was little support for social ecological factors, but measurement problems may have impacted this finding.

Conclusions

This study has confirmed that the predictors of intention to screen for CRC and screening behaviour, although overlapping, are not the same. Research should focus predominantly on those factors shown to predict participation. Perceptions about the barriers to screening and benefits of screening are key predictors of participation, and provide a focus for intervention programs.

Equity of colorectal cancer screening: which groups have inequitable participation and what can we do about it?

The National Bowel Cancer Screening Program (NBCSP) offers population-based screening for colorectal cancer (CRC) across Australia. The aims of this paper were to highlight the inequities in CRC screening in South Australia (SA) and the system-related barriers and enablers to CRC screening from the perspective of participants identified as having inequitable participation. First, de-identified data for the SA population of the NBCSP were statistically analysed and then mapped. Second, 117 in-depth interviews were conducted with culturally and linguistically diverse (CALD) groups, Indigenous and Anglo-Saxon Australians. Participation rates in the NBCSP were geographically and statistically significantly different (P < 0.0001) on the basis of gender (higher for women), age (higher for older people) and socioeconomic status (higher for more affluent people). The main system-related barriers were the lack of awareness of CRC or CRC screening within these groups, the problems with language due to most of the information being in English and the lack of recommendation by a doctor. This study revealed that inequity exists in the NBCSP participation in SA, and we identified both barriers and facilitators to CRC screening that require action at the level of both policy and practice. There is a large role in primary health care of both recommending CRC screening and facilitating equitable participation.

Effectiveness of the immunofecal occult blood test for colorectal cancer screening in a large population

BACKGROUND

Guaiac tests are the most widely used tests to detect colorectal cancer (CRC). However, their sensitivity is relatively low and results may be affected by various factors. Immunofecal occult blood test (IFOBT) is specific for human hemoglobin and does not require dietary restrictions.

AIMS

The aim of this study was to evaluate the effectiveness of IFOBT for the screening of precancerous lesions and CRC.

METHODS

From July 2006 to June 2007, IFOBT was performed on 5,919 adults who received periodic health examinations in our hospital. The positive cases were examined by colonoscopy and a double-contrast barium enema. Diagnosis was confirmed by histopathological analysis.

RESULTS

Positive IFOBT was detected in 314 of 5,919 cases (5.30%). Further examinations were made in 264 IFOBT-positive cases. Of these, 116 cases with colorectal cancer (16 cases) or precancerous lesions (94 cases with colorectal adenomatous polyps and 6 cases with active ulcerative colitis) were detected. The total detection rate of CRC and precancerous lesions was 43.94% (116/264). TNM classification of 16 CRC cases was as follows: TNM I in eight cases (50.00%), TNM II in seven cases (43.75%) and TNM III in one case (6.25%), indicating IFOBT can detect CRC in the early stages.

CONCLUSION

Regular IFOBT can detect precancerous lesions and CRC in early stages and can thus reduce mortality from CRC.

Understanding the barriers and facilitators of colorectal cancer screening among low income immigrant hispanics

Colorectal cancer (CRC) screening rates are low among Hispanics; thus understanding screening barriers and facilitators is essential. A survey, based on blended health promotion theories, was conducted with low income, mostly immigrant, Hispanics at community based organizations and health clinics in New York City. Correlates of undergoing colonoscopy screening were examined. Four hundred men (28%) and women were interviewed. Older age, longer US residence, having a regular health care provider and provider recommendation predicted colonoscopy receipt (P values <0.01). Greater fear and worry concerning colonoscopy and fewer perceived screening benefits were associated with reduced screening likelihood (P values <0.05). In a multivariate model, colonoscopy receipt was negatively associated with Medicaid and positively associated with English preference, physician recommendation for and encouragement of screening and less fear. Interventions that educate physicians and patients regarding colonoscopy screening guidelines, increase physicians' screening referrals, and reduce patients' fear are needed.

Community involvement in the development and feedback about a colorectal cancer screening media campaign in Ohio Appalachia

A community needs assessment focused on colorectal cancer (CRC) screening knowledge, behaviors, and barriers was completed in one Ohio Appalachia county. A CRC screening media campaign was developed based on the findings from the needs assessment and feedback was obtained about the media campaign. The survey was completed by 170 self-reported average-risk adults. In a multivariate model, the CRC screening rate was higher for participants who had received a doctor's recommendation (OR = 6.09) and had adequate CRC knowledge (OR = 2.88), and it was lower among participants employed full-time (OR = 0.23). Having health insurance (OR = 4.20) and being married (OR = 2.58) was associated with having received a doctor's recommendation for screening. Campaign feedback using a second survey completed by self-reported average-risk adults (n = 61) revealed that 69% recognized the campaign image and message, with a billboard being the most cited source. This study highlights the importance of involving community members in the development of CRC screening programs to reduce cancer disparities in Appalachia.