Community-based colorectal cancer screening trials with multi-ethnic groups: a systematic review

Patient Navigation Plus Tailored Digital Video Disc Increases Colorectal Cancer Screening Among Low-Income and Minority Patients Who Did Not Attend a Scheduled Screening Colonoscopy: A Randomized Trial

BACKGROUND

Up to 50% of people scheduled for screening colonoscopy do not complete this test and no studies have focused on minority and low-income populations. Interventions are needed to improve colorectal cancer (CRC) screening knowledge, reduce barriers, and provide alternative screening options. Patient navigation (PN) and tailored interventions increase CRC screening uptake, however there is limited information comparing their effectiveness or the effect of combining them.

PURPOSE

Compare the effectiveness of two interventions to increase CRC screening among minority and low-income individuals who did not attend their screening colonoscopy appointment-a mailed tailored digital video disc (DVD) alone versus the mailed DVD plus telephone-based PN compared to usual care.

METHODS

Patients (n = 371) aged 45-75 years at average risk for CRC who did not attend a screening colonoscopy appointment were enrolled and were randomized to: (i) a mailed tailored DVD; (ii) the mailed DVD plus phone-based PN; or (iii) usual care. CRC screening outcomes were from electronic medical records at 12 months. Multivariable logistic regression analyses were used to study intervention effects.

RESULTS

Participants randomized to tailored DVD plus PN were four times more likely to complete CRC screening compared to usual care and almost two and a half times more likely than those who were sent the DVD alone.

CONCLUSIONS

Combining telephone-based PN with a mailed, tailored DVD increased CRC screening among low-income and minority patients who did not attend their screening colonoscopy appointments and has potential for wide dissemination.

The Genomic Landscape of Colorectal Cancer in the Saudi Arabian Population Using a Comprehensive Genomic Panel

PURPOSE

Next-generation sequencing (NGS) technology detects specific mutations that can provide treatment opportunities for colorectal cancer (CRC) patients.

PATIENTS AND METHODS

We analyzed the mutation frequencies of common actionable genes and their association with clinicopathological characteristics and oncologic outcomes using targeted NGS in 107 Saudi Arabian patients without a family history of CRC.

RESULTS

Approximately 98% of patients had genetic alterations. Frequent mutations were observed in BRCA2 (79%), CHEK1 (78%), ATM (76%), PMS2 (76%), ATR (74%), and MYCL (73%). The APC gene was not included in the panel. Statistical analysis using the Cox proportional hazards model revealed an unusual positive association between poorly differentiated tumors and survival rates (p = 0.025). Although no significant univariate associations between specific mutations or overall mutation rate and overall survival were found, our preliminary analysis of the molecular markers for CRC in a predominantly Arab population can provide insights into the molecular pathways that play a significant role in the underlying disease progression.

CONCLUSIONS

These results may help optimize personalized therapy when drugs specific to a patient's mutation profile have already been developed.

Modelling tool to support decision-making in the NHS Health Check programme: workshops, systematic review and co-production with users

BACKGROUND

Local authorities in England commission the NHS Health Check programme to invite everyone aged 40-74 years without pre-existing conditions for risk assessment and eventual intervention, if needed. However, the programme's effectiveness, cost-effectiveness and equity impact remain uncertain.

AIM

To develop a validated open-access flexible web-based model that enables local commissioners to quantify the cost-effectiveness and potential for equitable population health gain of the NHS Health Check programme.

OBJECTIVES

The objectives were as follows: (1) co-produce with stakeholders the desirable features of the user-friendly model; (2) update the evidence base to support model and scenario development; (3) further develop our computational model to allow for developments and changes to the NHS Health Check programme and the diseases it addresses; (4) assess the effectiveness, cost-effectiveness and equity of alternative strategies for implementation to illustrate the use of the tool; and (5) propose a sustainability and implementation plan to deploy our user-friendly computational model at the local level.

DESIGN

Co-production workshops surveying the best-performing local authorities and a systematic literature review of strategies to increase uptake of screening programmes informed model use and development. We then co-produced the workHORSE (working Health Outcomes Research Simulation Environment) model to estimate the health, economic and equity impact of different NHS Health Check programme implementations, using illustrative-use cases.

SETTING

Local authorities in England.

PARTICIPANTS

Stakeholders from local authorities, Public Health England, the NHS, the British Heart Foundation, academia and other organisations participated in the workshops. For the local authorities survey, we invited 16 of the best-performing local authorities in England.

INTERVENTIONS

The user interface allows users to vary key parameters that represent programme activities (i.e. invitation, uptake, prescriptions and referrals). Scenarios can be compared with each other.

MAIN OUTCOME MEASURES

Disease cases and case-years prevented or postponed, incremental cost-effectiveness ratios, net monetary benefit and change in slope index of inequality.

RESULTS

The survey of best-performing local authorities revealed a diversity of effective approaches to maximise the coverage and uptake of NHS Health Check programme, with no distinct 'best buy'. The umbrella literature review identified a range of effective single interventions. However, these generally need to be combined to maximally improve uptake and health gains. A validated dynamic, stochastic microsimulation model, built on robust epidemiology, enabled service options analysis. Analyses of three contrasting illustrative cases estimated the health, economic and equity impact of optimising the Health Checks, and the added value of obtaining detailed local data. Optimising the programme in Liverpool can become cost-effective and equitable, but simply changing the invitation method will require other programme changes to improve its performance. Detailed data inputs can benefit local analysis.

LIMITATIONS

Although the approach is extremely flexible, it is complex and requires substantial amounts of data, alongside expertise to both maintain and run.

CONCLUSIONS

Our project showed that the workHORSE model could be used to estimate the health, economic and equity impact comprehensively at local authority level. It has the potential for further development as a commissioning tool and to stimulate broader discussions on the role of these tools in real-world decision-making.

FUTURE WORK

Future work should focus on improving user interactions with the model, modelling simulation standards, and adapting workHORSE for evaluation, design and implementation support.

STUDY REGISTRATION

This study is registered as PROSPERO CRD42019132087.

FUNDING

This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 25, No. 35. See the NIHR Journals Library website for further project information.

Which communication strategies can improve interventions aimed at tackling social inequalities in organized cancer screening in France?

Interventions to increase participation in cancer screening programs have been developed and evaluated by our research team. The results observed provide an opportunity to consider which methods of communication should be encouraged to improve those interventions. The objective of this commentary is to recommend communication strategies which should be adopted to efficiently reach and support disadvantaged individuals to engage in cancer screening, as a healthy behaviour.

Achieving Health Equity in Preventive Services: A Systematic Review for a National Institutes of Health Pathways to Prevention Workshop

BACKGROUND

Disadvantaged populations in the United States experience disparities in the use of preventive health services.

PURPOSE

To examine effects of barriers that create health disparities in 10 recommended preventive services for adults, and to evaluate the effectiveness of interventions to reduce them.

DATA SOURCES

English-language searches of Ovid MEDLINE, PsycINFO, SocINDEX, and the Veterans Affairs Health Services database (1 January 1996 to 5 July 2019); reference lists.

STUDY SELECTION

Trials, observational studies with comparison groups, and systematic reviews of populations adversely affected by disparities that reported effects of barriers on use of any of the 10 selected preventive services or that reported the effectiveness of interventions to reduce disparities in use of a preventive service by improving intermediate or clinical outcomes.

DATA EXTRACTION

Dual extraction and assessment of study quality, strength of evidence, and evidence applicability.

DATA SYNTHESIS

No studies reported effects of provider-specific barriers on preventive service use. Eighteen studies reporting effects of patient barriers, such as insurance coverage or lack of a regular provider, on preventive service use had mixed and inconclusive findings. Studies of patient-provider interventions (n = 12), health information technologies (n = 11), and health system interventions (n = 88) indicated higher cancer screening rates with patient navigation; telephone calls, prompts, and other outreach methods; reminders involving lay health workers; patient education; risk assessment, counseling, and decision aids; screening checklists; community engagement; and provider training. Single studies showed that clinician-delivered and technology-assisted interventions improved rates of smoking cessation and weight loss, respectively.

LIMITATION

Insufficient or low strength of evidence and applicability for most interventions except patient navigation, telephone calls and prompts, and reminders involving lay health workers.

CONCLUSION

In populations adversely affected by disparities, patient navigation, telephone calls and prompts, and reminders involving lay health workers increase cancer screening.

PRIMARY FUNDING SOURCE

National Institutes of Health Office of Disease Prevention through an interagency agreement with the Agency for Healthcare Research and Quality. (PROSPERO: CRD42018109263).

A Systematic Review of U.S.-Based Colorectal Cancer Screening Uptake Intervention Systematic Reviews: Available Evidence and Lessons Learned for Research and Practice

Background: We examined colorectal cancer screening (CRCS) intervention effectiveness, through the effect sizes associated with: (1) screening modality, (2) intervention level (e.g., client-directed), and (3) intervention component (e.g. client reminders) within published CRCS intervention systematic reviews (SRs).

Methods: A search of peer-reviewed CRCS SRs that were written in English was employed utilizing five databases: CINAHL, Cochrane Library, rTIPS, PubMed, and PsycINFO EBSCOHOST. SRs that included CRCS interventions with a randomized controlled trial, quasi-experimental, or single arm design were eligible. Data on effect sizes by screening modality, intervention level, and intervention component were extracted and synthesized.

Results: There were 16 eligible CRCS intervention SRs that included 116 studies published between 1986 and 2013. Reviews organized data by CRCS screening modality, or intervention component. Effect size reporting varied by format (i.e., ranges, medians of multiple studies, or effect size per study), and groupings of modalities and components. Overall, the largest effect sizes were for studies that utilized a combination of colonoscopy, fecal occult blood test (FOBT), and sigmoidoscopy as screening options (16–45 percentage point difference).

Conclusions: Evidence suggests that CRCS interventions which include a combination of screening modalities may be most effective. This is the first SR to examine effect sizes of published CRCS SRs. However, because some SRs did not report effect sizes and there were tremendous variability reporting formats among those that did, a standard reporting format is warranted. Synthesizing findings can contribute to improved knowledge of evidence-based best-practices, direct translation of findings into policy and practice, and guide further research in CRCS.

Colorectal Cancer: A Collaborative Approach to Improve Education and Screening in a Rural Population

BACKGROUND

Colorectal cancer (CRC) is the third most commonly diagnosed cancer and second leading cause of cancer death for men and women in the United States. Although early detection and diagnosis greatly affect survival rates, only about half of the U.S. population participates in screening.
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OBJECTIVES

The purpose of this project was to implement community-based CRC education and screening. Outcomes included CRC knowledge, CRC screening kit return rate, and rate of positive screening results. 
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METHODS

Partnering with a community hospital, CRC educational sessions and free screening opportunities were provided for 193 local city government employees. CRC knowledge was assessed before and after education with the Knowledge Assessment Survey. A paired t test indicated significant improvement in mean CRC knowledge.
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FINDINGS

More than half of the participants elected to take home fecal immunochemical test kits. Of the 29 participants who submitted their screening kits for evaluation, eight had positive results and received referral recommendations. All participants were notified of their screening results. The community-based CRC project was effective in improving CRC knowledge and screening participation.

Use of Evidence-Based Interventions and Implementation Strategies to Increase Colorectal Cancer Screening in Federally Qualified Health Centers

While colorectal cancer (CRC) screening rates have been increasing in the general population, rates are considerably lower in Federally Qualified Health Centers (FQHCs), which serve a large proportion of uninsured and medically vulnerable patients. Efforts to screen eligible patients must be accelerated if we are to reach the national screening goal of 80% by 2018 and beyond. To inform this work, we conducted a survey of key informants at FQHCs in eight states to determine which evidence-based interventions (EBIs) to promote CRC screening are currently being used, and which implementation strategies are being employed to ensure that the interventions are executed as intended. One hundred and forty-eight FQHCs were invited to participate in the study, and 56 completed surveys were received for a response rate of 38%. Results demonstrated that provider reminder and recall systems were the most commonly used EBIs (44.6%) while the most commonly used implementation strategy was the identification of barriers (84.0%). The mean number of EBIs that were fully implemented at the centers was 2.4 (range 0-7) out of seven. Almost one-quarter of respondents indicated that their FQHCs were not using any EBIs to increase CRC screening. Full implementation of EBIs was correlated with higher CRC screening rates. These findings identify gaps as well as the preferences and needs of FQHCs in selecting and implementing EBIs for CRC screening.

Interventions Promoting Colorectal Cancer Screening Among Latino Men: A Systematic Review

Introduction

Colorectal cancer, the second leading cause of cancer death in the United States, is also among the most preventable cancers. However, Latino men are less likely than non-Latino men to engage in preventive screening. Compared with 60% of non-Latino white men and women, only 42% of Latino men are up to date with colorectal cancer screening guidelines, which may result in diagnosis at advanced disease stages and increased deaths. We evaluated the literature on colorectal cancer screening interventions among Latino men to characterize intervention components effective in increasing colorectal cancer screening.

Methods

Two independent reviewers searched MEDLINE, CINAHL, and PsycINFO to identify articles on intervention studies that promote colorectal cancer screening among Latino men. Inclusion criteria were randomized controlled or comparative effectiveness trials, an outcome of any colorectal cancer screening test, published in English, US-based, results published from January 2004 through December 2016, Latino or Spanish-speaking male participants, and a minimum of one patient-level component. Two other reviewers independently assessed article quality and conducted data abstraction.

Results

Forty-four studies met the inclusion criteria; only 7 studies with 20% or more Latinos and 39% or more men were included in the final analyses. The most common intervention strategies included one-on-one interactions with a patient navigator and reducing structural barriers (eg, providing fecal occult blood tests). Interventions using small media produced mixed results.

Conclusion

Although intervention studies focused on colorectal cancer screening among men of racial/ethnic minorities are scarce, our findings highlight promising strategies that were effective at increasing colorectal cancer screening among Latino men. Additional research in the area of Latino men’s health is needed, especially to further develop and test theoretically grounded interventions that promote colorectal cancer screening with larger samples of men and across diverse geographic areas in the United States.

Interventions to reach underscreened populations: a narrative review for planning cancer screening initiatives

OBJECTIVES

This review was conducted to support knowledge translation (KT) and implementation of interventions to increase participation in organized cancer screening programs in the province of Ontario, Canada.

METHODS

A rigorously designed literature search yielded over 900 references which were then subjected to exclusion criteria. The remainder was organized according to type of intervention, based on the categories applied in two authoritative systematic reviews and an analysis of the level of evidence. Emerging themes in the literature were then identified to provide a bridge between high-level evidence and on-the-ground practice.

RESULTS

We identify three promising types of KT interventions: community-based health education; lay or peer health education; and targeted or tailored interventions. Each is summarized with illustrative examples and a summary of key themes and considerations.

CONCLUSIONS

The authors conclude with a summary the types and a decision tool designed to help KT and implementation teams select interventions which could be adapted to their own context.

Just telling and selling: current limitations in the use of digital media in public health: a scoping review

OBJECTIVE

To undertake a scoping review and to map research in the area of digital media use in public health.

STUDY DESIGN

Scoping review.

METHODS

PubMed, PsycINFO, Google and major textbooks of public health communication and health psychology were searched for primary studies or systematic reviews examining the use of digital media in a health context. Searches focussed on studies published between the start of 2000 and the end of June 2013. Abstracts of reviews of public health interventions were examined with respect to target groups, health topic, intervention characteristics, media used, study design, issues of quality and ethics, and outcomes. To map this area of work fully, this information was supplemented by adding information from primary studies. Areas were identified where systematic review evidence was scarce or non-existent by comparing the final map with information from the reviews analysed.

RESULTS

221 systematic reviews related to digital media use in a public health context were included. Most reviews included studies with an experimental design and general 'at risk' target populations. Specific settings were not specified in the majority of reviews. A large variety of health topics were covered. About a quarter of reviews did not specify a health topic but were concerned with broader issues of health promotion, disease prevention, or health education. Over half of the reviews focussed on eHealth and telemedicine, and another third were concerned with mass media - social marketing. Reviews most frequently reported behaviour-related outcomes or conducted some form of content analysis or analysis of the use of particular media. Research gaps were identified relating to community-based research, participation and empowerment, active media use (especially with respect to visual media und use of specific visual methodologies), and the use of salutogenic or assets-based approaches.

CONCLUSION

The available research relating to digital media use in public health is dominated by studies relating to eHealth, telehealth or social marketing; emphasising the passive reception of messages and a focus on individual behaviour change approaches. Issues of quality and ethics need to be taken into account more consistently. Further research is needed with respect to more participatory methods, particularly those which would seek to use digital media as a means to harness individual and community assets.

Fostering partnerships and program success

BACKGROUND

Fostering partnerships was critical to the success of the Colon Health Program (CHP) in Greater Seattle. The CHP was built on the Breast and Cervical Health Program (BCHP) framework. A replicable system to provide quality colorectal screening services for individuals with limited incomes and no health insurance was developed.

METHODS

Partners were recruited and engaged during 3 programmatic phases: 1) development and start-up, 2) implementation, and 3) sustainability planning. Several tactics were used to develop trust and build bridges among the partners and to create an effective work group.

RESULTS

The partners were critical to developing clinic policies, procedures, and systems to increase colorectal screening and improve follow-up; expanding access to colonoscopies; and initiating statewide dissemination of training and systems as well as policy change. The fecal occult blood test completion rate was 61%, and the colonoscopy completion rate was 78%. The colonoscopy navigation system was effective with a low "no show" rate (8%). The partners were instrumental in helping Washington State obtain funding from the Centers for Disease Control and Prevention to continue the CHP statewide.

CONCLUSIONS

During implementation, key elements for success included: building the project on the successful BCHP framework, meticulous training of clinic staff about colorectal cancer and screening methods, frequent consultation to identify and solve problems, active support of the clinic administration, and the presence of a CHP champion in the clinic. Institutionalization of the CHP depended on: assessing progress after the first year, documenting experience with the program, disseminating lessons learned, engaging new partners, and determining steps to expand the program.

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

OBJECTIVE

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

DATA SOURCES

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

STUDY ELIGIBILITY CRITERIA, PARTICIPANTS, AND INTERVENTIONS

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

RESULTS

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

LIMITATIONS

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

CONCLUSIONS AND IMPLICATIONS OF KEY FINDINGS

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