Evaluation of Interventions Intended to Increase Colorectal Cancer Screening Rates in the United States: A Systematic Review and Meta-analysis

Adherence to mt-sDNA testing for colorectal cancer screening among new users in a U.S. black population

OBJECTIVE

Colorectal cancer (CRC) poses significant mortality risks, particularly among Black individuals, who experience the highest CRC incidence and mortality rates in the U.S. This study examined adherence to multi-target stool DNA (mt-sDNA) testing in this population.

METHODS

This retrospective cohort analysis used Exact Sciences Laboratories (ESL)-linked claims data from January 2017 to December 2023 on Black patients in the U.S. aged 45 and older. High-risk individuals, those with payers other than commercial plans, managed care organizations, Medicare Advantage, Medicaid, or Medicare, and individuals with mt-sDNA prescriptions outside the study period were excluded. Adherence was defined as the percentage of patients returning the test kit with valid results within 365 days of shipment. Logistic regression analysis was used to identify factors associated with adherence.

RESULTS

Among 434,951 patients included in the study, the overall adherence to mt-sDNA testing was 62.0% (N = 266,981), with a mean time to adherence of 27.6 days (SD = 44.17) Females, older adults (76+ years), and rural residents had higher adherence than males, younger adults, and metropolitan patients (ORs = 1.05; all p < 0.001), respectively. Patients with orders from GI specialists had higher adherence than other prescribing clinicians (NP/PA: OR = 0.39, OB/GYN: OR = 0.54, Other: OR = 0.38, PCP: OR = 0.50; all p < 0.001). Digital outreach, especially SMS and email combination, was also associated with higher adherence (OR = 1.25, p < 0.001).

CONCLUSIONS

This large, national study found a 62.0% adherence rate to mt-sDNA testing among Black individuals. Higher adherence was associated with being female, older age, rural residence, and digital outreach. While the findings highlight the promise of mt-sDNA, further research is needed to explore its full potential in improving CRC screening adherence across different demographic groups.

Multilevel intervention for follow-up of abnormal FIT in the safety-net: IMProving Adherence to Colonoscopy through Teams and Technology (IMPACTT)

BACKGROUND

Fecal immunochemical testing (FIT) is a widely used first step for colorectal cancer (CRC) screening. Abnormal FIT results require a colonoscopy for screening completion and CRC diagnosis, but the rate of timely colonoscopy is low, especially among patients in safety-net settings. Multi-level factors at the clinic- and patient-levels influence colonoscopy completion after an abnormal FIT. Our study aims to implement a multi-level approach consisting of a clinic- and patient-level intervention to improve the completion of diagnostic colonoscopy after an abnormal FIT.

METHODS

We will test a multilevel intervention with one safety-net system across 12 primary care clinics - a clinic-level intervention using a stepped wedge design and a patient-level intervention with patient-level randomization. At the clinic level, we will implement a "best practices bundle" to improve workflow for primary care providers and staff using a stepped-wedge design. At the patient level, we will randomize 2000 patients to receive text messages and call reminders or usual care.

RESULTS

For the main analysis, we will use a mixed effects logistic model to assess the impact of the clinic intervention on the primary outcome (completion of colonoscopy within 180 days after abnormal FIT). Secondary outcomes include median days to colonoscopy completion, rate of referral to colonoscopy at 42 days, rate of scheduled colonoscopy at 56 days, and bowel preparation quality at colonoscopy.

DISCUSSION

This study will assess the extent to which a multi-level intervention can improve timely colonoscopy completion in a diverse patient population cared for in a safety-net setting.

TRIAL REGISTRATION

NCT, NCT06191185. Registered 20 December 2023, https://clinicaltrials.gov/study/NCT06191185.

Disparities in Colorectal Cancer Screening Before and After the Onset of the COVID Pandemic

BACKGROUND

Colorectal cancer (CRC) screening is underutilized among those with lower socioeconomic status and in racial and ethnic minoritized populations who have been disproportionately impacted by COVID.

OBJECTIVE

To compare disparities in CRC screening before and after the onset of the COVID pandemic among privately insured individuals.

DESIGN

Retrospective cohort study using deidentified claims data from the USA between January 1, 2017, and December 31, 2022.

PARTICIPANTS

Blue Cross Blue Shield beneficiaries aged 50-75 years with average risk of CRC.

MAIN MEASURE(S)

Mean screening use was compared by demographic and area-level socioeconomic factors between the periods preceding (January 1, 2017 to February 28, 2020) and following (July 1, 2020 to December 31, 2022) the onset of the COVID pandemic. Difference-in-differences analysis was used to evaluate changes in screening differences.

RESULTS

Our study included 21,724,223 beneficiaries. Compared to males, females had higher screening in both periods (p < 0.05), and this sex difference in screening increased 1.63% (95% confidence interval [CI]: 1.32%, 1.94%) following the onset of the pandemic. Compared to residents in areas with high socioeconomic status (SES), low SES area residents had lower screening (p < 0.001) during both periods. Furthermore, this difference grew 4.32% (95% CI, 3.76%, 4.88%) during the post-onset period. Metropolitan area residents had higher screening than non-metropolitan area residents during both periods (p < 0.001); however, this difference decreased 0.77% (95% CI, 0.34%, 1.20%) during the post-onset period. Among beneficiaries with high risk of CRC, the difference in screening based on social deprivation index and metropolitan area status increased 6.99% (95% CI, 5.77%, 8.20%) and 1.82% (95% CI, 0.88%, 2.74%), respectively.

CONCLUSIONS

Among privately insured individuals, CRC screening after the COVID pandemic recovered unevenly based on sex, area-level socioeconomic measures, and metropolitan area status, with pre-pandemic disparities persisting and even worsening for some of the factors.

Patient-Provider Communication and Colorectal Cancer Screening Completion Using Multi-target Stool DNA Testing

Colorectal cancer (CRC) screening continues to be underutilized in the USA despite the availability of multiple effective, guideline-recommended screening options. Provider recommendation has been consistently shown to improve screening completion. Understanding how patient-provider communication influences CRC screening can inform interventions to improve screening completion. We developed a behavioral theory-informed survey to identify patient-provider communication factors associated with multi-target stool DNA (mt-sDNA) screening completion. The survey was administered by RTI International between 03/2022 and 06/2022 to a sample of US adults ages 45-75 who received a valid order for mt-sDNA screening with a shipping date between 5/2021 and 9/2021. Respondents completed an electronic or paper survey. Multivariable logistic regression was used to identify patient-provider communication factors associated with mt-sDNA test completion. A total of 2973 participants completed the survey (response rate, 21.7%) and 81.6% of them (n = 2427) reported having had a conversation with provider about mt-sDNA testing before the test was ordered. Having a conversation with the provider about the test, including discussions about costs, the need for follow-up testing and test instructions were associated with higher odds of test completion and being "very likely" to use the test in the future. Lack of discussion about advantages and disadvantages of available CRC screening options and lack of patient involvement in CRC screening decision-making were associated with reduced odds of test completion and likelihood of future use. Healthcare providers play a key role in patient adherence to CRC screening and must be appropriately prepared and resourced to educate and to engage patients in shared decision-making about CRC screening.

Adherence to multi-target stool DNA testing for colorectal cancer screening in the United States

PURPOSE

Colorectal cancer (CRC) is the second leading cause of cancer mortality in the USA and is highly preventable, with early screening vital for improving outcomes. This study aimed to evaluate adherence rates of multi-target stool DNA (mt-sDNA) testing, following updated guidelines recommending screening starting at age 45.

METHODS

This retrospective cohort study used aggregated data from Exact Sciences Laboratories LLC, examining new users (first-time testers) aged 45-85 with commercial, Medicare, or Medicaid insurance who received mt-sDNA test kits (point-of-care) between January 1, 2023, and June 1, 2023. Adherence was defined as the percentage of eligible participants returning a valid non-empty test kit within 365 days of initial shipment date. Descriptive statistics and logistic regression were used to analyze adherence.

RESULTS

Among 1,557,915 patients, the overall adherence rate to mt-sDNA testing was 71.3% (commercial insurance 72.3%, Medicare Advantage 70.2%, Medicare 69.9%, Medicaid 52.0%) (p < 0.001). Females had slightly higher adherence than males, except for commercial insurance (72.2% vs. 72.6%, p < 0.001). Adherence was highest in commercial insurance for individuals aged 76-85 (79.2%, p < 0.001), gastroenterology patients (82.5%, p < 0.001), and rural residents (73.2%, p < 0.001), along with those in Medicare Advantage earning $200 K + (78.5%, p < 0.001).

CONCLUSIONS

Adherence to mt-sDNA testing was robust, particularly among individuals with commercial insurance, older adults, gastroenterology patients, higher income groups, and rural residents. With a 71% adherence rate, the test demonstrates substantial engagement and value in colorectal cancer screening. Future research should assess its long-term impact and address disparities to optimize its benefits.

A socioecological taxonomy of determinants to colorectal cancer screening in black men: Insights from a mixed-methods systematic review

Background

In the United States, African/Black American (henceforth Black) men face significantly higher mortality rates from colorectal cancer (CRC) compared to other gender, racial, and ethnic groups. Although CRC is preventable and treatable with early detection, screening rates among Black men remain low. This study aimed to synthesize existing literature on the barriers and facilitators (determinants) of CRC screening to offer guidance to primary care teams in their efforts to improve screening uptake.

Methods

We performed a comprehensive systematic review of full-text, peer-reviewed studies published in English to explore the various determinants influencing CRC screening among Black men. Using key terms like "Black or African American," "male," and "colorectal cancer screening," we searched databases including PubMed, PsychInfo, CINAHL, and Embase, published between 2009 and 2022.

Findings

The search identified 1235 articles, with 54 meeting the inclusion criteria. Most studies were cross-sectional, examining determinants across the socioecological system. Key barriers included a lack of CRC screening knowledge, poor patient-provider communication, lack of access to screening, and medical mistrust stemming from systemic racism. Significant facilitators included aging, receiving a provider recommendation, having social support, and effective culturally appropriate outreach strategies.

Conclusions

Key themes and significant findings from the review provide actionable strategies for primary care teams. These include enhancing knowledge about CRC screening within the patient population, improving patient-provider interactions, and reducing barriers to accessing screening. Future research should aim to develop culturally appropriate and collaborative preventive care strategies to improve screening adherence and CRC-related outcomes.

Colorectal cancer screening knowledge among community pharmacists: A national survey

BACKGROUND

Colorectal cancer (CRC) screening can reduce CRC morbidity and mortality. Community pharmacies could be a viable option for delivering home-based CRC screening tests such as fecal immunochemical tests (FITs). However, little is known about community pharmacists' knowledge about CRC screening guidelines.

OBJECTIVE

We assessed community pharmacists' knowledge about CRC screening to identify education and training needs for a pharmacy-based CRC screening program.

METHODS

Between September 2022 and January 2023, we conducted an online national survey of community pharmacists practicing in the United States. Responders were eligible if they were currently-licensed community pharmacists and currently practiced in the United States. The survey assessed knowledge of national CRC screening guidelines, including recommended starting age, frequency of screening, different screening modalities, and follow-up care. Using multiple linear regression, we evaluated correlates of community pharmacists' level of CRC screening knowledge, defined as the total number of knowledge questions answered correctly from "0" (no questions correct) to "5" (all questions correct).

RESULTS

A total of 578 eligible community pharmacists completed the survey, with a response rate of 59%. Most community pharmacists correctly answered the question about the next steps following a positive FIT (87%) and the question about where a FIT can be done (84%). A minority of community pharmacists responded correctly to questions about the age to start screening with FIT (34%) and how often a FIT should be repeated (28%). Only 5% of pharmacists answered all knowledge questions correctly. Community pharmacists answered more CRC screening knowledge questions correctly as their years in practice increased. Board-certified community pharmacists answered more CRC screening knowledge questions correctly compared to those who were not board-certified.

CONCLUSION

To ensure the successful implementation of a pharmacy-based CRC screening program, community pharmacists need to be educated about CRC screening and trained to ensure comprehensive patient counseling and preventive service delivery.

Colorectal cancer: local results and significance in Hungary

Background

Colorectal cancer (CRC) causes substantial morbidity and mortality internationally. In Hungary, the incidence and mortality of CRC are among the world's highest. Fortunately, CRC is a highly preventable disease, since there is a long asymptomatic phase before neoplastic transformation. Numerous countries have instituted programs for CRC screening. However, Hungary did not implement population-based screening programs until December 2018, consisting of a voluntary 2-step screening program based on the fecal immunochemical test (FIT) and if positive, referral to colonoscopy. Asymptomatic individuals aged over 50 years were invited to participate in the 2-step program. This study aims to analyze the results of these colonoscopies and raise public awareness of the CRC disease process and prevention, especially in Hungary.

Methods

Various literature sources were reviewed, and external information was gathered and consolidated based on CRC etiopathogenesis, management options, screening options, cost, benefits, modalities, and quality control. Semmelweis University Department of Internal Medicine and Hematology's database was accessed for the cross-sectional study results of 168 screening colonoscopies within the 2-step program from 2019 to 2020. I quantified and compared the results obtained during the colonoscopies with that of said literature within Hungary and worldwide.

Results

Colonoscopy was performed in 168 patients of average age 63.4 years. The incidence of CRCs in the population was 4.76%. Among the CRC cases, 75% were in the rectosigmoid area and 25% were in the remaining colon. The total adenoma detection rate (ADR) in the study was 57.1%, higher than the recommended 25% for adequate screening colonoscopy. The total number of resected polyps was 270; 8.1% were adenomas with high-grade dysplasia and 0.76% contained CRC. Out of the 185 resected adenomas, 141 were tubular, 34 were tubulovillous, and 10 were villous. Adenoma localizations included 14.6% rectum, 38.4% sigmoid, 11.9% descending colon, 8.6% transverse colon, 17.8% ascending colon, and 8.6% cecum. The average age of CRC patients was 63.9 years (range, 56-68 years) with a slight female predominance (5 females, 3 males). The ADR of the different endoscopists did not seem to correlate with experience. Optimal participation rate of the screening program would be >60%. Population outreach through mailed FIT is evidence-based and shown to increase CRC screening rates in underserved populations.

Conclusions

Hungary would benefit immensely in most aspects from mandatory, population-based CRC screening with this 2-step program. This alternative is proposed in lieu of 1-step screening, because of the limited capacity for colonoscopy in the country and the limited participation rates in the screened population. To reach maximum cost-benefit, the participation rate of the screened population must be >60%, with >80% of FIT positive test results being referred to colonoscopy. Consolidation and distribution of the screening program through population outreach will bring about substantial reductions in mortality from CRC. Further studies are warranted on the feasibility and sustainability of this 2-step program.

Negative spillover due to constraints on care delivery: a potential source of bias in pragmatic clinical trials

BACKGROUND

Pragmatic clinical trials evaluate the effectiveness of health interventions in real-world settings. Negative spillover can arise in a pragmatic trial if the study intervention affects how scarce resources are allocated across patients in the intervention and comparison groups.

MAIN BODY

Negative spillover can lead to overestimation of treatment effect and harm to patients assigned to usual care in trials of diverse health interventions. While this type of spillover has been addressed in trials of social welfare and public health interventions, there is little recognition of this source of bias in the medical literature. In this commentary, I examine what causes negative spillover and how it may have led clinical trial investigators to overestimate the effect of patient navigation, AI-based physiological alarms, and elective induction of labor. Trials discussed here are a convenience sample and not the result of a systematic review. I also suggest ways to detect negative spillover and design trials that avoid this potential source of bias.

CONCLUSION

As new clinical practices and technologies that affect care delivery are considered for widespread adoption, well-designed trials are needed to provide valid evidence on their risks and benefits. Understanding all sources of bias that could affect these trials, including negative spillover, is a critical part of this effort. Future guidance on clinical trial design should consider addressing this form of spillover, just as current guidance often discusses bias due to lack of blinding, differential attrition, or contamination.

Examining Racial Disparities in Colorectal Cancer Screening and the Role of Online Medical Record Use: Findings From a Cross-Sectional Study of a National Survey

Background

Colorectal cancer (CRC) is the second leading cause of cancer-related deaths in the United States. Early detection via routine CRC screening can significantly lower risks for CRC-specific morbidity and mortality. Public health initiatives between 2000 and 2015 nearly doubled CRC screening rates for some US adults. However, screening rates remain lowest for adults aged 45-49 years (20%), patients of safety net health care facilities (42%), adults without insurance (44%), and other subgroups compared with national averages (72%). Given the evolving landscape of digital health care and trends in web-based health information-seeking behaviors, leveraging online medical record (OMR) systems may be an underutilized resource to promote CRC screening utilization. Recognizing trends in OMR usage and patient demographics may enhance digital inclusion-a key social determinant of health-and support equitable web-based interventions aimed at boosting CRC screening across diverse populations.

Objective

This study examined the association of accessing an OMR with CRC screening utilization and corresponding sociodemographic characteristics of US adults.

Methods

In 2023, we conducted a secondary data analysis using a pooled, weighted sample from Health Information National Trends Survey (HINTS) 5 cycles, 2, 3, and 4 (2018-2020), a nationally representative survey assessing how US adults access and use health-related information. We analyzed the association between sociodemographic characteristics, medical conditions, OMR access, and CRC screening behaviors via logistic regression.

Results

The sample included adults aged 45-75 years (N=5143). The mean age was 59 (SD 8) years for those who reported CRC screening and 52 (SD 6) years for those never screened. Nearly 70% (4029/5143) of participants reported CRC screening and 52% (2707/5143) reported OMR access in the past year. Adjusted odds of CRC screening were higher among non-Hispanic African American or Black adults than among non-Hispanic White adults (odds ratio [OR] 1.76, 95% CI 1.22-2.53), adults who accessed an OMR (OR 1.89, 95% CI 1.45-2.46), older individuals (OR 1.18, 95% CI 1.16-1.21), the insured (OR 3.69, 95% CI 2.34-5.82), and those with a professional or graduate degree versus those with a high school diploma or less (OR 2.65, 95% CI 1.28-5.47). Individuals aged 65-75 years were significantly more likely (P<.001) to be screened (1687/1831, 91%) than those aged 45-49 years (190/610, 29%).

Conclusions

Promoting OMR access, especially among the most disadvantaged Americans, may assist in reaching national screening goals. Emphasis should be placed on the mutability of OMR use compared with most other statistically significant associations with CRC screening behaviors. OMR access provides an intervenable means of promoting CRC education and screening, especially among those facing structural barriers to cancer diagnoses and care. Future research should focus on tailored and accessible interventions that expand OMR access, particularly for younger populations.

Investigation of the expression level of methylated septin 9 gene and serological carcinoembryonic antigen to diagnose colorectal cancer. A meta-analysis study

Introduction

Colorectal cancer (CRC) is a rising threat, necessitating accurate early diagnosis.

Aim

This meta-analysis scrutinised methylated septin 9 (SEPT9) and carcinoembryonic antigen (CEA) in CRC.

Methods

From January 2012 to December 2022, databases including PubMed and Google Scholar were explored for English publications.

Results

The meta-analysis revealed SEPT9's superior diagnostic potential, boasting 71% sensitivity and 91% specificity, outshining CEA (49% and 53%). Notably, an 8-study analysis found a positive correlation between tumour grade and elevated CEA and SEPT9 levels, particularly in stages 3 and 4.

Conclusions

This meta-analysis supports SEPT9 as a potent CRC marker, urging its integration into diagnostic frameworks for enhanced precision and early intervention. The observed link between tumour grade and biomarker levels enhances clinical relevance. Implementing these findings promises improved CRC diagnosis precision, contributing to enhanced treatment outcomes and patient survival. Advocating for SEPT9's inclusion alongside traditional markers like CEA, this study pioneers more effective colorectal cancer management strategies.

Centralized Colorectal Cancer Screening Outreach in Federally Qualified Health Centers: A Randomized Clinical Trial

Importance

Colorectal cancer (CRC) screening is effective but remains underused in federally qualified health centers (FQHCs).

Objective

To assess the effectiveness of a centralized CRC screening outreach intervention involving mailed fecal immunochemical testing (FIT) outreach and patient navigation to colonoscopy after abnormal results of FIT.

Design, Setting, and Participants

A pragmatic randomized clinical trial was conducted, using intention-to-treat analysis. Participants were enrolled from July 6, 2020, to September 17, 2021, and analyses were performed from July 6, 2023, to January 31, 2024. The study was conducted at independent FQHCs comprising 12 clinical delivery sites in North Carolina. The outreach intervention was centralized at an academic cancer center. Active individuals aged 50 to 75 years at average risk for CRC and not current with screening per US Preventive Services Task Force recommendations were included.

Intervention

In addition to usual care, intervention participants received mailed screening outreach materials including an introductory letter, FIT kit packet with instructions and return postage, and 2 reminder letters if needed. Intervention participants with positive results of mailed FIT were offered navigation to facilitate follow-up colonoscopy completion. Control participants received usual care alone.

Main Outcomes and Measures

The primary outcome was completion of a US Preventive Services Task Force-recommended CRC screening test within 6 months determined by electronic health record review. Secondary outcomes were colonoscopy completion within 6 months after positive FIT results and detection of advanced colorectal neoplasia, defined as advanced adenoma or CRC.

Results

A total of 4002 participants were included (mean [SD] age, 59.6 [6.8] years; 2256 [56.4%] female; 364 (9.1%) Hispanic; 1082 [27.0%] non-Hispanic Black; 2288 [57.2%] non-Hispanic White; 1198 [29.9%] commercially insured; 617 [15.4%] Medicaid; 1227 [30.7%] Medicare; and 960 [24.0%] uninsured), with 2001 randomized to each group. Compared with controls, intervention participants were more likely to complete screening within 6 months of randomization (30.0% vs 9.7%; difference, 20.29 percentage points; 95% CI, 17.85-22.73 percentage points). The intervention was effective in all insurance types. In the intervention arm, 33 of 48 participants with positive FIT results (68.8%) completed follow-up colonoscopy within 6 months compared with 8 of 18 participants (44.4%) in the control arm (difference, 24.3 percentage points; 95% CI, -2.13 to 50.74 percentage points). Advanced colorectal neoplasia was detected in 29 intervention participants (1.4%) and 15 control participants (0.7%) (difference, 0.68 percentage points; 95% CI, 0.05-1.35 percentage points).

Conclusions and Relevance

In this randomized clinical trial of centralized screening outreach intervention in diverse patients served by independent FQHCs, CRC screening completion and advanced colorectal neoplasia detection were substantially increased. Future studies should examine the cost and scalability of this intervention in this context.

Trial Registration

ClinicalTrials.gov Identifier: NCT04406714.

Optimizing tracking and completion of follow-up colonoscopy after abnormal stool tests at health systems participating in the Centers for Disease Control and Prevention's Colorectal Cancer Control Program

PURPOSE

We present findings from an assessment of award recipients' partners from the Centers for Disease Control and Prevention's Colorectal Cancer Control Program (CRCCP). We describe partners' processes of identifying and tracking patients undergoing stool-based screening.

METHODS

We analyzed data from eight CRCCP award recipients purposively sampled and their partner health systems from 2019 to 2023. The data included number of stool-based tests distributed and returned; abnormal findings; referrals and completion of follow-up colonoscopies; and colonoscopy findings. We also report on strategies to improve tracking of stool-based tests and facilitation of follow-up colonoscopies.

RESULTS

Five of eight CRCCP award recipients reported that all or some partner health systems were able to report stool test return rates. Six had health systems that were able to report abnormal stool test findings. Two reported that health systems could track time to follow-up colonoscopy completion from date of referral, while four could report colonoscopy completion but not the timeframe. Follow-up colonoscopy completion varied substantially from 24.2 to 75.5% (average of 47.9%). Strategies to improve identifying and tracking screening focused mainly on the use of electronic medical records; strategies to facilitate follow-up colonoscopy were multi-level.

CONCLUSION

Health systems vary in their ability to track steps in the stool-based screening process and few health systems can track time to completion of follow-up colonoscopy. Longer time intervals can result in more advanced disease. CRCCP-associated health systems participating in this study could support the implementation of multicomponent strategies at the individual, provider, and health system levels to improve tracking and completion of follow-up colonoscopy.

Impact of racial disparities in follow-up and quality of colonoscopy on colorectal cancer outcomes

BACKGROUND

The benefits of colorectal cancer (CRC) screening programs rely on completing follow-up colonoscopy when a noncolonoscopy test is abnormal and on quality of colonoscopy screening as measured by the endoscopists' adenoma detection rate. Existing data demonstrate substantially lower follow-up colonoscopy rates and adenoma detection rate for Black Americans than White Americans. However, the contributions of racial differences in follow-up colonoscopy and adenoma detection rate on CRC outcomes have not been rigorously evaluated.

METHODS

We used established and validated CRC-Adenoma Incidence and Mortality (CRC-AIM) model as our analysis platform, with inputs from published literature that report lower follow-up colonoscopy rates and adenoma detection rate in Black adults compared with White adults (15% and 10% lower, respectively). We simulated screening with annual fecal immunochemical test, triennial multitarget stool DNA, and colonoscopy every 10 years between ages 45 and 75 years using real-world utilization of the screening modalities vs no screening. We reported lifetime outcomes per 1000 Black adults.

RESULTS

Elimination of Black-White disparities in follow-up colonoscopy rates would reduce CRC incidence and mortality by 5.2% and 9.3%, respectively, and improve life-years gained with screening by 3.4%. Elimination of Black-White disparities in endoscopists' adenoma detection rate would reduce CRC incidence and mortality by 9.4% and improve life-years gained by 3.7%. Elimination of both disparities would reduce CRC incidence and mortality by 14.6% and 18.7%, respectively, and improve life-years gained by 7.1%.

CONCLUSIONS

This modeling study predicts eliminating racial differences in follow-up colonoscopy rates, and quality of screening colonoscopy would substantially reduce Black-White disparities in CRC incidence and mortality.

A Randomized Trial of Choice Architecture and Mailed Colorectal Cancer Screening Outreach in a Community Health Setting

BACKGROUND & AIMS

Mailed outreach for colorectal cancer (CRC) screening increases uptake but it is unclear how to offer the choice of testing. We evaluated if the active choice between colonoscopy and fecal immunochemical test (FIT), or FIT alone, increased response compared with colonoscopy alone.

METHODS

This pragmatic, randomized, controlled trial at a community health center included patients between ages 50 and 74 who were not up to date with CRC screening. Patients were randomized 1:1:1 to the following: (1) colonoscopy only, (2) active choice of colonoscopy or FIT, or (3) FIT only. Patients received an outreach letter with instructions for testing (colonoscopy referral and/or an enclosed FIT kit), a reminder letter at 2 months, and another reminder at 3 to 5 months via text message or automated voice recording. The primary outcome was CRC screening completion within 6 months.

RESULTS

Among 738 patients in the final analysis, the mean age was 58.7 years (SD, 6.2 y); 48.6% were insured by Medicaid and 24.3% were insured by Medicare; and 71.7% were White, 16.9% were Black, and 7.3% were Hispanic/Latino. At 6 months, 5.6% (95% CI, 2.8-8.5) completed screening in the colonoscopy-only arm, 12.8% (95% CI, 8.6-17.0) in the active-choice arm, and 11.3% (95% CI, 7.4-15.3) in the FIT-only arm. Compared with colonoscopy only, there was a significant increase in screening in active choice (absolute difference, 7.1%; 95% CI, 2.0-12.2; P = .006) and FIT only (absolute difference, 5.7%; 95% CI, 0.8-10.6; P = .02).

CONCLUSIONS

Both choice of testing and FIT alone increased response and may align with patient preferences.

TRIAL REGISTRATION

clinicaltrials.gov NCT04711473.

The effect of mailed outreach on FIT completion among patients aged 45-50 in a safety net healthcare system

PURPOSE

Colorectal cancer screening is recommended starting at age 45, but there has been little research on strategies to promote screening in patients younger than 50.

METHODS

An outreach program quasi-randomly assigned patients aged 45-50 without recent fecal immunochemical test (FIT), colonoscopy or contraindications to screening to two intervention arms: electronic outreach with email and text (electronic outreach only) versus electronic outreach plus mailed outreach with FIT, an instructional letter and a prepaid return envelope (mailed + electronic outreach). In response to known disparities in screening uptake, all Black patients were assigned to receive mailed + electronic outreach.

RESULTS

Among patients quasi-randomly assigned to an intervention (non-Black patients), the 180-day FIT completion rate was 18.8% in the electronic outreach only group (n = 1,318) and 25.0% in the mailed + electronic outreach group (n = 1,364) (difference 6.2% [95% CI 3.0, 9.4]). FIT completion was 16.6% among Black patients (n = 469), 8.4% (95% CI 4.1, 12.6) lower than among non-Black patients also assigned to mailed + electronic outreach.

CONCLUSION

Among patients aged 45-50, mailed + electronic outreach had a greater effect on FIT completion than electronic outreach alone. Crossover between intervention groups likely lead to an underestimation of the effect of mailed outreach.

Community Collaboration to Advance Racial/Ethnic Equity in Colorectal Cancer Screening: Protocol for a Multilevel Intervention to Improve Screening and Follow-up in Community Health Centers

INTRODUCTION

Colorectal cancer (CRC) screening utilization is low among low-income, uninsured, and minority populations that receive care in community health centers (CHCs). There is a need for evidence-based interventions to increase screening and follow-up care in these settings.

METHODS

A multilevel, multi-component pragmatic cluster randomized controlled trial is being conducted at 8 CHCs in two metropolitan areas (Boston and Los Angeles), with two arms: (1) Mailed FIT outreach with text reminders, and (2) Mailed FIT-DNA with patient support. We also include an additional CHC in Rapid City (South Dakota) that follows a parallel protocol for FIT-DNA but is not randomized due to lack of a comparison group. Eligible individuals in participating clinics are primary care patients ages 45-75, at average-risk for CRC, and overdue for CRC screening. Participants with abnormal screening results are offered navigation for follow-up colonoscopy and CRC risk assessment.

RESULTS

The primary outcome is the completion rate of CRC screening at 90 days. Secondary outcomes include the screening completion rate at 180 days and the rate of colonoscopy completion within 6 months among participants with an abnormal result. Additional goals are to enhance our understanding of facilitators and barriers to CRC risk assessment in CHC settings.

CONCLUSIONS

This study assesses the effectiveness of two multilevel interventions to increase screening participation and follow-up after abnormal screening in under-resourced clinical settings, informing future efforts to address CRC disparities.

TRIAL REGISTRATION

NCT05714644.

A pragmatic randomized trial of mailed fecal immunochemical testing to increase colorectal cancer screening among low-income and minoritized populations

BACKGROUND

Colorectal cancer (CRC) screening is underused, particularly among low-income and minoritized populations, for whom the coronavirus disease 2019 (COVID-19) pandemic has challenged progress in achieving equity.

METHODS

A hub-and-spoke model was used. The hub was a nonacademic organization and the spokes were three community health center (CHC) systems overseeing numerous clinic sites. Via a cluster-randomized trial design, nine clinic sites were randomized to intervention and 16 clinic sites were randomized to usual care. Patient-level interventions included invitation letters, mailed fecal immunochemical tests (FITs), and call/text-based reminders. Year 1 intervention impact, which took place during the COVID-19 pandemic, was assessed as the proportion completing screening among individuals not up to date at baseline, which compared intervention and nonintervention clinics accounting for intraclinic cluster variation; confidence intervals (CIs) around differences not including 0 were interpreted as statistically significant.

RESULTS

Among 26,736 patients who met eligibility criteria, approximately 58% were female, 55% were Hispanic individuals, and 44% were Spanish speaking. The proportion completing screening was 11.5 percentage points (ppts) (95% CI, 6.1-16.9 ppts) higher in intervention versus usual care clinics. Variation in differences between intervention and usual care clinics was observed by sex (12.6 ppts [95% CI, 7.2-18.0 ppts] for females; 8.8 ppts [95% CI, 4.7-13.9 ppts] for males) and by racial and ethnic group (13.8 ppts [95% CI, 7.0-20.6 ppts] for Hispanic individuals; 13.0 ppts [95% CI, 3.6-22.4 ppts] for Asian individuals; 11.3 ppts [95% CI, 5.8-16.8 ppts] for non-Hispanic White individuals; 6.1 ppts [95% CI, 0.8-10.4 ppts] for Black individuals).

CONCLUSIONS

A regional mailed FIT intervention was effective for increasing CRC screening rates across CHC systems serving diverse, low-income populations.

Cultural shifts: an examination of cervical cancer stigma across age groups in the Caribbean

BACKGROUND

Cervical cancer-related stigma is common but understudied in the Caribbean. This study aims to describe the age difference of cervical cancer stigma and to evaluate the influence on the prevention practices among the Caribbean nonpatient population in Jamaica, Grenada, and Trinidad and Tobago.

METHODS

A cross-sectional study involving 1209 participants was conducted using a culturally trans-created Cancer Stigma Scale for the Caribbean context and supplemented with questions on cervical cancer and human papillomavirus (HPV) and HPV vaccine knowledge and beliefs. Descriptive analyses and χ2 tests were conducted.

RESULTS

The χ2 tests showed age is statistically significantly related to participants' response to stigma items such as "community members believe cervical cancer is viewed as shameful" (P = .0001); "women with cervical cancer are treated with less respect than usual by others" (P < .0001); "women with cervical cancer are rejected by family members" (P = .0007); "women with cervical cancer are rejected by intimate partners" (P < .0001); and "intimate partners blame women for having cervical cancer" (P = .0032). Additionally, age has statistically significant associations with endorsements of negative views of cervical cancer from the community (P < .0001) and family (P < .0001) as key barriers to cervical cancer care (item: "discourage women from seeking and obtaining screening and treatment"). Notably, younger respondents (18-25 years) are more sensitized to the unfair stigma and hold more stigma.

CONCLUSIONS

Among Caribbeans, age influences cervical cancer stigma. Younger persons acknowledged greater stigma within families and communities. This study can guide age-informed interventions and programs to reduce stigma and improve cervical cancer screening and care seeking to reduce cervical cancer burden and disparities.

The role of a social determinants of health summary measure on the association between cancer history status and colorectal cancer screening utilization among screening eligible adults

Objective

We sought to examine the influence of social needs on the relationship between cancer history and colorectal cancer (CRC) screening utilization among adults in the United States.

Methods

We conducted a cross-sectional analysis using data from the 2022 Behavioral Risk Factor Surveillance System. Our outcome of interest was utilization of guideline-concordant CRC screening and exposures of interest were cancer history/levels of social needs. Multivariable logistic regression was performed to examine the association.

Results

Among 74,743 eligible adults, a majority did not have a personal history of cancer (87.9 %), had at least one social need (58.4 %), and had undergone CRC screening (72.2 %). In multivariable analysis, a history of cancer was positively associated with use of CRC screening (OR = 1.59, 95 %CI, 1.35 - 1.87). Having at least one social need was associated with lower likelihood of being screened (one social need: OR = 0.85 95 %CI, 0.76 - 0.95; two + social needs: OR = 0.77, 95 % CI, 0.69 - 0.87). When exploring the effects of social needs, adults without a history of cancer who reported at least one need were 12-20 % less likely to be screened for CRC.

Conclusions

A personal history of cancer was associated with greater utilization of CRC screening, whilst having at least one social need had lower screening use. Having social needs plays an important role in reducing screening uptake among adults without a history of cancer. Integrated care that considers both cancer history and social needs may have implications for improved adherence of CRC screening recommendations.

Utilization of colorectal cancer screening tests: a systematic review and time trend analysis of nationally representative data

Background

The substantial and increasing global burden of colorectal cancer (CRC) underscores the imperative to enhance implementation and utilization of effective CRC screening offers. Therefore, we examined the lifetime and up-to-date use of CRC screening tests across various countries, and described utilization trends over time.

Methods

We conducted a systematic review on the extent and recent trends of utilization of CRC screening tests among people 45 years or older in different countries around the globe. PubMed/Medline, Web of Science, and Embase electronic databases were screened for eligible studies from inception to June 30, 2024. The study protocol was registered with international prospective register of systematic reviews (PROSPERO) (CRD42023391344).

Findings

A total of 50 studies, based on nationally-representative data, were finally included - 27 from the United States (US) and 23 from other countries. The overall utilization of CRC screening has steadily increased over time in many countries, reaching 74.9% in Denmark in 2018-2020, 64% in Korea in 2020, and 72% in the US in 2021. Nevertheless, the utilization rates remain far below the national or continental targets in most countries. In contrast to European and Asian countries, where screening was predominantly fecal test-based, the approach in the US was primarily driven by colonoscopy, and the uptake of fecal tests and sigmoidoscopy gradually declined in the past two decades.

Interpretation

Despite ongoing progress in CRC screening offers and utilization, there remains large potential for enhanced roll-out and utilization of effective CRC screening programs for enhanced control of CRC incidence and mortality in the years ahead.

Funding

There was no funding source for this study.

Disparities in Rates of Multitarget Stool DNA Test Completion for Colorectal Cancer Screening

GOALS

The aim was to assess patient adherence to multitarget stool DNA testing as well as factors associated with adherence.

BACKGROUND

In the United States, disparities in colorectal cancer screening exist along racial and socioeconomic lines. While some studies suggest that stool-based screening tests may help reduce the screening gap, the data for multitarget stool DNA testing is unclear.

STUDY

We conducted a single-center retrospective cohort study on multitarget stool DNA testing ordered between April 2020 and July 2021. We calculated the proportion of patients who completed testing and used multivariate logistic regression to identify covariates associated with test adherence.

RESULTS

Among 797 patients ordered for multitarget stool DNA testing, 481 patients (60.4%) completed testing. Adherence rates by patient subgroups ranged from 35.8% to 78.1%. Higher test adherence was found in Asian patients (odds ratio 2.65, 95% CI 1.36-5.18) and those who previously completed colorectal cancer screening (OR 1.45, 95% CI 1.01-2.09), while Black patients (OR 0.58, 95% CI 0.39-0.87), patients with resident primary care physicians (OR 0.34, 95% CI 0.21-0.56), and patients contacted through an outreach program (OR 0.47, 95% CI 0.25-0.87) had lower adherence.

CONCLUSIONS

A significant proportion of patients ordered for multitarget stool DNA testing did not complete testing. Differences in adherence rates among patient subgroups may be reflective of underlying disparities in health care access.

Improving uptake of colorectal cancer screening by complex patients at an academic primary care practice: a feasibility study

BACKGROUND

Regular screening reduces mortality from colorectal cancer (CRC). The Canton of Vaud, Switzerland, has a regional screening programme offering faecal immunochemical tests (FITs) or colonoscopy. Participation in the screening programme has been low, particularly among complex patients. Patient navigation has strong evidence for increasing the CRC screening rate.

DESIGN AND OBJECTIVE

This feasibility study tested patient navigation performed by medical assistants for complex patients at an academic primary care practice.

BASELINE MEASUREMENTS

A review of 328 patients' medical charts revealed that 51% were up-to-date with screening (16% within the programme), 24% were ineligible, 5% had a documented refusal and 20% were not up-to-date, of whom 58 (18%) were complex patients. INTERVENTION FEBRUARY 2023 TO MAY 2023: We tried to help complex patients participate in the screening programme using either in-person or telephone patient navigation. Each intervention was piloted by a physician-researcher and then performed by a medical assistant. Based on the reach, effectiveness, adoption, implementation, maintenance framework, we collected: Intervention participation and refusal, screening acceptance and completion and both patients and medical assistant acceptability (ie, qualitative interviews).

RESULTS

Only 4/58 (7%) patients participated in the in-person patient navigation test phase due to scheduling problems. All four patients accepted a prescription and 2/4 (50%) completed their test. We piloted a telephone intervention to bypass scheduling issues but all patients refused a telephone discussion with the medical assistant. At two months after the last intervention, the proportion of patients up-to-date increased from 51% to 56%.

CONCLUSION

Our overall approach was resource-intensive and had little impact on the overall participation rate. It was likely not sustainable. New approaches and reimbursement for a specific patient navigator role are needed to increase CRC screening of complex patients.

Assessment of barriers to cancer screening and interventions implemented to overcome these barriers in 27 Latin American and Caribbean countries

There is a gap in the understanding of the barriers to cancer screening participation and complying with downstream management in the Community of Latin American and Caribbean states (CELAC). Our study aimed to assess barriers across the cancer screening pathway from the health system perspective, and interventions in place to improve screening in CELAC. A standardized tool was used to collect information on the barriers across the screening pathway through engagement with the health authorities of 27 member states of CELAC. Barriers were organized in a framework adapted from the Tanahashi conceptual model and consisted of the following dimensions: availability of services, access (covering accessibility and affordability), acceptability, user-provider interaction, and effectiveness of services (which includes governance, protocols and guidelines, information system, and quality assurance). The tool also collected information of interventions in place, categorized in user-directed interventions to increase demand, user-directed interventions to increase access, provider-directed interventions, and policy and system-level interventions. All countries prioritized barriers related to the information systems, such as the population register not being accurate or complete (N = 19; 70.4%). All countries implemented some kind of intervention to improve cancer screening, group education being the most reported (N = 23; 85.2%). Training on screening delivery was the most referred provider-directed intervention (N = 19; 70.4%). The study has identified several barriers to the implementation of cancer screening in the region and interventions in place to overcome some of the barriers. Further analysis is required to evaluate the effectiveness of these interventions in achieving their objectives.

SIED-GISCOR recommendations for colonoscopy in screening programs: Part I - Diagnostic

The implementation of FIT programs reduces incidence and mortality from CRC in the screened subjects. The ultimate efficacy for CRC morbidity and mortality prevention in a FIT program depends on the colonoscopy in FIT+ subjects that has the task of detecting and removing these advanced lesions. Recently, there has been growing evidence on factors that influence the quality of colonoscopy specifically withing organized FIT programs, prompting to dedicated interventions in order to maximize the benefit/harm ratio of post-FIT colonoscopy. This document focuses on the diagnostic phase of colonoscopy, providing indications on how to standardise colonoscopy in FIT+ subjects, regarding timing of examination, management of antithrombotic therapy, bowel preparation, competence and sedation.

Leveraging Patient Education to Amplify Colorectal Cancer Screening in the United States: Strategies and Implications

Despite several available screening modalities, colorectal cancer (CRC) remains a leading cause of cancer deaths, especially among populations with lower screening rates. Barriers to screening include cost, access, awareness, and education disparities, with interventions such as patient education programs and mailed screening kits showing promise in increasing participation rates. The current review elucidates the correlation between patient awareness/knowledge and screening rates in the United States, highlighting the pivotal role of education in mitigating these deficiencies. Different educational models, including online resources, mailed information, community programs, direct provider-based interventions, and narratives, are explored in terms of their effectiveness and limitations. We also offer a blueprint for primary care providers (PCPs) that highlights the importance of tailored education, barrier identification, and utilization of available resources to enhance CRC screening uptake. Large-scale adoption of educational strategies has the potential to significantly increase CRC screening rates and consequently reduce mortality associated with this preventable malignancy.

Feasibility and efficacy of a novel audiovisual tool to increase colorectal cancer screening among rural Appalachian Kentucky adults

Introduction

Residents of Appalachian regions in Kentucky experience increased colorectal cancer (CRC) incidence and mortality. While population-based screening methods, such as fecal immunochemical tests (FITs), can reduce many screening barriers, written instructions to complete FIT can be challenging for some individuals. We developed a novel audiovisual tool ("talking card") to educate and motivate accurate FIT completion and assessed its feasibility, acceptability, and efficacy.

Materials and methods

We collected data on the talking card via: (1) cross-sectional surveys exploring perceptions of images, messaging, and perceived utility; (2) follow-up focus groups centered on feasibility and acceptability; and (3) efficacy testing in community-based FIT distribution events, where we assessed FIT completion rate, number of positive vs. negative screens, demographic characteristics of participants, and primary drivers of FIT completion.

Results

Across the three study phases, 692 individuals participated. Survey respondents positively identified with the card's sounds and images, found it highly acceptable, and reported high-to-very high self-efficacy and response efficacy for completing FIT, with nearly half noting greater likelihood to complete screening after using the tool. Focus group participants confirmed the acceptability of the individuals featured on the card. Nearly 75% of participants provided a FIT accurately completed it, with most indicating the talking card, either alone or combined with another strategy, helped with completion.

Discussion

To reduce CRC screening disparities among Appalachian Kentuckians, population-based screening using contextually relevant implementation strategies must be used alongside clinic-based education. The talking card represents a novel and promising strategy to promote screening uptake in both clinical and community settings.

Disparities in race, ethnicity, sex, and age inclusion in pancreatic cancer screening studies: a systematic review and meta-analysis

BACKGROUND AND AIMS

Substantial differences exist in pancreatic cancer outcomes across ethnoracial stratifications. We sought to assess racial, ethnic, sex, and age reporting and inclusion of participants in pancreatic cancer screening studies.

METHODS

A systematic search of Cochrane Library, Ovid Embase, Google Scholar, Ovid MEDLINE, PubMed, Scopus, and Web of Science Core Collection from inception to 2022 was conducted. Original studies on pancreatic cancer screening were identified and assessed for reporting and inclusion on race, ethnicity, sex, and age. The pooled proportions of study participants for these characteristics were calculated and compared with population-based benchmarks.

RESULTS

Among 27 eligible pancreatic cancer screening studies, 26 reported data on either sex, race, or ethnicity, with a total of 5273 participants. Information on participant sex was reported by 26, race by 12, and ethnicity by 8 studies. Participants in these studies were almost all white (pooled proportion, 93.1%; 95% confidence interval [CI], 89.7-96.4) and non-Latino (pooled proportion, 97.4%; 95% CI, 94.0-100), and these groups were over-represented when compared with the general population. Female participants were well represented, with a pooled proportion of 63.2% (95% CI, 59.9-66.6). When reported, mean or median participant age was <60 years. Meta-regression revealed higher proportions of female participants in studies from the United States (P = .002). No association between increasing participation of racial or ethnic under-represented populations and study quality, ascending year of publication, or source of study funding was noted.

CONCLUSIONS

Substantial disparities in race, ethnicity, sex, and age reporting and inclusion in pancreatic cancer studies were noted, even among high-quality and publicly funded studies.

Low Rates of Colorectal Cancer Screening in First-Degree Relatives of Our Patients: Are We Failing Them?

BACKGROUND

Guidelines recommend screening those with a family history of early-onset colorectal cancer at age 40 years or 10 years before the age of their relative's diagnosis. Currently, there is no literature reporting the screening rate in these individuals, and no protocols are in place to identify and target this population for screening awareness.

OBJECTIVE

This study aimed to assess adherence to current screening guidelines among first-degree relatives of patients with early-onset colorectal cancer.

DESIGN

Retrospective and qualitative study involving a telephone survey where patients were asked about relative's screening status and barriers to screening.

SETTINGS

Two community-based institutions between January 2018 and December 2021.

PATIENTS

Individuals diagnosed with early-onset colorectal cancer who had undergone surgery at our institutions.

MAIN OUTCOME MEASURES

Rate of screening in first-degree relatives of our patients with early-onset colorectal cancer. Other factors measured included demographics, clinicopathologic characteristics, and screening barriers.

RESULTS

Thirty-six patients were identified. The survey response rate was 66.6% (n = 24). A total of 88 first-degree relatives who met the screening criteria resulted in 67.1% of patients (n = 59) having a known screening status. Of the 59 patients with known screening status, only 44% (n = 26) had undergone screening. Patients of Black race, having stage III/IV disease, having Medicare/Medicaid insurance, and living within Baltimore City County were more likely to have family members with unknown or no screening. Lack of insurance coverage was the most common barrier, which was noted in 12.5% of patients (n = 3), whereas 54.1% of patients (n = 13) reported no barriers to screening.

LIMITATIONS

Retrospective design.

CONCLUSIONS

Most first-degree relatives of patients diagnosed with early-onset colorectal cancer do not undergo colorectal cancer screening. This could be attributed to the lack of protocols that could guarantee these individuals are informed of their elevated risk and the different options available for screening. Furthermore, our study suggests that racial and socioeconomic disparities exist among high-risk patients who should pursue screening. See Video Abstract .

BAJAS TASAS DE DETECCIN DEL CNCER COLORRECTAL EN LOS FAMILIARES DE PRIMER GRADO DE NUESTROS PACIENTES LES ESTAMOS FALLANDO

ANTECEDENTES:Las directrices recomiendan realizar pruebas de detección a las personas con antecedentes familiares de cáncer colorrectal de aparición temprana a los 40 años o 10 años antes de la edad del diagnóstico de su familiar. Actualmente, no hay literatura que informe la tasa de detección en estos individuos y no existen protocolos para identificar y dirigirse a esta población para concientizar sobre la detección.OBJETIVO:Evaluar el cumplimiento de las pautas de detección actuales entre los FDR de pacientes con cáncer colorrectal de aparición temprana.DISEÑO:Estudio retrospectivo y cualitativo que incluyó una encuesta telefónica en la que se preguntó a los pacientes sobre el estado de detección de sus familiares y las barreras para la detección.AJUSTES:Dos instituciones comunitarias entre enero de 2018 y diciembre de 2021.PACIENTES:Personas diagnosticadas con cáncer colorrectal de inicio temprano que habían sido intervenidas quirúrgicamente en nuestras instituciones.PRINCIPALES MEDIDAS DE RESULTADO:Tasa de detección en familiares de primer grado de nuestros pacientes con cáncer colorrectal de aparición temprana. Otros factores medidos incluyeron datos demográficos, características clínico-patológicas y barreras de detección.RESULTADOS:Se identificaron treinta y seis pacientes. La tasa de respuesta a la encuesta fue del 66,6% (n = 24). Resultaron un total de 88 familiares de primer grado que cumplieron con los criterios para la detección, y el 67,1% (n = 59) tenía un estado de detección conocido. De los 59 con estado de detección conocido, se informó que solo el 44% (n = 26) se había sometido a pruebas de detección. Los pacientes de raza afroamericana, enfermedad en etapa III/IV, Medicare/Medicaid y que vivían dentro del condado de la ciudad de Baltimore tenían más probabilidades de tener familiares con pruebas de detección desconocidas o sin ellas. La falta de cobertura de seguro fue la barrera más común observada por el 12,5% (n = 3); mientras que el 54,1% (n = 13) no informó ninguna barrera para el cribado.LIMITACIONES:Diseño retrospectivo.CONCLUSIONES:La mayoría de los familiares de primer grado de pacientes diagnosticados con cáncer colorrectal de aparición temprana no se someten a pruebas de detección de cáncer colorrectal. Esto podría atribuirse a la falta de protocolos que garanticen que estas personas estén informadas sobre su elevado riesgo y las diferentes opciones disponibles para el cribado. Además, nuestro estudio sugiere que existen disparidades raciales y socioeconómicas entre los pacientes de alto riesgo que deberían someterse a pruebas de detección. (Traducción-Dr. Francisco M. Abarca-Rendon).

Randomized Trial of Patient Outreach Approaches to De-implement Outdated Colonoscopy Surveillance Intervals

BACKGROUND AND AIMS

Guidelines now recommend patients with low-risk adenomas receive colonoscopy surveillance in 7-10 years and those with the previously recommended 5-year interval be re-evaluated. We tested 3 outreach approaches for transitioning patients to the 10-year interval recommendation.

METHODS

This was a 3-arm pragmatic randomized trial comparing telephone, secure messaging, and mailed letter outreach. The setting was Kaiser Permanente Northern California, a large integrated healthcare system. Participants were patients 54-70 years of age with 1-2 small (<10 mm) tubular adenomas at baseline colonoscopy, due for 5-year surveillance in 2022, without high-risk conditions, and with access to all 3 outreach modalities. Patients were randomly assigned to the outreach arm (telephone [n = 200], secure message [n = 203], and mailed letter [n = 201]) stratified by age, sex, and race/ethnicity. Outreach in each arm was performed by trained medical assistants (unblinded) communicating in English with 1 reminder attempt at 2-4 weeks. Participants could change their assigned interval to 10 years or continue their planned 5-year interval.

RESULTS

Sixty-day response rates were higher for telephone (64.5%) and secure messaging outreach (51.7%) vs mailed letter (31.3%). Also, more patients adopted the 10-year surveillance interval in the telephone (37.0%) and secure messaging arms (32.0%) compared with mailed letter (18.9%) and rate differences were significant for telephone (18.1%; 97.5% confidence interval: 8.3%-27.9%) and secure message outreach (13.1%; 97.5% confidence interval: 3.5%-22.7%) vs mailed letter outreach.

CONCLUSIONS

Telephone and secure messaging were more effective than mailed letter outreach for de-implementing outdated colonoscopy surveillance recommendations among individuals with a history of low-risk adenomas in an integrated healthcare setting. (ClinicalTrials.gov, Number: NCT05389397).

Costs and Projected Effect of a Federally Qualified Health Center-Based Mailed Colorectal Cancer Screening Program in Texas

Introduction

Mailed stool testing for colorectal cancer (CRC) may improve screening uptake and reduce the incidence and mortality of CRC, especially among patients at federally qualified health centers (FQHCs). To expand screening programs it is important to identify cost-effective approaches.

Methods

We developed a decision-analytic model to estimate the cost, effects on screening and patient outcomes (CRCs detected, CRCs prevented, CRC deaths prevented), and cost-effectiveness of implementing a state-wide mailed stool testing program over 5 years among unscreened, age-eligible (aged 50-75 y) patients at FQHCs in Texas. We compared various outreach strategies and organizational structures (centralized, regional, or a hybrid). We used data from our existing regional mailed stool testing program and recent systematic reviews to set parameters for the model. Costs included start-up and ongoing activities and were estimated in 2022 US dollars from the perspective of a hypothetical third-party payer. Cost-effectiveness was assessed by using both incremental and average cost-effectiveness ratios.

Results

Using either a statewide centralized or hybrid organizational configuration to mail stool tests to newly eligible FQHC patients and patients who have responded at least once since program inception is likely to result in the best use of resources over 5 years, enabling more than 110,000 additional screens, detecting an incremental 181 to 194 CRCs, preventing 91 to 98 CRCs, and averting 46 to 50 CRC deaths, at a cost of $10 million to $11 million compared with no program.

Conclusions

A statewide mailed stool testing program for FQHC patients can be implemented at reasonable cost with considerable effects on CRC screening outcomes, especially when its structure maximizes program efficiency while maintaining effectiveness.

Bundling Colorectal Cancer Screening Outreach with Screening for Social Risk in Federally Qualified Health Centers: A Stepped-Wedge Implementation-Effectiveness Study

BACKGROUND

Bundling is combining individual interventions to meet quality metrics. Bundling offers of cancer screening with screening for social determinants of health (SDOH) may enable health centers to assist patients with social risks and yield efficiencies.

OBJECTIVE

To measure effects of bundling fecal immunochemical testing (FIT) and SDOH screening in federally qualified health centers (FQHCs).

DESIGN

Clustered stepped-wedge trial.

PARTICIPANTS

Four Massachusetts FQHCs randomized to implement bundled FIT-SDOH over 8-week "steps."

INTERVENTION

Outreach to 50-75-year-olds overdue for CRC screening to offer FIT with SDOH screening. The implementation strategy used facilitation and training for data monitoring and reporting.

MAIN MEASURES

Implementation process descriptions, data from facilitation meetings, and CRC and SDOH screening rates. Rates were compared between implementation and control FQHCs in each "step" by fitting generalized linear mixed-effects models with random intercepts for FQHCs, patients, and "step" by FQHC.

KEY RESULTS

FQHCs tailored implementation processes to their infrastructure, workflows, and staffing and prioritized different groups for outreach. Two FQHCs used population health outreach, and two integrated FIT-SDOH within established programs, such as pre-visit planning. Of 34,588 patients overdue for CRC screening, 54% were female; 20% Black, 11% Latino, 10% Asian, and 47% white; 32% had Medicaid, 16% Medicare, 32% private insurance, and 11% uninsured. Odds of CRC screening completion in implementation "steps" compared to controls were higher overall and among groups prioritized for outreach (overall: adjusted odds ratio (aOR) 2.41, p = 0.005; prioritized: aOR 2.88, p = 0.002). Odds of SDOH screening did not differ across "steps."

CONCLUSIONS

As healthcare systems are required to conduct more screenings, it is notable that outreach for a long-standing cancer screening requirement increased screening, even when bundled with a newer screening requirement. This outreach was feasible in a real-world safety-net clinical population and may conserve resources, especially compared to more complex or intensive outreach strategies.

CLINICAL TRIALS REGISTRATION

NCT04585919.

Longitudinal adherence to annual colorectal cancer screening among Black persons living in the United States enrolled in a community-based randomized trial

BACKGROUND

This study examined repeat colorectal cancer screening rates at 12 and 24 months as part of a randomized intervention trial among Black persons living in the United States and factors associated with screening adherence.

METHODS

Participants completed a survey assessing demographics and Preventive Health Model (PHM) factors (e.g., self efficacy, susceptibility) and received either a culturally targeted photonovella plus free fecal immunochemical test (FIT) kits (intervention group) or a standard educational brochure plus free FIT kits (comparison group). FIT return was assessed at 6, 12, and 24 months. Descriptive statistics summarized patterns of repeat screening. Logistic regression models assessed FIT uptake overtime, and demographic and PHM factors associated with screening adherence.

RESULTS

Participants (N = 330) were U.S.-born (93%), non-Hispanic (97%), and male (52%). Initial FIT uptake within 6 months of enrollment was 86.6%, and subsequently dropped to 54.5% at 12 months and 36.6% at 24 months. Higher FIT return rates were observed for the brochure group at 24 months (51.5% vs 33.3% photonovella, p = .023). Multiple patterns of FIT kit return were observed: 37% completed FIT at all three time points (full adherence), 22% completed two of three (partial adherence), 29% completed one of three (partial adherence), and 12% did not return any FIT kits (complete nonadherence). Predictors of full adherence were higher levels of education and self-efficacy.

CONCLUSIONS

Full adherence to repeat screening was suboptimal. Most participants had partial adherence (one or two of three) to annual FIT screening. Future studies should focus on strategies to support repeat FIT screening.

The Reach of Calls and Text Messages for Mailed FIT Outreach in the PROMPT Stepped-Wedge Colorectal Cancer Screening Trial

BACKGROUND

Mailed fecal immunochemical test (FIT) outreach can improve colorectal cancer screening participation. We assessed the reach and effectiveness of adding notifications to mailed FIT programs.

METHODS

We conducted secondary analyses of a stepped-wedge evaluation of an enhanced mailed FIT program (n = 15 clinics). Patients were stratified by prior FIT completion. Those with prior FIT were sent a text message (Group 1); those without were randomized 1:1 to receive a text message (Group 2) or live phone call (Group 3). All groups were sent automated phone call reminders. In stratified analysis, we measured reach and effectiveness (FIT completion within 6 months) and assessed patient-level associations using generalized estimating equations.

RESULTS

Patients (n = 16,934; 83% Latino; 72% completed prior FIT) were reached most often by text messages (78%), followed by live phone calls (71%), then automated phone calls (56%). FIT completion was higher in patients with prior FIT completion versus without [44% (Group 1) vs. 19% (Group 2 + Group 3); P < 0.01]. For patients without prior FIT, effectiveness was higher in those allocated to a live phone call [20% (Group 3) vs. 18% (Group 2) for text message; P = 0.04] and in those who personally answered the live call (28% vs. 9% no call completed; P < 0.01).

CONCLUSIONS

Text messages reached the most patients, yet effectiveness was highest in those who personally answered the live phone call.

IMPACT

Despite the broad reach and low cost of text messages, personalized approaches may more successfully boost FIT completion.

Colorectal Cancer Screening After Sequential Outreach Components in a Demographically Diverse Cohort

Importance

Organized screening outreach can reduce differences in colorectal cancer (CRC) incidence and mortality between demographic subgroups. Outcomes associated with additional outreach, beyond universal outreach, are not well known.

Objective

To compare CRC screening completion by race and ethnicity, age, and sex after universal automated outreach and additional personalized outreach.

Design, Setting, and Participants

This observational cohort study included screening-eligible individuals aged 50 to 75 years assessed during 2019 in a community-based organized CRC screening program within the Kaiser Permanente Northern California (KPNC) integrated health care delivery setting. For KPNC members who are not up to date with screening by colonoscopy, each year the program first uses automated outreach (mailed prescreening notification postcards and fecal immunochemical test [FIT] kits, automated telephone calls, and postcard reminders), followed by personalized components for nonresponders (telephone calls, electronic messaging, and screening offers during office visits). Data analyses were performed between November 2021 and February 2023 and completed on February 5, 2023.

Exposures

Completed CRC screening via colonoscopy, sigmoidoscopy, or FIT.

Main Outcomes and Measures

The primary outcome was the proportion of participants completing an FIT or colonoscopy after each component of the screening process. Differences across subgroups were assessed using the χ2 test.

Results

This study included 1 046 745 KPNC members. Their mean (SD) age was 61.1 (6.9) years, and more than half (53.2%) were women. A total of 0.4% of members were American Indian or Alaska Native, 18.5% were Asian, 7.2% were Black, 16.2% were Hispanic, 0.8% were Native Hawaiian or Other Pacific Islander, and 56.5% were White. Automated outreach significantly increased screening participation by 31.1%, 38.1%, 29.5%, 31.9%, 31.8%, and 34.5% among these groups, respectively; follow-up personalized outreach further significantly increased participation by absolute additional increases of 12.5%, 12.4%, 13.3%, 14.4%, 14.7%, and 11.2%, respectively (all differences P < .05 compared with White members). Overall screening coverage at the end of the yearly program differed significantly among members who were American Indian or Alaska Native (74.1%), Asian (83.5%), Black (77.7%), Hispanic (76.4%), or Native Hawaiian or Other Pacific Islander (74.4%) compared with White members (82.2%) (all differences P < .05 compared with White members). Screening completion was similar by sex; older members were substantially more likely to be up to date with CRC screening both before and at the end of the screening process.

Conclusions and Relevance

In this cohort study of a CRC screening program, sequential automated and personalized strategies each contributed to substantial increases in screening completion in all demographic groups. These findings suggest that such programs may potentially reduce differences in CRC screening completion across demographic groups.

Stakeholder and Equity Data-Driven Implementation: a Mixed Methods Pilot Feasibility Study

We conducted a mixed methods pilot feasibility study of a Stakeholder and Equity Data-Driven Implementation (SEDDI) process to facilitate using healthcare data to identify patient groups experiencing gaps in the use of evidence-based interventions (EBIs) and rapidly adapt EBIs to achieve greater access and equitable outcomes. We evaluated the feasibility and acceptability of SEDDI in a pilot hybrid type 2 effectiveness-implementation trial of a paired colorectal cancer (CRC) and social needs screening intervention at four federally qualified community health centers (CHCs). An external facilitator partnered with CHC teams to support initial implementation, followed by the SEDDI phase focused on advancing health equity. Facilitation sessions were delivered over 8 months. Preliminary evaluation of SEDDI involved convergent mixed methods with quantitative survey and focus group data. CHCs used data to identify gaps in outreach and completion of CRC screening with respect to race/ethnicity, gender, age, and language. Adaptations to improve access and use of the intervention included cultural, linguistic, and health literacy tailoring. CHC teams reported that facilitation and systematic review of data were helpful in identifying and prioritizing gaps. None of the four CHCs completed rapid cycle testing of adaptations largely due to competing priorities during the COVID-19 response. SEDDI has the potential for advancing chronic disease prevention and management by providing a stakeholder and data-driven approach to identify and prioritize health equity targets and guide adaptations to improve health equity. ClinicalTrials.gov Identifier: NCT04585919.

Barriers and facilitators to implementing a multilevel, multicomponent intervention promoting colorectal cancer screening in health centers: a qualitative study of key informant perspectives

BACKGROUND

Colorectal cancer (CRC) continues to be a major cause of death in the U.S. despite the availability of effective screening tools. U.S. Latinos have lower rates of CRC screening and higher rates of death due to colorectal disease compared to non-Hispanic whites. Federally Qualified Health Centers (FQHCs) serve medically underserved populations, including many Latino patients. Given the low CRC screening rates, identifying culturally sensitive and cost-effective methods of promoting screening is a priority for many FQHCs.

METHODS

We interviewed FQHC leaders and providers using the Consolidated Framework for Implementation Research (CFIR) to identify barriers and facilitators to implementation of a multilevel, multicomponent (ML-MC) CRC screening intervention (i.e., promotor navigation and group-based education) in FQHCs. A rapid qualitative analysis approach was used to identify themes organized according to the following CFIR constructs: intervention characteristics, outer and inner settings, and characteristics of the individual.

RESULTS

We completed interviews with 13 healthcare professionals in leadership positions at six FQHCs. The participating FQHCs perceived the ML-MC screening CRC program as feasible and expressed interest in implementing the program at their sites. Facilitators included financial incentives for increasing screening rates, the need for patient education programming, and involving promotores to support the work of clinical teams. Barriers included concerns about available resources to implement new programs, lack of federal reimbursement for health education, competing priorities of other health concerns, and the need for more resources for confirmatory screening and treatment following a positive screen.

CONCLUSIONS

FQHCs provide essential primary care to millions of underserved patients in the U.S. and have the ability and motivation to provide screenings for colorectal cancer. Partnering with an academic institution to deliver a group-based, promotor-led CRC screening intervention for patients not up to date with screening could help increase screening rates. By identifying the specific barriers and facilitators to implementing CRC intervention, findings suggest that group-based, promotor-led interventions are a promising approach.

Educational interventions to improve bowel cancer awareness and screening in Organisation for Economic Co-operation and Development countries: A scoping review

Objectives

Summarise theory informed educational interventions for improving bowel cancer awareness and screening.

Methods

A search was conducted in PubMed, EMBASE, Web of Science and CINAHL. English studies from 2016 to 2022 which implemented community-based bowel cancer awareness and/or screening education interventions for adults in Organisation for Economic Co-operation and Development countries were included.

Results

Sixty-two studies were included, 32 measured both screening and awareness (24 measured screening only, 6 measured awareness only). Education interventions were grouped and summarised in five education types: lay community health education/counselling (n = 28), education material (n = 5), health professional education/counselling (n = 10), mass media (n = 5) and other (n = 19). Other included education interventions which did not fit into the four types previously mentioned. Six studies tested more than one education type. Each type within these studies were reported/summarised separately within the appropriate education type. Lay educators resulted in improved awareness and screening. Brochures were effective education materials for screening and combined with lay educators resulted in increased awareness. State-wide mass media campaigns significantly improved screening uptake for up to 2-months post-campaign. Fear and loss-framed messaging improved screening intentions compared to humour or gain-based messaging. Decision aids had limited improvements in awareness. Facebook campaign and telephone counselling had limited improvements in screening.

Conclusions

Lay community health educators, brochures, and mass media campaigns occurring multiple times a year may be effective interventions in improving screening and/or awareness. Such approaches should be considered when developing community education. Education interventions should include multiple components suggested above to maximise improvements of awareness and screening.

Temporal trends in colorectal cancer mortality rates (1999-2022) in the United States

Colorectal cancer (CRC) ranks as the third leading cause of cancer-related deaths in the United States (U.S.). Our study aims to analyze CRC mortality patterns in the U.S., focusing on gender and age groups from 1999 to 2022. We analyzed Age-Adjusted Mortality Rates (AAMRs) for CRC-related deaths using the CDC Wide-ranging Online Data for Epidemiologic Research (CDC WONDER) database and assessed differences between age and sex. CRC-related mortality decreased significantly from 1999 to 2011 (-2.81% APC) and from 2011 to 2020 (-1.95% APC) but a not significant uptrend from 2020 to 2022 (2% APC). Males experienced a more significant decrease. Among age groups, crude mortality decreased until 2020, except in age group 45-54, which showed an annual increase in mortality of 0.9% from 2004 to 2022. Furthermore, individuals aged 75-84 and 85+ saw a nonsignificant annual increase of 1.8% and 4.5% from 2020 to 2022, respectively. Our study highlights a significant decline in age and gender-specific CRC-related mortality from 1999 to 2020. However, the worrisome uptrend observed in the younger age group of 45-54 emphasizes the importance of implementing targeted public health measures and evidence-based interventions.

Provision of colonoscopy in rural settings: A qualitative assessment of provider context, barriers, facilitators, and capacity

PURPOSE

Colonoscopy can prevent morbidity and mortality from colorectal cancer (CRC) and is the most commonly used screening method in the United States. Barriers to colonoscopy at multiple levels can contribute to disparities. Yet, in rural settings, little is known about who delivers colonoscopy and facilitators and barriers to colonoscopy access through screening completion.

METHODS

We conducted a qualitative study with providers in rural Oregon who worked in endoscopy centers or primary care clinics. Semistructured interviews, conducted in July and August, 2021, focused on clinician experiences providing colonoscopy to rural Medicaid patients, including workflows, barriers, and access. We used thematic analysis, through immersion crystallization, to analyze interview transcripts and develop emergent themes.

FINDINGS

We interviewed 19 providers. We found two categories of colonoscopy providers: primary care providers (PCPs) doing colonoscopy on their own patients (n = 9; 47%) and general surgeons providing colonoscopy to patients referred to their services (n = 10; 53%). Providers described barriers to colonoscopy at the provider, community, and patient levels and suggested patient supports could help overcome them. Providers found current colonoscopy capacity sufficient, but noted PCPs trained to perform colonoscopy would be key to continued accessibility. Finally, providers shared concerns about the shrinking number of PCP endoscopists, especially with anticipated increased screening demand related to the CRC screening guideline shift.

CONCLUSIONS

These themes reflect opportunities to address multilevel barriers to improve access, colonoscopy capacity, and patient education approaches. Our results highlight that PCPs are an essential part of the workforce that provides colonoscopy in rural areas.

Interventions to Improve Surveillance for Hepatocellular Carcinoma in High-Risk Patients: A Scoping Review

PURPOSE

Hepatocellular carcinoma (HCC) is most often a sequela of chronic liver disease or chronic hepatitis B infection. Among high-risk patients, surveillance for HCC every 6 months is recommended by international guidelines. However, rates of HCC surveillance are suboptimal (11-64%). Barriers at the patient, provider, and healthcare delivery system levels have been identified.

METHODS

We performed a systemic scoping review to identify and characterize interventions to improve HCC surveillance that has previously been evaluated. Searches using key terms in PubMed and Embase were performed to identify studies examining interventions designed to improve the surveillance rate for HCC in patients with cirrhosis or chronic liver disease that were published in English between January 1990 and September 2021.

RESULTS

Included studies (14) had the following study designs: (1) randomized clinical trials (3, 21.4%), (2) quasi-experimental (2, 14.3%), (3) prospective cohort (6, 42.8%), and (4) retrospective cohort (3, 21.4%). Interventions included mailed outreach invitations, nursing outreach, patient education with or without printed materials, provider education, patient navigation, chronic disease management programs, nursing-led protocols for image ordering, automated reminders to physicians and nurses, web-based clinical management tools, HCC surveillance databases, provider compliance reports, radiology-led surveillance programs, subsidized HCC surveillance, and the use of oral medications. It was found that HCC surveillance rates increased after intervention implementation in all studies.

CONCLUSION

Despite improvements in HCC surveillance rates with intervention, compliance remained suboptimal. Further analysis of which interventions yield the greatest increases in HCC surveillance, design of multi-pronged strategies, and improved implementation are needed.

Unsatisfactory Fecal Immunochemical Tests for Colorectal Cancer Screening: Prevalence, Reasons, and Subsequent Testing

BACKGROUND

Fecal immunochemical test (FIT) is an effective colorectal cancer screening modality. Little is known about prevalence, reasons, and testing after unsatisfactory FIT, or a FIT that cannot be processed by the laboratory due to inadequate stool specimen or incomplete labeling.

METHODS

Our retrospective cohort study examined unsatisfactory FIT among average-risk individuals aged 50-74 years in a large, integrated, safety-net health system who completed an index FIT from 2010 to 2019. We determined prevalence of unsatisfactory FIT and categorized reasons hierarchically. We used multivariable logistic regression models to identify factors associated with: (i) unsatisfactory FIT; and (ii) subsequent testing within 15 months of the unsatisfactory FIT.

RESULTS

Of 56,980 individuals completing an index FIT, 10.2% had an unsatisfactory FIT. Reasons included inadequate specimen (51%), incomplete labeling (27%), old specimen (13%), and broken/leaking container (8%). Unsatisfactory FIT was associated with being male [OR, 1.10; confidence interval (CI), 1.03-1.16], Black (OR, 1.46; CI, 1.33-1.61), Spanish speaking (OR, 1.12; CI, 1.01-1.24), on Medicaid (OR, 1.42; CI, 1.28-1.58), and received FIT by mail (OR, 2.66; CI, 2.35-3.01). Among those with an unsatisfactory FIT, fewer than half (41%) completed a subsequent test within 15 months (median, 4.4 months). Adults aged 50-54 years (OR, 1.16; CI, 1.01-1.39) and those who received FIT by mail (OR, 1.92; CI, 1.49-2.09) were more likely to complete a subsequent test.

CONCLUSIONS

One in ten returned a FIT that could not be processed, mostly due to patient-related reasons. Fewer than half completed a subsequent test after unsatisfactory FIT.

IMPACT

Screening programs should address these breakdowns such as specimen collection and labeling to improve real-world effectiveness. See related In the Spotlight, p. 183.

The Role of Health Information Technology on Colorectal Cancer Screening Participation Among Smokers In The United States

Background: Despite advances in its prevention and early detection, colorectal cancer (CRC) remains a leading cause of morbidity and mortality in the United States and smokers are at an increased risk. Health information technology (HIT) has shown promise in the uptake of preventive health services, including CRC, and may prove useful among smokers. Methods: We obtained data from 7,419 adults who completed the 2018-2020 Health Information National Trends Survey. Using multivariable logistic regression models, we examined the relationship between HIT use and CRC screening participation. Results: Over 20% of current smokers had no access to HIT tools, and those with access were less likely than never smokers to use HIT in checking test results (odds ratio [OR] 0.58; 95% confidence interval [CI] [0.42-0.80]). Among former smokers, using HIT to check test results (OR 3.41; 95% CI [1.86-6.25]), look up health information online (OR 2.20; 95% CI [1.15-4.22]), and make health appointments (OR 2.86; 95% CI [1.39-5.89]) was associated with increased participation in CRC screening. Among current smokers, the use of HIT was not associated with a change in CRC screening participation. Conclusion: HIT use is associated with higher levels of CRC screening among former smokers, which is reassuring given their increased risk of CRC. The low ownership and use of HIT among current smokers of CRC screening age presents a challenge that may limit the integration of HIT into routine CRC screening services.

Delays in Colorectal Cancer Screening for Latino Patients: The Role of Immigrant Healthcare in Stemming the Rising Global Incidence of Colorectal Cancer

The significant global burden of colorectal cancer accentuates disparities in access to preventive healthcare in most low- and middle-income countries (LMICs) as well as large sections of underserved populations within high-income countries. The barriers to colorectal cancer screening in economically transitioning Latin America are multiple. At the same time, immigration from these countries to the USA continues to increase. This case highlights the delays in diagnosis experienced by a recent immigrant from a country with no established colorectal cancer screening program, to an immigrant population in the USA with similar poor screening coverage. We discuss common challenges faced by Latinos in their home countries and the USA, as well as strategies that could be implemented to improve screening coverage in US immigrant populations.

Effective strategies for Fecal Immunochemical Tests (FIT) programs to improve colorectal cancer screening uptake among populations with limited access to the healthcare system: a rapid review

BACKGROUND

Colorectal cancer (CRC) is one of the leading causes of cancer death globally. CRC screening can reduce the incidence and mortality of CRC. However, socially disadvantaged groups may disproportionately benefit less from screening programs due to their limited access to healthcare. This poor access to healthcare services is further aggravated by intersecting, cumulative social factors associated with their sociocultural background and living conditions. This rapid review systematically reviewed and synthesized evidence on the effectiveness of Fecal Immunochemical Test (FIT) programs in increasing CRC screening in populations who do not have a regular healthcare provider or who have limited healthcare system access.

METHODS

We used three databases: Ovid MEDLINE, Embase, and EBSCOhost CINAHL. We searched for systematic reviews, meta-analysis, and quantitative and mixed-methods studies focusing on effectiveness of FIT programs (request or receipt of FIT kit, completion rates of FIT screening, and participation rates in follow-up colonoscopy after FIT positive results). For evidence synthesis, deductive and inductive thematic analysis was conducted. The findings were also classified using the Cochrane Methods Equity PROGRESS-PLUS framework. The quality of the included studies was assessed.

RESULTS

Findings from the 25 included primary studies were organized into three intervention design-focused themes. Delivery of culturally-tailored programs (e.g., use of language and interpretive services) were effective in increasing CRC screening. Regarding the method of delivery for FIT, specific strategies combined with mail-out programs (e.g., motivational screening letter) or in-person delivery (e.g., demonstration of FIT specimen collection procedure) enhanced the success of FIT programs. The follow-up reminder theme (e.g., spaced out and live reminders) were generally effective. Additionally, we found evidence of the social determinants of health affecting FIT uptake (e.g., place of residence, race/ethnicity/culture/language, gender and/or sex).

CONCLUSIONS

Findings from this rapid review suggest multicomponent interventions combined with tailored strategies addressing the diverse, unique needs and priorities of the population with no regular healthcare provider or limited access to the healthcare system may be more effective in increasing FIT screening. Decision-makers and practitioners should consider equity and social factors when developing resources and coordinating efforts in the delivery and implementation of FIT screening strategies.

Methods for scaling up an outreach intervention to increase colorectal cancer screening rates in rural areas

BACKGROUND

Mailed fecal immunochemical test (FIT) outreach and patient navigation are evidence-based practices shown to improve rates of colorectal cancer (CRC) and follow-up in various settings, yet these programs have not been broadly adopted by health systems and organizations that serve diverse populations. Reasons for low adoption rates are multifactorial, and little research explores approaches for scaling up a complex, multi-level CRC screening outreach intervention to advance equity in rural settings.

METHODS

SMARTER CRC, a National Cancer Institute Cancer Moonshot project, is a cluster-randomized controlled trial of a mailed FIT and patient navigation program involving 3 Medicaid health plans and 28 rural primary care practices in Oregon and Idaho followed by a national scale-up trial. The SMARTER CRC intervention combines mailed FIT outreach supported by clinics, health plans, and vendors and patient navigation for colonoscopy following an abnormal FIT result. We applied the framework from Perez and colleagues to identify the intervention's components (including functions and forms) and scale-up dissemination strategies and worked with a national advisory board to support scale-up to additional organizations. The team is recruiting health plans, primary care clinics, and regional and national organizations in the USA that serve a rural population. To teach organizations about the intervention, activities include Extension for Community Healthcare Outcomes (ECHO) tele-mentoring learning collaboratives, a facilitation guide and other materials, a patient navigation workshop, webinars, and individualized technical assistance. Our primary outcome is program adoption (by component), measured 6 months after participation in an ECHO learning collaborative. We also assess engagement and adaptations (implemented and desired) to learn how the multicomponent intervention might be modified to best support broad scale-up.

DISCUSSION

Findings may inform approaches for adapting and scaling evidence-based approaches to promote CRC screening participation in underserved populations and settings.

TRIAL REGISTRATION

Registered at ClinicalTrials.gov (NCT04890054) and at the NCI's Clinical Trials Reporting Program (CTRP no.: NCI-2021-01032) on May 11, 2021.

Screening for Colorectal Cancer: The Role of Clinical Laboratories

BACKGROUND

Colorectal cancer (CRC) is a leading cause of cancer incidence and mortality. Screening can result in reductions in incidence and mortality, but there are many challenges to uptake and follow-up.

CONTENT

Here, we will review the changing epidemiology of CRC, including increasing trends for early and later onset CRC; evidence to support current and emerging screening strategies, including noninvasive stool and blood-based tests; key challenges to ensuring uptake and high-quality screening; and the critical role that clinical laboratories can have in supporting health system and public health efforts to reduce the burden of CRC on the population.

SUMMARY

Clinical laboratories have the opportunity to play a seminal role in optimizing early detection and prevention of CRC.

Abnormal Colorectal Cancer Test Follow-Up: A Quality Improvement Initiative at a Federally Qualified Health Center

INTRODUCTION/OBJECTIVES

Colonoscopy completion rates after an abnormal fecal immunochemical test (FIT) are suboptimal, resulting in missed opportunities for early detection and prevention of colorectal cancer. Patient navigation and structured follow-up may improve colonoscopy completion, but implementation of these strategies is not widespread.

METHODS

We conducted a quality improvement study using a Plan-Do-Study-Act (PDSA) Model to increase colonoscopy completion after abnormal FIT in a large federally qualified health center serving a diverse and low-income population. Intervention components included patient navigation, and a checklist to promote completion of key steps required for abnormal FIT follow-up. Primary outcome was proportion of patients achieving colonoscopy completion within 6 months of abnormal FIT, assessed at baseline for 156 patients pre-intervention, and compared to 208 patients during the intervention period from April 2017 to December 2019. Drop offs at each step in the follow-up process were assessed.

RESULTS

Colonoscopy completion improved from 21% among 156 patients with abnormal FIT pre-intervention, to 38% among 208 patients with abnormal FIT during the intervention (P < .001; absolute increase: 17%, 95% CI: 6.9%-25.2%). Among the 130 non-completers during the intervention period, lack of completion was attributable to absence of colonoscopy referral for 7.7%; inability to schedule a pre-colonoscopy specialist visit for 71.5%; failure to complete a pre-colonoscopy visit for 2.3%; the absence of colonoscopy scheduling for 9.2%; failure to show for a scheduled colonoscopy for 9.2%.

CONCLUSIONS

Patient navigation and structured follow-up appear to improve colonoscopy completion after abnormal FIT. Additional strategies are needed to achieve optimal rates of completion.

Provider communication contributes to colorectal cancer screening intention through improving screening outcome expectancies and perceived behavioral control

Colorectal cancer (CRC) screening continues to be underutilized in the US despite the availability of multiple effective, guideline-recommended screening options. Provider recommendation has been consistently shown to improve screening completion. Yet, available literature provides little information as to how specific information providers communicate influence patient decision-making about CRC screening. We tested the pathways through which information communicated by providers about the "Why" and "How" of CRC screening using the mt-sDNA test contributes to intention to complete the test. Data came from a behavioral theory-informed survey that we developed to identify psychosocial factors associated with mt-sDNA screening. RTI International administered the survey between 03/2022-06/2022 to a sample of US adults ages 45-75 who received a valid order for mt-sDNA screening with a shipping date between 5/2021-9/2021. Participants completed an electronic or paper survey. We tested the proposed relationships using structural equation modeling and tested indirect effects using Monte Carlo method. A total of 2,973 participants completed the survey (response rate: 21.7%) and 81.6% (n = 2,427) reported have had a conversation with their health care provider about mt-sDNA screening before the test was ordered. We found that "Why" information from providers was positively associated with perceived effectiveness of mt-sDNA screening, while "How" information was positively associated with perceived ease of use. "Why" information contributed to screening intention through perceived effectiveness while "How" information contributed to screening intention through perceived ease of use. These findings emphasize the critical role of provider communication in shaping patient decision-making regarding CRC screening. CRC screening interventions could consider implementing provider-patient communication strategies focusing on improving patient understanding of the rationale for CRC screening and the effectiveness of available screening options as well as addressing barriers and enhancing patients' self-efficacy in completing their preferred screening option.