The impact of screening on colorectal cancer mortality and incidence: has it really made a difference?

Interaction of Insurance and Neighborhood Income on Operative Colorectal Cancer Outcomes Within a National Database

INTRODUCTION

Sociodemographic disparities in colorectal cancer (CRC) surgical patients are known. Few studies, however, have examined the intersection of insurance type and median household income (MHI).

METHODS

In this retrospective analysis of the National Inpatient Sample from 2000 to 2019, all CRC surgery patients between 50 and 64 y old were included. Patients were further stratified based on insurance type (commercial, Medicaid, and uninsured) as well as county-level MHI quartiles. Outcomes included nonelective surgery (primary outcome), inpatient mortality, complications, and blood transfusions. Multivariate logistic regression adjusted for sociodemographic variables, medical comorbidities, and hospital-level factors.

RESULTS

Of 108,606 patients, 80.5% of patients had commercial insurance, while 5.8% were uninsured. On multivariate analysis, Medicaid or no insurance, especially when living in a lower-income community, were associated with significantly higher odds of nonelective surgery (ORs: 1.11-4.54). There was a stepwise effect on nonelective surgery by insurance type (uninsured with lower odds than insured) and MHI (each lower quartile had higher odds). There were similar trends for inpatient blood transfusions, but there were no significant differences in mortality or complications.

CONCLUSIONS

Especially when considered together, noncommercial insurance and lower MHI were associated with worse outcomes in CRC patients. Insurance was more protective than MHI against worse outcomes. These findings among a screening-aged cohort have policy planning implications for insurance expansions and healthcare funding allocations. Further research is needed to understand the complex underlying mechanisms that create this interaction between insurance and MHI.

From Crypts to Cancer: A Holistic Perspective on Colorectal Carcinogenesis and Therapeutic Strategies

Colorectal cancer (CRC) represents a significant global health burden, with high incidence and mortality rates worldwide. Recent progress in research highlights the distinct clinical and molecular characteristics of colon versus rectal cancers, underscoring tumor location's importance in treatment approaches. This article provides a comprehensive review of our current understanding of CRC epidemiology, risk factors, molecular pathogenesis, and management strategies. We also present the intricate cellular architecture of colonic crypts and their roles in intestinal homeostasis. Colorectal carcinogenesis multistep processes are also described, covering the conventional adenoma-carcinoma sequence, alternative serrated pathways, and the influential Vogelstein model, which proposes sequential APC, KRAS, and TP53 alterations as drivers. The consensus molecular CRC subtypes (CMS1-CMS4) are examined, shedding light on disease heterogeneity and personalized therapy implications.

Does a "Western Lifestyle" Confer a Higher Burden of Colorectal Cancer? A Comparison of EU15+ Countries versus Global Trends between 1990 and 2019

The incidence of colorectal cancer (CRC) in the U.S. is declining in adults 50 years and older; however, recent studies suggest an increasing disease burden among adults under age 50. This study aims to compare the incidence, mortality, and mortality-to-incidence ratios (MIRs) of CRC in EU15+ countries to determine if similar age-stratified occurrences are observed across these countries with similar "Western lifestyle"-related risk factors. Incidence and mortality rates for CRC between 1990 and 2019 were extracted using the Global Burden of Disease database. The data were age-stratified into groups between ages 25-49, 50-69, and greater than 69 years. We observed that the incidence of CRC increased globally for all age groups, with the highest increase observed for males (75.9%) and females (27.7%) aged 25-49. A similar trend was observed in 15 of the 19 EU15+ countries for males and 16 of the 19 EU15+ countries for females aged 25-49. Global mortality rates decreased for all age groups in females but increased for males in all age groups. This raises concerns regarding potentially modifiable risk factors contributing to increased CRC development and underscores the importance of implementing standardized screening at an earlier stage to ensure adequate detection in the younger population.

Association of Historical Housing Discrimination and Colon Cancer Treatment and Outcomes in the United States

PURPOSE

In the 1930s, the federally sponsored Home Owners' Loan Corporation (HOLC) used racial composition in its assessment of areas worthy of receiving loans. Neighborhoods with large proportions of Black residents were mapped in red (ie, redlining) and flagged as hazardous for mortgage financing. Redlining created a platform for systemic disinvestment in these neighborhoods, leading to barriers in access to resources that persist today. We investigated the association between residing in areas with different HOLC ratings and receipt of quality cancer care and outcomes among individuals diagnosed with colon cancer-a leading cause of cancer deaths amenable to early detection and treatment.

METHODS

Individuals who resided in zip code tabulation areas in 196 cities with HOLC rating and were diagnosed with colon cancer from 2007 to 2017 were identified from the National Cancer Database and assigned a HOLC grade (A, best; B, still desirable; C, definitely declining; and D, hazardous and mapped in red). Multivariable logistic regression models investigated association of area-level HOLC grade and late stage at diagnosis and receipt of guideline-concordant care. The product-limit method evaluated differences in time to adjuvant chemotherapy. Multivariable Cox proportional hazard models investigated differences in overall survival (OS).

RESULTS

There were 149,917 patients newly diagnosed with colon cancer with a median age of 68 years. Compared with people living in HOLC A areas, people living in HOLC D areas were more likely to be diagnosed with late-stage disease (adjusted odds ratio, 1.06 [95% CI, 1.00 to 1.12]). In addition, people living in HOLC B, C, and D areas had 8%, 16%, and 24% higher odds of not receiving guideline-concordant care, including lower receipt of surgery, evaluation of ≥12 lymph nodes, and chemotherapy. People residing in HOLC B, C, or D areas also experienced delays in initiation of adjuvant chemotherapy after surgery. People residing in HOLC C (adjusted hazard ratio [aHR], 1.09 [95% CI, 1.05 to 1.13]) and D (aHR, 1.13 [95% CI, 1.09 to 1.18]) areas had worse OS, including 13% and 20% excess risk of death for individuals diagnosed with early- and 6% and 8% for late-stage disease for HOLC C and D, respectively.

CONCLUSION

Historical housing discrimination is associated with worse contemporary access to colon cancer care and outcomes.

Colon Polyp Surveillance: Separating the Wheat From the Chaff

One goal of colorectal cancer (CRC) screening is to prevent CRC incidence by removing precancerous colonic polyps, which are detected in up to 50% of screening examinations. Yet, the lifetime risk of CRC is 3.9%-4.3%, so it is clear that most of these individuals with polyps would not develop CRC in their lifetime. It is, therefore, a challenge to determine which individuals with polyps will benefit from follow-up, and at what intervals. There is some evidence that individuals with advanced polyps, based on size and histology, benefit from intensive surveillance. However, a large proportion of individuals will have small polyps without advanced histologic features (ie, "nonadvanced"), where the benefits of surveillance are uncertain and controversial. Demand for surveillance will further increase as more polyps are detected due to increased screening uptake, recent United States recommendations to expand screening to younger individuals, and emergence of polyp detection technology. We review the current understanding and clinical implications of the natural history, biology, and outcomes associated with various categories of colon polyps based on size, histology, and number. Our aims are to highlight key knowledge gaps, specifically focusing on certain categories of polyps that may not be associated with future CRC risk, and to provide insights to inform research priorities and potential management strategies. Optimization of CRC prevention programs based on updated knowledge about the future risks associated with various colon polyps is essential to ensure cost-effective screening and surveillance, wise use of resources, and inform efforts to personalize recommendations.

Perceived Economic Strain, Subjective Social Status, and Colorectal Cancer Screening Utilization in U.S. Men-A Cross-Sectional Analysis

Although socioeconomic status (SES) is fundamentally related to underutilization of colorectal cancer (CRC) screening, the role of perceived economic strain and subjective social status with CRC screening is understudied. The aim of this study was to investigate whether greater perceived economic strain or lower subjective social status would decrease the odds of CRC screening uptake and being up-to-date with guideline-recommended CRC screening. We also explored interactions with household income and educational attainment. Cross-sectional survey-based data from men aged 45-75 years living in the United States (N = 499) were collected in February 2022. Study outcomes were ever completing a stool- or exam-based CRC screening test and being up-to-date with CRC screening. Perceived economic strain and subjective social status were the predictors. We conducted logistic regression models to estimate odds ratios (OR) and 95% confidence intervals (CI). Greater perceptions of economic strain decreased odds of being up-to-date with CRC screening. Household income modified the association between perceived economic strain and completing a stool-based test; the association was stronger for men from lower-income households. In unadjusted models, higher subjective social status increased odds of completing an exam-based test and being up-to-date with CRC screening. Our findings suggest that experiencing economic strain may interfere with men's CRC screening decisions and may capture additional information about barriers to CRC screening utilization beyond those captured by income or education.

Targeted Biodegradable Near-Infrared Fluorescent Nanoparticles for Colorectal Cancer Imaging

Colorectal cancer (CRC) is the third leading cause of cancer death in the U.S., and early detection and diagnosis are essential for effective treatment. Current methods are inadequate for rapid detection of early disease, revealing flat lesions, and delineating tumor margins with accuracy and molecular specificity. Fluorescence endoscopy can generate wide field-of-view images enabling detection of CRC lesions and margins; increased signal intensity and improved signal-to-noise ratios can increase both speed and sensitivity of cancer detection. For this purpose, we developed targeted near-infrared (NIR) fluorescent silica nanoparticles (FSNs). We tuned their size to 50-200 nm and conjugated their surface with an antibody to carcinoembryonic antigen (CEA) to prepare CEA-FSNs. The physicochemical properties and biodegradable profiles of CEA-FSN were characterized, and molecular targeting was verified in culture using HT29 (CEA positive) and HCT116 (CEA negative) cells. CEA-FSNs bound to the HT29 cells to a greater extent than to the HCT116 cells, and smaller CEA-FSNs were internalized into HT29 cells more efficiently than larger CEA-FSNs. After intravenous administration of CEA-FSNs, a significantly greater signal was observed from the CEA-positive HT29 than the CEA-negative HCT116 tumors in xenografted mice. In F344-PIRC rats, polyps in the intestine were detected by white-light endoscopy, and NIR fluorescent signals were found in the excised intestinal tissue after topical application of CEA-FSNs. Immunofluorescence imaging of excised tissue sections demonstrated that the particle signals coregistered with signals for both CRC and CEA. These results indicate that CEA-FSNs have potential as a molecular imaging marker for early diagnosis of CRC.

Colorectal cancer survival disparities in the five regions of Georgia

BACKGROUND/OBJECTIVE

The objective of this study was to examine 5-year colorectal cancer survival rates. We also determined whether demographics, tumor characteristics, and treatment modality were associated with 5-year CRC survival in the Clayton, West Central, East Central, Southeast, and Northeast Georgia regions because the significant higher CRC mortality rates in these regions in comparison to the overall rates in the State of Georgia.

METHODS

We conducted a retrospective cohort analysis using data from the 1975-2016 Surveillance, Epidemiology, and End Results program aggregated CRC patients to these five regions. Five-year CRC survival was calculated and stratified by the five regions of Georgia, using the Kaplan-Meier method with log-rank test. Cox proportional hazard regression was used to examine the mentioned association in these five regions.

RESULTS

Among 11,023 CRC patients, 5-year CRC survival was lowest in Clayton (65.9%) compared to the West Central (69.0%), East Central (68.2%), Southeast (70.5%), and Northeast regions (69.5%) (p-value = 0.02). In multivariable analysis, greater risk of CRC death was found in the Clayton region compared to the West Central (HR, 1.12; 95%, 1.00-1.25) region when adjusting for demographics, tumor characteristics, and treatment modality. Among Clayton Georgians, age of 75+ years (HR, 2.13; 95%, 1.56-2.89), grade 3 & 4 tumors (HR, 2.22; 95%, 1.64-3.00), and distant stage (HR, 20.95; 95%, 15.99-27.45) were negatively associated with CRC survival.

CONCLUSION

We observed place-based differences in CRC survival with significantly lower survival rates in the Clayton region. Factors associated with higher risk of CRC death include older age at diagnosis, high-grade tumors, and distant stage CRC among Clayton Georgians. Our study provides important evidence to all relevant stakeholders in furthering the development of culturally tailored CRC screening interventions aimed at CRC early detection and improved outcomes.

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

Objectives

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

Methods

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

Results

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

Conclusions

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

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.

Spatial mapping of colorectal cancer screening uptake and associated factors

OBJECTIVE

Over the past decades, it has been understood that the availability of screening tests has contributed to a steady decline in incidence of colorectal cancer (CRC). However, it is also seen that there is a geographic disparity in the use of such tests across small areas. The aim of this study is to examine small-area level barrier factors that may impact CRC screening uptake and to delineate coldspot (low uptake of screening) counties in Florida.

METHODS

Data on the percentages of county-level CRC screening uptakes in 2016 and county-level barrier factors for screening were obtained from the Florida Department of Health, Division of Public Health Statistics & Performance Management. Bayesian spatial beta models were used to produce posterior probability of deceedance to identify coldspots for CRC screening rates.

RESULTS

Unadjusted screening rates using sigmoidoscopy or colonoscopy test ranged from 56.8 to 85%. Bayesian spatial beta models were fitted to the proportion data. At an ecological level, we found that an increasing rate of CRC screening uptake for either of the test types (colon/rectum exam, stool-based test) was strongly associated with a higher health insurance coverage, and lower percentage of population that speak English less than very well (immigration) at county level. Eleven coldspot counties out of 67 total were also identified.

CONCLUSION

This study suggests that health insurance disparities in the use of CRC screening tests are an important factor that may need more attention for resource allocation and health policy targeting small areas with low uptake of screening.

Racial and Ethnic Disparities in Use of Colorectal Cancer Screening Among Adults With Chronic Medical Conditions: BRFSS 2012-2020

Introduction

People with chronic conditions and people with colorectal cancer (CRC) may share common risk factors; thus, CRC screening is important for people with chronic conditions. We examined racial and ethnic differences in the use of CRC screening among people with various numbers of chronic conditions.

Methods

We included data on adult respondents aged 50 to 75 years from the Behavioral Risk Factor Surveillance System in 2012 through 2020. We categorized counts of 9 conditions as 0, 1, 2, 3, and ≥4. We classified self-reported CRC screening status as up to date or not. We used Poisson models to estimate adjusted prevalence ratios (APRs) among the different counts of chronic conditions in 4 racial and ethnic groups: Hispanic adults with limited English proficiency (LEP), Hispanic adults without LEP, non-Hispanic Black adults, and non-Hispanic White adults.

Results

Overall, 66.5% of respondents were up to date with CRC screening. The prevalence of being up to date increased with the number of chronic conditions. We found disparities among racial and ethnic groups. Hispanic respondents with LEP had lower rates than non-Hispanic White adults of being up to date with CRC screening across all counts of chronic conditions (APR for 0 conditions = 0.67; 95% CI, 0.64-0.71; APR for ≥4 conditions = 0.85; 95% CI, 0.79-0.91). Hispanic respondents without LEP with 0, 1, or 2 conditions were less likely than non-Hispanic White respondents to be up to date with CRC screening. We found no significant differences between non-Hispanic Black and non-Hispanic White respondents.

Conclusion

We found disparities among Hispanic BRFSS respondents with LEP, who had lower rates than non-Hispanic White respondents of being up to date with CRC screening, regardless of the number of chronic conditions. Tailored interventions are needed to address these disparities and improve screening rates, particularly among Hispanic people.

Interval Cancer in Population-Based Colorectal Screening Programmes: Incidence and Characteristics of Tumours

The objective of this study is to evaluate interval cancer (IC) in colorectal cancer (CRC) screening, which is CRC diagnosed in an individual after having received a negative faecal occult blood test and before the next invitation to participate in screening. A follow-up study was conducted on a cohort of participants in the first three screening rounds of four colorectal cancer screening programmes in Spain, n = 664,993. A total of 321 ICs and 2120 screen-detected cancers (SCs) were found. The IC and SC rates were calculated for each guaiac (gFOBT) or immunochemical (FIT) test. A Cox regression model was used to estimate the hazard ratios (HR) of IC risk factors. A nested case-control study was carried out to compare IC and SC tumour characteristics. The IC rate was 1.16‱ with the gFOBT and 0.35‱ with the FIT. Men and people aged 60-69 showed an increased probability of IC (HR = 1.81 and HR = 1.95, respectively). There was a decreased probability of IC in individuals who regularly participated in screening, HR = 0.62 (0.47-0.82). IC risk gradually rose as the amount of Hb detected in the FIT increased. IC tumours were in more advanced stages and of a larger size than SC tumours, and they were mostly located in the cecum. These results may play a key role in future strategies for screening programmes, reducing IC incidence.

Cancer Screening Services: What Do Indigenous Communities Want? A Systematic Review

PURPOSE

Indigenous communities experience worse cancer outcomes compared with the general population partly because of lower cancer screening access. One-size-fits-all screening programs are unsuitable for reaching Indigenous communities. In this review, we summarize available evidence on the perspectives of these communities; with a view to informing the improvement of cancer screening services to achieve equitable access.

METHODS

We undertook a systematic review according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, using the databases MEDLINE, Scopus, PubMed, and Google Scholar. The search terms used were "Indigenous community or Indigenous communities," "cancer screening," and "facilitators, enablers, desires, or needs." Qualitative studies published up to the August 30, 2022 investigating the perspectives of Indigenous communities on factors encouraging screening participation were included in the study. The included studies were reviewed and analyzed inductively by two independent reviewers, and key themes regarding indigenous access to cancer screening were then extracted.

RESULTS

A total of 204 unique articles were identified from the search. The title and abstracts of these studies were screened, and 164 were excluded on the basis of the exclusion and inclusion criteria. The full texts of the remaining 40 studies were examined and 18 were included in the review. Four key themes were identified pertaining to culturally tailored education and information dissemination, community involvement, positive relationships with health care providers, and individual empowerment and autonomy.

CONCLUSION

Improvements, on the basis of the key themes identified from this review, must be made at all levels of the health care system to achieve equitable screening participation in Indigenous communities. However, we recommend an investigation into the perspectives of the local Indigenous communities before the initiation of cancer screening programs.

Machine Learning as a Tool for Early Detection: A Focus on Late-Stage Colorectal Cancer across Socioeconomic Spectrums

PURPOSE

To assess the efficacy of various machine learning (ML) algorithms in predicting late-stage colorectal cancer (CRC) diagnoses against the backdrop of socio-economic and regional healthcare disparities.

METHODS

An innovative theoretical framework was developed to integrate individual- and census tract-level social determinants of health (SDOH) with sociodemographic factors. A comparative analysis of the ML models was conducted using key performance metrics such as AUC-ROC to evaluate their predictive accuracy. Spatio-temporal analysis was used to identify disparities in late-stage CRC diagnosis probabilities.

RESULTS

Gradient boosting emerged as the superior model, with the top predictors for late-stage CRC diagnosis being anatomic site, year of diagnosis, age, proximity to superfund sites, and primary payer. Spatio-temporal clusters highlighted geographic areas with a statistically significant high probability of late-stage diagnoses, emphasizing the need for targeted healthcare interventions.

CONCLUSIONS

This research underlines the potential of ML in enhancing the prognostic predictions in oncology, particularly in CRC. The gradient boosting model, with its robust performance, holds promise for deployment in healthcare systems to aid early detection and formulate localized cancer prevention strategies. The study's methodology demonstrates a significant step toward utilizing AI in public health to mitigate disparities and improve cancer care outcomes.

Gastrointestinal Malignancy: Genetic Implications to Clinical Applications

Advances in molecular genetics have revolutionized our understanding of the pathogenesis, progression, and therapeutic options for treating gastrointestinal (GI) cancers. This chapter provides a comprehensive overview of the molecular landscape of GI cancers, focusing on key genetic alterations implicated in tumorigenesis across various anatomical sites including GIST, colon and rectum, and pancreas. Emphasis is placed on critical oncogenic pathways, such as mutations in tumor suppressor genes, oncogenes, chromosomal instability, microsatellite instability, and epigenetic modifications. The role of molecular biomarkers in predicting prognosis, guiding treatment decisions, and monitoring therapeutic response is discussed, highlighting the integration of genomic profiling into clinical practice. Finally, we address the evolving landscape of precision oncology in GI cancers, considering targeted therapies and immunotherapies.

County-level colorectal cancer screening rates on colorectal cancer survival in the state of Georgia: Does county-level rurality matter?

PURPOSE

Investigating CRC screening rates and rurality at the county-level may explain disparities in CRC survival in Georgia. Although a few studies examined the relationship of CRC screening rates, rurality, and/or CRC outcomes, they either used an ecological study design or focused on the larger population.

METHODS

We conducted a retrospective analysis utilizing data from the 2004-2010 Surveillance, Epidemiology, and End Results Program. The 2013 United States Department of Agriculture rural-urban continuum codes and 2004-2010 National Cancer Institute small-area estimates for screening behaviors were used to identify county-level rurality and CRC screening rates. Kaplan-Meier method and Cox proportional hazard regression were performed.

RESULTS

Among 22,160 CRC patients, 5-year CRC survival rates were lower among CRC patients living in low screening areas in comparison with intermediate/high areas (69.1% vs. 71.6% /71.3%; p-value = 0.030). Patients living in rural high-screening areas also had lower survival rates compared to non-rural areas (68.2% vs. 71.8%; p-value = 0.009). Our multivariable analysis demonstrated that patients living in intermediate (HR, 0.91; 95% CI, 0.85-0.98) and high-screening (HR, 0.92; 95% CI, 0.85-0.99) areas were at 8%-9% reduced risk of CRC death. Further, non-rural CRC patients living in intermediate and high CRC screening areas were 9% (HR, 0.91; 95% CI, 0.83-0.99) and 10% (HR, 0.90; 95% CI, 0.82-0.99) less likely to die from CRC.

CONCLUSIONS

Lower 5-year survival rates were observed in low screening and rural high-screening areas. Living in intermediate/high CRC screening areas was negatively associated with the risk of CRC death. Particularly, non-rural patients living in intermediate/high-screening areas were 8%-9% less likely to die from CRC. Targeted CRC screening resources should be prioritized for low screening and rural communities.

Barriers and facilitators of colorectal cancer screening among East African men in Minnesota: a qualitative investigation

Objective: This study aimed to explore barriers and facilitators to colorectal cancer (CRC) screening among East African men in Minnesota.Design: Six focus groups were conducted in Minneapolis and St. Paul, MN, USA. Participants were asked to describe individual and structural barriers to CRC screening, and discuss strategies that would address individual and structural barriers to screening. Audio-recorded conversations were transcribed verbatim and translated to English. The transcriptions were analyzed using a thematic analysis. Major themes that emerged on individual barriers were lack of knowledge, fear, and privacy.Results: Themes that emerged on structural barriers were distrust in the medical system, lack of health care coverage, and access to the health care system. Education, client reminders, mass media, increased clarity in communication with the provider and translator, and increased access to health care were frequently mentioned strategies to increase CRC screening in the East African community. Participants expressed favorable views toward the concept of patient navigation.Conclusion: Our findings indicate the need to develop culturally appropriate, multi-faced, intervention programs that are aimed at eliminating personal, cultural, and structural barriers.

Colorectal Cancer Knowledge and Screening Change in African Americans: Implementation Phase Results of the EPICS Cluster RCT

Introduction

African Americans are disproportionately affected by mortality risk for colorectal cancer. This study aimed to determine the most effective educational approach of 4 study arms that enhances the likelihood of pursuing subsequent colorectal cancer screening, and to identify the associated factors.

Methods

Age-eligible adults (N=2,877) were recruited to participate in a cluster randomized control dissemination and intervention implementation trial titled Educational Program to Increase Colorectal Cancer Screening. The project began in May 2012 and ended in March 2017 (the implementation phase lasted 36 months). Educational sessions were conducted through 16 community coalitions that were randomized into 1 of 4 conditions: website access (to facilitator training materials and toolkits) without technical assistance, website access with technical assistance, in-person training (provided by research staff and website access) without technical assistance, and in-person training with technical assistance. A follow-up to determine participant CRC screening was conducted 3 months later.

Results

Compared with the website access with technical assistance intervention group, 2 groups, in-person training with technical assistance and without technical assistance, indicated significantly higher odds for obtaining colorectal cancer screening (OR=1.31; 95% CI=1.04, 1.64; p=0.02 and OR=1.35; 95% CI=1.07, 1.71; p=0.01, respectively). Though sociodemographic factors were not significantly associated with pursuing subsequent colorectal cancer screening, the postintervention cancer knowledge increased significantly among the study participants.

Conclusions

The importance of in-person interactions, local coalitions, and community contexts may play a key role for successfully increasing colorectal cancer screening rates among African Americans as reflected through this study. The integration of telehealth and use of other virtual technologies to engage the public in research have increased since the COVID-19 pandemic and should be assessed to determine their impact on the degree to which in-person interventions are significantly more effective when compared with solely web-assisted ones.

Trial registration

The study is registered at www.clinicaltrials.gov NCT01805622.

Cancer Screening for Transgender Individuals: Guidelines, Best Practices, and a Proposed Care Model

Few transgender-specific cancer screening recommendations exist. This review aims to cover current guidelines and practice patterns of cancer screening in transgender patients and, where evidence-based data are lacking, to draw from cisgender screening guidelines to suggest best practices for transgender patients based on anatomic inventory. Sufficient evidence does not exist to determine the long-term effects of gender-affirming hormone therapy on cancer risk. In the future, cancer screening and prevention should be focused on anatomic inventory and high-risk behaviors.

Effect of Behavioral Interventions on the Uptake of Colonoscopy for Colorectal Cancer Screening: A Systematic Review and Meta-Analysis

INTRODUCTION

Screening decreases colorectal cancer incidence and mortality, but uptake in the United States remains suboptimal. Prior studies have investigated the effect of various interventions on overall colorectal cancer screening and stool-based testing, but the effect on colonoscopy-the predominant screening test in the United States-has not been fully examined. We performed a systematic review and meta-analysis to assess the effect of behavioral interventions on screening colonoscopy uptake.

METHODS

We searched PubMed, Embase, and Cochrane databases through January 2022 for controlled trials that assessed the effect of behavioral interventions on screening colonoscopy uptake. All titles, abstracts, and articles were screened by at least 2 independent reviewers. Odds ratios were extracted from the original article or calculated from the raw data. The primary outcome was the relative increase in screening colonoscopy completion with any behavioral intervention. We performed random-effects meta-analysis, with subgroup analysis by type of intervention.

RESULTS

A total of 25 studies with 30 behavioral interventions were analyzed. The most common interventions were patient navigation (n = 11) and multicomponent interventions (n = 6). Overall, behavioral interventions increased colonoscopy completion by 54% compared with controls (odds ratio [OR] 1.54, 95% confidence interval [CI] 1.26-1.88). Patient navigation (OR 1.78, 95% CI 1.35-2.34) and multicomponent interventions (OR 1.84, 95% CI 1.17-2.89) had the strongest effect on colonoscopy completion among interventions examined in multiple studies. Significant heterogeneity was observed both overall and by intervention type. There was no evidence of publication bias.

DISCUSSION

Behavioral interventions increase screening colonoscopy completion and should be adopted in clinical practice. In particular, patient navigation and multicomponent interventions are the best-studied and most effective interventions.

Participants' satisfaction with colorectal cancer screening programs: A systematic review

INTRODUCTION

Since satisfaction with cancer screening experience can increase adherence to programs and contribute to reduce morbidity and mortality, its assessment is crucial for programs´ effectiveness. Our aim was to conduct a systematic review about satisfaction of participants with organized colorectal cancer screening.

METHODS

We searched relevant scientific databases (MEDLINE, EMBASE, PsycINFO, and CINAHL) from inception to May 2022. We selected cross-sectional studies and clinical trials reporting a quantitative survey-based measure of satisfaction towards CRC screening.

RESULTS

A total of 15 studies were included, being published from 1992 to 2019 for an overall number of 21 surveys. Of those, 16 (76%) investigated satisfaction with screening tests (fecal occult blood test, fecal immunochemical test, sigmoidoscopy, colonoscopy, computed tomographic colonography), 4 (19%) with colonoscopy as assessment test after suspicious findings, and 2 (10%) with both the screening and assessment phase. None of the included surveys used a validated questionnaire. Most surveys reported a high level of satisfaction for both screening and further assessment phases. Temporary pain, discomfort, embarrassment, and anxiety while waiting for results were the commonest negative aspects perceived, with some variability across studies and considered procedures.

CONCLUSIONS

Satisfaction with the information and communication about screening was generally good, but some authors reported participants' sub-optimal understanding of informative material. Satisfaction with CRC screening is generally high, but its evaluation is performed using non-validated instruments, which limits the interpretation of results and prevents comparability of the current body of evidence.

Testing the validity of a new scale designed to assess beliefs and perceptions about colorectal cancer and colorectal cancer screening in Malaysia: a principal component analysis

OBJECTIVE

To conduct a cultural adaptation and validation of the Champion Health Belief Model Scale (CHBMS) for colorectal cancer (CRC) screening (CHBMS-CRC-M) in order to assess and investigate perceptions and beliefs about CRC screening in Malaysia.

DESIGNS AND PARTICIPANTS

The results from an evidence synthesis and the outcomes from an expert panel discussion were used to shape CHBMS scale content into an assessment of beliefs about CRC screening (CHBMS-CRC). This questionnaire assessment was translated into the official language of Malaysia. An initial study tested the face validity of the new scale or questionnaire with 30 men and women from various ethnic groups. Factorial or structural validity was investigated in a community sample of 954 multiethnic Malaysians.

SETTING

Selangor state, Malaysia.

RESULTS

The new scale was culturally acceptable to the three main ethnic groups in Malaysia and achieved good face validity. Cronbach's alpha coefficients ranged from 0.66 to 0.93, indicating moderate to good internal consistency. Items relating to perceived susceptibility to CRC 'loaded' on Factor 1 (with loadings scoring above 0.90); perceived benefits of CRC screening items loaded on factor 2 and were correlated strongly (loadings ranged between 0.63 and 0.83) and perceived barriers (PBA) to CRC screening (PBA) items loaded on factor 3 (range 0.30-0.72).

CONCLUSION

The newly developed CHBMS-CRC-M fills an important gap by providing a robust scale with which to investigate and assess CRC screening beliefs and contribute to efforts to enhance CRC screening uptake and early detection of CRC in Malaysia and in other Malay-speaking communities in the region.

Opportunities and Challenges in Screening for Colorectal Cancer

Colorectal cancer (CRC) is a leading cause of mortality in the United States. Outcomes are greatly improved if CRC is detected early; hence, screening is currently recommended for adults aged 45 years and older at average risk for the disease. Despite this recommendation and the availability of accurate screening tests, the CRC screening rates are below those recommended. The goal of this study was to identify temporal trends (from 2015 to 2019) in CRC screening rates and the utilization of screening tests recommended for CRC detection among average-risk individuals within the St Elizabeth Healthcare system in Kentucky, United States. The primary population of interest was patients aged 50-75 years (the CRC screening was recommended for this age group at the time of the study). Deidentified data were sourced from patients' electronic health records, and the results showed that screening rates increased significantly from 26% in 2015 to 49% in 2019 (<0.0001). The incidence of any screening test also increased significantly from 2015 to 2019, for those who were due for screening (P < 0.05) and for the entire cohort (P < 0.1). The use of multitarget stool DNA (mt-sDNA) increased 40-fold over the study timeframe (P < 0.05). These study results confirm that CRC screening rates remain suboptimal, although incidence and adherence improved significantly in those aged 50-75 years from 2015 to 2019. The growing adoption and availability of mt-sDNA may be correlated with an increase in overall screening in this average-risk population.

Colorectal cancer screening: The role of MT-sDNA testing

ABSTRACT

Because an estimated 10.5% of new colorectal cancer (CRC) cases occur in patients under age 50 years, the US Preventive Services Task Force in 2021 recommended CRC screening for adults ages 45 to 49 years. The prevalence of up-to-date CRC screening with any recommended test among patients age 45 years and older in the United States is only 59% in 2023, indicating that existing screening practices are ineffective. Screening options now include invasive and noninvasive measures. Multi-target stool DNA (MT-sDNA) testing is a simple, low-risk, noninvasive test that provides excellent sensitivity and specificity, is cost-effective, and may increase patient screening rates. CRC screening guideline recommendations and alternative screening methods may help improve patient outcomes and reduce morbidity and mortality. This article describes MT-sDNA testing, its effectiveness, recommended use, and potential expanding role as a screening option.

Association of Age With Treatment-Related Adverse Events and Survival in Patients With Metastatic Colorectal Cancer

Importance

While the incidence of early-onset metastatic colorectal cancer (mCRC) has been increasing, studies on the age-related disparity in this group of patients are limited.

Objective

To evaluate the association of age with treatment-related adverse events and survival in patients with mCRC and explore the potential underlying factors.

Design, Setting, and Participants

This cohort study included 1959 individuals. Individual data on 1223 patients with mCRC who received first-line fluorouracil and oxaliplatin therapy in 3 clinical trials, and clinical and genomic data of 736 patients with mCRC from Moffitt Cancer Center were used to assess genomic alterations and serve as an external validation cohort. All statistical analyses were conducted from October 1, 2021, through November 12, 2022.

Exposures

Metastatic colorectal cancer.

Main Outcomes and Measures

Survival outcomes and treatment-related adverse events were compared among patients in 3 age groups: younger than 50 (early onset), 50 to 65, and older than 65 years.

Results

In the total population of 1959 individuals, 1145 (58.4%) were men. Among 1223 patients from previous clinical trials, 179 (14.6%) in the younger than 50 years group, 582 (47.6%) in the 50 to 65 years group, and 462 (37.8%) in the older than 65 years group had similar baseline characteristics except for sex and race. The younger than 50 years group had significantly shorter progression-free survival (PFS) (hazard ratio [HR], 1.46; 95% CI, 1.22-1.76; P < .001) and overall survival (OS) (HR, 1.48; 95% CI, 1.19-1.84; P < .001) compared with the 50 to 65 years group after adjustment for sex, race, and performance status. Significantly shorter OS in the younger than 50 years group was confirmed in the Moffitt cohort. The younger than 50 years group had a significantly higher incidence of nausea and vomiting (69.3% vs 57.6% [50-65 years] vs 60.4% [>65 years]; P = .02), severe abdominal pain (8.4% vs 3.4% vs 3.5%; P = .02), severe anemia (6.1% vs 1.0% vs 1.5%; P < .001), and severe rash (2.8% vs 1.2% vs 0.4% P = .047). The younger than 50 years group also had earlier onset of nausea and vomiting (1.0 vs 2.1 vs 2.6 weeks; P = .01), mucositis (3.6 vs 5.1 vs 5.7 weeks; P = .05), and neutropenia (8.0 vs 9.4 vs 8.4 weeks; P = .04), and shorter duration of mucositis (0.6 vs 0.9 vs 1.0 weeks; P = .006). In the younger than 50 years group, severe abdominal pain and severe liver toxic effects were associated with shorter survival. The Moffitt genomic data showed that the younger than 50 years group had a higher prevalence of CTNNB1 mutation (6.6% vs 3.1% vs 2.3%; P = .047), ERBB2 amplification (5.1% vs 0.6% vs 2.3%; P = .005), and CREBBP mutation (3.1% vs 0.9% vs 0.5%; P = .05), but lower prevalence of BRAF mutation (7.7% vs 8.5% vs 16.7%; P = .002).

Conclusions and Relevance

In this cohort study of 1959 patients, those with early-onset mCRC showed worse survival outcomes and unique adverse event patterns, which could be partially attributed to distinct genomic profiles. These findings may inform individualized management approaches in patients with early-onset mCRC.

Primary and Secondary Prevention Interventions to Reduce Risk Factors Associated with Colorectal Cancer in High-Risk Groups: a Systematic Literature Review

In the USA, colorectal cancer (CRC) is the 2nd leading cause of cancer-related deaths. Certain groups in the USA are at an increased risk of developing CRC, including those with a genetic risk and family history. The purpose of this project was to synthesize primary and secondary prevention interventions for individuals who are at high risk of CRC due to family history or genetic predisposition. This study systematically reviewed articles from PubMed, Google Scholar, and EBSCO using specific search terms to find relevant articles. Sixteen articles were identified for full-text review, which were categorized as non-drug interventions (n = 7) and drug interventions (n = 9). Non-drug interventions focused primarily on increasing screening in those with a first-degree relative (FDR) with CRC or those with Lynch syndrome (LS). Interventions that increased CRC screening often had a tailored component and were otherwise varied in study designs and intervention type. Drug interventions focused on the use of NSAIDs on patients with familial adenomatous polyposis (FAP). Studies showed very little racial and ethnic diversity. Findings suggest that tailored interventions are particularly effective in increasing CRC screening, and greater diversity of sample is needed with respect to race and ethnicity.

Trends and Factors Associated with Fecal Occult Blood Test Utilization among Hispanic Adults in Puerto Rico and the United States: BRFSS 2012-2020

Identifying factors associated with colorectal cancer screening utilization is important to guide colorectal cancer prevention and control programs. We evaluated trends and factors associated with previous-year fecal occult blood test (FOBT) use among Hispanic adults living in Puerto Rico and the U.S. mainland. Using data from the Behavioral Risk Factor Surveillance System (2012-2020), trends in FOBT use were analyzed using joinpoint regression to estimate annual percentage change (APC). Logistic regression stratified by location identified factors associated with FOBT use. FOBT was more common among Hispanic adults ages 50 to 75 years living in Puerto Rico than in the U.S. mainland [Puerto Rico: 20.5%[2012] to 45.6%[2020], APC = 11.4%; U.S. mainland: 9.9%[2012] to 16.7%[2020], APC = 5.9%]. Factors inversely associated with FOBT use were similar in Puerto Rico and the U.S. mainland, including lack of health insurance, not having a personal doctor, having a checkup >12 months ago, and not being able to see a doctor due to cost, as were factors associated with higher FOBT use, including older age, retirement, or having two or more chronic diseases. Among Hispanics living in the U.S. mainland, lack of exercise and less education were inversely associated with FOBT. Factors related to poor access to healthcare were associated with lower use of FOBT among Hispanics. Efforts to improve colorectal cancer screening in Hispanics are necessary to address health disparities across the colorectal cancer care continuum.

PREVENTION RELEVANCE

Colorectal cancer screening reduces cancer incidence and mortality. All screening modalities, including less invasive FOBT tests, are underutilized, especially in non-White and low-income populations. Evaluation of trends and factors associated with the increase in the use of colorectal cancer screening can inform programs to address the lack of screening among racial minorities.

Reducing disparities and achieving health equity in colorectal cancer screening

Increases in colorectal cancer screening are linked to the declining incidence of the disease over the past three decades. These favorable trends, however, are not observed in marginalized racial and ethnic populations with disproportionately lower rates of screening, higher disease incidence, and increased mortality despite advances in health technology and policy. This review describes the differences in screening uptake and test selection amongst racial and ethnic groups, discusses known obstacles and facilitators that impact screening, and highlights existing frameworks developed to achieve health equity in colorectal cancer screening.

Association between trends of mortality and incidence, survival and stage at diagnosis for six digestive and respiratory cancers in United States (2009-2013)

BACKGROUND

A decrease in cancer mortality has been reported in the USA, possibly due to decreased incidence, downstaging and improved survival. The aim of the present study is to estimate the contribution of these factors on the trend in cancer mortality.

METHODS

Data on incidence, mortality, stage at diagnosis, and overall and stage-specific survival for six common digestive and respiratory cancers (esophagus, stomach, colorectal, liver, pancreas and lung) during 2009-2013 in the USA from the surveillance, epidemiology and end results (SEER) program, was analyzed using generalized linear models separately among men and women.

RESULTS

Our study showed a decrease in mortality for esophageal (-0.09/100 000/year and -0.03/100 000/year), stomach (-0.11/100 000/year and -0.05/100 000/year), colorectal (-0.45/100 000/year and -0.29/100 000/year) and lung cancer (-1.89/100 000/year in men and -0.78/100 000/year in women) in men and women, respectively: for all of them, except lung cancer in women, there was a decrease in the incidence of comparable or greater magnitude; stage distribution and survival also contributed to the decrease in mortality for lung and colorectal cancer. Mortality from pancreatic cancer was stable: an increase in incidence was counterbalanced by an improvement in survival. Mortality from liver cancer increased, driven by an increase in mortality that was not offset by favorable trends in stage distribution and survival.

CONCLUSIONS

Trends in mortality were primarily affected by changes in incidence; an increase in the proportion of local stage at diagnosis and improved survival, although evident for some cancers, played a lesser role in mortality trends.

Association between the colorectal cancer screening status of primary care physicians and their patients: Evidence from the Swiss Sentinella practice-based research network

Swiss health insurance reimburses screening for colorectal cancer (CRC) with either colonoscopy or fecal occult blood test (FOBT). Studies have documented the association between a physician's personal preventive health practices and the practices they recommend to their patients. We explored the association between CRC testing status of primary care physicians (PCP) and the testing rate among their patients. From May 2017 to September 2017, we invited 129 PCP who belonged to the Swiss Sentinella Network to disclose their CRC test status and whether they had been tested with colonoscopy or FOBT/other methods. Each participating PCP collected demographic data and CRC testing status from 40 consecutive 50- to 75-year-old patients. We analyzed data from 69 (54%) PCP 50 years or older and 2623 patients. Most PCP were men (81%); 75% were tested for CRC (67% with colonoscopy and 9% with FOBT). Mean patient age was 63; 50% were women; 43% had been tested for CRC (38%, 1000/2623 with colonoscopy and 5%, 131/2623, with FOBT or other non-endoscopic test). In multivariate adjusted regression models that clustered patients by PCP, the proportion of patients tested for CRC was higher among PCP tested for CRC than among PCP not tested (47% vs 32%; OR 1.97; 95% CI 1.36 to 2.85). Since PCP CRC testing status is associated with their patients CRC testing rates, it informs future interventions that will alert PCPs to the influence of their health decisions and motivate them to further incorporate the values and preferences of their patients in their practice.

Three-Year Interval for the Multi-Target Stool DNA Test for Colorectal Cancer Screening: A Longitudinal Study

Data supporting the clinical utility of multi-target stool DNA (mt-sDNA) at the guideline-recommended 3-year interval have not been reported.Between April 2015 and July 2016, candidates for colorectal cancer screening whose providers prescribed the mt-sDNA test were enrolled. Participants with a positive baseline test were recommended for colonoscopy and completed the study. Those with a negative baseline test were followed annually for 3 years. In year 3, the mt-sDNA test was repeated and colonoscopy was recommended independent of results. Data were analyzed using the Predictive Summary Index (PSI), a measure of the gain in certainty for dichotomous diagnostic tests (where a positive value indicates a net gain), and by comparing observed versus expected colorectal cancers and advanced precancerous lesions.Of 2,404 enrolled subjects, 2,044 (85%) had a valid baseline mt-sDNA result [284 (13.9%) positive and 1,760 (86.1%) negative]. Following participant attrition, the year 3 intention to screen cohort included 591 of 1,760 (33.6%) subjects with valid mt-sDNA and colonoscopy results, with no colorectal cancers and 63 advanced precancerous lesions [22 (34.9%) detected by mt-sDNA] and respective PSI values of 0% (P = 1) and 9.3% (P = 0.01). The observed 3-year colorectal cancer yield was lower than expected (one-sided P = 0.09), while that for advanced precancerous lesions was higher than expected (two-sided P = 0.009).Repeat mt-sDNA screening at a 3-year interval resulted in a statistically significant gain in detection of advanced precancerous lesions. Due to absence of year 3 colorectal cancers, the PSI estimate for colorectal cancer was underpowered and could not be reliably quantified. Larger studies are required to assess the colorectal cancer study findings.

PREVENTION RELEVANCE

Understanding the 3-year yield of mt-sDNA for colorectal cancer and advanced precancerous polyps is required to ensure the clinical appropriateness of the 3-year interval and to optimize mt-sDNA's screening effectiveness.

Cancer Screening Differences Among Muslims and Non-Muslims: Insights from the Chicago Multiethnic Prevention and Surveillance Study

BACKGROUND

While cancer screening disparities along socioeconomic and racial/ethnic lines are well studied, differences based on religious affiliation are under-researched. Though diverse in terms of race/ethnicity, Muslim Americans appear to share values and beliefs that similarly inform their health and healthcare seeking behaviors. Cancer screening disparities among Muslim Americans are also understudied.

METHODS

To examine differences in cancer screening behaviors based on Muslim affiliation, we analyzed data from a longitudinal cohort study examining lifestyle, healthcare access, environmental, and genetic factors on the health of Chicagoans.

RESULTS

Of 7552 participants, 132 (1.7%) were Muslim. Between Muslim and non-Muslims, there were no significant differences in prostate, cervical, and breast cancer screening rates, but Muslims were less likely to undergo colorectal cancer screening. When differences in obesity and insurance status were accounted for in a multivariate regression model, religious affiliation was no longer significantly associated with screening rates.

DISCUSSION

Religious values can influence cancer screening behaviors; hence, tracking cancer screening along religious lines may illuminate previously unknown disparities. Our analysis of a predominately African American cohort of Chicagoans, however, did not reveal religious affiliation to predict cancer screening disparities.

Concurrent participation in breast, cervical, and colorectal cancer screening programmes in Denmark: A nationwide registry-based study

Women in Denmark are invited to breast, cervical, and colorectal cancer screening in their fifties and sixties. We determined the patterns of concurrent participation in the three programmes. Participation in organised cancer screening was determined using the highly complete Danish population and health care registers for all women aged 53-65 years on 31 March 2018 who continuously resided in Denmark since 1 April 2012. Data were linked using unique personal identification numbers. We studied overall and cancer-specific proportions of women undergoing screening for all three, two, one, and none of the cancers. Among all 468,507 women, 406,306 (87%) participated in breast, 345,768 (74%) in cervical, and 316,496 (68%) in colorectal cancer screening. Despite high participation, only 255,698 (55%) women were screened for all three cancers, while 123,469 (26%) were screened for two, 54,538 (12%) for one, and 34,802 (7%) were not screened for any cancer. Cancer-specific patterns were highly heterogeneous across the population but changed little after accounting for women's medical history. A significant proportion of women who are screened for a specific cancer remain unscreened for other cancers. The consistency of these data at the international level requires a reconsideration of invitational practices for organised screening.

Use of 2-Stage Modeling to Identify How Colorectal Cancer Risk Changes With Period and Cohort

Colorectal cancer (CRC) incidence rates have decreased among adults aged 50 years or older while increasing in adults under age 50 years. Understanding these trends is challenging because of the multiple related time scales of age, diagnosis period, and birth cohort. We analyzed incidence rates of rectal, distal colon, and proximal colon cancer for individuals aged 20 years or more from the Surveillance, Epidemiology, and End Results Program for diagnosis years 1978-2017. We used a 2-stage generalized linear model to determine age, period, and cohort effects for CRC incidence. We first estimated birth cohort effects among people under age 45 years. We used these results to specify prior distributions for cohort effects in a Bayesian model to estimate period effects among people aged 45 years or more. There was no evidence of period effects for people under age 45 years. Risks of rectal and distal colon cancer increased for later birth cohorts. Compared with the 1943-1952 birth cohort, the 1983-1992 birth cohort had 2.2 times the risk of rectal cancer, 1.9 times the risk of distal colon cancer, and 1.3 times the risk of proximal colon cancer. For people aged ≥45 years, period effects showed declines in CRC risk that were attributable to screening.

Long-Term Impact of Medicaid Expansion on Colorectal Cancer Screening in Its Targeted Population

INTRODUCTION

Colorectal cancer screening continuously decreased its mortality and incidence. In 2010, the Affordable Care Act extended Medicaid eligibility to low-income and childless adults. Some states elected to adopt Medicaid at different times while others chose not to. Past studies on the effects of Medicaid expansion on colorectal cancer screening showed equivocal results based on short-term data following expansion.

AIMS

To examine the long-term impact of Medicaid expansion on colorectal cancer screening among its targeted population at its decade mark.

METHODS

Behavioral Risk Factor Surveillance System data were extracted for childless adults below 138% federal poverty level in states with different Medicaid expansion statuses from 2012 to 2020. States were stratified into very early expansion states, early expansion states, late expansion states, and non-expansion states. Colorectal cancer screening prevalence was determined for eligible respondents. Difference-in-differences analyses were used to examine the effect of Medicaid expansion on colorectal cancer screening in states with different expansion statuses.

RESULTS

Colorectal cancer screening prevalence in very early, early, late, and non-expansion states all increased during the study period (40.45% vs. 48.14%, 47.52% vs 61.06%, 46.06% vs 58.92%, and 43.44% vs 56.70%). Difference-in-differences analysis showed significantly increased CRC screening prevalence in very early expansion states during 2016 compared to non-expansion states (Crude difference-in-differences + 16.45%, p = 0.02, Adjusted difference-in-differences + 15.9%, p = 0.03). No statistical significance was observed among other years and groups.

CONCLUSIONS

Colorectal cancer screening increased between 2012 and 2020 in all states regardless of expansion status. However, Medicaid expansion is not associated with long-term increased colorectal cancer screening prevalence.

Lower Utilization of Colorectal Cancer Screening Among Vegetarians, Adventist Health Study-2

This study aims to examine lifestyle predictors of the utilization of colorectal cancer screening. Using modified Poisson regression, we studied self-reported colorectal cancer screening utilization (colonoscopy or fecal occult blood test) with various dietary and lifestyle characteristics among 33,922 subjects aged 51 + years in the Adventist Health Study-2, a large population-based prospective cohort study. According to the multivariable-adjusted models, vegetarians were less likely to report screening: vegans, prevalence ratio (PR) = 0.80 (95% confidence interval 0.77-0.83); lacto-ovo-vegetarians (0.95 [0.93-0.97]); and semi-vegetarians (0.97 [0.94-0.99]) compared to non-vegetarians. Blacks were more likely than non-Blacks to be screened (1.04 [1.02-1.06]) and males were less likely (0.93 [0.92-0.95]) to utilize the screening tests. Older subjects were more likely to be screened, and unmarried and divorced/widowed subjects were less likely to screen. Education, personal income, and BMI were positively associated with screening, with p-value for trend < 0.001 for all three variables. A family history of colorectal cancer was associated with higher screening prevalence (1.15 [1.12-1.17]). Our stratified analyses on race and gender with dietary patterns showed non-Hispanic White vegans (PR = 0.77 [0.74-0.81]) and male vegans (PR = 0.76 [0.72-0.81]) were least likely compliant with colorectal cancer screening (p = 0.009 and p = 0.04, respectively). Vegans may believe that their personal risk for colorectal cancer is low due to their healthy lifestyle, resulting in lack of compliance to colorectal cancer screening. It remains to be seen whether vegans in AHS-2 also experience higher incidence of colorectal cancer or are diagnosed at a later stage.

Impact of race-specific screening guideline on the uptake of colorectal cancer screening among young African Americans

BACKGROUND

African Americans (AAs) have had lower colorectal cancer (CRC) screening rates, higher incidence rate, and earlier mean age at onset. The 2017 U.S. Multi-Society Task Force (MSTF) recommended initiating CRC screening at age 45 for AAs and age 50 for non-AAs.

OBJECTIVE

To investigate the impact of the 2017 MSTF's race-specific guidelines on CRC screening rate among young AAs.

DESIGN, SETTING, AND PARTICIPANTS

We used the 2015 and 2018 National Health Interview Survey to provide nationally representative estimates. The study sample included adults aged between 45 and 75 without a history of CRC, excluding screening recipients for diagnosis or surveillance purposes.

MAIN MEASURES

The outcome is a binary variable of CRC screening. Primary independent variables were age and race category (non-AAs aged 45-49, AAs 45-49, non-AAs 50-75, AAs 50-75), a binary variable indicating before or after the 2017 MSTF guideline (2015 vs. 2018), and their interaction terms. We employed a multivariable logistic model, adjusting for individual characteristics, and accounting for complex survey design.

KEY RESULTS

Among the total sample (n = 21,735), CRC screening rate increased from 54.6% in 2015 to 58.5% in 2018 (p < 0.01). By age and race, the screening rate exhibited an increase for all age and race groups except for young non-AAs. Compared to young non-AAs, the adjusted predicted probability (APP) of screening for young AAs was significantly higher by 0.10 (average marginal effect, 0.10; 95% confidence interval, 0.01-0.19) in 2018, while the difference was insignificant in 2015. Racial differences in screening among older adults were not significant in both years. The CRC screening rate was substantially lower among young AAs compared to older AAs (17.2% vs. 65.5% in 2018).

CONCLUSION

The race-specific recommendation is an effective policy tool to increase screening uptake and would contribute to reducing cancer disparities among racial/ethnic minorities.

A simplified multiplex methylated DNA testing for early detection of colorectal cancer in stool DNA

Background

ColoDefense1.0 assay has demonstrated its excellent sensitivity and specificity for early detection of colorectal cancer (CRC) by detecting the methylation levels of SDC2 and SEPT9, while exhibited limitations on relatively large sample capacity required and limited detection throughput by applying triplicate PCR reactions for each sample. In this study, ColoDefense1.0 was simplified and optimized into ColoDefense2.0 in a single PCR reaction.

Methods

A total 529 stool specimens were collected, and 244 CRC patients, 34 patients with advanced adenomas (AA), 64 with small polyps (SP) and 187 control subjects were divided in training and validation cohorts. Methylation levels of SEPT9 and SDC2 were examined by qPCR reactions in triplicate or single.

Results

The stool DNA quantity stored in preservative buffer at 37 °C up to 7 days exhibited no significant decrease. In the training cohort, when the number of replicates reduced from 3 to 1, the overall performance of ColoDefense2.0 was identical to that of ColoDefense1.0, showing sensitivities of 71.4% for AA and 90.8% for all stage CRC with a specificity of 92.9%. In the validation cohort, sensitivities of SP, AA and CRC using ColoDefense2.0 were 25.0%, 55.0% and 88.2%, increased from 14.1% (20.3%), 40.0% (40.0%) and 79.4% (67.6%) using SDC2 (SEPT9) alone; along with an overall specificity of 90.2%, decreased from 94.1% (95.1%) using SDC2 (SEPT9) alone.

Conclusion

The simplified ColoDefense test maintained the overall performance while reduced the number of PCR reactions to 1/3, and provided an effective and convenient tool to detect early CRC and precancerous lesions and potentially improve the compliance of screening.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12876-022-02512-6.

Effects of Attendance to an Organized Fecal Immunochemical Test Screening Program on the Risk of Colorectal Cancer: An Observational Cohort Study

BACKGROUND & AIMS

This cohort study compared colorectal cancer (CRC) incidence and mortality between people who participated in an Italian regional biennial fecal immunochemical test (FIT) screening program and people who did not.

METHODS

The program started in 2005. The target population included over 1,000,000 people aged 50 to 69 years. The FIT was a one-sample OC-Sensor (Eiken Chemical Co, Tokyo, Japan) (cutoff, ≥20 μg hemoglobin/g feces). The average annual response rate to invitation was 51.4%. The records of people invited up to June 2016 were extracted from the screening data warehouse. Attenders were subjects who responded to the first 2 invitations or to the single invitation sent them before they became ineligible. Non-attenders were subjects who did not respond to any of these invitations. The records were linked with the regional CRC registry. People registered up to December 2016 were identified. Self-selection-adjusted incidence rate ratios (IRRs) and incidence-based CRC mortality rate ratios (MRRs) for attenders to non-attenders, with 95% confidence intervals (CIs), were calculated.

RESULTS

The cohort generated 2,622,131 man-years and 2,887,845 woman-years at risk with 4490 and 3309 CRC cases, respectively. The cohort of attenders was associated with an IRR of 0.65 (95% CI, 0.61-0.69) for men, 0.75 (95% CI, 0.70-0.80) for women and 0.69 (95% CI, 0.66-0.72) for both sexes combined. The self-selection-adjusted IRR was 0.67 (95% CI, 0.62-0.72) for men and 0.79 (95% CI, 0.72-0.88) for women. The IRR for stage I, II, III, and IV CRC was 1.35 (95% CI, 1.20-1.50), 0.61 (95% CI, 0.53-0.69), 0.60 (95% CI, 0.53-0.68) and 0.28 (95% CI, 0.24-0.32) for men and 1.64 (95% CI, 1.43-1.89), 0.60 (95% CI, 0.52-0.69), 0.73 (95% CI, 0.63-0.85) and 0.35 (95% CI, 0.30-0.42) for women. The overall incidence-based CRC MRR was 0.32 (95% CI, 0.28-0.37) for men, 0.40 (95% CI, 0.34-0.47) for women and 0.35 (95% CI, 0.31-0.39) for both sexes combined. The adjusted MRR was 0.35 (95% CI, 0.29-0.41) for men and 0.46 (95% CI, 0.37-0.58) for women.

CONCLUSIONS

Attendance to a FIT screening program is associated with a CRC incidence reduction of 33% among men and 21% among women, and a CRC mortality reduction of 65% and 54%, respectively.

Single CT Appointment for Double Lung and Colorectal Cancer Screening: Is the Time Ripe?

Annual screening of lung cancer (LC) with chest low-dose computed tomography (CT) and screening of colorectal cancer (CRC) with CT colonography every 5 years are recommended by the United States Prevention Service Task Force. We review epidemiological and pathological data on LC and CRC, and the features of screening chest low-dose CT and CT colonography comprising execution, reading, radiation exposure and harm, and the cost effectiveness of the two CT screening interventions. The possibility of combining chest low-dose CT and CT colonography examinations for double LC and CRC screening in a single CT appointment is then addressed. We demonstrate how this approach appears feasible and is already reasonable as an opportunistic screening intervention in 50–75-year-old subjects with smoking history and average CRC risk. In addition to the crucial role Computer Assisted Diagnosis systems play in decreasing the test reading times and the need to educate radiologists in screening chest LDCT and CT colonography, in view of a single CT appointment for double screening, the following uncertainties need to be solved: (1) the schedule of the screening CT; (2) the effectiveness of iterative reconstruction and deep learning algorithms affording an ultra-low-dose CT acquisition technique and (3) management of incidental findings. Resolving these issues will imply new cost-effectiveness analyses for LC screening with chest low dose CT and for CRC screening with CT colonography and, especially, for the double LC and CRC screening with a single-appointment CT.

Evaluation of Blood Soluble CD26 as a Complementary Biomarker for Colorectal Cancer Screening Programs

Fecal hemoglobin immunodetection (FIT) in combination with endoscopy has been implemented to reduce mortality from colorectal cancer (CRC), although there are issues that can be improved in relation to participation rates. We studied whether the blood biomarker soluble-CD26 (sCD26), related at least in part to the immune system and inflammation, and/or its dipeptidyl peptidase enzyme activity (DPP4), could help reduce false positives. In a cohort of 1703 individuals who underwent colonoscopy and had a serum sample, sCD26 and DPP4 activity showed statistically significant differences regarding sex and age. According to the colonoscopy findings, sCD26 and DPP4 activity progressively decreased in advanced adenomas and CRC, with statistically significant differences, even between both groups; 918 of them had a FIT result (n = 596 positive cases) with approximately 70% of these (n = 412) false positives. With cut-offs of 440 ng/mL for sCD26, 42 mU/mL for DPP4, and 11 ng/mU for their ratio, the combined information of the three biomarkers (at least positive for one biomarker) identified almost all advanced adenomas and CRC cases in the FIT cohort with approximately half of the false positives compared to FIT. A sequential testing strategy with FIT and our blood biomarker test is proposed.

Predictors of Nonadherence to Colorectal Cancer Screening among Hospitalized Women

OBJECTIVES

Despite proven mortality benefit, disparities in colorectal cancer (CRC) screening utilization persist, especially among younger women, minorities, and low-income women, even those who are insured. The purpose of the present study is to evaluate and estimate the effects of sociodemographic and clinical variables associated with nonadherence to CRC screening among hospitalized women.

METHODS

A cross-sectional bedside survey was conducted to collect sociodemographic and clinical comorbidity data believed to affect CRC screening adherence of hospitalized women aged 50 to 75 years who were cancer free (except skin cancer) at enrollment. Logistic regression models were used to assess the association between these factors and nonadherence CRC screening.

RESULTS

In total, 510 women were enrolled for participation in the study. After adjustment for sociodemographic and clinical predictors, only two variables were found to be independently associated with nonadherence to CRC screening: age younger than 60 years (odds ratio [OR] 2.62, 95% confidence interval [CI] 1.58-4.33) and nonadherence to breast cancer screening (OR 3.72, 95% CI 2.29-6.04). By contrast, hospitalized women at high risk for CRC were more likely to be compliant with CRC screening (OR 0.14, 95% CI 0.04-0.50).

CONCLUSIONS

Both younger age and behavior toward screening remain barriers to CRC screening. Hospitalization creates an environment where patients are in close proximity to healthcare resources, and strategies could be used to capitalize on this opportunity to counsel, educate, and motivate patients toward this screening that is necessary for health maintenance. Seizing on this opportunity may help improve CRC screening adherence.

Colonoscopy Needs for Implementation of a Colorectal Cancer Screening Program in Ukraine

BACKGROUND

In Ukraine, there is no established colorectal cancer screening program. We aimed to project the number of screening colonoscopies needed for implementation of various CRC screening strategies in Ukraine.

METHODS

We modified a previously developed Markov microsimulation model to reflect the natural history of adenoma and CRC progression among average-risk 50-74-year-olds. We simulated colonoscopies needed for the following screening strategies: no screening, fecal occult blood test yearly, FOBT yearly with flexible sigmoidoscopy every 5 years, FS every 5 years, fecal immunohistochemistry test (FIT) yearly, or colonoscopy every 10 years. Assuming 80% screening adherence, we estimated colonoscopies required at 1 and 5 years depending on the implementation rate. In one-way sensitivity analyses, we varied implementation rate, screening adherence, sensitivity, and specificity.

RESULTS

Assuming an 80% screening adherence and complete implementation (100%), besides a no screening strategy, the fewest screening colonoscopies are needed with an FOBT program, requiring on average 6,600 and 26,800 colonoscopies per 100,000 persons at 1 and 5 years post-implementation, respectively. The most screening colonoscopies are required with a colonoscopy program, requiring on average 76,600 and 101,000 colonoscopies per 100,000 persons at 1 and 5 years post-implementation, respectively. In sensitivity analyses, the biggest driver of number of colonoscopies needed was screening adherence.

CONCLUSIONS

The number of colonoscopies needed and therefore the potential strain on the healthcare system vary substantially by screening test. These findings can provide valuable information for stakeholders on equipment needs when implementing a national screening program in Ukraine.

Global, regional, and national burden of colorectal cancer and its risk factors, 1990-2019: a systematic analysis for the Global Burden of Disease Study 2019

BACKGROUND

Colorectal cancer is the third leading cause of cancer deaths worldwide. Given the recent increasing trends in colorectal cancer incidence globally, up-to-date information on the colorectal cancer burden could guide screening, early detection, and treatment strategies, and help effectively allocate resources. We examined the temporal patterns of the global, regional, and national burden of colorectal cancer and its risk factors in 204 countries and territories across the past three decades.

METHODS

Estimates of incidence, mortality, and disability-adjusted life years (DALYs) for colorectal cancer were generated as a part of the Global Burden of Diseases, Injuries and Risk Factors Study (GBD) 2019 by age, sex, and geographical location for the period 1990-2019. Mortality estimates were produced using the cause of death ensemble model. We also calculated DALYs attributable to risk factors that had evidence of causation with colorectal cancer.

FINDINGS

Globally, between 1990 and 2019, colorectal cancer incident cases more than doubled, from 842 098 (95% uncertainty interval [UI] 810 408-868 574) to 2·17 million (2·00-2·34), and deaths increased from 518 126 (493 682-537 877) to 1·09 million (1·02-1·15). The global age-standardised incidence rate increased from 22·2 (95% UI 21·3-23·0) per 100 000 to 26·7 (24·6-28·9) per 100 000, whereas the age-standardised mortality rate decreased from 14·3 (13·5-14·9) per 100 000 to 13·7 (12·6-14·5) per 100 000 and the age-standardised DALY rate decreased from 308·5 (294·7-320·7) per 100 000 to 295·5 (275·2-313·0) per 100 000 from 1990 through 2019. Taiwan (province of China; 62·0 [48·9-80·0] per 100 000), Monaco (60·7 [48·5-73·6] per 100 000), and Andorra (56·6 [42·8-71·9] per 100 000) had the highest age-standardised incidence rates, while Greenland (31·4 [26·0-37·1] per 100 000), Brunei (30·3 [26·6-34·1] per 100 000), and Hungary (28·6 [23·6-34·0] per 100 000) had the highest age-standardised mortality rates. From 1990 through 2019, a substantial rise in incidence rates was observed in younger adults (age <50 years), particularly in high Socio-demographic Index (SDI) countries. Globally, a diet low in milk (15·6%), smoking (13·3%), a diet low in calcium (12·9%), and alcohol use (9·9%) were the main contributors to colorectal cancer DALYs in 2019.

INTERPRETATION

The increase in incidence rates in people younger than 50 years requires vigilance from researchers, clinicians, and policy makers and a possible reconsideration of screening guidelines. The fast-rising burden in low SDI and middle SDI countries in Asia and Africa calls for colorectal cancer prevention approaches, greater awareness, and cost-effective screening and therapeutic options in these regions.

FUNDING

Bill & Melinda Gates Foundation.

When History and Heterogeneity Matter: A Tutorial on the Impact of Markov Model Specifications in the Context of Colorectal Cancer Screening

BACKGROUND

Markov models are used in health research to simulate health care utilization and disease states over time. Health phenomena, however, are complex, and the memoryless assumption of Markov models may not appropriately represent reality. This tutorial provides guidance on the use of Markov models of different orders and stratification levels in health decision-analytic modeling. Colorectal cancer (CRC) screening is used as a case example to examine the impact of using different Markov modeling approaches on CRC outcomes.

METHODS

This study used insurance claims data from commercially insured individuals in Oregon to estimate transition probabilities between CRC screening states (no screen, colonoscopy, fecal immunochemical test or fecal occult blood test). First-order, first-order stratified by sex and geography, and third-order Markov models were compared. Screening trajectories produced from the different Markov models were incorporated into a microsimulation model that simulated the natural history of CRC disease progression. Simulation outcomes (e.g., future screening choices, CRC incidence, deaths due to CRC) were compared across models.

RESULTS

Simulated CRC screening trajectories and resulting CRC outcomes varied depending on the Markov modeling approach used. For example, when using the first-order, first-order stratified, and third-order Markov models, 30%, 31%, and 44% of individuals used colonoscopy as their only screening modality, respectively. Screening trajectories based on the third-order Markov model predicted that a higher percentage of individuals were up-to-date with CRC screening as compared with the other Markov models.

LIMITATIONS

The study was limited to insurance claims data spanning 5 y. It was not possible to validate which Markov model better predicts long-term screening behavior and outcomes.

CONCLUSIONS

Findings demonstrate the impact that different order and stratification assumptions can have in decision-analytic models.

HIGHLIGHTS

This tutorial uses colorectal cancer screening as a case example to provide guidance on the use of Markov models of different orders and stratification levels in health decision-analytic models.Colorectal cancer screening trajectories and projected health outcomes were sensitive to the use of alternate Markov model specifications.Although data limitations precluded the assessment of model accuracy beyond a 5-y period, within the 5-y period, the third-order Markov model was slightly more accurate in predicting the fifth colorectal cancer screening action than the first-order Markov model.Findings from this tutorial demonstrate the importance of examining the memoryless assumption of the first-order Markov model when simulating health care utilization over time.

How a faecal immunochemical test screening programme changes annual colorectal cancer incidence rates: an Italian intention-to-screen study

Background

This study aimed to evaluate the effectiveness of a biennial faecal immunochemical test (FIT) screening programme in reducing annual colorectal cancer (CRC) incidence in its dynamic target population.

Methods

The target population included over 1,000,000 persons aged 50–69 living in a region of northern Italy. The average annual response rate to invitation was 51.4%. Each observed annual age-standardised (Europe) rate per 100,000 persons between 2005, the year of introduction of the programme, and 2016 was compared with each expected annual rate as estimated with age-period-cohort (men) and age-period (women) models.

Results

For both sexes, the rates observed in 1997–2004 and those expected in 2005–2016 were stable. Observed rates increased in 2005, peaked in 2006 (the first full year of screening), dropped significantly below the expected level in 2009, and continued to decrease until 2013 (the eighth full year), after which no further significant changes occurred. In the pooled years 2013–2016, the observed incidence rate per 100,000 persons was 102.2 [95% CI: 97.4, 107.1] for men, 75.6 [95% CI: 71.6, 79.7] for women and 88.4 [95% CI: 85.3, 91.5] for both sexes combined, with an observed:expected incidence rate ratio of 0.68 [95% CI: 0.65, 0.71], 0.79 [95% CI: 0.76, 0.82] and 0.72 [95% CI: 0.66, 0.81], respectively.

Discussion

The study provided multiple consistent proofs of a causal relationship between the introduction of screening and a stable 28% decrease in annual CRC incidence after eight years.

Engaging the Community on Colorectal Cancer Screening Education: Focus Group Discussions Among African Americans

Colorectal cancer (CRC) is the third most diagnosed cancer in the USA, and African Americans experience disproportionate CRC diagnosis and mortality. Early detection could reduce CRC incidence and mortality, and reduce CRC health disparities, which may be due in part to lower screening adherence and later stage diagnosis among African Americans compared to whites. Culturally tailored interventions to increase access to and uptake of CRC stool-based tests are one effective strategy to increase benefits of screening among African Americans. The objectives of this study were to obtain feedback from African Americans on CRC educational materials being developed for a subsequent behavioral clinical trial and explore participants' knowledge, attitudes, and beliefs about CRC and CRC screening. Seven focus groups were conducted between February and November 2020. Participants were African Americans recruited through community contacts. Four focus groups were held in-person and three were conducted virtually due to Covid-19 restrictions. Participants ranked CRC educational text messages and provided feedback on a culturally tailored educational brochure. A focus group guide with scripted probes was used to elicit discussion and transcripts were analyzed using traditional content analysis. Forty-two African Americans participated. Four themes were identified from focus group discussions: (1) knowledge, attitudes, and beliefs on CRC and CRC screening; (2) reliable sources of cancer education information; (3) cultural factors affecting perspectives on health; and (4) community insights into cancer education. Participant input on the brochure was incorporated in content creation. Engaging African American community members to qualitatively examine cancer prevention has value in improving implementation strategy and planning for behavioral clinical trials.