Colorectal cancer screening among primary care patients: does risk affect screening behavior?

The relationship of cancer history and chronic disease status to colorectal cancer screening: A cross-sectional analysis of 2020-2021 Behavioral Risk Factor Surveillance System

PURPOSE

We examined whether having a history of cancer and chronic diseases was associated with guideline-concordant colorectal cancer (CRC) screening utilization.

METHODS

Self-reported data from the 2020 and 2021 Behavioral Risk Factor Surveillance System in Oregon and West Virginia were used. Guideline-concordant CRC screening was the outcome of interest. The exposure was having a personal history of cancer, chronic diseases, or both. Multivariable logistic regressions were applied to assess the abovementioned association.

RESULTS

Among 10,373 respondents aged 45-75 years, 75.5% of those with a history of cancer and chronic diseases had guideline-concordant CRC screening use versus 52.8% of those without any history (p-value < 0.05). In multivariable analysis, having a history of cancer (OR 1.74; 95% CI 1.11-2.71), chronic diseases (OR 1.35; 95% CI 1.14-1.59), and both cancer and chronic diseases (OR 2.14; 95% CI 1.62-2.82) were positively associated with screening uptake compared to respondents without any history. Regardless of disease history, older age was associated with greater CRC screening uptake (p-value < 0.05). Among respondents with chronic diseases only or without any condition, those with a health care provider had 1.7-fold and 2.7-fold increased odds of receiving CRC screening, respectively. However, current smokers were 28% and 34% less likely to be screened for CRC among those with chronic diseases only and without any conditions, respectively.

CONCLUSION

Having a personal history of cancer and chronic diseases appears to be positively associated with guideline-concordant CRC screening use. Effective implementation of patient-centered communication through primary care initiatives may increase adherence to CRC screening recommendations.

Enrollee characteristics and receipt of colorectal cancer testing in Pennsylvania after adoption of the Affordable Care Act Medicaid expansion

BACKGROUND

Colorectal cancer (CRC) is the fourth most common cancer and the second leading cause of cancer-related death in the U.S. Despite increased CRC screening rates, they remain low among low-income non-older adults, including Medicaid enrollees who are more likely to be diagnosed at advanced stages.

OBJECTIVES

Given limited evidence regarding CRC screening service use among Medicaid enrollees, we examined multilevel factors associated with CRC testing among Medicaid enrollees in Pennsylvania after Medicaid expansion in 2015.

RESEARCH DESIGN

Using the 2014-2019 Medicaid administrative data, we performed multivariable logistic regression models to assess factors associated with CRC testing, adjusting for enrollment length and primary care services use.

SUBJECTS

We identified 15,439 adults aged 50-64 years newly enrolled through Medicaid expansion.

MEASURES

Outcome measures include receiving any CRC testing and by modality.

RESULTS

About 32% of our study population received any CRC testing. Significant predictors for any CRC testing include being male, being Hispanic, having any chronic conditions, using primary care services ≤4 times annually, and having a higher county-level median household income. Being 60-64 years at enrollment, using primary care services >4 times annually, and having higher county-level unemployment rates were significantly associated with a decreased likelihood of receiving any CRC tests.

CONCLUSIONS

CRC testing rates were low among adults newly enrolled in Medicaid under the Medicaid expansion in Pennsylvania relative to adults with high income. We observed different sets of significant factors associated with CRC testing by modality. Our findings underscore the urgency to tailor strategies by patients' racial, geographic, and clinical conditions for CRC screening.

An Assessment of Physicians’ Recommendations for Colorectal Cancer Screening and International Guidelines Awareness and Adherence: Results From a Thai National Survey

Background

Colorectal cancer (CRC) screening uptake is generally low in the Asia Pacific and physicians’ recommendations affect the screening participation.

Objective

The study aimed to assess Thai physicians’ recommendations for CRC screening, and the awareness of and adherence to international guidelines.

Methods

A survey containing questions assessing physicians’ demographic data, screening recommendations, and awareness of the international CRC screening guidelines assessed by clinical vignettes. Independent predictors of physicians’ recommendations for CRC screening were determined by logistic regression analysis.

Results

Five hundred and eighty-sixth of 1,286 (46%) physicians completed the survey, and 58% of them offered CRC screening. The majority of colorectal surgeons (91%) and gastroenterologists (86%) endorsed screening, whereas 35% of primary care physicians recommended screening. The patient’s age was the only factor influencing the physician’s decision to offer CRC screening (OR, 2.75: 95% CI, 1.61–4.67). Colonoscopy was the most recommended modality among specialists, whereas 60% of primary care physicians offered fecal occult blood tests (FOBTs). The guidelines awareness was noted in 81% of participants, with the highest rates among gastroenterologists and colorectal surgeons. Gastroenterologists were more likely to adhere to the guidelines than surgeons, but both recommended shorter interval surveillance colonoscopy than guidelines recommendations in cases of small hyperplastic rectosigmoid polyps.

Conclusions

Recommendations for CRC screening and awareness of guidelines vary among different specialties. A low proportion of primary care physicians recommended screening and colorectal surgeons and gastroenterologists recommended shorter intervals for surveillance of small hyperplastic polyp than suggested by guidelines.

Patient Preferences for Surgery or Antibiotics for the Treatment of Acute Appendicitis

Importance

Studies have compared surgical with nonsurgical therapy for acute uncomplicated appendicitis, but none of these studies have a patient-centered perspective.

Objectives

To evaluate how patients might choose between surgical and nonsurgical therapy for acute uncomplicated appendicitis and to identify targets to make antibiotic treatment more appealing.

Design, Setting, and Participants

This study comprised an online survey and an in-person sensitivity analysis survey. For the web survey, a convenience sample of 1728 respondents were asked to imagine that they or their child had acute uncomplicated appendicitis, provided information about laparoscopic and open appendectomy and antibiotic treatment alone, and asked which treatment they might choose. The web survey was open from April 17, 2016, through June 16, 2016, and was disseminated via email link, a poster with a Quick Response code, and social media. For the sensitivity analysis, 220 respondents were given the same scenario and options. Those who chose surgery were asked whether certain factors influenced their decision; each factor was incrementally improved during questioning about whether respondents would consider switching to antibiotics. These participants were recruited at public venues from June 3, 2016, to July 31, 2016. Web survey data were analyzed from June 17, 2016, to September 21, 2017. Sensitivity analysis data were analyzed from August 1, 2016, to September 21, 2017.

Main Outcomes and Measures

Treatment preferences.

Results

Among the 1728 web survey respondents, 1225 (70.9%) were female and 500 (28.9%) were male (3 [0.2%] either did not answer or responded as "gender fluid" within the comments section of the survey), and most self-reported being between 50 and 59 years of age (391 [22.6%]) and being non-Hispanic white (1563 [90.5%]). For themselves, 1482 respondents (85.8%) chose laparoscopic appendectomy, 84 (4.9%) chose open appendectomy, and 162 (9.4%) chose antibiotics alone. For their child, 1372 respondents (79.4%) chose laparoscopic appendectomy, 106 (6.1%) open appendectomy, and 250 (14.5%) antibiotics alone. Respondents were somewhat more likely to choose antibiotics for themselves if they had education beyond college (105 [12.6%]; P < .001), identified as other than non-Hispanic white (24 [14.9%]; P < .001), or did not know anyone who had previously been hospitalized (12 [15.8%]; P = .02), but they were less likely to choose antibiotics if they were surgeons (11 [5.4%]; P = .008). Of the 220 participants interviewed for the sensitivity analysis, 120 (54.5%) were female and 100 (45.5%) were male, and most self-reported being between 18 and 24 years of age (53 [24.1%]) and being non-Hispanic white (204 [92.7%]). Their responses suggested that improvements in the short- and long-term failure rate of antibiotic treatment-rather than reductions in the duration of hospitalization or antibiotic treatment-were more likely to increase the desirability of choosing antibiotics.

Conclusions and Relevance

Most patients may choose surgical intervention over antibiotics alone in treatment of acute uncomplicated appendicitis, but a meaningful number may choose nonoperative management. Therefore, from a patient-centered perspective, this option should be discussed with patients, and future research could be directed at reducing the failure and recurrence rates of antibiotic treatment for appendicitis.

Risk Scores for Predicting Advanced Colorectal Neoplasia in the Average-risk Population: A Systematic Review and Meta-analysis

OBJECTIVES

A systematic review and meta-analysis was performed to summarize the available evidence on risk scores for predicting advanced colorectal neoplasia (advanced adenomas and cancer) in average-risk and asymptomatic populations undergoing screening colonoscopy.

METHODS

PubMed, EMBASE, and Web of Science databases were searched up to 28 March 2018. Studies that developed or validated a risk score to predict the risk of advanced colorectal neoplasia were included. Two reviewers independently extracted study characteristics including diagnostic performance indicators and assessed risk of bias and applicability in the included studies. Meta-analyses were conducted to determine the overall discrimination of risk scores evaluated by more than 1 study.

RESULTS

A total of 22 studies including 17 original risk scores were identified. Risk scores included a median number of 5 risk factors. Factors most commonly included were age, sex, family history in first-degree relatives, body mass index and smoking. The area under the receiver operating characteristic curve of risk scores ranged from 0.62 to 0.77 in the individual studies and from 0.61 to 0.70 in the meta-analyses.

CONCLUSIONS

Although the majority of available risk scores had relatively weak discriminatory power, they may be of some use for risk stratification in CRC screening. Rather than developing more risk scores based on environmental risk factors, future research should focus on exploring possibilities of enhancing predictive power by combining risk factor data with novel laboratory matters, such as polygenetic risk scores.

Colorectal cancer and screening awareness and sources of information in the Hungarian population

Background

This study aims to survey the level of awareness of colorectal cancer and screening and to identify sources of information among the population under investigation.

Methods

A cross-sectional study was conducted among 1150 adults between the ages of 40 and 70 using quota sampling. Data were collected through self-made questionnaires to be completed by respondents.

Results

32.7% of the participants correctly identified the recommended beginning of colorectal cancer screening, these participants were more likely to see their physician more frequently in the past years than those answering to the qusetion incorrectly (p = 0.008). 22.4% of the respondents were in possession of appropriate information on the frequency of colorectal cancer screening and had a relatively high level of educational attainment (p < 0.001). Very few respondents were well-informed about the risk factors and symptoms of colorectal cancer. Those who were well-informed were likely to live in a county town (p < 0.001) and to have a relatively high level of educational attainment (p < 0.001). They were most likely to have accessed their information on the internet. 27.0% of respondents had not heard of CRC screening methods before. They were likely to be male and relatively young and to have a relatively low level of educational attainment. Furthermore, they saw their doctor relatively seldom. The respondents who had heard about screening methods were most likely to have gathered their information from health workers. Conclusions: The majority of respondents did not have sufficient information about colorectal cancer and screening. This is particularly true of less educated, younger male participants who do not live in a county town and of respondents who see their physician relatively seldom. Sources of information should be used more effectively, thus yielding an increased level of awareness.

Electronic supplementary material

The online version of this article (10.1186/s12875-018-0799-1) contains supplementary material, which is available to authorized users.

The role of the lipidome in obesity-mediated colon cancer risk

Obesity is a state of chronic inflammation influenced by lipids such as fatty acids and their secondary oxygenated metabolites deemed oxylipids. Many such lipid mediators serve as potent signaling molecules of inflammation, which can further alter lipid metabolism and lead to carcinogenesis. For example, sphingosine-1-phosphate activates cyclooxygenase-2 in endothelial cells resulting in the conversion of arachidonic acid (AA) to prostaglandin E₂ (PGE₂). PGE₂ promotes colon cancer cell growth. In contrast, the less studied path of AA oxygenation via cytochrome p450 enzymes produces epoxyeicosatetraenoic acids (EETs), whose anti-inflammatory properties cause shrinking of enlarged adipocytes, a characteristic of obesity, through the liberation of fatty acids. It is now thought that EET depletion occurs in obesity and may contribute to colon cell carcinogenesis. Meanwhile, gangliosides, a type of sphingolipid, are cell surface signaling molecules that contribute to the apoptosis of colon tumor cells. Many of these discoveries have been made recently and the mechanisms are still not fully understood, leading to an exciting new chapter of lipidomic research. In this review, mechanisms behind obesity-associated colon cancer are discussed with a focus on the role of small lipid signaling molecules in the process. Specifically, changes in lipid metabolite levels during obesity and the development of colon cancer, as well as novel biomarkers and targets for therapy, are discussed.

Family Physicians' Knowledge, Attitudes, and Practices Toward Colorectal Cancer Screening

The purpose of this study was to assess family physicians' knowledge, attitudes, and practices toward colorectal cancer (CRC) screening. The population in this cross-sectional study consisted of 290 family physicians working in Samsun, Turkey, contacted between 15 June and 15 July 2015 and agreeing to participate. A questionnaire prepared by the authors on the basis of the relevant literature was applied at face-to-face interviews. The first part of the questionnaire inquired into sociodemographic information, while the second contained questions evaluating family physicians' knowledge, attitudes, and practices toward CRC screening. Physicians completed the questionnaire in approximately 10 min. 65.9 % of the family physicians in the study were men. Mean age of the participants was 43.40 ± 6.54 years, and mean number of years in service was 18.43 ± 6.42. The average number of patients seen by physicians on a daily basis was 51-99. CRC screening was performed by 83.1 % of physicians. The fecal occult blood test (FOBT) was recommended at the correct frequency by 30.7 % of physicians and colonoscopy by 11.7 %. A further 68.6 % of physicians followed no CRC guideline. Only 3.8 % of those reporting using a guideline were able to name it. The great majority of physicians in this study apply CRC screening. However, family physicians lack sufficient information concerning the ages at which screening tests should be started and concluded and how frequently they should be performed. They also do not attach sufficient importance to CRC guidelines. This results in excessive demand for screening tests.

Racial Disparities and Factors Affecting Michigan Colorectal Cancer Screening

INTRODUCTION

The objective of this study was to investigate the various factors that influence colorectal cancer screening in Michigan using 6091 participants in the Michigan Behavioral Risk Factor Surveillance System representing adults ≥ 50 years old.

METHODS

Screening for colorectal cancer was assessed as fecal occult blood testing or colonoscopy/sigmoidoscopy. Full models simultaneously adjusted for alcohol use, angina/coronary heart disease, stroke, heart attack, gender, income, marital status, race, age, diabetes, disability, exercise, health care coverage, health care access, smoking, and mental health. Data analysis included cross-tabulation and logistic regression modeling.

RESULTS

Minorities were 1.3 (unadjusted odds ratio; 95% confidence interval = 1.03-1.57) times more likely to never have a colonoscopy/sigmoidoscopy than non-Hispanic whites. Race/ethnicity was not significant in the full model, but adults with the following characteristics were significantly (p < 0.05) more likely to never have a colonoscopy/sigmoidoscopy: no personal doctor/health care provider, no health care coverage, light alcohol consumption ≤ 25% of days, no alcohol consumption, low income < $15,000, 50-64 years old, no diabetes, no activity limitation, no exercise, smoked daily, and smoked some days.

CONCLUSION

The racial disparity in colorectal cancer screening in Michigan was explained by other characteristics. The healthcare community can work to eliminate racial disparities in colorectal cancer screening by increasing screening efforts for individuals with these characteristics.

A cross-sectional survey assessing factors associated with reading cancer screening information: previous screening behaviour, demographics and decision-making style

Background

There is broad agreement that cancer screening invitees should know the risks and benefits of testing before deciding whether to participate. In organised screening programmes, a primary method of relaying this information is via leaflets provided at the time of invitation. Little is known about why individuals do not engage with this information. This study assessed factors associated with reading information leaflets provided by the three cancer screening programmes in England.

Methods

A cross-sectional survey asked screening-eligible members of the general population in England about the following predictor variables: uptake of previous screening invitations, demographic characteristics, and ‘decision-making styles’ (i.e. the extent to which participants tended to make decisions in a way that was avoidant, rational, intuitive, spontaneous, or dependent). The primary outcome measures were the amount of the leaflet that participants reported having read at their most recent invitation, for any of the three programmes for which they were eligible. Associations between these outcomes and predictor variables were assessed using binary or ordinal logistic regression.

Results

After exclusions, data from 275, 309, and 556 participants were analysed in relation to the breast, cervical, and bowel screening programmes, respectively. Notable relationships included associations between regularity of screening uptake and reading (more of) the information leaflets for all programmes (e.g. odds ratio: 0.16 for participants who never/very rarely attended breast screening vs. those who always attended previously; p = .009). Higher rational decision-making scores were associated with reading more of the cervical and bowel screening leaflets (OR: 1.13, p < .0005 and OR: 1.11, p = .045, respectively). Information engagement was also higher for White British participants compared with other ethnic groups for breast (OR: 3.28, p = .008) and bowel (OR: 2.58, p = .015) information; an opposite relationship was observed for older participants (OR: 0.96, p = .048; OR: 0.92, p = .029).

Conclusions

Interventions that increase screening uptake may also increase subsequent engagement with information. Future research could investigate how to improve engagement at initial invitations. There may also be scope to reduce barriers to accessing non-English information and alternative communication strategies may benefit participants who are less inclined to weigh up advantages and disadvantages as part of their decision-making.

Patient factors associated with non-attendance at colonoscopy after a positive screening faecal occult blood test

Background Screening participants with abnormal faecal occult blood test results who do not attend further testing are at high risk of colorectal cancer, yet little is known about their reasons for non-attendance. Methods We conducted a medical record review of 170 patients from two English Bowel Cancer Screening Programme centres who had abnormal guaiac faecal occult blood test screening tests between November 2011 and April 2013 but did not undergo colonoscopy. Using information from patient records, we coded and categorized reasons for non-attendance. Results Of the 170 patients, 82 were eligible for review, of whom 66 had at least one recorded reason for lack of colonoscopy follow-up. Reasons fell into seven main categories: (i) other commitments, (ii) unwillingness to have the test, (iii) a feeling that the faecal occult blood test result was a false positive, (iv) another health issue taking priority, (v) failing to complete bowel preparation, (vi) practical barriers (e.g. lack of transport), and (vii) having had or planning colonoscopy elsewhere. The most common single reasons were unwillingness to have a colonoscopy and being away. Conclusions We identify a range of apparent reasons for colonoscopy non-attendance after a positive faecal occult blood test screening. Education regarding the interpretation of guaiac faecal occult blood test findings, offer of alternative confirmatory test options, and flexibility in the timing or location of subsequent testing might decrease non-attendance of diagnostic testing following positive faecal occult blood test.

Assessing family history of chronic disease in primary care: Prevalence, documentation, and appropriate screening

OBJECTIVE

To assess the proportion of primary care patients who report a family history (FH) of type 2 diabetes, coronary artery disease, breast cancer, or colorectal cancer (CRC); assess concordance of FH information derived from the electronic medical record (EMR) compared with patient-completed health questionnaires; and assess whether appropriate screening was informed by risk based solely on FH.

DESIGN

Data from the BETTER (Building on Existing Tools to Improve Chronic Disease Prevention and Screening in Primary Care) trial were used. Patients were mailed questionnaires. Baseline FH and screening data were obtained for enrolled patients from the EMR and health questionnaires.

SETTING

Ontario and Alberta.

PARTICIPANTS

Randomly selected patients from 8 family practices.

MAIN OUTCOME MEASURES

Agreement on FH between the EMR and questionnaire was determined; logistic regression was used to assess significant predictors of screening.

RESULTS

In total, 775 of 789 (98%) patients completed the health questionnaire. The mean age of participants was 52.5 years and 72% were female. A minimum of 12% of patients (range 12% to 36%) had a reported FH of 1 of 4 chronic diseases. Among patients with positive FH, the following proportions of patients had that FH recorded in the EMR compared with the questionnaire: diabetes, 24% in the EMR versus 36% on the questionnaire, κ = 0.466; coronary artery disease, 35% in the EMR versus 22% on the questionnaire, κ = 0.225; breast cancer, 21% in the EMR versus 22% on the questionnaire, κ = 0.241; and CRC, 12% in the EMR versus 14% on the questionnaire, κ = 0.510. There was moderate agreement for diabetes and CRC. The presence of FH was a significant predictor of CRC screening (odds ratio 1.9, 95% CI 1.1 to 3.1).

CONCLUSION

A moderate prevalence of FH was found for 4 conditions for which screening recommendations vary with risk based on FH. Having patients self-complete an FH was thought to be feasible; however, questions about FH accuracy and completeness from both self-report and EMR remain. Work is needed to determine how to facilitate the adoption of FH tools into practice as well as strategies linking familial risk to appropriate screening.Trial registration number ISRCTN07170460 (ISRCTN Registry).

Strategies for recruiting South Asian women to cancer screening research and the lessons learnt

AIMS

The aim of this study was to describe and discuss the recruitment strategies used in a research study of cervical cancer screening among South Asian women, the challenges encountered and the lessons learnt from the experience.

BACKGROUND

Ethnic minority populations face different barriers to participating in research studies. Strategies have been developed to recruit this population to health-related research in Western countries, but there is little information about such research in the Asian region.

DESIGN

Discussion paper.

DATA SOURCES

The discussion is based on our previous experience. The source of this experience is the recruitment strategies used, their results and the challenges encountered during the process.

IMPLICATIONS FOR NURSING

Culturally, relevant strategies and maintaining good relationships with stakeholders improved participant recruitment. Familiarity with South Asians' traditional calendar - when cultural and religious festivals are held every year - would aid the setting up of appropriate schedules for participant recruitment, either before or after the periods when they cannot be reached, such as Ramadan. South Asian women are often busy with childcare and housework. This is their major responsibility in the family and any failure to fulfil such duties is a source of stress and may foster feelings of guilt. A better understanding of their daily routines is therefore important. Such information enables the establishment of daily meeting schedules to increase the success rate of recruitment.

CONCLUSION

Recruitment is a tedious process, but appropriate planning and taking account of cultural and religious practices and daily schedules will help to improve its rate of success.

Diabetes Status and Being Up-to-Date on Colorectal Cancer Screening, 2012 Behavioral Risk Factor Surveillance System

Introduction

Although screening rates for colorectal cancer are increasing, 22 million Americans are not up-to-date with recommendations. People with diabetes are an important and rapidly growing group at increased risk for colorectal cancer. Screening status and predictors of being up-to-date on screening are largely unknown in this population.

Methods

This study used logistic regression modeling and data from the 2012 Behavioral Risk Factor Surveillance System to examine the association between diabetes and colorectal cancer screening predictors with being up-to-date on colorectal cancer screening according to criteria of the US Preventive Services Task Force for adults aged 50 or older. State prevalence rates of up-to-date colorectal cancer screening were also calculated and mapped.

Results

The prevalence of being up-to-date with colorectal cancer screening for all respondents aged 50 or older was 65.6%; for respondents with diabetes, the rate was 69.2%. Respondents with diabetes were 22% more likely to be up-to-date on colorectal cancer screening than those without diabetes. Among those with diabetes, having a routine checkup within the previous year significantly increased the odds of being up-to-date on colorectal cancer screening (odds ratio, 1.90). Other factors such as age, income, education, race/ethnicity, insurance status, and history of cancer were also associated with up-to-date status.

Conclusion

Regardless of diabetes status, people who had a routine checkup within the past year were more likely to be up-to-date than people who had not. Among people with diabetes, the duration between routine checkups may be of greater importance than the frequency of diabetes-related doctor visits. Continued efforts should be made to ensure that routine care visits occur regularly to address the preventive health needs of patients with and patients without diabetes.

Risk Prediction Models for Colorectal Cancer: A Systematic Review

Colorectal cancer is the second leading cause of cancer-related death in Europe and the United States. Survival is strongly related to stage at diagnosis and population-based screening reduces colorectal cancer incidence and mortality. Stratifying the population by risk offers the potential to improve the efficiency of screening. In this systematic review we searched Medline, EMBASE, and the Cochrane Library for primary research studies reporting or validating models to predict future risk of primary colorectal cancer for asymptomatic individuals. A total of 12,808 papers were identified from the literature search and nine through citation searching. Fifty-two risk models were included. Where reported (n = 37), half the models had acceptable-to-good discrimination (the area under the receiver operating characteristic curve, AUROC >0.7) in the derivation sample. Calibration was less commonly assessed (n = 21), but overall acceptable. In external validation studies, 10 models showed acceptable discrimination (AUROC 0.71-0.78). These include two with only three variables (age, gender, and BMI; age, gender, and family history of colorectal cancer). A small number of prediction models developed from case-control studies of genetic biomarkers also show some promise but require further external validation using population-based samples. Further research should focus on the feasibility and impact of incorporating such models into stratified screening programmes.

Do recent epidemiologic observations impact who and how we should screen for CRC?

Colorectal cancer (CRC) screening is recommended to begin at age 50 for those patients with no significant family history of CRC. However, even within this group of average-risk patients, there is data to suggest that there may be variation in CRC risk. These observations suggest that perhaps CRC screening should be tailored to target those patients at higher risk for earlier or more invasive screening as compared to those individuals at lower risk. The strategy of how to identify those higher-risk patients may not be straightforward. One method might be to use single risk factors such as smoking or elevated BMI as has been suggested in the recent American College of Gastroenterology CRC screening guidelines. Another paradigm involves the use of models which incorporate several risk factors to stratify patients by risk. This article will highlight recent large studies that examine recognized CRC risk factors as well as review recently developed CRC risk models. There will also be a discussion of the application of these factors and models in an effort to make CRC screening more efficient.

Association between documented family history of cancer and screening for breast and colorectal cancer

BACKGROUND

Previous research on ascertainment of cancer family history and cancer screening has been conducted in urban settings.

PURPOSE

To examine whether documented family history of breast or colorectal cancer is associated with breast or colorectal cancer screening.

METHODS

Medical record reviews were conducted on 3433 patients aged 55 and older from four primary care practices in two rural Oregon communities. Data collected included patient demographic and risk information, including any documentation of family history of breast or colorectal cancer, and receipt of screening for these cancers.

RESULTS

A positive breast cancer family history was associated with an increased likelihood of being up-to-date for mammography screening (OR 2.09, 95% CI 1.45-3.00 relative to a recorded negative history). A positive family history for colorectal cancer was associated with an increased likelihood of being up-to-date with colorectal cancer screening according to U.S. Preventive Services Task Force low risk guidelines for males (OR 2.89, 95% CI 1.15-7.29) and females (OR 2.47, 95% CI 1.32-4.64) relative to a recorded negative family history. The absence of any recorded family cancer history was associated with a decreased likelihood of being up-to-date for mammography screening (OR 0.70, 95% CI 0.56-0.88 relative to recorded negative history) or for colorectal cancer screening (OR 0.75, 95% CI 0.60-0.96 in females, OR 0.68, 95% CI 0.53-0.88 in males relative to recorded negative history).

CONCLUSION

Further research is needed to determine if establishing routines to document family history of cancer would improve appropriate use of cancer screening.

Burden of emergency and non-emergency colorectal cancer surgeries in West Virginia and the USA

PURPOSE

Elective surgical resection is the curative treatment for colorectal cancer (CRC). Up to 30 % of patients present as surgical emergencies. The objective was to determine the association between presenting with an emergency condition and consequent outcomes of CRC surgery in the Appalachian state of West Virginia (WV) in comparison to the rest of the USA.

METHODS

Patients diagnosed with CRC who underwent a surgical procedure from January 1, 2003 to December 31, 2007 were selected, and those with a diagnosis requiring emergency surgery were identified. Primary outcome measures were length of stay (LOS), total hospital charges, and inpatient death.

RESULTS

Mean LOS was higher for WV. Mean charges were higher for the USA than for WV. Inpatient deaths in WV were greater than the rest of the USA. Those undergoing emergency surgery spent 51.9 % (β=0.40) more days in the hospital than those who did not. For WV, LOS was 7.6 % (β=0.07) higher than that of the US. Hospital charges for those that underwent emergency resection were 68.3 % (β=0.52) higher than those who did not. The odds of in-hospital death were 1.68 (95 % CI=1.42-1.98) times greater in WV than in the USA. Those that underwent emergency surgery had a nearly four times (OR 3.88; 95 % CI=3.74-4.03) greater chance of in-hospital death.

CONCLUSIONS

The study stresses the ongoing burden of emergency surgeries in many states around the nation and the need to increase awareness about CRC screening practices, especially in patients who are at increased risk of the disease.

Risk assessment and clinical decision making for colorectal cancer screening

BACKGROUND

Shared decision making (SDM) related to test preference has been advocated as a potentially effective strategy for increasing adherence to colorectal cancer (CRC) screening, yet primary care providers (PCPs) are often reluctant to comply with patient preferences if they differ from their own. Risk stratification advanced colorectal neoplasia (ACN) provides a rational strategy for reconciling these differences.

OBJECTIVE

To assess the importance of risk stratification in PCP decision making related to test preference for average-risk patients and receptivity to use of an electronic risk assessment tool for ACN to facilitate SDM.

DESIGN

Mixed methods, including qualitative key informant interviews and a cross-sectional survey.

PARTICIPANTS

PCPs at an urban, academic safety-net institution.

MAIN MEASURES

Screening preferences, factors influencing patient recommendations and receptivity to use of a risk stratification tool.

KEY RESULTS

Nine PCPs participated in interviews and 57 completed the survey. Despite an overwhelming preference for colonoscopy by 95% of respondents, patient risk (67%) and patient preferences (63%) were more influential in their decision making than patient comorbidities (31%; P < 0.001). Age was the single most influential risk factor (excluding family history), with <20% of respondents choosing factors other than age. Most respondents reported that they would be likely to use a risk stratification tool in their practice either 'often' (43%) or sometimes (53%).

CONCLUSIONS

Risk stratification was perceived to be important in clinical decision making, yet few providers considered risk factors other than age for average-risk patients. Providers were receptive to the use of a risk assessment tool for ACN when recommending an appropriate screening test for select patients.

Colorectal cancer risk factors in the detection of advanced adenoma and colorectal cancer

Several risk factors for colorectal cancer (CRC) have been identified. If individuals with risk factors are more likely to harbor cancer or it precursors screening programs should be targeted toward this population. We evaluated the predictive value of colorectal cancer risk factors for the detection of advanced colorectal adenoma in a population based CRC colonoscopy screening program. Data were collected in a multicenter trial conducted in the Netherlands, in which 6600 asymptomatic men and women between 50 and 75 years were randomly selected from a population registry. They were invited to undergo a screening colonoscopy. Based on a review of the literature CRC risk factors were selected. Information on risk factors was obtained from screening attendees through a questionnaire. For each CRC risk factor, we estimated its odds ratio (OR) relative to the presence of advanced neoplasia as detected at colonoscopy. Of the 1426 screening participants who underwent a colonoscopy, 1236 (86%) completed the risk questionnaire. 110 participants (8.9%) had advanced neoplasia. The following risk factors were significantly associated with advanced neoplasia detected by colonoscopy: age (OR: 1.06 per year; 95% CI: 1.03-1.10), calcium intake (OR: 0.99 per mg; 95% CI: 0.99-1.00), positive CRC family history (OR: 1.55 per first degree family member; 95%CI: 1.11-2.16) and smoking (OR: 1.75; 95%CI: 1.09-2.82). Elderly screening participants, participants with lower calcium intake, a CRC family history, and smokers are at increased risk of harboring detectable advanced colorectal neoplasia at screening colonoscopy.

Physician recommendation and patient adherence for colorectal cancer screening

BACKGROUND

Physician recommendation is one of the strongest, most consistent predictors of colorectal cancer (CRC) screening. Little is known regarding characteristics associated with patient adherence to physician recommendations in community and academic based primary care settings.

METHODS

Data were analyzed from 975 patients, aged ≥50 years, recruited from 25 primary care practices in New Jersey. Chi-square and generalized estimate equation analyses determined independent correlates of receipt of and adherence to physician recommendation for CRC.

RESULTS

Patients reported high screening rates for CRC (59%). More than three fourths of patients reported either screening or having received a screening recommendation (82%). Men (P = .0425), nonsmokers (P = .0029), and patients who were highly educated (P = .0311) were more likely to receive a CRC screening recommendation. Patients more adhere to CRC screening recommendations were older adults (P < .0001), nonsmokers (P = .0005), those who were more highly educated (P = .0365), Hispanics (P = .0325), and those who were married (P < .0001).

CONCLUSIONS

Community and academic primary care clinicians appropriately recommended screening to high-risk patients with familial risk factors. However, they less frequently recommended screening to others (ie, women and smokers) also likely to benefit. To further increase CRC screening, clinicians must systematically recommend screening to all patients who may benefit.

Public perceptions and preferences for CT colonography or colonoscopy in colorectal cancer screening

OBJECTIVES

To examine public perceptions of and preferences for colonoscopy vs. CT colonography (CTC) as technologies for colorectal cancer (CRC) screening.

METHODS

Six discussion groups were carried out with 30 adults aged 49-60 years (60% female). Information about different aspects of the tests (e.g. sensitivity, practical issues) was presented sequentially using a semi-structured, step-by-step topic guide. Discussions were recorded and analyzed using framework analysis.

RESULTS

CTC was favored on the parameters of invasiveness, extra-colonic evaluation and interference with daily life, whereas sensitivity, avoiding false-positives and the capacity to remove polyps immediately were perceived to be important advantages of colonoscopy. Ultimately, there was no strong preference for either test: with 46% preferring colonoscopy vs. 42% for CTC.

CONCLUSION

With comprehensive information, colonoscopy and CTC were seen as having different advantages and disadvantages, yielding no clear preferences between the two. The sensitivity of colonoscopy was a decisive factor for some people, but the lower invasiveness of CTC was seen as an asset in the screening context.

PRACTICE IMPLICATIONS

CTC may be an acceptable alternative to colonoscopy in CRC screening. Healthcare professionals working in the screening context should be sensitive to the range of characteristics that can determine preferences for CRC screening tests.

Body mass index and colon cancer screening: a systematic review and meta-analysis

BACKGROUND

Obesity is associated with increased colon cancer mortality and lower rates of mammography and Pap testing.

METHODS

We conducted a systematic review to determine whether obesity is associated with lower rates of colon cancer screening. We searched the PubMed, CINAHL, and Cochrane Library databases. Two investigators reviewed citations, abstracts, and articles independently. Two investigators abstracted study information sequentially and evaluated quality independently using standardized forms. We included all studies in our qualitative syntheses. We used random effects meta-analyses to combine those studies providing screening results by the following body mass index (BMI) categories: Normal, 18.5-24.9 kg/m(2) (reference); overweight, 25-29.9 kg/m(2); class I obesity, 30-34.9 kg/m(2); class II obesity, 35-39.9 kg/m(2); and class III obesity, ≥ 40 kg/m(2).

RESULTS

Of 5,543 citations, we included 23 articles. Almost all studies were cross-sectional and ascertained BMI and screening through self-report. BMI was not associated with colon cancer screening overall. The subgroup of obese white women reported lower rates of colon cancer screening compared with those with a normal BMI with combined ORs (95% CI) of 0.87 (0.82-0.93), 0.80 (0.65-0.99), and 0.73 (0.58-0.94) for class I, II, and III obesity, respectively. Results were similar among white men with class II obesity.

CONCLUSIONS

Overall, BMI was not associated with colon cancer screening. Obese white men and women may be less likely to undergo colon cancer screening compared with those with a normal BMI.

IMPACT

Further investigation of this disparity may reduce the risk of obesity-related colon cancer death.