Adherence to repeat screening flexible sigmoidoscopy in the Prostate, Lung, Colorectal, and Ovarian (PLCO) Cancer Screening Trial

Cost-effectiveness Analysis of Colorectal Cancer Screening Strategies Using Active Learning and Monte Carlo Simulation

INTRODUCTION

Detection of colorectal cancer (CRC) in the early stages through available screening tests increases the patient's survival chances. Multimodal screening policies can benefit patients by providing more diverse screening options and balancing the risks and benefits of screening tests. We investigate the cost-effectiveness of a wide variety of multimodal CRC screening policies.

METHODS

We developed a Monte Carlo simulation framework to model CRC dynamics. We proposed an innovative calibration process using machine learning models to estimate age- and size-specific adenomatous polyps' progression and regression rates. The proposed approach significantly expedites the model parameter space search.

RESULTS

Two multimodal proposed policies (i.e., 1] colonoscopy at 50 y and fecal occult blood test annually between 60 and 75 y and 2] colonoscopy at 50 and 60 y and fecal immunochemical test annually between 70 and 75 y) are identified as efficient frontier policies. Both policies are cost-effective at a willingness to pay of $50,000. Sensitivity analyses were performed to assess the sensitivity of results to a change in screening test costs as well as adherence behavior. The sensitivity analysis results suggest that the proposed policies are mostly robust to the considered changes in screening test costs, as there is a significant overlap between the efficient frontier policies of the baseline and the sensitivity analysis cases. However, the efficient frontier policies were more sensitive to changes in adherence behavior.

CONCLUSION

Generally, combining stool-based tests with visual tests will benefit patients with higher life expectancy and a lower expected cost compared with unimodal screening policies. Colonoscopy at younger ages (when the colonoscopy complication risk is lower) and stool-based tests at older ages are shown to be more effective.

HIGHLIGHTS

We propose a detailed Markov model to capture the colorectal cancer (CRC) dynamics. The proposed Markov model presents the detailed dynamics of adenomas progression to CRC.We use more than 44,000 colonoscopy reports and available data in the literature to calibrate the proposed Markov model using an innovative approach that leverages machine learning models to expedite the calibration process.We investigate the cost-effectiveness of a wide variety of multimodal CRC screening policies and compare their performances with the current in-practice policies.

Comparison of patients' tolerance between computed tomography enterography and double-balloon enteroscopy

BACKGROUND

Computed tomography enterography (CTE) and double-balloon enteroscopy (DBE) are widely used in diagnosis of small bowel diseases. Both of these examinations bring discomfort to patients. The aim of this study was to compare patients' tolerance and preference between CTE and DBE.

METHODS

From August 1, 2014 to December 31, 2016, patients with suspected or known small bowel diseases who underwent both CTE and DBE were prospectively enrolled in our study. They were asked to fill out a questionnaire evaluating discomfort of the procedure after each examination.

RESULTS

One hundred and seven patients completed our study. Abdominal distension, painfulness, tenesmus, general discomfort, prolonged duration, difficulty in completing the test, and discomfort after the examination were significantly lower with CTE than with DBE (P<0.001, respectively). Mannitol intake (47.7%), bowel preparation (31.9%), and radiation exposure (15.0%) were regarded as the three most intolerable burdens in CTE. Painfulness (38.3%), bowel preparation (26.2%), and invasiveness (16.8%) were considered as the three most unacceptable parts of DBE. More patients (61.7%) preferred to repeat CTE rather than DBE (P<0.001).

CONCLUSION

Compared to DBE, CTE was a more tolerable and less burdensome examination and enjoyed higher preference by most patients.

Beverage intake preference and bowel preparation laxative taste preference for colonoscopy

AIM: To examine whether non-alcoholic beverage intake preferences can guide polyethylene glycol (PEG)-based bowel laxative preparation selection for patients.

METHODS: We conducted eight public taste test sessions using commercially procured (A) unflavored PEG, (B) citrus flavored PEG and (C) PEG with ascorbate (Moviprep). We collected characteristics of volunteers including their beverage intake preferences. The volunteers tasted the laxatives in randomly assigned orders and ranked the laxatives as 1^st, 2^nd, and 3^rd based on their taste preferences. Our primary outcome is the number of 1^st place rankings for each preparation.

RESULTS: A total of 777 volunteers completed the study. Unflavored PEG was ranked as 1^st by 70 (9.0%), flavored PEG by 534 (68.7%) and PEG with ascorbate by 173 (22.3%) volunteers. Demographic, lifestyle characteristics and beverage intake patterns for coffee, tea, and carbonated drinks did not predict PEG-based laxative preference.

CONCLUSION: Beverage intake pattern was not a useful guide for PEG-based laxative preference. It is important to develop more tolerable and affordable bowel preparation laxatives for colonoscopy. Also, patients should taste their PEG solution with and without flavoring before flavoring the entire gallon as this may give them more opportunity to pick a pattern that may be more tolerable.

Concerns and challenges in flexible sigmoidoscopy screening

In 1992, two well-conducted case-control studies used data from two different health maintenance organizations and demonstrated a 59-79% reduction in mortality from colorectal cancer (CRC) following exposure to sigmoidoscopy. These studies highlight the possibility of reducing mortality from CRC using population-based endoscopic screening. The development of fiber optics improved the technology, and the ease of performing flexible sigmoidoscopy (FS) with widespread adoption of this screening modality. To date, FS is the only endoscopic screening modality that has been shown to reduce mortality in randomized clinical trials. This article reviews the development of sigmoidoscopy, its use in CRC screening and the current reduced role of this proven screening modality, and explores new frontiers for population-based FS screening.

Factors associated with inadequate colorectal cancer screening with flexible sigmoidoscopy

BACKGROUND AND STUDY AIM

Inadequate colorectal cancer screening wastes limited endoscopic resources. We examined patients factors associated with inadequate flexible sigmoidoscopy (FSG) screening at baseline screening and repeat screening 3-5 years later in 10 geographically-dispersed screening centers participating in the ongoing Prostate, Lung, Colorectal, and Ovarian Cancer Screening Trial.

METHODS

A total of 64,554 participants (aged 55-74) completed baseline questionnaires and underwent FSG at baseline. Of these, 39,385 participants returned for repeat screening. We used logistic regression models to assess factors that are associated with inadequate FSG (defined as a study in which the depth of insertion of FSG was <50 cm or visual inspection was limited to <90% of the mucosal surface but without detection of a polyp or mass).

RESULTS

Of 7084 (11%) participants with inadequate FSG at baseline, 6496 (91.7%) had <50 cm depth of insertion (75.3% due to patient discomfort) and 500 (7.1%) participants had adequate depth of insertion but suboptimal bowel preparation. Compared to 55-59 year age group, advancing age in 5-year increments (odds ratios (OR) from 1.08 to 1.51) and female sex (OR = 2.40; 95% confidence interval (CI): 2.27-2.54) were associated with inadequate FSG. Obesity (BMI > 30 kg/m(2)) was associated with reduced odds (OR = 0.67; 95% CI: 0.62-0.72). Inadequate FSG screening at baseline was associated with inadequate FSG at repeat screening (OR = 6.24; 95% CI: 5.78-6.75).

CONCLUSIONS

Sedation should be considered for patients with inadequate FSG or an alternative colorectal cancer screening method should be recommended.

Screening based on risk for colorectal cancer is the most cost-effective approach

BACKGROUND & AIMS

Performing single endoscopic examinations or selective screening based on risk might be more practical than recommended screening strategies for colorectal cancer (CRC). We investigated the cost effectiveness of these strategies, under real-life conditions of suboptimal compliance, and the societal cost perspective.

METHODS

We used Markov modeling to analyze data from 787,000 individuals in Singapore, aged 50 to 75 years, with an age-standardized rate of CRC of 30 to 40/100,000 in 2009. Potential outcomes, incremental cost-effectiveness ratio, and net health benefit were compared between single sigmoidoscopy or colonoscopy and current recommended screening strategies, and also with a strategy of selective screening based on risk of CRC.

RESULTS

Performing single sigmoidoscopies on individuals when they are 60 years old was the cheapest screening strategy; it would reduce CRC incidence by 19% and mortality by 16%, compared with no screening. A single colonoscopy is less cost effective than a single sigmoidoscopy, unless the proportion of right-sided lesions exceeds 65%. The fecal occult blood test (iFOBT) had the lowest incremental cost-effectiveness ratio when all strategies were compared with no screening; iFOBT and colonoscopic examinations every 10 years each had extended dominance over other strategies. Screening subjects 50 to 60 years old by iFOBT and subjects 60 to 72 years old with colonoscopies every 10 years was the most cost-effective strategy (US$25,000/quality-adjusted life-years). Risk for CRC, adherence, and cost of colonoscopy were the main determinants of cost effectiveness, based on sensitivity analysis.

CONCLUSIONS

Markov modeling analysis indicates that selectively screening individuals for CRC based on risk is the most cost-effective approach; it limits the cost and number of colonoscopies needed and significantly reduces CRC mortality.

Flexible sigmoidoscopy in the randomized prostate, lung, colorectal, and ovarian (PLCO) cancer screening trial: added yield from a second screening examination

BACKGROUND

Among randomized trials evaluating flexible sigmoidoscopy (FSG) for its effect on colorectal cancer mortality, only the Prostate, Lung, Colorectal, and Ovarian (PLCO) Cancer Screening Trial screened its participants more than one time. We report outcomes from the PLCO screening FSG program and evaluate the increased yield produced by a second FSG.

METHODS

Participants were screened by 60-cm FSG in 10 regional screening centers at study entry and 3 or 5 years later, depending on the time of random assignment. Results from subsequent diagnostic intervention were tracked and recorded in a standardized fashion, and outcomes were compared according to sex and age. The protocol discouraged repeat FSG in persons with colorectal cancer or adenoma diagnosed after the initial FSG.

RESULTS

Of 77 447 enrollees, 67 073 (86.6%) had at least one FSG and 39 443 (50.9%) had two FSGs. Diagnostic intervention occurred in 74.9% after a positive first FSG and in 78.7% after a positive repeat FSG. The second FSG increased the screening yield by 32%: Colorectal cancer or advanced adenoma was detected in 37.8 per 1000 persons after first screening and in 49.8 per 1000 persons after all screenings. The second FSG increased the yield of cancer or advanced adenoma by 26% in women and by 34% in men. Of 223 subjects who received a diagnosis of colorectal carcinoma within 1 year of a positive FSG, 64.6% had stage I and 17.5% had stage II disease.

CONCLUSIONS

Repeat FSG increased the detection of colorectal cancer or advanced adenoma in women by one-fourth and in men by one-third. Screen-detected carcinomas were early stage (stage I or II) in greater than 80% of screened persons. Colorectal cancer mortality data from the PLCO, as the definitive endpoint, will follow in later publications.

Quality assurance of endoscopy in colorectal cancer screening

This chapter explores the concept of quality assurance of colorectal cancer screening. It argues that effective quality assurance is critical to ensure that the benefits of screening outweigh the harms. The three key steps of quality assurance, definition of standards, measurement of standards and enforcement of standards, are explained. Quality is viewed from the perspective of the patient and illustrated by following the path of patients accessing endoscopy within screening services. The chapter discusses the pros and cons of programmatic versus non-programmatic screening and argues that quality assurance of screening can and should benefit symptomatic services. Finally, the chapter emphasises the importance of a culture of excellence underpinned by continuous quality improvement and effective service leadership.

Does participation to screening unintentionally influence lifestyle behaviour and thus lifestyle-related morbidity?

Cancer is a leading cause of death worldwide and the burden could be reduced by evidence-based strategies for the primary prevention of cancer, the early detection of malignancies and more adequate treatment of cancer patients. Previous research has shown that lifestyle factors are associated with common cancers and that several cancer screening programmes are cost-effective in reducing cancer-specific mortality. But, some recent studies reported that participants of screening programs might unintentionally change their lifestyle. Cancer screening might be a teachable moment or, on the other hand, have a false health certificate effect. Despite that the evidence is scarce, cancer screening might have opportunities for lifestyle improvements, although a possible health certificate effect still remains. Integrated approaches to combine primary and secondary prevention have the potential to optimise the efforts to improve cancer prevention and survival. More research is warranted to investigate evidence-based approaches.

A 9-year follow-up study of participants and nonparticipants in sigmoidoscopy screening: importance of self-selection

BACKGROUND

Self-selection may compromise cost-effectiveness of screening programs. We hypothesized that nonparticipants have generally higher morbidity and mortality than participants.

METHODS

A Swedish population-based random sample of 1,986 subjects ages 59 to 61 years was invited to sigmoidoscopy screening and followed up for 9 years by means of multiple record linkages to health and population registers. Gender-adjusted cancer incidence rate ratio (IRR) and overall and disease group-specific and mortality rate ratio (MRR) with 95% confidence intervals (95% CI) were estimated for nonparticipants relative to participants. Cancer and mortality rates were also estimated relative to the age-matched, gender-matched, and calendar period-matched Swedish population using standardized incidence ratios and standardized mortality ratios.

RESULTS

Thirty-nine percent participated. The incidence of colorectal cancer (IRR, 2.2; 95% CI, 0.8-5.9), other gastrointestinal cancer (IRR, 2.7; 95% CI, 0.6-12.8), lung cancer (IRR, 2.2; 95% CI, 0.8-5.9), and smoking-related cancer overall (IRR, 1.4; 95% CI, 0.7-2.5) tended to be increased among nonparticipants relative to participants. Standardized incidence ratios for most of the studied cancers tended to be >1.0 among nonparticipants and <1.0 among participants. Mortality from all causes (MRR, 2.4; 95% CI, 1.7-3.4), neoplastic diseases (MRR, 1.9; 95% CI, 1.1-3.5), gastrointestinal cancer (MRR, 4.7; 95% CI, 1.1-20.7), and circulatory diseases (MRR, 2.3; 95% CI, 1.2-4.2) was significantly higher among nonparticipants than among participants. Standardized mortality ratio for the studied outcomes tended to be increased among nonparticipants and was generally decreased among participants.

CONCLUSION

Individuals who might benefit most from screening are overrepresented among nonparticipants. This self-selection may attenuate the cost-effectiveness of screening programs on a population level.

MRI of the small bowel with oral contrast or nasojejunal intubation in Crohn's disease: randomized comparison of patient acceptance

OBJECTIVE

Magnetic resonance imaging of the small bowel with an oral contrast (MRI per os) is believed to generate fewer adverse symptoms compared with installation of the contrast in a nasojejunal catheter (MRE). However, there is very little evidence to support this assumption. The aim of this study was to evaluate the compliance of patients examined with both of these MRI methods.

MATERIAL AND METHODS

Patients with suspected or known Crohn's disease referred for MRI of the small bowel underwent both MRI per os and MRE within 7 days. A questionnaire was answered immediately and 24 h after the procedure. Adverse symptoms were graded on a visual analogue scale (VAS). Responses were compared with paired and independent sample t-tests and signed-rank tests. Correlation of each symptom to the overall discomfort was evaluated with Spearman's correlation coefficient.

RESULTS

Thirty-eight patients (18 F, 20 M) were included in the analysis. Abdominal pain and discomfort were lower with MRI per os than with MRE (mean VAS pain score immediately after: 10 mm and 33 mm, respectively, p < 0.001; mean VAS discomfort score 24 h after: 18 mm and 62 mm, respectively, p < 0.001). Nausea and abdominal pain were correlated with overall discomfort after MRI per os (r = 0.56 for both, p < 0.001). No symptoms were significantly correlated with discomfort experienced with MRE. More patients accepted repeat MRI per os examination (n = 36) than MRE (n = 22, p = 0.001).

CONCLUSION

Patients preferred and experienced less abdominal pain and discomfort with MRI per os than with MRE.

Multiple behavioral risk factors for colorectal cancer and colorectal cancer screening status

BACKGROUND

Individuals who are not adherent to colorectal cancer screening have a greater prevalence of several other behavioral risk factors for colorectal cancer than adherent individuals. However, previous relevant studies have typically not considered the co-occurrence of such behavioral risk factors at the individual level. In the current study, we examined the prevalence, patterns, and predictors of multiple behavioral risk factors for colorectal cancer according to colorectal cancer screening status (adherent versus not adherent).

METHODS

The study sample consisted of 11,090 individuals ages 50 years and older who participated in the 2000 National Health Interview Survey. Based on responses to survey questions, individuals were categorized as being adherent or not adherent to colorectal cancer screening guidelines and were also denoted as having or not having each of seven behavioral risk factors for colorectal cancer (smoking, low physical activity, low fruit and vegetable intake, high caloric intake from fat, obesity, high alcohol intake, and low intake of multivitamins).

RESULTS

Individuals who were not adherent to screening reported having a greater number of risk factors than adherent individuals. For each screening group, there was a high prevalence of having low physical activity, low fruit and vegetable intake, and low intake of multivitamins. Demographic and health-related correlates of behavioral risk factor prevalence were identified in both screening groups.

CONCLUSIONS

In combination with efforts to promote colorectal cancer screening uptake and adherence, there is a need to develop interventions to modify the colorectal cancer behavioral risk factors that are common among screening-adherent and nonadherent individuals.

Colorectal cancer screening: health impact and cost effectiveness

BACKGROUND

Colorectal cancer is the second leading cause of cancer-related death in the United States, yet recommended screenings are not delivered to most people. This assessment of colorectal cancer screening's value to the U.S. population is part of the update to a 2001 ranking of recommended clinical preventive services found in the accompanying article. This article describes the burden of disease prevented and cost-effectiveness as a result of offering patients a choice of colorectal cancer screening tools.

METHODS

Methods used were designed to ensure consistent estimates across many services and are described in more detail in the companion articles. In a secondary analysis, the authors also estimated the impact of increasing offers for colorectal cancer screening above current levels among the current cross-section of adults aged 50 and older.

RESULTS

If a birth cohort of 4 million were offered screening at recommended intervals, 31,500 deaths would be prevented and 338,000 years of life would be gained over the lifetime of the birth cohort. In the current cross-section of people aged 50 and older, 18,800 deaths could be prevented each year by offering all people in this group screening at recommended intervals. Only 58% of these deaths are currently being prevented. In year 2000 dollars, the cost effectiveness of offering patients aged 50 and older a choice of colorectal cancer screening options is $11,900 per year of life gained.

CONCLUSIONS

Colorectal cancer screening is a high-impact, cost-effective service used by less than half of persons aged 50 and older.

Colorectal cancer screening and surveillance

Screening and surveillance substantially reduce both the incidence and mortality of colorectal cancer. Screening of normal-risk individuals may be accomplished by several methods, including fecal occult blood testing, fiberoptic sigmoidoscopy, double contrast barium enema, and colonoscopy. New technologies for screening are being developed, such as fecal immunochemical testing for blood,fecal DNA testing, and virtual colonoscopy. Patients at increased risk for colorectal cancer, such as those with a positive family history, previous adenomatous polyps or cancer, and inflammatory bowel disease, should be offered more intensive evaluation and surveillance.

Lifestyle characteristics among participants in a Norwegian colorectal cancer screening trial

The aim of the present study was to evaluate to what extent lifestyle-related variables predict participation for flexible sigmoidoscopy (FS) screening when the compliance is relatively high. During 2001, a randomized sample of 6961 men and women, born between 1946 and 1950, were invited to have a flexible sigmoidoscopy screening examination. Attendees (n = 4111) were asked to fill in a questionnaire focusing on physical activity, body weight, smoking habits and diet. The questionnaire was sent by mail to non-attendees (n = 2628) and a randomized corresponding control group not invited to screening (n = 7000). Sixty-one percent attended for screening. The questionnaire response rate among attendees, non-attendees and controls was 97, 11 and 61%, respectively. Attendees were more physically active (P < 0.001), and showed more adherence to general dietary recommendations, compared with controls. Opposing their healthy exercise and dietary habits, however, attendees were more likely to be moderate smokers compared with controls. The present offer of FS screening, achieving a relatively high compliance rate, may have reached attendees using screening as a supplement to an already healthy lifestyle, but also those who seek amelioration through health checks for risks behaviour that they are perfectly well aware of, such as smoking.

Collaborative colorectal cancer screening: a successful quality improvement initiative

PROBLEM

Low screening and referral rates for colorectal cancer at a primary care clinic suggest the need for alternative methods to identify patients and complete the screening process.

DESIGN

A review of >5000 medical charts established baseline screening and referral data. After a 3-month trial of a screening protocol, the research team conducted a follow-up medical chart review to determine referral levels.

BACKGROUND AND SETTING

The clinic is an 8-physician primary care facility in Southlake, Texas, and is one of 36 clinics affiliated with HealthTexas Provider Network.

KEY MEASURES FOR IMPROVEMENT

The goal was to increase referrals for colorectal cancer to at least 85% among patients aged 50 to 75 years.

STRATEGIES FOR IMPROVEMENT

The entire staff of the primary care clinic and the gastroenterology office became involved in the referral process. The team used simple tools such as chart stickers to draw attention to patients requiring screening, generation of referral forms that were numbered for follow-up and faxed to the gastroenterologists, and patient educational material on colorectal cancer screening. These tools were designed to overcome specific barriers to successful screening that the team had identified.

EFFECTS OF CHANGE

Referrals for sigmoidoscopy, colonoscopy, and double-contrast barium enema increased from 47% to 86%. Fecal occult blood testing was arranged for additional patients through the primary care office. Revenues related to colonoscopies increased by about 50% for the gastroenterologist group, the hospital, and the pathology group affiliated with Southlake Family Medicine.

LESSONS LEARNED

This colorectal cancer screening protocol succeeded in its 3-month trial because it was collaborative, opportunistic, simple, and made good business sense. The protocol is now being implemented at other HealthTexas Provider Network offices.

Selecting patients for flexible sigmoidoscopy. Determinants of incomplete depth of insertion

BACKGROUND

Flexible sigmoidoscopy (FS) is an effective method to prevent and reduce mortality from colorectal carcinoma (CRC). Incomplete depth of insertion (IDI) during FS may result in missed polyps and carcinomas. To determine whether it is possible to predict IDI, the authors analyzed factors that affected the depth of insertion in FS.

METHODS

For the current study, FS results were recorded prospectively over a 5-year period. A questionnaire was administered to the patient by the investigator prior to FS to collect data, including age, gender, weight, comorbid illnesses, history of prior abdominal and pelvic surgeries, family history of colon carcinoma or polyps, and prior FS or colonoscopies. The depth of insertion of the flexible sigmoidoscope from the anal verge, which was defined as the reading on the outside of the instrument at its maximal insertion, was measured in centimeters. IDI was defined as a depth of insertion < 50 cm. Classification and regression tree analysis was used to develop a model that included variables predictive of IDI.

RESULTS

The best classification tree included gender, age < 69 years (in women), and a history of hysterectomy. Men had a < 5% risk of an IDI and women age < 69 years without a hysterectomy fared as well (6.6%). Older women and younger women who underwent hysterectomy had higher rates of IDI (29.2% and 22.3%, respectively.)

CONCLUSIONS

The authors developed a model based on age, gender, and hysterectomy status that, after further validation, may be useful for predicting which patients likely will have an incomplete examination. In those patients who have a high probability of IDI, the choice can be made to offer colonoscopy or perform FS under sedation, with analgesia, or with the help of distraction techniques.

Quality of life and trial adherence among participants in the prostate, lung, colorectal, and ovarian cancer screening trial

BACKGROUND

The National Cancer Institute's Prostate, Lung, Colorectal, and Ovarian (PLCO) Cancer Screening Trial was designed to examine whether annual screening tests for these four tumor sites result in reduced disease-related mortality. We assessed the impact of trial participation on both health-related quality of life (HRQL) and trial adherence.

METHODS

Participants (N = 432; 217 in the control arm and 215 in screening arm) were accrued from the Georgetown University PLCO site from May through December 1998. Screening-arm participants were interviewed by telephone at baseline (prescreening), shortly after notification of screening results (short-term follow-up), and 9 months after notification of screening results (intermediate-term follow up). Control-arm participants completed a baseline and 1-year follow-up assessment. Logistic regression analyses were conducted.

RESULTS

Participants reported high levels of HRQL and satisfaction with their decision to participate. Screening-arm participants with abnormal screening results had a higher level of intrusive thoughts about cancer than those with all normal results (odds ratio [OR] = 2.9, 95% confidence interval [CI] = 1.3 to 6.3) at the short-term follow-up but not at the intermediate-term follow-up (when abnormal test results were known to be false positive; OR = 1.9, 95% CI = 0.89 to 4.2). Trial adherence was statistically significantly better among participants who had received all normal results in the previous year's screening tests (93.7% versus 78.7%; OR = 3.7, CI = 1.1 to 12.0) than in those who received at least one abnormal result. In the control arm, adherence (defined as returning annual questionnaires) was positively associated with education (OR = 3.4, 95% CI = 1.4 to 8.4) and sex, with women being more likely to return questionnaires than men (OR = 2.1, 95% CI = 1.05 to 4.4).

CONCLUSIONS

It is feasible to collect HRQL measures as part of a large cancer screening trial. Prior abnormal screening results were related to short-term HRQL but not to intermediate-term HRQL. Trial adherence was poorer among those who had received previous false-positive results. These results suggest several methods for improving adherence in this and other subgroups.

The evolution to stool DNA testing for colorectal cancer

Despite a variety of screening strategies and recent trends showing death rate stabilization, colorectal cancer still remains the second leading cause of overall cancer death. Current screening tools suffer from performance limitations, low patient acceptability, and marginal reliable access within the health care system. Noninvasive strategies present the lowest risk with the highest potential for patient satisfaction. However, serious implementation barriers exist requiring consistent programmatic screening, strict patient adherence, and poor sensitivity for adenomas. Colonoscopy remains an invasive screening test with the best sensitivity and specificity, but faces large financial costs, manpower requirements, patient access and adherence. Development of advanced molecular techniques identifying altered DNA markers in exfoliated colonocytes signify early or precancerous growth. Stool-based DNA testing provides an entirely noninvasive population-based screening strategy which patients can perform easier than faecal occult blood testing (FOBT). Large-scale prospective randomized control trials currently pending should help characterize accurate test performance, screening intervals, cost-effectiveness, direct comparison to FOBT and analysis of patient adherence. As tumour development pathways and potential target genes are further elucidated, refinements in multi-assay stool-based DNA testing portend enhanced test characteristics to detect and treat this genetically heterogeneous disease.

Barriers to endoscopic colorectal cancer screening: are women different from men?

OBJECTIVES

The goals of this study were to compare women and men's understanding of screening flexible sigmoidoscopy (FS) and to identify predictors of endoscopic colorectal cancer (CRC) screening.

METHODS

We mailed a 36-item questionnaire to asymptomatic patients aged 50 years or older who were scheduled for routine health assessments at a large multispecialty health-care group. Data collection included demographics, health behaviors, psychosocial factors, and CRC screening compliance. We followed participants for 1 year and assessed completion of endoscopic CRC screening. Both cross-sectional results examining previous screening and prospective results examining screening 1 year later were evaluated.

RESULTS

554 (54%) of 998 patients responded to the survey. Responses of 13 patients were excluded in the analyses due to unverifiable screening outcome. The majority of the respondents were white, and their average age was 62 years. Women reported significantly more embarrassment and fear about having FS than men. Women were more willing to consider having a FS if a female endoscopist performed the procedure. Of the 334 participants who were eligible to have endoscopic CRC screening, 53 (16%) had the procedure within a year. The odds of having the endoscopic procedures increased with the length of time the patients were under the care of their primary care providers and how strongly patients believed that one should have an FS even without symptoms.

CONCLUSION

Our findings suggest some unique gender-specific attitudes and beliefs that act as potential barriers for CRC screening and further support the important role of primary care providers in facilitating timely completion of screening.