Public health impact of achieving 80% colorectal cancer screening rates in the United States by 2018

Improving esophageal cancer screening across the globe: Translating knowledge into action

Esophageal cancer (EC) is a pressing global health concern, ranking as the eighth most common cancer and the sixth leading cause for cancer-related deaths worldwide. Esophageal adenocarcinoma (EAC) and esophageal squamous cell carcinoma (ESCC) are the two major histological types of esophageal cancer associated with distinct risk factors and geographical distributions. Unfortunately, the outcomes for both types of EC remain discouraging, with a five-year survival rate of less than 20% when diagnosed at advanced stages. Advanced endoscopic techniques have the potential to vastly enhance patient outcomes and impede the progression of pre-malignant lesions to cancer. However, low screening rates with endoscopy due to its invasive nature and high cost hinder its effectiveness. Despite extensive research on risk predictors, a significant number of cases still go undiagnosed, highlighting the need for improved screening techniques that can be implemented at the population level. To increase uptake, a shift towards minimally invasive, well-tolerated and cost-effective non-endoscopic technologies is crucial. The implementation of such devices in primary care settings, specifically targeting high-risk populations, can be a promising strategy. With early detection and enrollment in surveillance programs, there is hope for substantial improvement in morbidity and mortality rates through modern minimally invasive endoscopic and surgical techniques.

Individual and geospatial factors associated with receipt of colorectal cancer screening: a state-wide mixed-level analysis

BACKGROUND

Colorectal cancer (CRC) is the second leading cause of cancer death in US adults but can be reduced by screening. The roles of individual and contextual factors, and especially physician supply, in attaining universal CRC screening remains uncertain.

METHODS

We used data from adults 50-75 years old participating in the 2018 New York (NY) Behavioural Risk Factor Surveillance System linked to county-level covariates, including primary care physician (PCP) density and gastroenterologist (GI) density. Data were analysed in 2023-2024. Our analyses included (1) ecological and geospatial analyses of county-level CRC screening prevalence and (2) individual-level Poisson regression models of receipt of screening, adjusted for socioeconomic and county-level contextual variables.

RESULTS

Mean prevalence of up-to-date CRC screening was 71% (95% CI 70% to 73%) across NY's 62 counties. County-level CRC screening demonstrated significant spatial patterning (Global Moran's I=0.14, p=0.04), consistent with the existence of county-level contextual factors. In both county-level and individual-level analyses, lack of health insurance was associated with lower likelihood of up-to-date screening (ß=-1.09 (95% CI -2.00 to -0.19); adjusted prevalence ratio 0.68 (95% CI 0.60 to 0.77)), even accounting for age, race/ethnicity and education. In contrast, county-level densities of both PCPs and GIs were completely unassociated with screening at either the county or individual level. As expected, other determinants at the individual level included education status and age.

CONCLUSION

In this state-wide representative analysis, physician density was completely unassociated with CRC screening, although health insurance status remains strongly related. In similar screening environments, broadened insurance coverage for CRC screening is likely to improve screening far more effectively than increased physician supply.

Trends in management and outcomes of colon cancer in the United States over 15 years: Analysis of the National Cancer Database

Management of colon cancer has changed over the last few decades. We assessed the trends in management and outcomes using the US National Cancer Database (NCDB). A retrospective analysis of all patients with colonic adenocarcinoma between 2005 and 2019 was conducted. The cohort was divided into three equal time periods: Period 1 (2005-2009), Period 2 (2010-2014), and Period 3 (2015-2019) to examine treatment and outcomes trends. The primary outcome was 5-year overall survival (OS). The study included 923,275 patients. A significant increase in patients with stage IV disease was noted in Period 3 compared to Period 1 (47.9% vs. 27.9%, respectively), whereas a reciprocal reduction was seen in patients with locally advanced disease (stage II: 20.8%-12%; stage III: 14.5%-7.7%). Use of immunotherapy significantly increased from 0.3% to 7.6%. Mean 5-year OS increased (43.6 vs. 42.1 months) despite the increase in metastatic disease and longer time from diagnosis to definitive surgery (7 vs. 14 days). A reduction in 30-day readmission (5.1%-4.2%), 30- (3.9%-2.8%), and 90-day mortality (7.1%-5%) was seen. Laparoscopic and robotic surgery increased from 45.8% to 53.1% and 2.9% to 12.7%, respectively. Median postoperative length of hospital stay decreased by 2 days. Rate of positive resection margins (7.2%-6%) and median number of examined lymph nodes (14-16) also improved. Minimally invasive surgery and immunotherapy for colon cancer significantly increased in recent years. Patient outcomes including OS improved over time.

Quantified trends in provider reimbursement and utilization volume in colorectal cancer screenings: analysis of Medicare claims from 2000 to 2019

AIM

Colorectal cancer (CRC) screening rates in the United States remain persistently below guideline targets, partly due to suboptimal patient utilization and provider reimbursement. To guide long-term national utilization estimates and set reasonable screening adherence targets, this study aimed to quantify trends in utilization of and reimbursement for CRC screenings using Medicare claims.

METHOD

Inflation-adjusted reimbursements and utilization volume associated with each CRC screening code were abstracted from Medicare claims between 2000 and 2019. Screenings, screenings/100 000 enrolees and reimbursement/screening were analysed with linear regression and compared with the equality of slopes tests. Average reimbursement per screening was compared using analysis of variance with Dunnett's T3 multiple comparisons test.

RESULTS

The growth rate of multitarget stool DNA tests (mt-sDNA)/100 000 was the highest at 170.4 screenings/year (R2 = 0.99, p ≤ 0.001), while that of faecal occult blood tests/100 000 was the lowest at -446.4 screenings/year (R2 = 0.90, p ≤ 0.001) (p ≤ 0.001). Provider reimbursements averaged $546.95 (95% CI $520.12-$573.78) per mt-sDNA screening, significantly higher than reimbursements for all invasive screenings. Only FOBTs significantly increased in reimbursement per screening at $0.62/year (R2 = 0.91, p ≤ 0.001).

CONCLUSION

We derived forecastable trend numbers for utilization and provider reimbursement. Faecal immunochemical tests/100 000 and mt-sDNA screenings/100 000 increased most rapidly during the entire study period. The number of nearly all invasive screenings/100 000 decreased rapidly; the number of colonoscopies/100 000 increased slightly, probably due to superior diagnostic strength. These trends indicate the that replacement of other invasive modalities with accessible noninvasive screenings will account for much of future screening behaviour and thus reductions in CRC incidence and mortality, especially given providers' reimbursement incentive to screen average-risk patients with stool-based tests.

Screening, awareness and challenges for colorectal cancer treatment in Saudi Arabia: an update

Colorectal cancer (CRC) is the second most common cancer in the world. In Saudi Arabia, CRC is the most common cancer in males and the third most common in females, and its incidence rate is rising as the country continues to develop. However, the country does not have a national CRC screening program for CRC. This review aims to review recent studies that have attempted to address and rectify this issue and discern the most notable and prevalent barriers. Despite these efforts, guidelines are still lacking. Two prospective studies have been conducted in recent years, one of which was a national pilot screening program conducted by the Ministry of Health (MOH). While both had a similar number of participants, the colonoscopy rate for patients with a positive fecal immunochemical test (FIT) in the MOH program was only 20% compared to 75.8% in the Al-Kharj program. Awareness of the Saudi population regarding CRC and its screening appears to be insufficient. The most common barriers to patients' willingness to undergo screening were embarrassment, fear, and pain. Barriers to physicians are mostly related to factors outside their hands, such as lack of equipment and time. We conclude that efforts should be made to establish a national screening program and improve awareness of the population and physicians.

Social Determinants of Health and the Link to Colorectal Cancer Outcomes

OPINION  STATEMENT: Colorectal cancer (CRC) remains the second most deadly cancer in the United States, behind only lung cancer. Despite improvements in incidence due to screening and mortality in part due to better treatments, there are some groups that have not seen these promising changes. American Indian/Alaska Native and non-Hispanic Black individuals, certain geographic regions, and lower socioeconomic groups have all been shown to have worse CRC outcomes. A significant body of evidence has linked these disparities in outcomes to social determinants of health (SDH). SDH are defined by the WHO as "the non-medical factors that influence health outcomes." These factors include but are not limited to income, education, social support, neighborhood of residence, and access to healthcare. Individuals who are negatively impacted by SDH have been shown to have a higher incidence of CRC. These individuals are also less likely to receive adequate CRC screening, are less likely to receive appropriate treatment, and have increased CRC mortality. Interventions that target different SDH domains have been shown to lead to increased rates of CRC screening and receipt of appropriate treatment while simultaneously improving CRC mortality. The aim of this review is to highlight the connection between SDH and CRC outcomes while also exploring interventions that target SDH and thereby improve CRC outcomes.

Colorectal cancer screening uptake and adherence by modality at a large tertiary care center in the United States: a retrospective analysis

OBJECTIVE

Real-world data is crucial to inform existing opportunistic colorectal cancer (CRC) prevention programs. This study aimed to assess CRC screening adherence and utilization of various screening modalities within a Primary Care network over a three-year period (2017-2019).

METHODS

A retrospective review of individuals aged 50-75 years at average CRC risk, with at least one clinic visit in the previous 24 months. The primary outcome, CRC screening adherence (overall and by modality) was examined among the entire eligible population and newly adherent individuals each calendar year. The final sample included 107,366 patients and 218,878 records.

RESULTS

Overall CRC screening adherence increased from 71% in 2017 to 78% in 2019. For "up-to-date" individuals, colonoscopy was the predominant modality (accounting for approximately 74%, versus 4% of adherence for non-invasive options). However, modality utilization trends changed over time in these individuals: mt-sDNA increased 10.2-fold, followed by FIT (1.6-fold) and colonoscopy (1.1-fold). Among newly adherent individuals, the proportion screened by colonoscopy and FOBT decreased over time (89% to 80% and 2.4% to 1.2%, respectively), while uptake of FIT and mt-sDNA increased (7.7% to 11.5% and 0.9% to 6.8%, respectively). Notably, FIT and mt-sDNA increases were most evident in age and race-ethnicity groups with the lowest screening rates.

CONCLUSIONS

In an opportunistic CRC screening program, adherence increased but remained below the national 80% goal. While colonoscopy remained the most utilized modality, new colonoscopy uptake declined, compared with rising mt-sDNA and FIT utilization. Among minority populations, new uptake increased most with mt-sDNA and FIT.

Why is early detection of colon cancer still not possible in 2023?

Colorectal cancer (CRC) screening is a fundamental tool in the prevention and early detection of one of the most prevalent and lethal cancers. Over the years, screening, particularly in those settings where it is well organized, has succeeded in reducing the incidence of colon and rectal cancer and improving the prognosis related to them. Despite considerable advancements in screening technologies and strategies, the effectiveness of CRC screening programs remains less than optimal. This paper examined the multifaceted reasons behind the persistent lack of effectiveness in CRC screening initiatives. Through a critical analysis of current methodologies, technological limitations, patient-related factors, and systemic challenges, we elucidated the complex interplay that hampers the successful reduction of CRC morbidity and mortality rates. While acknowledging the advancements that have improved aspects of screening, we emphasized the necessity of addressing the identified barriers comprehensively. This study aimed to raise awareness of how important CRC screening is in reducing costs for this disease. Screening and early diagnosis are not only important in improving the prognosis of patients with CRC but can lead to an important reduction in the cost of treating a disease that is often diagnosed at an advanced stage. Spending more sooner can mean saving money later.

How pharmacists would design and implement a community pharmacy-based colorectal cancer screening program

Background

Distributing CRC screening through pharmacies, a highly accessible health service, may create opportunities for more equitable access to CRC screening. However, providing CRC screening in a new context introduces a substantial implementation challenge.

Methods

We conducted 23 semi-structured interviews with community pharmacists practicing in Washington state and North Carolina about distributing fecal immunochemical tests (FIT) to patients in the pharmacy. The Consolidated Framework for Implementation Research (CFIR) was used to guide analysis.

Results

Pharmacists believed that delivering FITs was highly compatible with their environment, workflow, and scope of practice. While knowledge about FIT eligibility criteria varied, pharmacists felt comfortable screening patients. They identified standardized eligibility criteria, patient-facing educational materials, and continuing education as essential design features. Pharmacists proposed adapting existing pharmacy electronic health record systems for patient reminders/prompts to facilitate FIT completion. While pharmacists felt confident that they could discuss test results with patients, they also expressed a need for stronger communication and care coordination with primary care providers.

Discussion

When designing a pharmacy-based CRC screening program, pharmacists desired programmatic procedures to fit their current knowledge and context. Findings indicate that if proper attention is given to multi-level factors, FIT delivery can be extended to pharmacies.

High accuracy of a blood ctDNA-based multimodal test to detect colorectal cancer

BACKGROUND

Detection of circulating tumor DNA (ctDNA) is a minimally invasive and convenient blood-based screening strategy that may increase effectiveness of colorectal cancer (CRC) screening.

PATIENTS AND METHODS

A novel multimodal ctDNA-based blood assay that integrates genomics, epigenomics and fragmentomics, as well as proteomics in a refined version, was tested in blood samples from two cohorts: (i) consecutive fecal immunochemical test (FIT)-positive individuals from the CRC Barcelona stool-based screening program; (ii) patients diagnosed with CRC. Primary endpoint was the performance of the test to detect CRC at different tumor-node-metastasis (TNM) stages. Secondary endpoint was the ability of the test to detect advanced precancerous lesions (advanced adenoma or advanced serrated lesion).

RESULTS

A total of 623 blood samples were analyzed in the primary analysis. Sensitivity and specificity of the assay to detect CRC was 93% and 90%, respectively. The sensitivity of CRC detection according to TNM stages was 84% for stage I, 94% for stage II and 96% for stage III (70/73) (P< 0.024). Sensitivity to detect advanced precancerous lesions was 23% with a refined version of the test (including protein and updating bioinformatic thresholding).

CONCLUSION

A blood-based multimodal ctDNA assay detected CRC with high accuracy. This minimally invasive, accessible and convenient assay may help to increase the effectiveness of CRC screening.

Predictive biomarkers for colorectal cancer: a state-of-the-art systematic review

INTRODUCTION

Colorectal cancer (CRC) poses a substantial health burden, with early detection paramount for improved prognosis. This study aims to evaluate potential CRC biomarkers and detection techniques.

MATERIALS AND METHODS

This systematic review, reported in adherence to PRISMA Statement 2020 guidelines, collates the latest research on potential biomarkers and detection/prognosis methods for CRC, spanning the last decade.

RESULTS

Out of the 38 included studies, diverse biomarkers and detection methods emerged, with DNA methylation markers like SFRP2 and SDC2, microRNAs including miR-1290, miR-506, and miR-4316, and serum and plasma markers such as NTS levels and U2 snRNA fragments standing out. Methylated cfDNA and m5C methylation alteration in immune cells of the blood, along with circular RNA, showed promise as diagnostic markers. Meanwhile, techniques involving extracellular vesicles and lateral flow immunoassays exhibited potential for swift and effective CRC screening.

DISCUSSION

Our state-of-the-art review identifies potential biomarkers, including SFRP2, SDC2, miR-1290, miR-506, miR-4316, and U2 snRNA fragments, with significant potential in enhancing CRC detection. However, comprehensive validation studies and a rigorous evaluation of clinical utility and cost-effectiveness remain necessary before integration into routine clinical practice.

CONCLUSION

The findings emphasize the need for continued research into biomarkers and detection methods to improve patient outcomes.

Prevalence of incidental colorectal cancer and polyps in autopsies of different populations: a systematic review with meta-regression analysis

The colorectal cancer (CRC) and polyps incidentally found in autopsies represent the lesions that have not actually caused problems throughout the lifetime and thus may not need to be removed during screening. This study aimed to investigate the prevalence of incidental CRC (iCRC) and polyps in autopsies of different populations. A systematic search was performed on 19 August 2022 to identify autopsy studies that provided data on prevalence of iCRC, adenomatous polyps, hyperplastic polyps, and/or all polyps combined. The prevalence was pooled with the random-effects model. Subgroup and multivariable meta-regression analyses were conducted to investigate the heterogeneity. Forty-three eligible studies including 59,656 autopsies were identified, with 94% conducted before 1990 when CRC screening was uncommon or not available. The pooled prevalence was 0.7% (95% confidence interval [CI], 0.3-1.2%) for iCRC, 18.4% (95% CI, 13.3-24.1%) for adenomatous polyps, 16.4% (95% CI, 8.7-25.9%) for hyperplastic polyps, 26.3% (95% CI, 15.4-38.8%) for all polyps combined, and 29.9% (95% CI, 14.8-47.6%) for iCRC plus polyps. The prevalence of iCRC was higher (1.2%) in white-predominant populations but lower (0.4%) after excluding low-quality studies. Multivariable analyses showed that the prevalence of polyps was higher in white-predominant populations and higher-quality studies, increased with age, and showed a downward trend from "before 1975" through "after 1985". In conclusion, the prevalence of iCRC in autopsies was not low, considering the average lifetime risk of CRC, while incidental polyps were common. Both varied greatly in different populations. These findings may have implications when weighing the benefits and harms of screening.

Involvement in treatment decision-making and self-reported efficacy among patients with advanced colorectal cancer: a nationwide multi-center cross-sectional study

Introduction

This cross-sectional study evaluated the involvement of patients with advanced colorectal cancer (CRC) in treatment decision-making, assessed the treatment efficacy according to their self-reports, and investigated the influencing factors.

Methods

Patients with advanced CRC were recruited from 19 hospitals from March 2020 to March 2021 by a multi-stage multi-level sampling method. A self-designed questionnaire was used to collect demographic and clinical characteristics, involvement of CRC patients in treatment decision-making, treatment methods, and self-reported efficacy. Univariate and unordered multinomial logistic regression analyses were used to evaluate the factors affecting the involvement in treatment decision-making and self-reported efficacy.

Results

We enrolled 4533 patients with advanced CRC. The average age at diagnosis was 58.7 ± 11.8 years. For the treatment method, 32.4% of patients received surgery combined with chemotherapy, 13.1% of patients underwent surgery combined with chemotherapy and targeted therapy, and 9.7% of patients were treated with surgery alone. For treatment decision-making, 7.0% of patients were solely responsible for decision-making, 47.0% of patients shared treatment decision-making with family members, 19.0% of patients had family members solely responsible for treatment decision-making, and 27.0% of patients had their physicians solely responsible for treatment decision-making. Gender, age, education level, family income, marital status, treatment cost, hospital type, and treatment method were significantly associated with the involvement of patients in treatment decision-making. A total of 3824 patients submitted self-reported efficacy evaluations during treatment. The percentage of patients with good self-reported efficacy was 76.5% (for patients treated for the first time), 61.7% (for patients treated for the second time), and 43.2% (for patients treated after recurrence and metastasis), respectively. Occupation, education level, average annual family income, place of residence, time since cancer diagnosis, hospital type, clinical stage, targeted therapy, and involvement in treatment decision-making were the main influencing factors of self-reported efficacy of treatment.

Discussion

Conclusively, CRC patients are not highly dominant in treatment decision-making and more likely to make treatment decisions with their family and doctors. Timely and effective communication between doctors and patients can bolster patient involvement in treatment decision-making.

Colorectal cancer statistics, 2023

Colorectal cancer (CRC) is the second most common cause of cancer death in the United States. Every 3 years, the American Cancer Society provides an update of CRC statistics based on incidence from population-based cancer registries and mortality from the National Center for Health Statistics. In 2023, approximately 153,020 individuals will be diagnosed with CRC and 52,550 will die from the disease, including 19,550 cases and 3750 deaths in individuals younger than 50 years. The decline in CRC incidence slowed from 3%-4% annually during the 2000s to 1% annually during 2011-2019, driven partly by an increase in individuals younger than 55 years of 1%-2% annually since the mid-1990s. Consequently, the proportion of cases among those younger than 55 years increased from 11% in 1995 to 20% in 2019. Incidence since circa 2010 increased in those younger than 65 years for regional-stage disease by about 2%-3% annually and for distant-stage disease by 0.5%-3% annually, reversing the overall shift to earlier stage diagnosis that occurred during 1995 through 2005. For example, 60% of all new cases were advanced in 2019 versus 52% in the mid-2000s and 57% in 1995, before widespread screening. There is also a shift to left-sided tumors, with the proportion of rectal cancer increasing from 27% in 1995 to 31% in 2019. CRC mortality declined by 2% annually from 2011-2020 overall but increased by 0.5%-3% annually in individuals younger than 50 years and in Native Americans younger than 65 years. In summary, despite continued overall declines, CRC is rapidly shifting to diagnosis at a younger age, at a more advanced stage, and in the left colon/rectum. Progress against CRC could be accelerated by uncovering the etiology of rising incidence in generations born since 1950 and increasing access to high-quality screening and treatment among all populations, especially Native Americans.

Analysis of the Mortality Trends of 23 Major Cancers in the Indian Population Between 2000 and 2019: A Joinpoint Regression Analysis

PURPOSE

Cancer mortality trends have not been documented across the population of India. We, therefore, analyzed the overall and individual cancer mortality trends for 23 major cancers between 2000 and 2019 on the basis of Global Health Observatory (GHO) database.

MATERIALS AND METHODS

This study examined cancer mortality trends for 23 major cancer sites on the basis of 12.85 million cancer deaths obtained from the GHO of the WHO between 2000 and 2019. A joinpoint regression model was used to analyze the long-term trends of cancer mortality. Annual percentage change (APC) and average APC were estimated for various cancer sites.

RESULTS

Between 2000 and 2019, 12.85 million deaths occurred in India from 23 major cancers. The most common lethal cancers were mouth and oropharyngeal (15.6%), stomach (10.6%), lung (9.6%), breast (9%), and colorectal (8%) cancers. The mortality trend decreased by 0.19% annually among men and increased nonsignificantly by 0.25% among women; an increase of 0.02% was observed among combined sexes. Increasing mortality trends were seen among cancers of the lung, breast, colorectum, lymphoma, multiple myeloma, gallbladder, pancreas, kidney, and mesothelioma between 2000 and 2019. The highest annual increase in mortality was observed in pancreatic cancer among both sexes: 2.7%, 2.1% among men, and 3.7% in women. The cancers of the stomach, esophagus, leukemia, larynx, and melanoma showed a declining cancer mortality trend irrespective of sex.

CONCLUSION

A multifaceted strategy is required to tackle the rising cancer mortality rates in India; the best long-term strategy could be implementing awareness on cancer symptoms among the population as well as cancer prevention policies with improved health infrastructure and specifically dedicated human resources.

Health Equity and Colorectal Cancer Awareness: a Community Health Educator Initiative

Disparities in colorectal cancer (CRC) incidence and mortality persist in rural and underserved communities. Our Community Outreach and Engagement (COE) activities are grounded in a bi-directional Community-to-Bench model in which the National Outreach Network Community Health Educator (NON CHE) Screen to Save (S2S) initiative was implemented. In this study, we assessed the impact of the NON CHE S2S in rural and underserved communities. Descriptive and comparative analyses were used to examine the role of the NON CHE S2S on CRC knowledge and CRC screening intent. Data included demographics, current CRC knowledge, awareness, and future CRC health plans. A multivariate linear regression was fit to survey scores for CRC knowledge. The NON CHE S2S engaged 441 participants with 170 surveys completed. The difference in participants' CRC knowledge before and after the NON CHE S2S intervention had an overall mean of 0.92 with a standard deviation of 2.56. At baseline, White participants had significantly higher CRC knowledge scores, correctly answering 1.94 (p = 0.007) more questions on average than Black participants. After the NON CHE S2S intervention, this difference was not statistically significant. Greater than 95% of participants agreed that the NON CHE S2S sessions impacted their intent to get screened for CRC. Equity of access to health information and the health care system can be achieved with precision public health strategies. The COE bi-directional Community-to-Bench model facilitated community connections through the NON CHE and increased awareness of CRC risk reduction, screening, treatment, and research. The NON CHE combined with S2S is a powerful tool to engage communities with the greatest health care needs and positively impact an individual's intent to "get screened" for CRC.

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

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

Patterns of initial colorectal cancer screenings after turning 50 years old and follow-up rates of colonoscopy after positive stool-based testing among the average-risk population

OBJECTIVES

Effective colorectal cancer (CRC) screening requires proper adherence beginning at the recommended screening age. For those with positive results on stool-based tests (SBTs), a follow-up colonoscopy is warranted. The objectives of this study were to 1) examine initial screening rates after turning 50 years old; and 2) assess rates of follow-up colonoscopy after a positive SBT.

METHODS

This retrospective study used de-identified administrative claims data from 01/01/2006 to 06/30/2020 for commercially insured and Medicare Advantage enrollees. For objective 1, the index year was the year enrollees turned 50. Rates of CRC screening during and after the index year were captured. For objective 2, the index date was the claim date of a fecal immunochemical test (FIT) or multitarget stool DNA test (mt-sDNA) where linked lab data indicated a positive test result. Rates and time to follow-up colonoscopy after a positive SBT were assessed.

RESULTS

Approximately 53% of enrollees initiated CRC screening within five years after turning 50 (50+ cohort N = 718,562). Among enrollees with an available lab result indicating a positive SBT (N = 7329; 2110 FIT and 5219 mt-sDNA), overall follow-up colonoscopy within 6 months of the positive result was less than optimal (65%) and varied by modality; 72% vs 46% (p < .001) among enrollees with a positive mt-sDNA test compared to FIT test, respectively.

CONCLUSION

There is potential for improving CRC screening among the eligible average-risk population, both to start screening once they reach the screening-eligible age, and to complete the CRC screening paradigm after a positive stool-based screen.

Robotic, self-propelled, self-steerable, and disposable colonoscopes: Reality or pipe dream? A state of the art review

Robotic colonoscopes could potentially provide a comfortable, less painful and safer alternative to standard colonoscopy. Recent exciting developments in this field are pushing the boundaries to what is possible in the future. This article provides a comprehensive review of the current work in robotic colonoscopes including self-propelled, steerable and disposable endoscopes that could be alternatives to standard colonoscopy. We discuss the advantages and disadvantages of these systems currently in development and highlight the technical readiness of each system to help the reader understand where and when such systems may be available for routine clinical use and get an idea of where and in which situation they can best be deployed.

Process Evaluation of a Mailed Interactive Educational DVD in a Comparative Effectiveness Trial to Promote Colorectal Cancer Screening

A process evaluation was conducted as part of a comparative effectiveness trial of a mailed interactive educational DVD intervention to promote colorectal cancer screening among average-risk patients who did not attend a scheduled colonoscopy. Participants (n = 371) for the trial were randomized to (1) mailed DVD, (2) mailed DVD plus patient navigation, or (3) usual care. Participants (n = 243) randomized to the two DVD intervention arms were called 2 weeks after mailing materials to complete a process evaluation interview about the DVD (September 2017-February 2020). Forty-nine (20%) participants were not reached, and 194 (80%) participants watched the DVD and completed the interview. The process evaluation assessed whether (1) the DVD content was helpful, (2) any new information was learned by participants, (3) the appropriate amount of information was included in the DVD, (4) participants were engaged when watching the DVD, (5) the DVD content was relevant, (6) participants were satisfied with the DVD (7) participants would recommend the DVD to others, and (8) their opinion about colorectal cancer screening was changed by watching the DVD. Among participants who watched the DVD, 99% reported the screening information was very or somewhat helpful, 47% learned new information, 75% said the DVD included the right amount of information, they were engaged (M = 3.35 out of 4, SD = 0.49), 87% reported all or most information applied to them, they were satisfied (M = 3.42 out of 4, SD = 0.39) with DVD content, 99% would recommend the DVD to others, and 45% reported changing their opinion about screening. To understand the effects of interventions being tested in trials and to plan the dissemination of evidence-based interventions, process evaluation is critical to assess the dose received and acceptability of behavioral interventions.

Costs of colorectal cancer screening with colonoscopy, including post-endoscopy events, among adults with Medicaid insurance

OBJECTIVE

To examine the healthcare utilization and costs associated with colorectal cancer (CRC) screening by colonoscopy, including costs associated with post-endoscopy events, among average-risk adults covered by Medicaid insurance.

METHODS

This cohort study evaluated a population of adults (ages 50-75 years) with CRC screening between 1/1/2014 and 12/31/2018 (index = earliest test) from the IBM MarketScan Multi-State Medicaid database. Individuals at above-average risk for CRC or with prior CRC screening were excluded. CRC screening was reported by screening type: colonoscopy, fecal immunochemical test [FIT], fecal occult blood test [FOBT], multi-target stool DNA [mt-sDNA]. Frequency and costs of events potentially related to colonoscopy (defined as occurring within 30 days post-endoscopy) were reported overall, by event type, and by individual event.

RESULTS

We identified a total of 13,134 average-risk adults covered by Medicaid insurance who received screening by colonoscopy; 63.6% (8350) had Medicare dual-eligibility while 36.4% (4785) did not have Medicare dual-eligibility. The mean (SD) cost of a colonoscopy procedure was $684 ($907) and mean (SD) out-of-pocket costs were $6 ($132). Serious gastrointestinal (GI) events (perforation and bleeding) were observed in 4.6% of individuals with colonoscopy, 4.3% had other GI events, and 3.0% had an incident cardiovascular/cerebrovascular event. Mean (SD) event-related costs were $1233 ($5784) among individuals with a serious GI event, $747 ($1961) among individuals with other GI events, and $4398 ($19,369) among individuals with a cardiovascular/cerebrovascular event.

CONCLUSIONS

This large, claims-based cohort study reports average (SD) out-of-pocket costs for Medicaid beneficiaries at $6 ($132), which could be one factor contributing to the accessibility of CRC screening by colonoscopy. The incidence of events potentially associated with colonoscopy (i.e. within 30 days after the screening) was 3-4%, and the event-related costs were considerable.

The Development and Validation of the Colonoscopy Joking Scale

Joking is an important communication behavior that helps people cope with colorectal cancer and colonoscopy screening. However, whether joking serves a beneficial or maladaptive function in the context of colorectal cancer screening remains unknown. The lack of a valid scale impedes our understanding of how joking influences colonoscopy uptake. This study aims to develop and validate the Colonoscopy Joking Scale, a scale of joking behaviors in colonoscopy screening. A sample of Mturk participants aged 50-75 (N = 105) who were not compliant with colonoscopy screening recommendations was recruited to rate items for three joking factors and a measure of colonoscopy screening intentions. Two joking factors (i.e., screening-related and sexual connotation) related to colonoscopy screening and one related to general health were identified in the analysis. The psychometric analysis demonstrated strong convergent, predictive, and discriminant validity. The Colonoscopy Joking Scale will be helpful to understand what joking factor is associated with specific barriers to colonoscopy for different patients so that effective educational and interventional programs can be implemented.

Colorectal cancer screening by fecal immunochemical test or colonoscopy in France: how many people are actually covered? Focus on the Provence-Alpes-Côte d'Azur region

BACKGROUND

Colorectal cancer (CRC) screening with fecal immunochemical test (FIT) remains low in France, particularly in the Provence-Alpes-Côte-d'Azur (PACA) region. The aim of this study was to compare insured persons (50-74 years) who had FIT and/or colonoscopy in PACA with the general French population.

METHODS

FIT and colonoscopy rates were calculated according to SP-France and National Health Data System data.

RESULTS

The rate of FIT in 2016-2017 was lower in PACA than in France (25.6 vs. 29.1%, P < 0.001). Conversely, in 2013-2017, the rate of colonoscopy in the past 5 years was higher in PACA than in France (23.1 vs. 20.1%, P < 0.001). Total rate for FIT within 2 years and/or colonoscopy within 5 years was 46.0% in PACA vs. 46.5% in France (P < 0.001). Overuse was higher for diagnostic (1.21) than therapeutic colonoscopies (1.05). Therapeutic colonoscopy occurred more with FIT than without (47.88 vs. 38.7%, P < 0.001). According to USA criteria, persons with FIT within 2 years and/or sigmoidoscopy and/or colonoscopy within 10 years was 59.4% in PACA vs. 54.7% in France (P < 0.001).

CONCLUSION

Low participation in FIT in France must be improved to increase the rate of therapeutic colonoscopies and reduce the incidence of CRC. The higher colonoscopy rate in PACA could explain the lower CRC mortality. Efforts should be focused on the more than 40% of French insured who are not screened by either FIT or colonoscopy.

Colorectal cancer screening preferences among physicians and individuals at average risk: A discrete choice experiment

BACKGROUND

Guidelines include several options for average-risk colorectal cancer (CRC) screening that vary in aspects such as invasiveness, recommended frequency, and precision. Thus, patient and provider preferences can help identify an appropriate screening strategy. This study elicited CRC screening preferences of physicians and individuals at average risk for CRC (IAR).

METHODS

IAR aged 45-75 years and licensed physicians (primary care or gastroenterology) completed an online discrete choice experiment (DCE). Participants were recruited from representative access panels in the US. Within the DCE, participants traded off preferences between screening type, screening frequency, true-positive, true-negative, and adenoma true positive (physicians only). A mixed logit model was used to obtain predicted choice probabilities for colonoscopy, multi-target stool DNA (mt-sDNA), fecal immunochemical test (FIT), and methylated septin 9 (mSEPT9) blood test.

RESULTS

Preferences of IAR and physicians were affected by screening precision and screening type. IAR also valued more regular screening. Physicians preferred colonoscopy (96.8%) over mt-sDNA (2.8%; p < 0.001), FIT (0.3%; p < 0.001) and mSEPT9 blood test (0.1%; p < 0.01). IAR preferred mt-sDNA (38.8%) over colonoscopy (32.5%; p < 0.001), FIT (19.2%; p < 0.001), and mSEPT9 blood test (9.4%; p < 0.001). IAR naïve to screening preferred non-invasive screening (p < 0.001), while the opposite was found for those who previously underwent colonoscopy or sigmoidoscopy.

CONCLUSIONS

While physicians overwhelmingly preferred colonoscopy, preferences of IAR were heterogenous, with mt-sDNA being most frequently preferred on average. Offering choices in addition to colonoscopy could improve CRC screening uptake among IAR. This study used a discrete choice experiment in the US to elicit preferences of physicians and individuals at average risk for colorectal cancer screening modalities and their characteristics.

Applying evidence-based intervention (EBI) mapping to identify the components and logic of colorectal cancer screening interventions

Implementation of evidence-based interventions (EBIs) can help to increase colorectal cancer screening (CRCS). Potential users of CRCS EBIs are often unclear about the specific features, logic, and core elements of existing EBIs, making it challenging to use or adapt them. We used EBI Mapping, a systematic process developed from Intervention Mapping that identifies an EBI's components and logic, to characterize existing CRCS EBIs from the National Cancer Institute's Evidence-Based Cancer Control Programs website. The resulting information can facilitate intervention adoption, adaptation, and/or implementation. Two trained coders independently coded intervention materials to describe intervention components and logic (n = 20). We display CRCS EBI components (potential mechanism of change) using evidence tables and heat maps. All EBIs addressed completion of at least one CRCS behavior (stool-based test, n = 9; stool-based test or another CRCS test, n = 8; colonoscopy, n = 3; colonoscopy or sigmoidoscopy, n = 1). The psychosocial determinants most frequently addressed by these interventions were knowledge (n = 19), attitudes (n = 17), risk perception/perceived susceptibility (n = 16), skills (n = 15), and overcoming barriers (n = 15). Multi-level EBIs (n = 9) attempted to change an average of 2.1 ± 1.1 conditions in the patients' environment (e.g., accessibility of CRCS); only four EBIs used environmental change agents (e.g., providers, nurses). From the heat maps of EBIs, we describe common theoretical change methods' (e.g., facilitation) used for addressing determinants (e.g., overcoming barriers). EBI Mapping can help users identify important components of a CRCS EBI's logic; these proposed mechanisms of action can inform adoption, adaptation, and implementation in new settings, and facilitate scale up of EBIs.

Design of a randomized controlled trial to assess the comparative effectiveness of a multifaceted intervention to improve three-year adherence to colorectal cancer screening among patients cared for in rural community health centers

Colorectal cancer (CRC) screening has been shown to decrease CRC mortality, yet significant disparities persist among those living in rural areas, from minority backgrounds, and those having low income. The purpose of this two-arm randomized controlled trial is to test the effectiveness and fidelity of a stepped care (increasing intensity as needed) approach to promoting 3-year adherence to CRC screening via fecal immunochemical testing (FIT) or colonoscopy in rural community clinics serving high rates of low-income and minority patients. We hypothesize that, compared to enhanced usual care (EUC), patients receiving the multifaceted CRC screening intervention will demonstrate higher rates of CRC screening completion over 3 years. Participants from six federally qualified health centers (FQHCs; N = 1200 patients) serving predominately low-income populations in rural Louisiana will be randomized to the intervention or EUC arm. All participants will receive health literacy-directed CRC counseling, simplified materials about both the FIT and colonoscopy procedures, and motivational interviewing to aid in the determination of test preference. Participants in the intervention arm will also receive motivational reminder messages from their primary care provider (via audio recording or tailored text) for either a scheduled colonoscopy or return of a completed FIT. Participants in the EUC arm will receive the standard follow-up provided by their clinic or colonoscopy facility. The primary outcome will be completion of either colonoscopy or annual FIT over 3 years. Results will provide evidence on the effectiveness of the intervention to decrease disparities in CRC screening completion related to health literacy, race, and gender. Trial registration:Clinicaltrials.gov Identifier NCT04313114.

Colorectal Cancer Screening and Yield in a Mailed Outreach Program in a Safety-Net Healthcare System

BACKGROUND

Screening with fecal immunochemical testing (FIT) reduces colorectal cancer mortality; however, screening remains low in underserved populations. Mailed outreach, including an invitation letter, FIT, and test instructions, is an evidence-based strategy to improve screening.

AIMS

To examine screening completion and yield in a mailed outreach program in a safety-net healthcare system.

METHODS

We identified and mailed outreach invitations to patients due for screening in a large safety-net system between September 1, 2018, and August 31, 2019. We examined: (1) screening completion, the proportion of patients completing FIT or screening colonoscopy within 6 months of the mailed invitation; and (2) timely diagnostic colonoscopy, the proportion of patients completing colonoscopy within 6 months of positive FIT.

RESULTS

We mailed 14,879 invitations to 13,190 patients. Nearly half (n = 6098, 46.2%) of patients completed screening: 4,896 (80.3%) completed FIT through mailed outreach; 1,114 (18.3%) FIT through usual care; and 88 (1.4%) screening colonoscopy through usual care. Of patients with a positive FIT (n = 289), 50.5% completed diagnostic colonoscopy within 6 months, 10.7% within 6-12 months, and 4.8% after 12 months. A total of 8 cancers and 83 advanced adenomas were detected in the 191 patients completing diagnostic colonoscopy.

CONCLUSION

After implementing and scaling up mailed outreach in a safety-net system, about half of patients completed screening, and the majority did so through mailed outreach. However, many patients failed to complete diagnostic colonoscopy after positive FIT. Results highlight the importance of adapting mailed outreach programs to local contexts and constraints of healthcare systems, in order to support efforts to improve CRC screening in underserved populations.

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

The long term participation trend for the colorectal cancer screening after the 2011 triple disaster in Minamisoma City, Fukushima, Japan

Colorectal cancer (CRC) screening is a well-established cancer screening method, and its effectiveness depends on maintaining a high participation rate in the target population. In this study, we analyzed the trends in CRC screening participation rates over 10 years in Minamisoma City, where residents were forced to evacuate after the 2011 triple disaster in Fukushima, Japan. The immunochemical fecal occult blood test is provided as municipal CRC screening. We calculated the annual CRC screening participation rate and analyzed the factors associated with participation in screening. Overall, 4069 (12.3%) and 3839 (11.7%) persons participated in CRC screening in 2009 and 2010, respectively; however, the number decreased significantly to 1090 (3.4%) in 2011 when the earthquake occurred. Over the following 3 years, the rate gradually recovered. Multivariable logistic analysis showed that age < 65 years, living alone, and evacuation were significant associated factors for non-participation after 2011 (p < 0.05). In conclusion, the CRC screening participation rate decreased significantly during the Great East Japan Earthquake but recovered over the next 3 years. Further analysis of factors preventing CRC screening participation and research on the long-term effects of its post-disaster decline are important to consider in assessing the need for intervention in post-disaster cancer screening.

A Teachable Moment: Colorectal Cancer Screening Among Companions Waiting for Outpatients Undergoing a Colonoscopy

To determine colorectal cancer (CRC) screening knowledge, attitudes, behaviors, and preferences for a future CRC screening educational intervention among adults (companions) waiting for outpatients undergoing a colonoscopy. We approached 384 companions at three endoscopy centers associated with one healthcare system to complete a survey from March to July 2017. The survey assessed CRC and CRC screening knowledge, attitudes, behaviors, and preferences for a future CRC screening educational intervention. There were 164 companions at average risk for CRC that completed a self-administered survey. Among average-risk companions, 23% were not within screening guidelines. Additionally, 74% of those not within guidelines reported that they had never completed a CRC screening test. The most frequently reported barriers to CRC screening were the perception of not needing screening because they were asymptomatic and lack of a provider recommendation for screening. Companions suggested that a future CRC screening intervention include a brochure and/or a brief video, featuring men and women from different races/ethnicities, a CRC survivor, and a healthcare professional. Almost one-fourth of average-risk companions waiting at endoscopy centers were not within CRC screening guidelines, providing a teachable moment to recruit companions to participate in an educational intervention to encourage screening. Companions provided suggestions (e.g., content and channel) for a future intervention to promote CRC screening in this population.

Screening and prevention of colorectal cancer

Mortality from colorectal cancer is reduced through screening and early detection; moreover, removal of neoplastic lesions can reduce cancer incidence. While understanding of the risk factors, pathogenesis, and precursor lesions of colorectal cancer has advanced, the cause of the recent increase in cancer among young adults is largely unknown. Multiple invasive, semi- and non-invasive screening modalities have emerged over the past decade. The current emphasis on quality of colonoscopy has improved the effectiveness of screening and prevention, and the role of new technologies in detection of neoplasia, such as artificial intelligence, is rapidly emerging. The overall screening rates in the US, however, are suboptimal, and few interventions have been shown to increase screening uptake. This review provides an overview of colorectal cancer, the current status of screening efforts, and the tools available to reduce mortality from colorectal cancer.

Utilization of a Colorectal Cancer Screening Test Among Individuals With Average Risk

IMPORTANCE

Colorectal cancer (CRC) screening reduces CRC incidence and mortality. It is important to examine screening patterns over time, including after the introduction of new screening modalities.

OBJECTIVE

To compare use of CRC screening tests before and after the availability of the multitarget stool DNA (mt-sDNA) test, given that endorsed options have changed.

DESIGN, SETTING, AND PARTICIPANTS

This longitudinal cohort study used administrative claims data to examine CRC screening use in 2 discrete periods: before (August 1, 2011, to July 31, 2014) and after (August 1, 2016, to July 31, 2019) the mt-sDNA test became available. The MarketScan Commercial and Medicare Supplemental databases were queried for individuals aged 45 to 75 years between August 1, 2011, and July 31, 2019, with average risk of CRC and with continuous enrollment in the databases from August 1, 2001, to July 31, 2019.

MAIN OUTCOMES AND MEASURES

The proportion of individuals up to date or not due for CRC screening during each measurement year and the type of screening test used among individuals due for screening. Data were reported overall and among individuals aged 45 to 49 or 50 years and older on August 1, 2011.

RESULTS

A total of 97 776 individuals with average risk were identified. Individuals had a mean (SD) age of 50.8 (3.5) years, and 54 227 (55.5%) were women. The proportion of individuals with average risk aged 50 to 75 years with commercial or Medicare supplemental insurance who were up to date with CRC screening increased from 50.4% in 2011 (30 605 of 60 770) to 69.7% in 2019 (42 367 of 60 770). Among individuals due for screening and screened, the use of high-sensitivity fecal occult blood test (FOBT) decreased between 2011 (1088 of 6241 eligible individuals [17.7%]) and 2019 (195 of 2943 eligible individuals [6.6%]), and the use of mt-sDNA increased between 2016 (58 of 3014 eligible individuals [1.9%]) and 2019 (418 of 2943 eligible individuals [14.2%]). No consistent trends were observed with fecal immunochemical test (FIT) or screening colonoscopy. Computed tomography colonography, double-contrast barium enema, and flexible sigmoidoscopy were rarely performed.

CONCLUSIONS AND RELEVANCE

In this cohort study, the proportion of individuals with average risk who were up to date with CRC screening increased between 2011 and 2019 but remained suboptimal. There were no substantial changes in the use of the colonoscopy or FIT; however, there was an increase in the adoption of mt-sDNA and a decrease in the use of FOBT during the study period.

Implications of the growing incidence of global colorectal cancer

The expanding worldwide burden of colorectal cancer (CRC) is a significant public health issue. Understanding the shift in the geo-demographic, socioeconomic, environmental, and biogenetic distribution of CRC is paramount. The Human Development Index (HDI) measuring life expectancy, education, and gross national income is a composite index comparing health outcomes between countries. This has been shown to be a useful comparison tool in measuring the health dimension among high, middle, and low-income countries. CRC has a wide global distribution in incidence and mortality with majority of cases occurring in countries with a high or very high HDI. However, in developing countries and in those undergoing rapid socioeconomic growth, there has also been a marked rise in CRC rates as well. This pattern is noted globally and seems to correlate with increase in a country's specific HDI. Additionally, another unique pattern of CRC incidence has emerged with more cancers being diagnosed in adults younger than 50 years old. Further investigation is needed to determine CRC risks reduction and implementation of primary prevention and early detection strategies within different country specific healthcare systems. Globally, improvement in healthcare equality, access to medical care and screening for CRC particularly in resource-limited (low HDI) countries is essential.

Mitochondrial DNA haplogroup M7 confers a reduced risk of colorectal cancer in a Han population from northern China

Mitochondria are central eukaryotic organelles in cellular metabolism and ATP production. Mitochondrial DNA (mtDNA) alterations have been implicated in the development of colorectal cancer (CRC). However, there are few reports on the association between mtDNA haplogroups or single nucleotide polymorphisms (SNPs) and the risk of CRC. The mtDNA of 286 Northern Han Chinese CRC patients were sequenced by next-generation sequencing technology. MtDNA data from 811 Han Chinese population controls were collected from two public data sets. Then, logistic regression analysis was used to determine the effect of mtDNA haplogroup or SNP on the risk of CRC. We found that patients with haplogroup M7 exhibited a reduced risk of CRC when compared to patients with other haplogroups (odds ratio [OR] = 0.532, 95% confidence interval [CI] = 0.285-0.937, p = 0.036) or haplogroup B (OR = 0.477, 95% CI = 0.238-0.916, p = 0.030). Furthermore, haplogroup M7 was still associated with the risk of CRC when the validation and combined control cohort were used. In addition, several haplogroup M7 specific SNPs, including 199T>C, 4071C>T and 6455C>T, were significantly associated with the risk of CRC. Our results indicate the risk potential of mtDNA haplogroup M7 and SNPs in CRC in Northern China.

Impact of the National Endoscopy Database (NED) on colonoscopy withdrawal time: a tertiary centre experience

OBJECTIVE

Colonoscopy withdrawal time (CWT) is a key performance indicator affecting polyp detection rate (PDR) and adenoma detection rate (ADR). However, studies have shown wide variation in CWT and ADR between different endoscopists. The National Endoscopy Database (NED) was implemented to enable quality assurance in all endoscopy units across the UK and also to reduce variation in practice. We aimed to assess whether CWT changed since the introduction of NED and whether CWT affected PDR.

METHODS

We used NED to retrospectively collect data regarding CWT and PDR of 25 endoscopists who performed (n=4459 colonoscopies) in the four quarters of 2019. We then compared this data to their performance in 2016, before using NED (n=4324 colonoscopies).

RESULTS

Mean CWT increased from 7.66 min in 2016 to 9.25 min in 2019 (p=0.0001). Mean PDR in the two periods was 29.9% and 28.3% (p=0.64). 72% of endoscopists (18/25) had CWT>6 min in 2016 versus 100% (25/25) in 2019, the longer CWT in 2019 positively correlated with the PDR (r=0.50, p=0.01). Gastroenterology consultants and trainee endoscopists had longer CWT compared with colorectal surgeons both before and after using NED.

CONCLUSION

NED usage increased withdrawal times in colonoscopy. Longer withdrawal times were associated with higher PDR. A national colonoscopy audit using data from NED is required to evaluate whether wide variations in practice across endoscopy units in the UK still exist and to ensure minimum colonoscopy quality standards are achieved.

Changes in colorectal cancer knowledge and screening intention among Ohio African American and Appalachian participants: The screen to save initiative

African Americans and Appalachians experience greater incidence and mortality rates of colorectal cancer due to factors, such as reduced prevalence of screening. An educational session (the Screen to Save Initiative) was conducted to increase intent to screen for colorectal cancer among African Americans and Appalachians in Ohio. Using a community-based approach, from April to September 2017, 85 eligible participants were recruited in Franklin County and Appalachia Ohio. Participants completed a knowledge assessment on colorectal cancer before and after participating in either an educational PowerPoint session or a guided tour through an Inflatable Colon. Logistic regression models were used to determine what factors were associated with changes in colorectal cancer knowledge and intent to screen for colorectal cancer. The majority (71.79%) of participants gained knowledge about colorectal cancer after the intervention. Multivariate results showed that race (OR = 0.30; 95% CI: 0.11–0.80 for African Americans versus White participants) and intervention type (OR = 5.97; 95% CI: 1.94–18.43 for PowerPoint versus Inflatable Colon) were associated with a change in knowledge. The association between education and intent to screen was marginally statistically significant (OR = 0.42; 95% CI: 0.16–1.13 for college graduate versus not a college graduate). A change in colorectal cancer knowledge was not associated with intent to screen. Future educational interventions should be modified to increase intent to screen and screening for colorectal cancer. Further research with these modified interventions should aim to reduce disparities in CRC among underserved populations while listening to the voices of the communities.

Sexual Assault and Cancer Screening Among Men and Women

Emerging research has shown that experiences of sexual violence are associated with cancer screening behaviors. However, to date, little attention has been given to the impact of sexual assault on cancer screening behaviors, particularly among men. To address this, we used data from the 2014 Kansas Behavioral Risk Factor Surveillance System. This survey is conducted annually via telephone. Logistic regressions were used to calculate odds of ever engaging (i.e., lifetime) in specific screening behaviors (clinical breast exam [CBE], mammogram, Pap test, colonoscopy/sigmoidoscopy, fecal occult blood test and prostate-specific antigen [PSA] test) and current compliance with cancer screening recommendations (CBE, mammogram, Pap test, colorectal cancer screening, and PSA test), with lifetime sexual assault as the independent variables. Colorectal cancer screening models were stratified by gender. All models adjusted for confounders. Sexual assault was associated with lower odds of ever receiving a PSA test and, for women, higher odds of ever receiving a colonoscopy or sigmoidoscopy. Sexual assault was associated with lower odds of current compliance with CBE, mammogram, Pap test, and PSA test screening recommendations. A history of sexual assault was associated with lower odds of current compliance with cancer screening procedures, with the notable exception of colorectal cancer screening. Less consistent patterns were seen for lifetime screenings. Results suggest that alternatives to currently recommended procedures (like self-collection of HPV [human papilloma virus] DNA) or modified screening procedures may be a promising route to increase current compliance with cancer screening among a population that may avoid these procedures due to pain or fear of retraumatization.

Comparative Effectiveness of Commercial Bowel Preparations in Ambulatory Patients Presenting for Screening or Surveillance Colonoscopy

BACKGROUND

Inadequate bowel preparation (IBP) is associated with reduced adenoma detection. However, limited research has examined the impact of different commercial bowel preparations (CBPs) on IBP and adenoma detection. We aim to determine whether type of CBP used is associated with IBP or adenoma detection.

METHODS

We retrospectively evaluated outpatient, screening or surveillance colonoscopies performed in the Cleveland Clinic health system between January 2011 and June 2017. IBP was defined by the Aronchick scale. Multilevel mixed-effects logistic regression was performed to assess the association between CBP type and IBP and adenoma detection. Fixed effects were defined as demographics, comorbidities, medication use, and colonoscopy factors. Random effect of individual endoscopist was considered.

RESULTS

Of 153,639 colonoscopies, 75,874 records met inclusion criteria. Median age was 54; 50% were female; 17.7% had IBP, and adenoma detection rate was 32.6%. In adjusted analyses, compared to GoLYTELY, only NuLYTELY [OR 0.66 (95% CI 0.60, 0.72)] and SuPREP [OR 0.53 (95% CI 0.40, 0.69)] were associated with reduced IBP. Adenoma detection did not vary based on the type of bowel preparation used.

CONCLUSIONS

Among patients referred for screening or surveillance colonoscopy, choice of CBP was not associated with adenoma detection. Decisions about CBP should be based on other factors, such as tolerability, cost, or safety.

Barriers to home bowel cancer screening

OBJECTIVE

To develop and test a psychometric instrument for measuring common barriers to completing and returning home bowel cancer screening kits.

METHODS

One hundred and ten items were reviewed by an expert panel (n = 15) and presented in an online cross-sectional survey with 427 Australian adults. Exploratory factor analysis was used to identify an optimal factor solution of latent barrier types and aggregated factor scores were examined and compared between demographic groups.

RESULTS

Common barriers included having already been screened (32.3%), forgetting about the kit (24.4%), and a lack of planning (21.8%). Barriers reflecting hygiene concerns were also endorsed by over 15% of the sample. Four clear barrier types were evident reflecting disgust, avoidance, lack of autonomy, and physical difficulties.

CONCLUSIONS

Findings support calls to apply multi-faceted interventions strategies that address a broad range of barrier types, particularly that which encourage planning, and prompt and facilitate easy stool collection.

Multitarget Stool RNA Test for Noninvasive Detection of Colorectal Neoplasias in a Multicenter, Prospective, and Retrospective Cohort

INTRODUCTION

Effective colorectal cancer (CRC) prevention and screening requires sensitive detection of all advanced neoplasias (CRC and advanced adenomas [AA]). However, existing noninvasive screening approaches cannot accurately detect adenomas with high sensitivity.

METHODS

Here, we describe a multifactor assay (RNA-FIT test) that combines 8 stool-derived eukaryotic RNA biomarkers, patient demographic information (smoking status), and a fecal immunochemical test (FIT) to sensitively detect advanced colorectal neoplasias and other non-advanced adenomas in a 1,305-patient, average-risk, prospective cohort. This cohort was supplemented with a 22-patient retrospective cohort consisting of stool samples obtained from patients diagnosed with AA or CRC before treatment or resection. Participants within these cohorts were evaluated with the RNA-FIT assay and an optical colonoscopy. RNA-FIT test results were compared with colonoscopy findings.

RESULTS

Model performance was assessed through 5-fold internal cross-validation of the training set (n = 939) and by using the model on a hold out testing set (n = 388). When used on the hold out testing set, the RNA-FIT test attained a 95% sensitivity for CRC (n = 22), 62% sensitivity for AA (n = 52), 25% sensitivity for other non-AA (n = 139), 80% specificity for hyperplastic polyps (n = 74), and 85% specificity for no findings on a colonoscopy (n = 101).

DISCUSSION

The RNA-FIT assay demonstrated clinically relevant detection of all grades of colorectal neoplasia, including carcinomas, AAs, and ONAs. This assay could represent a noninvasive option to screen for both CRC and precancerous adenomas.

A stepped randomized trial to promote colorectal cancer screening in a nationwide sample of U.S. Veterans

BACKGROUND

Colorectal cancer (CRC) screening (CRCS) facilitates early detection and lowers CRC mortality.

OBJECTIVES

To increase CRCS in a randomized trial of stepped interventions. Step 1 compared three modes of delivery of theory-informed minimal cue interventions. Step 2 was designed to more intensively engage those not completing CRCS after Step 1.

METHODS

Recruitment packets (60,332) were mailed to a random sample of individuals with a record of U.S. military service during the Vietnam-era. Respondents not up-to-date with CRCS were randomized to one of four Step 1 groups: automated telephone, telephone, letter, or survey-only control. Those not completing screening after Step 1 were randomized to one of three Step 2 groups: automated motivational interviewing (MI) call, counselor-delivered MI call, or Step 2 control. Intention-to-treat (ITT) analyses assessed CRCS on follow-up surveys mailed after each step.

RESULTS

After Step 1 (n = 1784), CRCS was higher in the letter, telephone, and automated telephone groups (by 1%, 5%, 7%) than in survey-only controls (43%), although differences were not statistically significant. After Step 2 (n = 516), there were nonsignificant increases in CRCS in the two intervention groups compared with the controls. CRCS following any combination of stepped interventions overall was 7% higher (P = 0.024) than in survey-only controls (55.6%).

CONCLUSIONS

In a nationwide study of Veterans, CRCS after each of two stepped interventions of varying modes of delivery did not differ significantly from that in controls. However, combined overall, the sequence of stepped interventions significantly increased CRCS.

Colorectal cancer lifetime risk accuracy and behavior change intentions before and after risk assessment

PURPOSE

This study examined accuracy of perceived lifetime risk of colorectal cancer prior to and following receipt of cancer risk assessment (CRA) feedback among average risk adults. The specific aims were to identify predictors of improved risk perceptions and assess whether improvement in perceived lifetime risk accuracy was associated with changes in behavioral intentions for physical activity, diet, and colorectal cancer screening.

METHODS

Adults with no known history of colorectal cancer (n = 419) were enrolled in a study examining the impact of colorectal cancer risk assessment feedback. Risk perceptions and behavioral intentions were ascertained before and after risk assessment administration.

RESULTS

Accuracy of perceived lifetime risk significantly improved after CRA feedback, often as a result of lowered perceived risk. Those who were White, married, attended some college, and had higher numeracy were more likely to report accurate lifetime risk post-CRA. No differences in behavioral intentions were reported between those with and without improved accuracy.

CONCLUSION

Minorities and those with low numeracy were less likely to report accurate perceptions post-CRA. Although improved accuracy was not associated with increased behavioral intentions as expected, it is reassuring that intentions for health behaviors were not inhibited as perceived risk decreased.

Negative emotions and cancer fatalism are independently associated with uptake of Faecal Immunochemical Test-based colorectal cancer screening: Results from a population-based study

Although systematic colorectal cancer screening is efficacious, many programmes suffer from low uptake. Few behavioural or attitudinal factors have been identified as being associated with participation in colorectal cancer screening. We explored knowledge, beliefs about cancer, subjective health literacy, emotional attitudes to screening, and social influences among individuals invited to a population-based screening programme. Regression modelling of a cross-sectional survey of 2299 individuals (users and non-users) of a population-based Faecal Immunochemical Test (FIT) screening programme in Dublin was conducted. Questions were derived from previous theoretically-informed qualitative work and assessed using previously used and validated measures. The primary outcome variable was uptake status (User/Participation or Non-User/Non-participation); multivariable logistic regression was used to estimate the odds ratios (OR) for screening participation. Stronger fatalistic beliefs independently predicted lower uptake (OR = 0.94; 95% CI 0.90-0.98; P = 0.003). Those aged <65 who disagreed that "cancer can often be cured" also had lower uptake (OR = 0.43; 95% CI 0.22-0.82: P = 0.017). Agreement that the test was disgusting and tempting fate predicted lower uptake (OR = 0.16: 95% CI 0.10-0.27: p < 0.001), while the influence of a partner on decision to be screened was associated with higher uptake (OR = 1.32; 95% CI 1.15-1.50: P < 0.001). Negative cancer-related and screening-related beliefs and emotions are associated with non-participation in FIT (-based screening). Research is warranted to explore if these negative beliefs and emotions are modifiable and, if so, whether this would improve screening uptake. The association between the influence of a partner and screening participation present a challenge around improving uptake among those not in co-habiting relationships.

Short Message Service reminders reduce outpatient colonoscopy nonattendance rate: A randomized controlled study

BACKGROUND AND AIM

Nonattendance of outpatient colonoscopy leads to inefficient use of health-care resources. We aimed to study the effectiveness of using Short Message Service (SMS) reminder prior in patients scheduled for outpatient colonoscopy on their nonattendance rate.

METHODS

Patients who scheduled for an outpatient colonoscopy and had access of SMS were recruited from three clinics in Hong Kong. Patients were randomized to SMS group and standard care (SC) group. All patients were given a written appointment slip on the booking date. In addition, patients in the SMS group received an SMS reminder 7-10 days before their colonoscopy appointment. Patients' demographics, attendance, colonoscopy completion, and bowel preparation quality were recorded. Logistic regression was performed to identify predictors of nonattendance.

RESULTS

From November 2013 to October 2019, a total of 2225 eligible patients were recruited. A total of 1079 patients were allocated to the SMS group and 1146 to the SC group. The nonattendance rate of patients in the SMS group was significantly lower than that in the SC group (8.9% vs 11.9%, P = 0.022). There were no significant differences in their baseline characteristics and colonoscopy completion rate and bowel preparation quality. A trend towards a higher rate of adequate bowel preparation was observed in the SMS group when compared with the SC group (69.9% vs 65.8%, P = 0.053). Independent predictors for nonattendance included younger age, underprivilege, and existing diabetes.

CONCLUSIONS

An SMS reminder for outpatient colonoscopy is effective in reducing the nonattendance rate and may potentially improve the bowel preparation quality.

Society of Behavioral Medicine Update: retain support for the National Colorectal Cancer Roundtable's call to action to reach 80% colorectal cancer screening

Colorectal cancer (CRC) remains the third most commonly diagnosed cancer and the third leading cause of cancer-related death in the USA. CRC can be prevented through regular screening and removal of precancerous polyps. However, roughly one third of eligible adults in the USA are not up to date with recommended CRC screening. To increase timely CRC screening uptake in the USA, in 2014, the National Colorectal Cancer Roundtable (NCCRT) launched 80% by 2018. This multilevel effort involved more than 1,500 pledged organizations targeting patients, providers, health care systems, and policymakers to increase U.S. CRC screening rates to 80% by 2018. Concurrent with this campaign, between 2012 and 2018, CRC screening rates increased nationwide by 3.6% from 65.2% to 68.8%, meaning that about 9.3 million more U.S. adults are being screened. NCCRT attributes these successes to widespread implementation of center- and system-wide evidence-based interventions to increase screening uptake, including direct patient communication, provider reminders via electronic health records, and patient navigation, among others. Moving beyond 2018, NCCRT has rebranded the initiative as the 80% Pledge and has since identified several targeted campaigns, including increased outreach to Hispanics, Latinos, and Asians, whose CRC screening uptake remains less than 50%; encouragement of Medicaid outreach activities around CRC screening in all 50 states; and advocacy for screening right at 50 years of age. Society of Behavioral Medicine continues to support NCCRT and encourages policymakers to do the same by taking legislative action to assure funding for Medicaid outreach, research innovations, and clinical quality improvement that supports the 80% Pledge.

Colorectal Cancer Screening Uptake: Differences Between Rural and Urban Privately-Insured Population

Earlier studies investigated rural-urban colorectal cancer (CRC) screening disparities among older adults or used surveys. The objective was to compare screening uptake between rural and urban individuals 50–64 years of age using private health insurance. Data were analyzed from 58,774 Blue Cross Blue Shield of Nebraska beneficiaries. Logistic regression was used to assess the association between rural-urban and CRC screening use. Results indicate that rural individuals were 56% more likely to use the Fecal Occult Blood Test (FOBT) compared with urban residents, but rural females were 68% less likely to use FOBT. Individuals with few Primary Care Physician (PCP) visits and rural-women are the least to receive screening. To enhance CRC screening, a policy should be devised for the training and placement of female PCP in rural areas. In particular, multilevel interventions, including education, more resources, and policies to increase uptake of colorectal cancer screening, are needed. Further research is warranted to investigate barriers to CRC screening in rural areas.

Framework and Strategies to Eliminate Disparities in Colorectal Cancer Screening Outcomes

Preventable differences in colorectal cancer (CRC) mortality across racial/ethnic, economic, geographic, and other groups can be eliminated by assuring equitable access and quality across the care continuum, but few interventions have been demonstrated to do so. Multicomponent strategies designed with a health equity framework may be effective. A health equity framework takes into account social determinants of health, multilevel influences (policy, community, delivery, and individual levels), screening processes, and community engagement. Effective strategies for increasing screening uptake include patient navigation and other interventions for structural barriers, reminders and clinical decision support, and data to continuously track metrics and guide targets for improvement. Community resource gaps should be addressed to assure high-quality services irrespective of racial/ethnic and socioeconomic status. One model combinespopulation-based proactive outreach screening with screening delivery at in-person or virtual points of contact, as well as community engagement. Patient- and provider-based behavioral interventions may be considered for increasing screening demand and delivery. Providing a choice of screening tests is recommended for CRC screening, and access to colonoscopy is required for completion of the CRC screening process.

Factors associated with participation in colorectal cancer screening: A population-based study of 7200 individuals

OBJECTIVE

This study aimed to evaluate how the knowledge and perception towards colorectal cancer (CRC) screening had been changed in a large population, and identified factors associated with its participation based on factors pertinent to the Health Belief Model (HBM).

METHODS

Data from 3600 screening participants and 3600 non-participants were collected through a telephone survey via simple random sampling of telephone numbers in a territory-wide directory from December 2016 to November 2018. Sociodemographic factors; the enabling factors of screening as well as the barriers of screening were collected. The changes in these factors were evaluated by Pearson's chi-square trend test. A logistic regression model was constructed to identify the association between the above factors and CRC screening participation.

RESULTS

The knowledge level (67.9% to 85.4%, p < 0.001), perceived severity of having CRC (37.7%-42.8%, p < 0.01), perceived benefits of screening (54.9%-72.1%, p < 0.001), and reductions in barriers (14.1%-5.1%, p < 0.001) of CRC screening significantly improved among the non-users. Subjects with older age (adjusted odds ratio (AOR): 2.01, p < 0.001), higher knowledge level of screening methods (AOR: 6.68, p < 0.001), greater perceived severity (AOR: 2.04, p < 0.001) and coverage of insurance (AOR: 1.22, p < 0.01) were more likely to participate. In contrast, more affluent subjects (AOR: 0.69, p < 0.001), female individuals (AOR: 0.63, p < 0.001), higher level of perceived psychological (AOR: 0.54, p < 0.001) and access barriers (AOR: 0.55, p < 0.001) were associated with poorer participation.

CONCLUSION

These findings demonstrated a substantial increase in the enabling factors of CRC screening, including knowledge, perceived severity and perceived benefits. The study also identified the target groups such as younger individuals, females and more affluent people among whom more intensive educational initiatives are needed to enhance their participation.