Screening patients with a family history of colorectal cancer

Colorectal cancer literacy and related factors in northeast of Iran: A cross-sectional study

BACKGROUND

Colorectal cancer (CRC) is a health challenge and the second most common cancer worldwide. Increasing colorectal cancer literacy (CRCL) is one of the most effective factors in CRC prevention.

AIM

The aim of this study was to determine and evaluate CRCL and its related factors in Torbat Heydarieh, northeastern Iran.

METHODS AND RESULTS

This study was a cross-sectional survey conducted in 2021 in Torbat Heydarieh, a city in northeastern Iran, on 200 clients presenting to a comprehensive health service centers. In addition to collecting sociodemographic characteristics, participants were administered the Knowledge and Attitude Questionnaire and the Colorectal Cancer Literacy Questionnaire (CRCLQ). Data were analyzed with SPSS software version 25 using independent samples t-tests, one-way analysis, chi-square, and Pearson correlation coefficients. The statistical significance level was set at p < .05. The results showed that the mean age of the participants was 51.12 ± 8.45 years. The majority of participants (84%) stated that their friends and relatives had no history of CRC. Pearson correlation coefficient results showed a significant correlation between knowledge and attitude toward CRC (r = .15, p = .041). A significant correlation was also found between knowledge and CRCL (r = .4, p ≤ .001).

CONCLUSION

We found low CRCL among clients of comprehensive health service centers. More targeted educational interventions are needed to promote CRCL among Iranian adults.

Individuals With a Family History of Colorectal Cancer Warrant Tailored Interventions to Address Patient-Reported Barriers to Screening

INTRODUCTION

Population health interventions to increase colorectal cancer (CRC) screening rates often exclude individuals with a family history of CRC, and interventions to increase screening in this high-risk group are rare. We aimed to determine the screening rate and barriers and facilitators to screening in this population to inform interventions to increase screening participation.

METHODS

We performed a retrospective chart review and cross-sectional survey of patients excluded from mailed fecal immunochemical test (FIT) outreach because of a family history of CRC in a large health system. We used χ 2 , Fisher exact, and Student t tests to compare demographic and clinical characteristics of patients overdue and not overdue for screening. We then administered a survey (mailed and telephone) to overdue patients to assess barriers and facilitators to screening.

RESULTS

There were 296 patients excluded from mailed FIT outreach, and 233 patients had a confirmed family history of CRC. Screening participation was low (21.9%), and there were no significant demographic or clinical differences between those overdue and not overdue for screening. There were 79 survey participants. Major patient-reported barriers to screening colonoscopy were patient forgetfulness (35.9%), fear of pain during colonoscopy (17.7%), and hesitancy about bowel preparation (29.4%). To facilitate screening colonoscopy, patients recommended reminders (56.3%), education about familial risk (50%), and colonoscopy education (35.9%).

DISCUSSION

Patients with a family history of CRC who are excluded from mailed FIT outreach have low screening rates and report multiple mutable barriers to screening. They warrant targeted efforts to increase screening participation.

Colorectal Cancer Risk Assessment and Precision Approaches to Screening: Brave New World or Worlds Apart?

Current colorectal cancer (CRC) screening recommendations take a "one-size-fits-all" approach using age as the major criterion to initiate screening. Precision screening that incorporates factors beyond age to risk stratify individuals could improve on current approaches and optimally use available resources with benefits for patients, providers, and health care systems. Prediction models could identify high-risk groups who would benefit from more intensive screening, while low-risk groups could be recommended less intensive screening incorporating noninvasive screening modalities. In addition to age, prediction models incorporate well-established risk factors such as genetics (eg, family CRC history, germline, and polygenic risk scores), lifestyle (eg, smoking, alcohol, diet, and physical inactivity), sex, and race and ethnicity among others. Although several risk prediction models have been validated, few have been systematically studied for risk-adapted population CRC screening. In order to envisage clinical implementation of precision screening in the future, it will be critical to develop reliable and accurate prediction models that apply to all individuals in a population; prospectively study risk-adapted CRC screening on the population level; garner acceptance from patients and providers; and assess feasibility, resources, cost, and cost-effectiveness of these new paradigms. This review evaluates the current state of risk prediction modeling and provides a roadmap for future implementation of precision CRC screening.

Early age onset colorectal cancer

The incidence and mortality associated with colorectal cancer (CRC) diagnosed in patients under the age of 50 have been steadily increasing. The exact etiology of these epidemiologic trends is unclear. This chapter will provide a comprehensive review on the topic of early age onset colorectal cancer (EAO-CRC), defined as colorectal cancer (CRC) diagnosed in patients under the age of 50. Topics reviewed will include the epidemiology of EAO-CRC around the world, clinical and pathological features of EAO-CRC in contrast to later age onset CRC (CRC diagnosed on those over the age of 50) and the observed molecular and somatic characteristics. This chapter will review the etiologies to EAO-CRC and the established, as well as proposed risk factors for disease. Evidence-based approaches to prevention, early detection, treatment and survivorship will be presented.

Doctor-Patient Cancer Screening Communications among Church-based Chinese Adults - The Role of Caregiver Experience and Family History

Objective:

Significant gap exists in the literature examining cancer screening communication related factors among Chinese immigrants. This study examined the role of cancer caregiver experience and family history on doctor-patient cancer screening communication among church-based Chinese adults.

Methods:

A self-administered survey was conducted among adults from 9 Chinese churches (n=372). Cancer Communication was measured by “Dr. recommended screenings” and “Talked to doctors about cancer screenings”. The survey was developed in English and translated in Chinese.

Results:

Mean age was 44.31 (SD=14.74), 60% were males, 72% were married, majority had college education (85%), and 17% reported had been a primary cancer caregiver and 54% reported having family cancer history. Cancer caregivers scored higher on doctor-patient cancer communication, as well as cancer knowledge and screening norms. Participants with family cancer history were also more likely to talk to doctor about screening, as well as perceived higher cancer risk, lower health status, and screening barriers. Multiple regression analyses showed that primary caregiver experience was still a significant predictor on talking to doctors about cancer screenings (OR=2.1; 95%CI=[1.10, 4.01]; p=0.025), yet doctors more like to recommend screening among caregivers became non-significant. The significant influence of family cancer history on talking with doctors on cancer screenings also disappeared. Older age (OR=2.52; p=0.006) and being married (OR=2.45; p=0.022) were significant on predicting communication of cancer screenings with doctors. Data also showed that doctors were more likely to recommend cancer screenings to older (OR=2.75, p<.001), married (OR=2.57; p=0.006) adults.

Conclusion:

Current study calls attentions to primary cancer caregiver experience, family history, age, and marital factors when designing tailored doctor-patient cancer screening communication programs among church-based Chinese to address cancer disparities.

AGA White Paper: Roadmap for the Future of Colorectal Cancer Screening in the United States

The American Gastroenterological Association's Center for Gastrointestinal Innovation and Technology convened a consensus conference in December 2018, entitled, "Colorectal Cancer Screening and Surveillance: Role of Emerging Technology and Innovation to Improve Outcomes." The goal of the conference, which attracted more than 60 experts in screening and related disciplines, including the authors, was to envision a future in which colorectal cancer (CRC) screening and surveillance are optimized, and to identify barriers to achieving that future. This White Paper originates from that meeting and delineates the priorities and steps needed to improve CRC outcomes, with the goal of minimizing CRC morbidity and mortality. A one-size-fits-all approach to CRC screening has not and is unlikely to result in increased screening uptake or desired outcomes owing to barriers stemming from behavioral, cultural, and socioeconomic causes, especially when combined with inefficiencies in deployment of screening technologies. Overcoming these barriers will require the following: efficient utilization of multiple screening modalities to achieve increased uptake; continued development of noninvasive screening tests, with iterative reassessments of how best to integrate new technologies; and improved personal risk assessment to better risk-stratify patients for appropriate screening testing paradigms.

An action plan to address the rising burden of colorectal cancer in younger adults

Aim: The National Colorectal Cancer Roundtable convened a national Summit to discuss the causes of early-onset colorectal cancer and clinical challenges to mitigating burden of this disease. Materials & methods: Information presented was synthesized through scientific consensus building to determine priorities for new research and practice change. Results: Research priorities include evaluating role of novel risk factors, understanding natural history and identifying ways to implement evidenced-based practices for identifying and managing at-risk persons. Practice change should focus on adoption of guidelines for collecting family history, screening in young adults at risk, provider and population awareness about risk and symptoms, and universal tumor testing. Conclusion: Successful implementation of strategies to address research and practice change will require collaboration from multiple partners.

Colorectal Cancer in Persons Under Age 50: Seeking Causes and Solutions

Early onset colorectal cancer (EOCRC) refers to colorectal cancer (CRC) in individuals under age 50. Although the incidence and mortality due to later onset CRC (≥50 years) has been declining over several decades, both are increasing in those under 50. EOCRC is more likely to occur in the distal colon and rectum. There are some unique pathologic and genetic features to these tumors; they are not usually associated with a germline mutation in a gene that predisposes to cancer, and at least some may have a distinct pathogenesis. Initiating CRC screening at an earlier age (40-45 years of age) would presumably detect more early stage and asymptomatic EOCRCs, but this would imply a major additional health care burden. The understanding of EOCRC and the optimal management approach to this problem are unsolved problems.

Potential impact of family history-based screening guidelines on the detection of early-onset colorectal cancer

BACKGROUND

Initiating screening at an earlier age based on cancer family history is one of the primary recommended strategies for the prevention and detection of early-onset colorectal cancer (EOCRC), but data supporting the effectiveness of this approach are limited. The authors assessed the performance of family history-based guidelines for identifying individuals with EOCRC.

METHODS

The authors conducted a population-based, case-control study of individuals aged 40 to 49 years with (2473 individuals) and without (772 individuals) incident CRC in the Colon Cancer Family Registry from 1998 through 2007. They estimated the sensitivity and specificity of family history-based criteria jointly recommended by the American Cancer Society, the US Multi-Society Task Force on CRC, and the American College of Radiology in 2008 for early screening, and the age at which each participant could have been recommended screening initiation if these criteria had been applied.

RESULTS

Family history-based early screening criteria were met by approximately 25% of cases (614 of 2473 cases) and 10% of controls (74 of 772 controls), with a sensitivity of 25% and a specificity of 90% for identifying EOCRC cases aged 40 to 49 years. Among 614 individuals meeting early screening criteria, 98.4% could have been recommended screening initiation at an age younger than the observed age of diagnosis.

CONCLUSIONS

Of CRC cases aged 40 to 49 years, 1 in 4 met family history-based early screening criteria, and nearly all cases who met these criteria could have had CRC diagnosed earlier (or possibly even prevented) if earlier screening had been implemented as per family history-based guidelines. Additional strategies are needed to improve the detection and prevention of EOCRC for individuals not meeting family history criteria for early screening.

An update on risk assessment for familial and hereditary colorectal cancer

Family history risk assessment can identify individuals at increased risk of colorectal cancer (CRC) who would benefit from earlier or more frequent CRC screening. Clinicians should evaluate the patient's family history as well as personal history to identify red flags and patterns that may suggest predisposition to CRC and then use that information to stratify risk into average, increased, and high risk categories to inform genetic counseling recommendations and personalized management.

Cancer risk awareness and screening uptake in individuals at higher risk for colon cancer: a cross-sectional study

OBJECTIVE

We aimed to measure cancer knowledge and feasibility of a screening colonoscopy among a cohort of individuals at higher risk of colon cancer.

METHODS

This study was conducted as part of an ongoing screening cohort, in which first degree relatives (FDRs) of patients with colon cancer are invited to participate in a free of charge screening colonoscopy. We enrolled 1017 FDRs in the study between 2013 and 2014 measuring their data on demographics, cancer knowledge and colonoscopy uptake. A p value of <0.05 was considered statistically significant.

RESULTS

The relative's mean age was 48.7 years. Only about 28% of FDRs were aware of their increased risk for cancer, near 35.0% had ever heard about colonoscopy with 22% aware of the correct age to start screening. Comparing cancer knowledge of FDRs at high risk versus those at moderate risk, we recorded non-significant differences (p>0.05). Almost two-thirds of FDRs expressed willingness to undergo a colonoscopy and 49.2% completed the procedure, of which 12.8% had advanced neoplasm.

CONCLUSIONS

Our data indicated that remarkable numbers of FDRs were not still informed of their cancer risk or never received a physician recommendation for screening. The desirable uptake at first invitation, which would be higher over successive invitations, supports the feasibility of a family-based recruitment approach for early screening. This has promising implications to introduce targeted screening colonoscopy into the healthcare system in Iran and other developing nations.

Understanding the contribution of family history to colorectal cancer risk and its clinical implications: A state-of-the-science review

Persons with a family history (FH) of colorectal cancer (CRC) or adenomas that are not due to known hereditary syndromes have an increased risk for CRC. An understanding of these risks, screening recommendations, and screening behaviors can inform strategies for reducing the CRC burden in these families. A comprehensive review of the literature published within the past 10 years has been performed to assess what is known about cancer risk, screening guidelines, adherence and barriers to screening, and effective interventions in persons with an FH of CRC and to identify FH tools used to identify these individuals and inform care. Existing data show that having 1 affected first-degree relative (FDR) increases the CRC risk 2-fold, and the risk increases with multiple affected FDRs and a younger age at diagnosis. There is variability in screening recommendations across consensus guidelines. Screening adherence is <50% and is lower in persons under the age of 50 years. A provider's recommendation, multiple affected relatives, and family encouragement facilitate screening; insufficient collection of FH, low knowledge of guidelines, and poor family communication are important barriers. Effective interventions incorporate strategies for overcoming barriers, but these have not been broadly tested in clinical settings. Four strategies for reducing CRC in persons with familial risk are suggested: 1) improving the collection and utilization of the FH of cancer, 2) establishing a consensus for screening guidelines by FH, 3) enhancing provider-patient knowledge of guidelines and communication about CRC risk, and 4) encouraging survivors to promote screening within their families and partnering with existing screening programs to expand their reach to high-risk groups. Cancer 2016. © 2016 American Cancer Society. Cancer 2016;122:2633-2645. © 2016 American Cancer Society.

Patients' knowledge and fear of colorectal cancer risk in inflammatory bowel disease

OBJECTIVE

To investigate knowledge and fear of colorectal cancer (CRC) risk in inflammatory bowel disease (IBD) patients.

METHODS

A 12-item self-administered questionnaire, developed after a careful literature review, was administered to all consecutive IBD patients treated with infliximab who were followed up at Nancy University Hospital (Vandoeuvre-lès-Nancy, France) between February and May 2012.

RESULTS

Altogether 100 patients including 72 with Crohn's disease (CD) were included. Only 7.0% of patients spontaneously mentioned CRC risk as a main feature of IBD and 37.0% as a potential IBD complication. CRC was the most feared complication by 26 patients [ulcerative colitis (UC) 46.4% vs CD 18.1%, P < 0.01]. Two-thirds of patients knew that IBD increases CRC risk (UC 81.9% vs CD 57.1%, P = 0.02). Their main source of information was their gastroenterologist (52.0%). On the best screening method for CRC, 86.0% of the respondents mentioned colonoscopy. Only 32.0% of patients knew that it has to be performed 10 years after diagnosis. In case of dysplasia, 51.0% of the patients would not undergo colectomy (CD 59.7% vs UC 28.6%, P < 0.01), mainly due to the fear of having ostomy bags. Only one-quarter of UC patients were aware of the chemopreventive effect of 5-aminosalicylates on CRC risk.

CONCLUSIONS

Two-thirds of IBD patients are aware of the risk of CRC. UC patients have a better knowledge of this risk and are more afraid of this complication. Our results underscore the need for therapeutic education about CRC in IBD patients.

Screening behaviors, health beliefs, and related factors of first-degree relatives of colorectal cancer patients with ongoing treatment in Turkey

BACKGROUND

Colorectal cancer (CRC) is one of the most common cancers. Family history is an important risk factor; first-degree relatives (FDRs) are most at risk. Studies are needed to determine the screening behavior of FDRs and factors affecting their health behaviors.

OBJECTIVE

The purpose of this study was to investigate the screening behaviors, health beliefs, and related factors of FDRs (parent, sibling, or child) of CRC patients undergoing treatment.

METHODS

A cross-sectional design was used with 400 FDRs of patients undergoing treatment at 2 hospitals in Turkey. Data were collected using the Colorectal Cancer Risk Questionnaire and the Turkish Colorectal Cancer Health Belief Model Scale.

RESULTS

A slight majority of the participants were male (51.3%), with a mean of age 37.7 years. The rate of having at least 1 colonoscopy in FDRs was 22.2%. First-degree relatives reported high perceived confidence-benefits scores on average (mean, 48.4 ± 5.2) and high perceived barrier scores on average (mean, 15.5 ± 3.8). Health motivation of FDRs was the strongest predictor of their having a colonoscopy (odds ratio, 7.50; 95% confidence interval, 3.40-16.5).

CONCLUSIONS

First-degree relatives have a low rate of having a colonoscopy but are more likely to have had this procedure if they have strong health motivation.

IMPLICATIONS FOR PRACTICE

Nurses working with CRC patients must develop strategies to increase FDRs' knowledge of, awareness of, and motivation for CRC screening tests. Risk counseling of FDRs during the treatment period might increase screening rates.

Patient Electronic Health Records as a Means to Approach Genetic Research in Gastroenterology

Electronic health records (EHRs) are being increasingly utilized and form a unique source of extensive data gathered during routine clinical care. Through use of codified and free text concepts identified using clinical informatics tools, disease labels can be assigned with a high degree of accuracy. Analysis linking such EHR-assigned disease labels to a biospecimen repository has demonstrated that genetic associations identified in prospective cohorts can be replicated with adequate statistical power and novel phenotypic associations identified. In addition, genetic discovery research can be performed utilizing clinical, laboratory, and procedure data obtained during care. Challenges with such research include the need to tackle variability in quality and quantity of EHR data and importance of maintaining patient privacy and data security. With appropriate safeguards, this novel and emerging field of research offers considerable promise and potential to further scientific research in gastroenterology efficiently, cost-effectively, and with engagement of patients and communities.

Colonoscopy screening among US adults aged 40 or older with a family history of colorectal cancer

INTRODUCTION

Colonoscopy screening reduces colorectal cancer (CRC) incidence and mortality. CRC screening is recommended at age 50 for average-risk people. Screening of first-degree relatives of CRC patients is recommended to begin at age 40 or 10 years before the age at diagnosis of the youngest relative diagnosed with CRC. CRC incidence has increased recently among younger Americans while it has declined among older Americans. The objective of this study was to determine whether first-degree relatives of CRC patients are being screened according to recommended guidelines.

METHODS

We studied colonoscopy screening rates among the US population reporting a CRC family history using 2005 and 2010 National Health Interview Survey data.

RESULTS

Of 26,064 study-eligible respondents, 2,470 reported a CRC family history; of those with a family history, 45.6% had a colonoscopy (25.2% in 2005 and 65.8% 2010). The colonoscopy rate among first-degree relatives aged 40 to 49 in 2010 (38.3%) was about half that of first-degree relatives aged 50 or older (69.7%). First-degree relatives were nearly twice as likely as nonfirst-degree relatives to have a colonoscopy (adjusted odds ratio [AOR], 1.7; 95% confidence interval, 1.5-1.9), but those aged 40 to 49 were less likely to have a colonoscopy than those in older age groups (AOR, 2.6 for age 50-64; AOR, 3.6 for age ≥65). Interactions with age, insurance, and race/ethnicity were not significant. Having health insurance tripled the likelihood of screening.

CONCLUSION

Despite a 5-fold increase in colonoscopy screening rates since 2005, rates among first-degree relatives younger than the conventional screening age have lagged. Screening promotion targeted to this group may halt the recent rising trend of CRC among younger Americans.

Practical opportunities to improve early detection and prevention of colorectal cancer (CRC) in members of high-risk families

Colorectal cancer (CRC) incidence and mortality are steadily declining and CRC screening rates are increasing in the United States. Although this a very good news, several definable groups still have very low screening rates including younger (under age 50) members of high-risk CRC families. This opinion piece describes five strategies that could be incorporated into routine practice to improve identification and guideline-based screening in members of high-risk families. Routine incorporation of a simple family history screening tool and outreach to high-risk family members could substantially improve guideline-based screening in this population. Identification of CRCs and advanced adenomas in the endoscopy suite defines another group of high-risk families for similar outreach. Lynch syndrome families can be identified by testing CRCs and selected adenomas for microsatellite instability or loss of DNA repair protein expression. Finally, selective addition of aspirin to surveillance endoscopy can decrease the risk of new adenomas and CRCs. The rationale for these strategies as well as mechanisms for their implementation and evaluation in clinical practice is described.

Intention to undergo colonoscopy screening among relatives of colorectal cancer cases: a theory-based model

BACKGROUND

It is recommended that persons having familial risk of colorectal cancer begin regular colonoscopy screening at an earlier age than those in the general population. However, many individuals at increased risk do not adhere to these screening recommendations.

PURPOSE

The goal of this study was to examine cognitive, affective, social, and behavioral motivators of colonoscopy intention among individuals at increased risk of familial colorectal cancer.

METHODS

Relatives of colorectal cancer cases (N = 481) eligible for colonoscopy screening completed a survey assessing constructs from several theoretical frameworks including fear appeal theories.

RESULTS

Structural equation modeling indicated that perceived colorectal cancer risk, past colonoscopy, fear of colorectal cancer, support from family and friends, and health-care provider recommendation were determinants of colonoscopy intention.

CONCLUSIONS

Future interventions to promote colonoscopy in this increased risk population should target the factors we identified as motivators. (ClinicalTrials.gov number NCT01274143).

Screening participation for people at increased risk of colorectal cancer due to family history: a systematic review and meta-analysis

We conducted a systematic review and a meta-analysis of observational studies to identify and summarise the level of colorectal cancer (CRC) screening participation for people at increased risk due to family history of the disease. Medline, Cinhal, Embase and PsychInfo databases were comprehensively searched between January 1995 and May 2012 to identify relevant articles. To be included, studies had to report on screening for people who had at least one first-degree relative with CRC and no previous personal diagnosis of the disease. Pooled screening participation levels were calculated for each screening modality. Seventeen studies, accounting for a total of 13,269 subjects with a family history of CRC met the inclusion criteria. Seven studies, including a total of 6,901 subjects had a pooled faecal occult blood testing screening participation (at least once) of 25 % (95 % CI 12-38). Five studies including a total of 5,091 subjects had a pooled sigmoidoscopy-based screening participation (at least once) of 16 % (95 % CI 7-27). Seven studies including a total of 9,965 subjects had pooled participation colonoscopy-based screening (at least once) of 40 % (95 % CI 26-54). There was a significant level of screening heterogeneity between studies. This review identified a substantial underuse of CRC screening for people at increased risk of developing the disease. It highlights the potential opportunity that exists for increasing screening participation among this segment of the population and the need to adjust the current CRC screening policies towards that objective.

Screening patterns in patients with a family history of colorectal cancer often do not adhere to national guidelines

BACKGROUND

Currently, there are no data on adherence to guidelines for colorectal cancer (CRC) screening in patients with a family history.

AIM

We conducted a retrospective study to assess if such patients were being appropriately screened according to American Gastroenterological Association (AGA) guidelines.

METHODS

Two independent reviewers performed a comprehensive medical record review of family and CRC screening history on 362 adults with a family history of CRC in a first-degree relative who had recently undergone screening colonoscopy. The endpoint was appropriate initiation of screening and endoscopist-recommended subsequent screening intervals, as compared to AGA guideline recommendations.

RESULTS

Of 362 subjects, only 146 (40.3 %) were screened appropriately; 213 (58.9 %) had late initiation of screening (i.e., screening was started ≥5 years later than the age recommended by guidelines) and three (0.8 %) had premature initiation (i.e., screening was started ≥1 year too early). Of cases involving delayed screening initiation, 126 were not under primary care at the time when screening was supposed to have started, while most of the remaining received either no or incorrect screening recommendations from their primary care provider. Of 270 subjects with no neoplasia found on initial screening, 112 (41.5 %) had endoscopist-recommended subsequent screening intervals that were ≥2 years shorter than that recommended by guidelines. Results were similar if American Society of Gastrointestinal Endoscopy or American College of Gastroenterology guidelines were used.

CONCLUSIONS

Patients with a family history often suffer from late initiation of screening and overly short endoscopist-recommended subsequent intervals for colonoscopy. Further education of patients and providers on screening recommendations may be helpful.

Perceived versus predicted risks of colorectal cancer and self-reported colonoscopies by members of mismatch repair gene mutation-carrying families who have declined genetic testing

People carrying germline mutations in mismatch repair genes are at high risk of colorectal cancer (CRC), yet about half of people from mutation-carrying families decline genetic counselling and/or testing to identify mutation status. We studied the association of quantitative measures of risk perception, risk prediction and self-reported screening colonoscopy in this elusive yet high-risk group. The sample of 26 participants (mean age 43.1 years, 14 women) in the Australasian Colorectal Cancer Family Registry were relatives of mutation carriers; had not been diagnosed with any cancer at the time of recruitment and had declined an invitation to attend genetic counselling and/or testing. A structured elicitation protocol captured perceived CRC risk over the next 10 years. Self-reported colonoscopy screening was elicited during a 45-minute semi-structured interview. Predicted 10-year CRC risk based on age, gender, known mutation status and family history was calculated using "MMRpro." Mean perceived 10-year risk of CRC was 31 % [95 % CI 21, 40], compared with mean predicted risk of 4 % [2, 7] (p < 0.001); this was independent of age and sex (p = 0.9). Among those reporting any medical advice and any screening colonoscopy (n = 18), those with higher risk perception had less frequent colonoscopy (Pearson's r = 0.49 [0.02, 0.79]). People who decline genetic testing for CRC susceptibility mutations perceive themselves to be at substantially higher risk than they really are. Those with high perceived risk do not undertake screening colonoscopy more often than those who perceive themselves to be at average risk.

Examining the challenges of family recruitment to behavioral intervention trials: factors associated with participation and enrollment in a multi-state colonoscopy intervention trial

BACKGROUND

Colonoscopy is one of the most effective methods of cancer prevention and detection, particularly for individuals with familial risk. Recruitment of family members to behavioral intervention trials remains uniquely challenging, owing to the intensive process required to identify and contact them. Recruiting at-risk family members involves contacting the original cancer cases and asking them to provide information about their at-risk relatives, who must then be contacted for study enrollment. Though this recruitment strategy is common in family trials, few studies have compared influences of patient and relative participation to nonparticipation. Furthermore, although use of cancer registries to identify initial cases has increased, to our knowledge no study has examined the relationship between registries and family recruitment outcomes.

METHODS

This study assessed predictors of case participation and relative enrollment in a recruitment process that utilized state cancer registries. Participation characteristics were analyzed with separate multivariable logistic regressions in three stages: (1) cancer registry-contacted colorectal cancer (CRC) cases who agreed to study contact; (2) study-contacted CRC cases who provided at-risk relative information; and (3) at-risk relatives contacted for intervention participation.

RESULTS

Cancer registry source was predictive of participation for both CRC cases and relatives, though relative associations (odds ratios) varied across registries. Cases were less likely to participate if they were Hispanic or nonwhite, and were more likely to participate if they were female or younger than 50 at cancer diagnosis. At-risk relatives were more likely to participate if they were from Utah, if another family member was also participating in the study, or if they had previously had a colonoscopy. The number of eligible cases who had to be contacted to enroll one eligible relative varied widely by registry, from 7 to 81.

CONCLUSIONS

Family recruitment utilizing cancer registry-identified cancer cases is feasible, but highly dependent on both the strategies and protocols of those who are recruiting and on participant characteristics such as sex, race, or geography. Devising comprehensive recruitment protocols that specifically target those less likely to enroll may help future research meet recruitment goals.

TRIAL REGISTRATION

Family Colorectal Cancer Awareness and Risk Education Project NCT01274143.

Patients undergoing colorectal cancer screening underestimate their cancer risk and delay presentation for screening

BACKGROUND

Colorectal cancer (CRC) is the third most common cancer in Canada. Screening guidelines recommend that first-time screening should occur at 50 years of age for average-risk individuals and at 40 years of age for those with a family history of CRC.

OBJECTIVE

To examine whether persons with a positive CRC family history were achieving screening at 40 years of age and whether average-risk persons were achieving screening at 50 years of age.

METHODS

The present study was a cross-sectional analysis of subjects who entered a colon cancer screening program and were undergoing CRC screening for the first time.

RESULTS

A total of 778 individuals were enrolled in the present study: 340 (174 males) with no family history of CRC, and 438 (189 males) with a positive family history of CRC. For the group with a positive family history, the mean (± SD) age for primary screening was 54.4 ± 8.5 years, compared with 58.2 ± 6.4 years for the group with no family history. On average, those with a positive family history initiated screening 3.8 years (95% CI 2.8 to 4.8; P<0.05) earlier than those without. Adenoma polyp detection rate for the positive family history group was 20.8% (n=91) compared with 23.5 % (n=80) for the group with no family history.

CONCLUSIONS

Individuals with a positive CRC family history are initiating screening approximately four years earlier than those without a family history; nevertheless, both groups are undergoing screening well past current guideline recommendations.

Colorectal cancer screening of high-risk populations: A national survey of physicians

Background

The incidence of colorectal cancer can be decreased by appropriate use of screening modalities. Patients with a family history of colon cancer and of African-American ethnicity are known to be at higher risk of developing colorectal cancer. We aimed to determine if there is a lack of physician knowledge for colorectal cancer screening guidelines based on family history and ethnicity. Between February and April 2009 an anonymous web-based survey was administered to a random sample selected from a national list of 25,000 internists, family physicians and gastroenterologists. A stratified sampling strategy was used to include practitioners from states with high as well as low CRC incidence. All data analyses were performed following data collection in 2009.

Results

The average knowledge score was 37 ± 18% among the 512 respondents. Gastroenterologists averaged higher scores compared to internists, and family physicians, p = 0.001. Only 28% of physicians correctly identified the screening initiation point for African-Americans while only 12% of physicians correctly identified the screening initiation point and interval for a patient with a family history of CRC. The most commonly cited barriers to referring high-risk patients for CRC screening were "patient refusal" and "lack of insurance reimbursement."

Conclusions

There is a lack of knowledge amongst physicians of the screening guidelines for high-risk populations, based on family history and ethnicity. Educational programs to improve physician knowledge and to reduce perceived barriers to CRC screening are warranted to address health disparities in colorectal cancer.

The Family Health Promotion Project (FHPP): design and baseline data from a randomized trial to increase colonoscopy screening in high risk families

Colorectal cancer (CRC) is a significant cause of mortality and morbidity in the United States, much of which could be prevented through adequate screening. Consensus guidelines recommend that high-risk groups initiate screening earlier with colonoscopy and more frequently than average risk persons. However, a large proportion of high risk individuals do not receive regular colonoscopic screening. The Family Health Promotion Project (FHPP) is a randomized-controlled trial to test the effectiveness of a telephone-based counseling intervention to increase adherence to risk-appropriate colonoscopy screening in high risk individuals. Unaffected members of CRC families from two national cancer family registries were enrolled (n=632) and randomized to receive either a single session telephone counseling intervention using Motivational Interviewing techniques or a minimal mail-out intervention. The primary endpoint, rate of colonoscopy screening, was assessed at 6, 12 and 24 months post-enrollment. In this paper, we describe the research design and telephone counseling intervention of the FHPP trial, and report baseline data obtained from the two high risk cohorts recruited into this trial. Results obtained at baseline confirm the need for interventions to promote colonoscopy screening among these high risk individuals, as well as highlighting several key opportunities for intervention, including increasing knowledge about risk-appropriate screening guidelines, and providing both tailored risk information and barriers counseling.

Disparities in cancer screening in individuals with a family history of breast or colorectal cancer

BACKGROUND

Understanding racial/ethnic disparities in cancer screening by family history risk could identify critical opportunities for patient and provider interventions tailored to specific racial/ethnic groups. The authors evaluated whether breast cancer (BC) and colorectal cancer (CRC) disparities varied by family history risk using a large, multiethnic population-based survey.

METHODS

By using the 2005 California Health Interview Survey, BC and CRC screening were evaluated separately with weighted multivariate regression analyses, and stratified by family history risk. Screening was defined for BC as mammogram within the past 2 years for women aged 40 to 64 years; for CRC, screening was defined as annual fecal occult blood test, sigmoidoscopy within the past 5 years, or colonoscopy within the past 10 years for adults aged 50 to 64 years.

RESULTS

The authors found no significant BC screening disparities by race/ethnicity or income in the family history risk groups. Racial/ethnic disparities were more evident in CRC screening, and the Latino-white gap widened among individuals with family history risk. Among adults with a family history for CRC, the magnitude of the Latino-white difference in CRC screening (odds ratio [OR], 0.28; 95% confidence interval [CI], 0.11-0.60) was more substantial than that for individuals with no family history (OR, 0.74; 95% CI, 0.59-0.92).

CONCLUSIONS

Knowledge of their family history widened the Latino-white gap in CRC screening among adults. More aggressive interventions that enhance the communication between Latinos and their physicians about family history and cancer risk could reduce the substantial Latino-white screening disparity in Latinos most susceptible to CRC.

Electronic patient messages to promote colorectal cancer screening: a randomized controlled trial

BACKGROUND

Colorectal cancer is a leading cause of cancer mortality, yet effective screening tests are often underused. Electronic patient messages and personalized risk assessments delivered via an electronic personal health record could increase screening rates.

METHODS

We conducted a randomized controlled trial in 14 ambulatory health centers involving 1103 patients ranging in age from 50 to 75 years with an active electronic personal health record who were overdue for colorectal cancer screening. Patients were randomly assigned to receive a single electronic message highlighting overdue screening status with a link to a Web-based tool to assess their personal risk of colorectal cancer. The outcomes included colorectal cancer screening rates at 1 and 4 months.

RESULTS

Screening rates were higher at 1 month for patients who received electronic messages than for those who did not (8.3% vs 0.2%, P < .001), but this difference was no longer significant at 4 months (15.8% vs 13.1%, P = .18). Of 552 patients randomized to receive the intervention, 296 (54%) viewed the message, and 47 (9%) used the Web-based risk assessment tool. Among 296 intervention patients who viewed the electronic message, risk tool users were more likely than nonusers to request screening examinations (17% vs 4%, P = .04) and to be screened (30% vs 15%, P = .06). One-fifth of patients (19%) using the risk assessment tool were estimated to have an above-average risk for colorectal cancer.

CONCLUSION

Electronic messages to patients produce an initial increase in colorectal cancer screening rates, but this effect is not sustained over time.

TRIAL REGISTRATION

clinicaltrials.gov Identifier: NCT01032746.

Increasing incidence of rectal cancer in patients aged younger than 40 years: an analysis of the surveillance, epidemiology, and end results database

BACKGROUND

The incidence of rectal cancer in the United States in young patients is considered to be low. Underestimating this incidence may result in a failure to diagnose younger patients with rectal cancer in a timely manner.

METHODS

The authors conducted a retrospective cohort study using Surveillance, Epidemiology, and End Results (SEER) cancer registry data. A total of 7661 patients with colon, rectal, and rectosigmoid cancer who were diagnosed at age <40 years were identified between 1973 and 2005. The change in incidence over time for colon and rectal/rectosigmoid cancer was calculated and the annual percent change for anatomic subsites of colorectal cancer compared.

RESULTS

SEER data demonstrated an increase in the incidence of rectal cancer without any increase in colon cancer (annual percent change of 2.6% vs -0.2%). The difference was statistically significant and extended to rectosigmoid cancer, but not cancer of the sigmoid colon or descending colon (annual percent change of 2.2% vs 0.4% and -2.8%, respectively). Joinpoint analysis of the slope of the curve of rectal and rectosigmoid cancer incidence identified the beginning of the increase to be 1984. All races and both sexes demonstrated similar statistically significant increases in the incidence of rectal and rectosigmoid cancer.

CONCLUSIONS

The incidence of rectal and rectosigmoid cancer appears to be increasing in patients aged <40 years. Patients presenting with rectal bleeding or other alarming signs or symptoms should be evaluated with this finding in mind.

The current state of cancer family history collection tools in primary care: a systematic review

Systematic collection of family history is a prerequisite for identifying genetic risk. This study reviewed tools applicable to the primary care assessment of family history of breast, colorectal, ovarian, and prostate cancer. MEDLINE, EMBASE, CINAHL, and Cochrane Central were searched for publications. All primary study designs were included. Characteristics of the studies, the family history collection tools, and the setting were evaluated. Of 40 eligible studies, 18 relevant family history tools were identified, with 11 developed for use in primary care. Most collected information on more than one cancer and on affected relatives used self-administered questionnaires and paper-based formats. Eleven tools had been evaluated relative to current practice, demonstrating 46-78% improvement in data recording over family history recording in patient charts and 75-100% agreement with structured genetic interviews. Few tools have been developed specifically for primary care settings. The few that have been evaluated performed well. The very limited evidence, which depends in part on extrapolation from studies in settings other than primary care, suggests that systematic tools may add significant family health information compared with current primary care practice. The effect of their use on health outcomes has not been evaluated.

Will knowledge of gene-based colorectal cancer disease risk influence quality of life and screening behavior? Findings from a population-based study

BACKGROUND

Several gene variants conveying a modestly increased risk for disease have been described for colorectal cancer. Patient acceptance of gene variant testing in clinical practice is not known. We evaluated the potential impact of hypothetical colorectal-cancer-associated gene variant testing on quality of life, health habits and cancer screening behavior.

METHODS

First-degree relatives of colorectal cancer patients and controls from the Seattle Colorectal Cancer Familial Registry were invited to participate in a web-based survey regarding testing for gene variants associated with colorectal cancer risk.

RESULTS

310 relatives and 170 controls completed the questionnaire. Quality of life for the hypothetical carrier state was modestly and nonsignificantly lower than current health after adjustment for sociodemographic and health factors. In the positive test scenario, 30% of respondents expressed willingness to change their diet, 25% to increase exercise, and 43% to start colorectal cancer screening. The proportions willing to modify these habits did not differ between groups.

CONCLUSIONS

Testing for gene variants associated with colorectal cancer risk may not influence quality of life, but may impact health habits and screening adherence. Changing behaviors as a result of testing may help to reduce cancer incidence and mortality, particularly among those at higher risk for colorectal cancer.

Colonoscopy screening in African Americans and Whites with affected first-degree relatives

BACKGROUND

Family history is a risk factor for colon cancer, and guidelines recommend initiating screening at age 40 years in individuals with affected relatives. Racial differences in colon cancer mortality could be related to variations in screening of increased-risk individuals.

METHODS

Baseline data from 41 830 participants in the Southern Community Cohort Study were analyzed to determine the proportion of colonoscopy procedures in individuals with strong family histories of colon cancer, and whether differences existed based on race.

RESULTS

In participants with multiple affected first-degree relatives (FDRs) or relatives diagnosed before age 50 years, 27.3% (95% confidence interval [CI], 23.5%-31.1%) of African Americans reported having a colonoscopy within the past 5 years compared with 43.1% (95% CI, 37.0%-49.2%) of white participants (P<.001). African Americans in this group had an odds ratio of 0.51 (95% CI, 0.38-0.68) of having undergone recommended screening procedures compared with white participants after adjusting for age, sex, educational status, annual income, insurance status, total number of affected and unaffected FDRs, and time since last medical visit. African Americans with multiple affected FDRs or relatives diagnosed before age 50 years and who had ever undergone endoscopy were less likely to report a personal history of colon polyps (odds ratio, 0.29; 95% CI, 0.20-0.42) when compared with whites with similar family histories.

CONCLUSIONS

African Americans who have FDRs with colon cancer are less likely to undergo colonoscopy screening compared with whites who have affected relatives. Increased efforts need to be directed at identifying and managing underserved populations at increased risk for colon cancer based on their family histories.

Familial risk and colorectal cancer screening health beliefs and attitudes in an insured population

OBJECTIVE

To examine the relationship between health beliefs and attitudes toward colorectal cancer screening, strength of family history risk, and being appropriately screened for colorectal cancer.

METHODS

In February 2004, 7000 randomly selected members of a multi-specialty group practice located in Boston, MA were mailed a brief survey that was used to ascertain colorectal cancer family history. A follow-up survey that contained questions representing selected constructs of the Health Belief Model, Theory of Planned Behavior, and healthcare experiences was then mailed to all 355 individuals who reported a family history in the initial survey and 710 randomly selected participants with no colorectal cancer family history.

RESULTS

Participants who were appropriately screened had higher mean scores for perceived cancer risk, subjective norms, and perceived benefits and lower scores for perceived barriers. Multivariate findings indicate that having high perceptions of risk for colorectal cancer was a significant correlate of being screened appropriately among individuals with a strong family history.

CONCLUSIONS

For those at greatest colorectal cancer risk due to family history, ensuring that these individuals understand their personal risk might lead to increased colorectal cancer screening participation. Future intervention research is warranted to examine if raising perceptions of risk can increase screening behaviors in individuals with colorectal cancer risk due to family history.