Fecal occult blood testing beliefs and practices of U.S. primary care physicians: serious deviations from evidence-based recommendations

Patterns of Care Following a Positive Fecal Blood Test for Colorectal Cancer: A Mixed Methods Study

BACKGROUND/OBJECTIVE

Multilevel barriers to colonoscopy after a positive fecal blood test for colorectal cancer (CRC) are well-documented. A less-explored barrier to appropriate follow-up is repeat fecal testing after a positive test. We investigated this phenomenon using mixed methods.

DESIGN

This sequential mixed methods study included quantitative data from a large cohort of patients 50-89 years from four healthcare systems with a positive fecal test 2010-2018 and qualitative data from interviews with physicians and patients.

MAIN MEASURES

Logistic regression was used to evaluate whether repeat testing was associated with failure to complete subsequent colonoscopy and to identify factors associated with repeat testing. Interviews were coded and analyzed to explore reasons for repeat testing.

KEY RESULTS

A total of 316,443 patients had a positive fecal test. Within 1 year, 76.3% received a colonoscopy without repeat fecal testing, 3% repeated testing and then received a colonoscopy, 4.4% repeated testing without colonoscopy, and 16.3% did nothing. Among repeat testers (7.4% of total cohort, N = 23,312), 59% did not receive a colonoscopy within 1 year. In adjusted models, those with an initial positive test followed by a negative second test were significantly less likely to receive colonoscopy than those with two successive positive tests (OR 0.37, 95% CI 0.35-0.40). Older age (65-75 vs. 50-64 years: OR 1.37, 95% CI 1.33-1.41) and higher comorbidity score (≥ 4 vs. 0: OR 1.75, 95% CI 1.67-1.83) were significantly associated with repeat testing compared to those who received colonoscopy without repeat tests. Qualitative interview data revealed reasons underlying repeat testing, including colonoscopy avoidance, bargaining, and disbelief of positive results.

CONCLUSIONS

Among patients in this cohort, 7.4% repeated fecal testing after an initial positive test. Of those, over half did not go on to receive a colonoscopy within 1 year. Efforts to improve CRC screening must address repeat fecal testing after a positive test as a barrier to completing colonoscopy.

Patient Navigation After Positive Fecal Immunochemical Test Results Increases Diagnostic Colonoscopy and Highlights Multilevel Barriers to Follow-Up

BACKGROUND

The fecal immunochemical test (FIT) is a common colorectal cancer screening modality in the USA but often is not followed by diagnostic colonoscopy.

AIMS

We investigated the efficacy of patient navigation to increase diagnostic colonoscopy after positive FIT results and determined persistent barriers to follow-up despite navigation in a large, academic healthcare system.

METHODS

The study cohort included all health system outpatients with an assigned primary care provider, a positive FIT result between 12/01/2016 and 06/01/2019, and no documentation of colonoscopy after positive FIT. Two non-clinical patient navigators engaged patients and providers to encourage follow-up, offer solutions to barriers, and assist with colonoscopy scheduling. The primary intervention endpoint was completion of colonoscopy within 6 months of navigation. We documented reasons for persistent barriers to colonoscopy despite navigation and determined predictors of successful follow-up after navigation.

RESULTS

There were 119 patients who received intervention. Of these, 37 (31.1%) patients completed colonoscopy at 6 months. In 41/119 (34.5%) cases, the PCP did not recommend colonoscopy, most commonly due to a normal colonoscopy prior to the positive FIT (19, 46.3%). There were 41/119 patients (34.5%) that declined colonoscopy despite the patient navigator and the PCP order. Male sex and younger age were significant predictors of follow-up (aOR = 2.91, 95%CI, 1.18-7.13; aOR = 0.92, 95%CI, 0.87-0.99).

CONCLUSIONS

After implementation of patient navigation, diagnostic colonoscopy was completed for 31.1% of patients with a positive FIT result. However, navigation also highlighted persistent multilevel barriers to follow-up. Future work will develop targeted solutions for these barriers to further increase FIT follow-up rates in our health system.

Risk of colorectal cancer in patients with positive results of fecal immunochemical test performed within 5 years since the last colonoscopy

BACKGROUND/AIMS

Annual fecal immunochemical tests (FITs) are often repeated within the recommended colonoscopy surveillance intervals. However, it remains unclear whether interval FITs are useful. To answer this question, we assessed the risk of colorectal cancer (CRC) according to the interval from the last colonoscopy to an FIT.

METHODS

Using the Korean National Cancer Screening Program database, we collected data on patients who underwent FITs in 2011. Patients with positive FIT results were classified into three groups according to their previous colonoscopy interval: 0.5 to 5 years (group 1), 5 to 10 years (group 2), and ≥ 10 years or no colonoscopy (group 3). CRC incidence was defined as CRC diagnosed within 1 year after an FIT.

RESULTS

Among 177,660 patients with positive FIT results, the incidence of CRC in groups 1, 2, and 3 was 0.72% (n = 214/29,575), 1.28% (n = 116/9,083), and 3.88% (n = 5,387/139,002), respectively. The age- and sex-adjusted risk for CRC was higher in groups 2 (odds ratio [OR], 1.79; 95% confidence interval [CI], 1.43 to 2.25) and 3 (OR, 5.56; 95% CI, 4.85 to 6.38) than in group 1. Among patients who did and did not undergo a polypectomy during the previous colonoscopy, those in group 2 had a higher rate of CRC than those in group 1 (without polypectomy: 1.15% vs. 0.63%; OR, 1.79; 95% CI, 1.37 to 2.34) (with polypectomy: 2.37% vs. 0.93 %; OR, 2.30; 95% CI, 1.44 to 3.69).

CONCLUSION

In patients with positive FIT results who had undergone a colonoscopy within the past 5 years, the risk of CRC is very low, regardless of whether a polypectomy was performed, suggesting that interval FITs are not useful.

Factors to Improve Endoscopic Screening for Colorectal Cancer

INTRODUCTION

Colorectal cancer is one of the most sprayed cancers; the gold standard of diagnostic is a colonoscopy. The quality of this examination is depended on many factors, which includes doctors' experience.

PURPOSE

The purpose of this study is to establish the main factors affecting the completeness of colonoscopy in colorectal cancer screening.

MATERIALS AND METHODS

Endoscopists were questioned; descriptive statistics methods and logistic regression were used.

RESULTS AND DISCUSSION

The main factors that influence the quality of screening colonoscopy were identified: experience in colonoscopy, theoretical training, participation in the screening program, and number of annual colonoscopies. The calculated odds ratio for the selected dependent variable is calculated.

CONCLUSIONS

The experience for more than 5 years (p = 0.017) and at least 200 colonoscopies per year (p = 0.004) are the main factors that allow to perform complete colonoscopy in 90% or more of cases.

Physician-office vs home uptake of colorectal cancer screening using FOBT/FIT among screening-eligible US adults

Background

Guidelines of the American Cancer Society and US Preventive Services Task Force specify that colorectal cancer (CRC) screening using guaiac‐based fecal occult blood test (FOBT)/fecal immunochemical test (FIT) should be done at home. We therefore examined the prevalence and correlates of CRC screening using FOBT/FIT in physicians' office vs at home.

Methods

Analysis of 9493 respondents 50‐75 years old from the Cancer Control Supplement of the 2015 National Health Interview Survey was conducted. Weighted multivariable logistic regression was used to identify the determinants of in‐office vs home use of FOBT/FIT for CRC screening.

Results

Of the overall sample of screening‐eligible adults (n = 9403), only 937 (10.4%) respondents underwent CRC screening using FOBT/FIT within the past year; among this screening population, 279 (28.3%) respondents were screened in‐office. We found that sociodemographic factors alone, not CRC risk factors, determined whether FOBT/FIT would be used in‐office or at home. Hispanics had greater odds of being screened in‐office using FOBT/FIT (aOR: 2.04; 95% CI: 1.05‐3.99). Compared with those 50‐59 years old, respondents 70‐75 years old were less likely to be screened in‐office using FOBT/FIT (aOR: 0.44, 95% CI: 0.25‐0.79). Similarly, individuals residing in the Western region of the country had lower odds of in‐office FOBT/FIT (aOR: 0.26; 95% CI: 0.11‐0.58).

Conclusion

Amid low overall uptake rates of FOBT/FIT in the United States, in‐physician office testing is high, indicative of a missed opportunity for effective screening and poor adherence of physicians to national guidelines. Sociodemographic factors are determinants of uptake of FOBT/FIT at home or in‐office and should be considered in designing interventions aimed at providers and the general population.

Amid low overall uptake rates of FOBT/FIT in the United States, in‐physician office testing is high, indicative of a missed opportunity for effective screening and poor adherence of physicians to national guidelines.

Use and abuse of fecal occult blood tests: a community hospital experience

Background

The Fecal Occult Blood Test (FOBT) is one of the diagnostic modalities indicated for screening patients for Colorectal Cancer (CRC). Despite being approved only for screening for CRC, numerous studies in the past have illustrated misuse of the FOBT. We examined utilization of the FOBT for patients admitted to a community teaching hospital.

Methods

The study was conducted at Saint Joseph Hospital, Chicago USA. A retrospective review of Electronic Medical Records (EMRs) of patients admitted from January 2016 to December 2017 was performed.

Results

We reviewed the EMRs of 729 patients who received the stool testing for occult blood (FOBT). All tests (100%) were carried out for purposes other than CRC screening. Anemia (38%) was the most common reason documented for carrying out the FOBT. Further, 88% of the tests were ordered on patients who either did not fulfill CRC screening criteria or had other contraindications for testing. Usage of contraindicated medication was the most important factor (58% of patients) that made the candidates ineligible for testing. A total 73 Colonoscopies were ordered for patients who received the test inappropriately with a resulting low yield (0.47%) of CRC diagnosis.

Conclusion

The stool occult blood test continues to be utilized for reasons other than CRC screening. Majority of patients who underwent the test were not suitable candidates due to the presence of contraindications for testing. Unsuitable FOBT testing led to further unnecessary investigations.

Variations in Screening Quality in a Federal Colorectal Cancer Screening Program for the Uninsured

Introduction

Screening can decrease colorectal cancer incidence and mortality and is recommended in clinical practice guidelines. Poor quality of colorectal cancer screening can negate the benefit of screening. The objective of this study was to assess the quality of screening services provided by the Centers for Disease Control and Prevention’s Colorectal Cancer Control Program from July 2009 through June 2015.

Methods

We collected data from the program’s 29 grantees, funded to provide colorectal cancer screening and diagnostic services to asymptomatic, low-income, and underinsured or uninsured adults aged 50 to 64. We collected data on the dates and results of all screening and diagnostic tests and, for colonoscopies, on whether the cecum was reached, whether bowel preparation was adequate, and endoscopists’ recommendations for the next test.

Results

Overall, 82.9% (range among grantees, 50.0%–97.2%) of positive FOBTs/FITs were followed up by colonoscopy; 95.2% of colonoscopies occurred within 180 days of the positive stool test. Cecal intubation rates ranged among grantees from 94.2% to 100%. Adenoma detection rates met recommended threshold levels for almost all grantees. Recommendations for rescreening and surveillance intervals deviated from guidelines in both directions. Of clients with normal colonoscopies, 85.3% (range, 37.7%–99.7%) were told to return in 10 years, as recommended in national guidelines. Of clients with advanced adenomas, 55.2% (range, 20.0%–84.6%) were told to return in 3 years as recommended, 25.4% (range, 3.8%–56.6%) in 5 or more years, and 18.6% (range, 0%–47.2%) in less than 3 years.

Conclusion

Although overall screening quality was good, it varied considerably. Ongoing monitoring to identify performance problems is essential for all colorectal cancer screening activities, so that efforts designed to improve performance can be targeted to individual clinicians.

Developing Patient-Refined Messaging for a Mailed Colorectal Cancer Screening Program in a Latino-Based Community Health Center

INTRODUCTION

Colon cancer is the second leading cause of cancer death in the United States, and screening rates are disproportionately low among Latinos. One factor thought to contribute to the low screening rate is the difficulty Latinos encounter in understanding health information, and therefore in taking appropriate health action. Therefore, we used Boot Camp Translation (BCT), a patient engagement approach, to engage Latino stakeholders (ie, patients, clinic staff) in refining the messages and format of colon cancer screening reminders for a clinic-based direct mail fecal immunochemical testing (FIT) program.

METHODS

Patient participants were Latino, ages 50 to 75 years, able to speak English or Spanish, and willing to participate in the in-person kickoff meeting and follow-up phone calls over a 3-month period. We held separate BCT sessions for English- and Spanish-speaking participants. As part of the in-person meetings, a bilingual colon cancer expert presented on colon health and screening messages and BCT facilitators led interactive sessions where participants reviewed materials and reminder messages in various modalities (eg, letter, text). Participants considered what information about colon cancer screening was important, the best methods to share these messages, and the timing and frequency with which these messages should be delivered to patients to encourage FIT completion. We used follow-up phone calls to iteratively refine materials developed based on key learnings from the in-person meeting.

RESULTS

Twenty-five adults participated in the in-person sessions (English [n = 12]; Spanish [n = 13]). Patient participants were primarily enrolled in Medicaid/uninsured (76%) and had annual household incomes less than $20,000 (67%). Key themes distilled from the sessions included increasing awareness that screening can prevent colon cancer, stressing the urgency of screening, emphasizing the motivating influence of family, and using personalized messages from the practice such as 'I' or 'we' statements in letters or automated phone call reminders delivered by humans. Participants in both sessions noted the importance of receiving an automated or live alert before a FIT kit is mailed and a reminder within 2 weeks of FIT kit mailing.

DISCUSSION

Using BCT, we successfully incorporated participant feedback to adapt culturally relevant health messages to promote FIT testing among Latino patients served by community clinics. Materials will be tested in the larger Participatory Research to Advance Colon Cancer Prevention (PROMPT) trial.

Yield of repeat colonoscopy in asymptomatic individuals with a positive fecal immunochemical test and recent colonoscopy

BACKGROUND AND AIMS

A fecal immunochemical test (FIT) is often repeated annually, even after a recent colonoscopy. However, there are no published data on the proper approach to FIT-positive patients after a recent colonoscopy. We compared colorectal cancer (CRC) and advanced colorectal neoplasia (ACRN) prevalence based on the interval since the last colonoscopy.

METHODS

We reviewed asymptomatic screenees aged ≥50 years who underwent FIT and colonoscopy.

RESULTS

Of 2228 FIT-positive participants, 514 had a colonoscopy less than 3 years before (group 1), 427 had a colonoscopy had a colonoscopy 3 to 10 years before (group 2), and 1287 had a colonoscopy >10 years before or no colonoscopy (group 3). The prevalence of CRC in groups 1, 2, and 3 was 2.1%, 1.6%, and 7.2%, respectively, and that for ACRN was 10.9%, 12.6%, and 26.0%, respectively. Even after adjusting for confounders, CRC and ACRN detection rates in group 1 were lower than those in group 3 but not lower than those in group 2. Among 6135 FIT-negative participants, the prevalence of CRC in the 3 groups was .7%, .4%, and 3.4%, respectively, and that for ACRN was 6.0%, 6.1%, and 14.7%, respectively. CRC and ACRN detection rates were significantly higher in FIT-positive participants than in FIT-negative participants in all 3 groups.

CONCLUSIONS

In FIT-positive patients who underwent colonoscopy within the prior 3 years, CRC and ACRN prevalence was not low. Our findings support the U.S. Multi-Society Task Force on the CRC screening recommendation that repeat colonoscopy be offered to patients with positive FIT results and recent colonoscopy.

Patient-Refined Messaging for a Mailed Colorectal Cancer Screening Program: Findings from the PROMPT Study

BACKGROUND

Improving uptake of colorectal cancer screening has the potential of saving thousands of lives. We compared the effectiveness of automated and live prompts and reminders as part of a mailed fecal immunochemical test (FIT) outreach program.

DESIGN AND METHODS

Participants were 1767 adults aged 50 to 75 eyars who were not up-to-date with colorectal cancer screening recommendations at a participating community health center clinic. In addition to a mailed FIT kit, participants were randomized to receive (1) a text message prompt and 2 automated phone call reminders (automated condition); (2) up to 3 live call reminders (live condition); or (3) a text message prompt, 2 automated call reminders, and up to 3 live reminders (combined automated plus live condition). We assessed FIT completion rates in each group 6 months following randomization.

KEY RESULTS

Nearly one-third of participants completed an FIT within 6 months. Compared with adults allocated to the automated condition, FIT completion rates were higher in adults allocated to the live condition (32.3% vs 26.0%; adjusted difference, 6.3 percentage points; 95% CI, 1.1-11.4) and in adults allocated to the combined automated plus live condition (35.7% vs 26.0%; adjusted difference, 9.7 percentage points; 95% CI, 4.4-14.9). The number of kits needed to mail to achieve a completed FIT ranged from 2.8 in the combined automated plus live condition to 3.8 in the automated condition.

CONCLUSIONS

Among unscreened individuals in this population, live phone call reminders either alone or in combination with automated prompts and reminders outperformed automated approaches alone.

Implementing Colon Cancer Screening Guidelines Into the Primary Care Setting

Colon cancer is the second leading cause of all cancers deaths. Despite public awareness, many healthcare providers and patients remain uninformed about colon cancer screening options alternative to colonoscopy. Research supports the lack of providers' education and patient knowledge. At a clinic for veterans in Central Florida, 2 educational presentations were delivered to primary care providers (N = 46) on the clinical pathway for colon cancer screening options. A pilot study with a quantitative pretest-post-test design was used to evaluate differences between screening orders 3 months before and after the presentations. A 10-item survey on the usefulness of the educational information was also administered to providers. Results of a 1-way analysis of variance indicated no significant differences between the two 3-month periods. However, with exclusion of the lowest month, a significance level resulted of .087, 91.3% confidence level. Survey responses indicated a positive impact, with most answers ranging from agree to strongly agree. The study revealed that the educational clinical pathway contributed to providers' increased recommendations of screening options and the educational information was useful. Additional research is recommended on the effectiveness of education and providers' use of screening options for colon cancer for average-risk veterans in healthcare institutions.

Coping With Prediagnosis Symptoms of Colorectal Cancer: A Study of 244 Individuals With Recent Diagnosis

BACKGROUND

Colorectal cancer (CRC) symptoms are often vague and vary in severity, intensity, type, and timing. Receipt of medical care is dependent on symptom recognition and assessment, which may impede timely diagnosis.

OBJECTIVE

The aim of this study was to describe and categorize how CRC patients coped with symptoms prior to seeking medical care, examine sociodemographic differences in these coping strategies, and determine the strategies associated with time to seek medical care and overall time to diagnosis.

METHODS

Two hundred forty-four white and African American patients in Virginia and Ohio who received a diagnosis of CRC and who experienced symptoms prior to diagnosis were administered a semistructured interview and the Brief COPE questionnaire.

RESULTS

Eighty-three percent used more than 1 coping strategy. Common symptom-specific coping strategies were to "wait-and-see," self-treat, and rationalize symptoms. Males were more likely to wait and see (P < .001); African Americans and Medicaid recipients were more likely to self-treat via lifestyle changes (P's < .01). Younger individuals (<50 years old) had higher Brief COPE reframing, planning, and humor scores; those with lower education and income had higher denial scores (P's < .01). Using more symptom-specific coping strategies and engaging in avoidance/denial were associated with longer time to seek medical care and overall time to diagnosis (P's < .01).

CONCLUSIONS

Individuals experiencing CRC symptoms use multiple, diverse coping strategies that are influenced by sociodemographic characteristics. Denial is particularly relevant for delay in seeking care and timely diagnosis.

IMPLICATIONS FOR PRACTICE

Public health campaigns could focus on secondary prevention of CRC by targeting at-risk groups such as males, African Americans, or Medicaid recipients, who choose waiting or self-treatment in response to initial symptoms.

Recommendations on Fecal Immunochemical Testing to Screen for Colorectal Neoplasia: A Consensus Statement by the US Multi-Society Task Force on Colorectal Cancer

The use of the fecal occult blood test (FOBT) for colorectal cancer (CRC) screening is supported by randomized trials demonstrating effectiveness in cancer prevention and widely recommended by guidelines for this purpose. The fecal immunochemical test (FIT), as a direct measure of human hemoglobin in stool has a number of advantages relative to conventional FOBT and is increasingly used relative to that test. This review summarizes current evidence for FIT in colorectal neoplasia detection and the comparative effectiveness of FIT relative to other commonly used CRC screening modalities. Based on evidence, guidance statements on FIT application were developed and quality metrics for program implementation proposed.

Cancer screening in the United States, 2017: A review of current American Cancer Society guidelines and current issues in cancer screening

Answer questions and earn CME/CNE Each year, the American Cancer Society publishes a summary of its guidelines for early cancer detection, data and trends in cancer screening rates, and select issues related to cancer screening. In this issue of the journal, the authors summarize current American Cancer Society cancer screening guidelines, describe an update of their guideline for using human papillomavirus vaccination for cancer prevention, describe updates in US Preventive Services Task Force recommendations for breast and colorectal cancer screening, discuss interim findings from the UK Collaborative Trial on Ovarian Cancer Screening, and provide the latest data on utilization of cancer screening from the National Health Interview Survey. CA Cancer J Clin 2017;67:100-121. © 2017 American Cancer Society.

Screening for colorectal cancer: the role of the primary care physician

In recent years, the role of primary care physicians (PCPs) in the diagnosis and management of gastrointestinal disorders, including screening for colorectal cancer (CRC), has been recognized as very important. The available data indicate that PCPs are not adequately following CRC screening guidelines because a number of factors have been identified as significant barriers to the proper application of CRC screening guidelines. These factors include lack of time, patient reluctance, and challenges related to scheduling colonoscopy. Further positive engagement of PCPs with CRC screening is required to overcome these barriers and reach acceptable levels in screening rates. To meet the expectations of modern medicine, PCPs should not only be able to recommend occult blood testing or colonoscopy but also, under certain conditions, able to perform colonoscopy. In this review, the authors aim to provide the current knowledge of the role of PCPs in increasing the rate and successfully implementing a screening program for CRC by applying the relevant international guidelines.

Recommendations on Fecal Immunochemical Testing to Screen for Colorectal Neoplasia: A Consensus Statement by the US Multi-Society Task Force on Colorectal Cancer

The use of the fecal occult blood test (FOBT) for colorectal cancer (CRC) screening is supported by randomized trials demonstrating effectiveness in cancer prevention and widely recommended by guidelines for this purpose. The fecal immunochemical test (FIT), as a direct measure of human hemoglobin in stool has a number of advantages relative to conventional FOBT and is increasingly used relative to that test. This review summarizes current evidence for FIT in colorectal neoplasia detection and the comparative effectiveness of FIT relative to other commonly used CRC screening modalities. Based on evidence, guidance statements on FIT application were developed and quality metrics for program implementation proposed.

Influences and Practices in Colorectal Cancer Screening Among Health Care Providers Serving Northern Plains American Indians, 2011-2012

Introduction

The epidemiology of colorectal cancer, including incidence, mortality, age of onset, stage of diagnosis, and screening, varies regionally among American Indians. The objective of the Improving Northern Plains American Indian Colorectal Cancer Screening study was to improve understanding of colorectal cancer screening among health care providers serving Northern Plains American Indians.

Methods

Data were collected, in person, from a sample of 145 health care providers at 27 health clinics across the Northern Plains from May 2011 through September 2012. Participants completed a 32-question, self-administered assessment designed to assess provider practices, screening perceptions, and knowledge.

Results

The proportion of providers who ordered or performed at least 1 colorectal cancer screening test for an asymptomatic, average-risk patient in the previous month was 95.9% (139 of 145). Of these 139 providers, 97.1% ordered colonoscopies, 12.9% ordered flexible sigmoidoscopies, 73.4% ordered 3-card, guaiac-based, fecal occult blood tests, and 21.6% ordered fecal immunochemical tests. Nearly two-thirds (64.7%) reported performing in-office guaiac-based fecal occult blood tests using digital rectal examination specimens. Providers who reported receiving a formal update on colorectal cancer screening during the previous 24 months were more likely to screen using digital rectal exam specimens than providers who had received a formal update on colorectal cancer screening more than 24 months prior (73.9% vs 56.9%, respectively, χ² = 4.29, P = .04).

Conclusion

Despite recommendations cautioning against the use of digital rectal examination specimens for colorectal cancer screening, the practice is common among providers serving Northern Plains American Indian populations. Accurate up-to-date, ongoing education for patients, the community, and health care providers is needed.

Achieving health equity in colorectal cancer: a call to action

Whether defined by race, ethnicity, or socioeconomic status, there are clear health disparities in colon cancer-disparities that exist whether you measure screening, incidence, or mortality. Rather than rehash disparity statistics, the purpose of this educational article is to highlight important resources and how they can be used to help narrow these disparities. Although the logistics can be complex, the general solutions to eliminating colon cancer health disparities are not complex. They are as follows: Asymptomatic persons need to be screened. After being screened, they need to be diagnosed. After being diagnosed, they need to receive appropriate treatment in a timely fashion. After receiving treatment, they have to receive appropriate follow-up and information and advice on lifestyle changes. If we can implement these measures, then cancer-specific mortality disparities will be dramatically reduced, if not eliminated.

Colorectal cancer screening at community health centers: A survey of clinicians' attitudes, practices, and perceived barriers

Objective

Colorectal cancer (CRC) screening rates remain lower among some racial/ethnic groups and individuals with low income or educational attainment who are often cared for within community health centers (CHCs). We surveyed clinicians in a network of CHCs to understand their attitudes, practice patterns, and perceived barriers to CRC screening.

Methods

A clinician survey was conducted in 2013 within the Community Health Applied Research Network (CHARN).

Results

180 clinicians completed the survey (47.9% response rate). Participants had an average of 11.5 (SD: 9.8) years in practice, 62% were female, and 57% were physicians. The majority of respondents somewhat agreed (30.2%) or strongly agreed (57.5%) that colonoscopy was the best screening test. However, only 15.8% of respondents strongly agreed and 32.2% somewhat agreed that colonoscopy was readily available for their patients. Fecal immunochemical testing (FIT), a type of fecal occult blood test (FOBT), was viewed less favorably; 24.6% rated FIT as very effective.

Conclusions

Although there are no data showing that screening colonoscopy is superior to FIT, CHC clinicians believe colonoscopy is the best CRC screening test for their patients, despite the high prevalence of financial barriers to colonoscopy. These attitudes could be due to lack of knowledge about the evidence supporting long-term benefits of fecal occult blood testing (FOBT), lack of awareness about the improved test characteristics of FIT compared to older guaiac-based FOBT, or the absence of systems to ensure adherence to regular FOBT screening. Interventions to improve CRC screening at CHCs must address clinicians' negative attitudes towards FIT.

•

We surveyed primary care clinicians in a nationwide network of Community Health Centers.

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The vast majority believed that colonoscopy was the best screening test for colorectal cancer.

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However, less than half agreed that colonoscopy was readily available for their patients.

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Fecal occult blood testing was viewed far less favorably than colonoscopy.

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These attitudes and barriers must be overcome to improve screening and reduce disparities.

Knowledge of Polyp History and Recommended Follow-Up Among a Predominately African American Patient Population and the Impact of Patient Navigation

BACKGROUND AND AIMS

Colorectal screening (CRS) rates in minority and uninsured populations have increased through patient navigation (PN) interventions. However, patient knowledge of colonoscopy results and follow-up recommendations has not been described in an African American (AA) population or following PN. Our objectives were to determine patient knowledge of colonoscopy results and follow-up recommendations within an AA patient population and to compare post-colonoscopy knowledge among patients who received either PN or usual care.

METHODS

This is a prospective observational study of patients who completed a screening colonoscopy in 2014. A semi-structured telephone survey was completed by 96 participants (69 % AA, 78 % female, and mean age 63 years). The survey assessed patient recall of polyp results and follow-up recommendations. Responses were compared with the medical record.

RESULTS

Of 96 patients surveyed (response rate, 68 %), 83 % accurately reported if polyps were detected and 66 % accurately reported their recommended follow-up. The identification of adenomatous polyps on colonoscopy was a predictor of accurate recall of colonoscopy results and follow-up recommendations. Uninsured patients who completed PN (18 of 96) were more likely to accurately report polyp results (100 vs. 80 %; P = 0.036), but the rates of accurate follow-up recall were not statistically significant (44 vs. 71 %; P = 0.053) when compared to usual care patients.

CONCLUSIONS

In an AA population, post-colonoscopy polyp recall rates were similar to those described in white populations. Uninsured patients who completed PN were more likely than insured usual care patients to accurately report the presence of polyps on colonoscopy.

Annual Fecal Occult Blood Testing can be Safely Suspended for up to 5 Years After a Negative Colonoscopy in Asymptomatic Average-Risk Patients

OBJECTIVES

Annual fecal occult blood testing (FOBT) is often continued in patients who have had a recent negative colonoscopy, despite recommendations to the contrary. This prospective study aimed to determine the proportion of patients with a positive FOBT who had adenomas and cancers on colonoscopy stratified according to the duration of time since the last negative colonoscopy.

METHODS

A total of 1,119 asymptomatic average-risk patients ≥50 years of age referred for a positive FOBT were prospectively identified and stratified by the duration of time since the last colonoscopy (never, >10 years, 5-10 years, or <5 years). The proportion of patients in each category with adenomas of any size, adenomas ≥10 mm, advanced neoplasms, and cancers was assessed.

RESULTS

The mean age (68.9±9.6 years), sex (95.2% male), and race (48.1% white, 32.1% black, 15.6% Hispanic, and 4.2% other) did not differ between the four groups. Overall, adenomas of any size were detected in 42.8% of patients, adenomas ≥10 mm in 14.7%, advanced neoplasms in 20.7%, and cancers in 7.3%. Advanced neoplasms were detected in 30.4% of patients who have never had a colonoscopy, 27% in those who have had one greater than 10 years prior, 10.0% in 5-10 years prior, and 1.1% in less than 5 years prior.

CONCLUSIONS

In asymptomatic average-risk patients with a negative colonoscopy within the last 5 years, the prevalence of adenomas is low, and no patient was diagnosed with cancer. These findings support the CDC recommendations to suspend annual FOBT for up to 5 years after a negative colonoscopy.

Lack of follow-up colonoscopy after positive FOBT in an organized colorectal cancer screening program is associated with modifiable health care practices

BACKGROUND

ColonCancerCheck (CCC), Ontario's organized colorectal cancer (CRC) screening program, uses guaiac fecal occult blood testing (gFOBT). To reduce CRC-related mortality, persons with a positive gFOBT must have colonoscopy. We identified factors associated with failure to have colonoscopy within 6months of a positive gFOBT.

METHODS

Population-based, retrospective cohort analysis of CCC participants with positive gFOBT (April 2008 to December 2009) using health administrative data. Patient, physician and health care utilization factors associated with a lack of follow-up colonoscopy were identified using descriptive and multivariate analyses.

RESULTS

There were 21,839 participants with a positive gFOBT; 14,091 (64%) had colonoscopy within 6months. The strongest factors associated with failure to follow-up were recent colonoscopy (in 2years prior vs. >10years or never, OR: 4.31, 95% C.I.: 3.82, 4.86), as well as repeat gFOBT (OR: 6.08, 95% C.I.: 5.46, 6.78) and hospital admission (OR: 4.35, 95% C.I.: 3.57, 5.26) in the follow-up period.

CONCLUSION

In the first 18months of the CCC Program, 1/3 of those with a positive gFOBT did not have colonoscopy within 6months. Identification of potentially modifiable factors associated with failure to follow up lay the groundwork for interventions to address this critical quality gap.

Use of Tracking and Reminder Systems for Colorectal Cancer Screening in Indian Health Service and Tribal Facilities

BACKGROUND

Colorectal cancer (CRC) is a significant cause of morbidity and mortality among American Indian/Alaska Native (AI/AN) people. Screening at recommended intervals can detect CRC in its early, most treatable stages, or prevent CRC through removal of precancerous polyps. However, CRC screening percentages remain low among AI/AN people. Reminder and tracking systems can be used to improve CRC screening percentages.

PURPOSE

In this study we assessed the prevalence of CRC screening reminder and tracking systems in Indian Health Service (IHS), Tribal, or Urban (I/T/U) health facilities.

METHODS

A telephone survey of randomly selected small, medium and large I/T/U health facilities nationwide was conducted. Three health facilities from each of the 12 IHS areas nationwide were selected from a list of I/T/U healthcare facilities that provide CRC screening or refer patients to another facility for screening, with the goal of having one small, one medium, and one large I/T/U health facility from each IHS area.

RESULTS

Thirty-four facilities (94%) participated in the telephone survey between April 1 and September 24, 2010. All facilities used the IHS Resource and Patient Management System to manage their patient care, and 82% used the Electronic Health Record (EHR) version. Over half of these facilities (55%) performed in-office fecal occult blood tests (FOBT) collected during a digital rectal exam, all of which reported that they also sent FOBT cards home with patients. Fifty-three percent of facilities used an opportunistic, visit-based approach to CRC screening. Nearly a third (32%) of facilities reported using a reminder system to notify patients that they were due for CRC screening. Almost two-thirds (65%) of facilities used a reminder system to notify health care providers that patients were due for CRC screening. While 73% of facilities used a system to track whether patients were due for CRC screening, only 61% used a system to track patient results for CRC screening, and 42% used a system to track patients with a personal history of polyps or CRC.

CONCLUSIONS

A majority of facilities performed in-office FOBT tests using a digital rectal exam, which is a practice that is contrary to national CRC screening recommendations. Additionally, the majority of facilities reported not using an organized system for CRC screening. Use of patient reminders was suboptimal. However, facilities did report use of provider reminders, tracking when patients were due for CRC screening, and tracking CRC screening results. As the EHR system becomes more widely used and established, I/T/U facilities could be encouraged to increase their use of the EHR tools available to aid in systematically increasing CRC screening percentages.

Organizational predictors of colonoscopy follow-up for positive fecal occult blood test results: an observational study

BACKGROUND

This study assessed the contribution of organizational structures and processes identified from facility surveys to follow-up for positive fecal occult blood tests [FOBT-positive (FOBT(+))].

METHODS

We identified 74,104 patients with FOBT(+) results from 98 Veterans Health Administration (VHA) facilities between August 16, 2009 and March 20, 2011, and followed them until September 30, 2011, for completion of colonoscopy. We identified patient characteristics from VHA administrative records, and organizational factors from facility surveys completed by primary care and gastroenterology chiefs. We estimated predictors of colonoscopy completion within 60 days and six months using hierarchical logistic regression models.

RESULTS

Thirty percent of patients with FOBT(+) results received colonoscopy within 60 days and 49% within six months. Having gastroenterology or laboratory staff notify gastroenterology providers directly about FOBT(+) cases was a significant predictor of 60-day [odds ratio (OR), 1.85; P = 0.01] and six-month follow-up (OR, 1.25; P = 0.008). Additional predictors of 60-day follow-up included adequacy of colonoscopy appointment availability (OR, 1.43; P = 0.01) and frequent individual feedback to primary care providers about FOBT(+) referral timeliness (OR, 1.79; P = 0.04). Additional predictors of six-month follow-up included using guideline-concordant surveillance intervals for low-risk adenomas (OR, 1.57; P = 0.01) and using group appointments and combined verbal-written methods for colonoscopy preparation instruction (OR, 1.48; P = 0.0001).

CONCLUSION

Directly notifying gastroenterology providers about FOBT(+) results, using guideline-concordant adenoma surveillance intervals, and using colonoscopy preparations instruction methods that provide both verbal and written information may increase overall follow-up rates. Enhancing follow-up within 60 days may require increased colonoscopy capacity and feedback to primary care providers.

IMPACT

These findings may inform organizational-level interventions to improve FOBT(+) follow-up.

Physicians' beliefs about effectiveness of cancer screening tests: a national survey of family physicians, general internists, and obstetrician-gynecologists

OBJECTIVE

To study physicians' beliefs about the effectiveness of different tests for cancer screening.

METHODS

Data were examined from the Women's Health Survey of 1574 Family Medicine, Internal Medicine, and Obstetrics-Gynecology physicians to questions about their level of agreement about the clinical effectiveness of different tests for breast, cervical, ovarian, and colorectal cancer screening among average risk women. Data were weighted to the U.S. physician population based on the American Medical Association Masterfile. Multivariable logistic regression identified physician and practice characteristics significantly associated with physicians' beliefs.

RESULTS

There were 1574 respondents, representing a 62% response rate. The majority of physicians agreed with the effectiveness of mammography for women aged 50-69years, Pap tests for women aged 21-65years, and colonoscopy for individuals aged ≥50years. A substantial proportion of physicians believed that non-recommended tests were effective for screening (e.g., 34.4% for breast MRI and 69.1% for annual pelvic exam). Physicians typically listed their respective specialty organizations as a top influential organization for screening recommendations.

CONCLUSIONS

There were several substantial inconsistencies between physician beliefs in the effectiveness of cancer screening tests and the actual evidence of these tests' effectiveness which can lead both to underuse and overuse of cancer screening tests.

Fostering partnerships and program success

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Assessing screening quality in the CDC's Colorectal Cancer Screening Demonstration Program

BACKGROUND

Gaps in screening quality in community practice have been well documented. The authors examined recommended indicators of screening quality in the Centers for Disease Control and Prevention's Colorectal Cancer Screening Demonstration Program (CRCSDP), which provided colorectal cancer screening and diagnostic services between 2005 and 2009 for asymptomatic, low-income, underinsured, or uninsured individuals at 5 sites around the United States.

METHODS

For each client screened in the CRCSDP, a standardized set of colorectal cancer clinical data elements was collected. Data regarding client age, screening history, risk level, screening test indication, results, and recommendation for the next test were analyzed. For colonoscopies, data were analyzed regarding whether the cecum was reached, bowel preparation was adequate, and identified lesions were completely removed.

RESULTS

Overall, 53% of the fecal occult blood tests (FOBTs) (2295 tests) distributed were completed and returned. At the 2 sites with adequate numbers of FOBTs, 77% and 97%, respectively, of clients with positive results received follow-up colonoscopies. Site-specific cecal intubation rates ranged from 90% to 98%. Adenoma detection rates were 32% for men and 21% for women. For approximately one-third of colonoscopies, the recommended interval to the next test was shorter than recommended by national guidelines. At some sites, endoscopists failed to report on the adequacy of bowel preparation and completeness of polyp removal.

CONCLUSIONS

Cecal intubation rates and adenoma detection rates met recommended levels. The authors identified the need for improvements in the follow-up of positive FOBTs, documentation of important elements in colonoscopy reports, and recommendations for rescreening or surveillance intervals after colonoscopy. Monitoring quality indicators is important to improve screening quality.

Vital signs: colorectal cancer screening test use--United States, 2012

BACKGROUND

Strong evidence exists that screening with fecal occult blood testing (FOBT), sigmoidoscopy, or colonoscopy reduces the number of deaths from colorectal cancer (CRC). The percentage of the population up-to-date with recommended CRC screening increased from 54% in 2002 to 65% in 2010, primarily through increased use of colonoscopy.

METHODS

Data from the 2012 Behavioral Risk Factor Surveillance System survey were analyzed to estimate percentages of adults aged 50-75 years who reported CRC screening participation consistent with United States Preventive Services Task Force recommendations.

RESULTS

In 2012, 65.1% of U.S. adults were up-to-date with CRC screening, and 27.7% had never been screened. The proportion of respondents who had never been screened was greater among those without insurance (55.0%) and without a regular care provider (61.0%) than among those with health insurance (24.0%) and a regular care provider (23.5%). Colonoscopy was the most commonly used screening test (61.7%), followed by FOBT (10.4%). Colonoscopy was used by more than 53% of the population in every state. The percentages of blacks and whites up-to-date with CRC screening were equivalent. Compared with whites, a higher percentage of blacks across all income and education levels used FOBT.

CONCLUSIONS

Many age-eligible adults did not use any type of CRC screening test as recommended. Organized, population-based approaches might increase CRC screening among those who have never been screened. Promoting both FOBT and colonoscopy as viable screening test options might increase CRC screening rates and reduce health disparities.

Use of fecal immunochemical tests in the Iowa Research Network

Although the fecal immunochemical test (FIT) has recently emerged as an effective and affordable colorectal cancer screening option, many family physician offices continue to use guaiac-based tests. The purpose of this study was to assess the use of FITs in the Iowa Research Network and to assess physicians' knowledge about FITs. A cover letter and questionnaire were faxed twice to the 291 physician members followed up by a mailing. One hundred and seven (37%) questionnaires were returned. Participants' mean age was 55 years with 78 male responders. Fifty-two (49%) of the physician's offices were in a nonmetro area. Fifty-one (49%) reported using guaiac-based tests and 39 (39%) reported using FITs. Many physicians were unsure of the answers for the FIT knowledge questions. FIT use is not widespread in Iowa Research Network physician offices, and not all physicians are aware of the type of fecal occult blood test being conducted in their office.

The National Prevention Strategy and breast cancer screening: scientific evidence for public health action

Mammography screening rates in the United States have remained fairly stable over the past decade, and screening rates remain low for some groups. We examined insights from recent public health research on breast cancer screening to identify promising new approaches to improve screening rates and address persistent health disparities in mammography use. We considered this research in the context of the four strategic directions of the National Prevention Strategy: elimination of health disparities, empowered people, healthy and safe community environments, and clinical and community preventive services. This research points to the value of direct outreach and case management services, interventions to support more patient-centered models of care, and more organized, population-based approaches to identify women who are eligible to be screened, encourage participation, and monitor results.

Colorectal cancer screening with blood-based biomarkers: cost-effectiveness of methylated septin 9 DNA versus current strategies

BACKGROUND

Screening reduces colorectal cancer mortality, but many persons remain unscreened. Screening with a blood test could improve screening rates. We estimated the comparative effectiveness and cost-effectiveness of colorectal cancer screening with emerging biomarkers, illustrated by a methylated Septin 9 DNA plasma assay ((m)SEPT9), versus established strategies.

METHODS

We conducted a cost-utility analysis using a validated decision analytic model comparing (m)SEPT9, fecal occult blood testing (FOBT), fecal immunochemical testing (FIT), sigmoidoscopy, and colonoscopy, projecting lifetime benefits and costs.

RESULTS

In the base case, (m)SEPT9 decreased colorectal cancer incidence by 35% to 41% and colorectal cancer mortality by 53% to 61% at costs of $8,400 to $11,500/quality-adjusted life year gained versus no screening. All established screening strategies were more effective than (m)SEPT9. FIT was cost saving, dominated (m)SEPT9, and was preferred among all the alternatives. Screening uptake and longitudinal adherence rates over time strongly influenced the comparisons between strategies. At the population level, (m)SEPT9 yielded incremental benefit at acceptable costs when it increased the fraction of the population screened more than it was substituted for other strategies.

CONCLUSIONS

(m)SEPT9 seems to be effective and cost-effective compared with no screening. To be cost-effective compared with established strategies, (m)SEPT9 or blood-based biomarkers with similar test performance characteristics would need to achieve substantially higher uptake and adherence rates than the alternatives. It remains to be proven whether colorectal cancer screening with a blood test can improve screening uptake or long-term adherence compared with established strategies.

IMPACT

Our study offers insights into the potential role of colorectal cancer screening with blood-based biomarkers.

Comparative effectiveness and cost-effectiveness of screening colonoscopy vs. sigmoidoscopy and alternative strategies

OBJECTIVES

Fecal occult blood testing (FOBT) and sigmoidoscopy are proven to decrease colorectal cancer (CRC) incidence and mortality. Sigmoidoscopy's benefit is limited to the distal colon. Observational data are conflicting regarding the degree to which colonoscopy affords protection against proximal CRC. Our aim was to explore the comparative effectiveness and cost-effectiveness of colonoscopy vs. sigmoidoscopy and alternative CRC screening strategies in light of the latest published data.

METHODS

We performed a contemporary cost-utility analysis using a Markov model validated against data from randomized controlled trials of FOBT and sigmoidoscopy. Persons at average CRC risk within the general US population were modeled. Screening strategies included those recommended by the United States (US) Preventive Services Task Force, including colonoscopy every 10 years (COLO), flexible sigmoidoscopy every 5 years (FS), annual fecal occult blood testing, annual fecal immunochemical testing (FIT), and the combination FS/FIT. The main outcome measures were quality-adjusted life-years (QALYs) and costs.

RESULTS

In the base case, FIT dominated other strategies. The advantage of FIT over FS and COLO was contingent on rates of uptake and adherence that are well above current US rates. Compared with FIT, FS and COLO both cost <$50,000/QALY gained when FIT per-cycle adherence was <50%. COLO cost $56,800/QALY gained vs. FS in the base case. COLO cost <$100,000/QALY gained vs. FS when COLO yielded a relative risk of proximal CRC of <0.5 vs. no screening. In probabilistic analyses, COLO was cost-effective vs. FS at a willingness-to-pay threshold of $100,000/QALY gained in 84% of iterations.

CONCLUSIONS

Screening colonoscopy may be cost-effective compared with FIT and sigmoidoscopy, depending on the relative rates of screening uptake and adherence and the protective benefit of colonoscopy in the proximal colon. Colonoscopy's cost-effectiveness compared with sigmoidoscopy is contingent on the ability to deliver ~50% protection against CRC in the proximal colon.

A future for faecal haemoglobin measurements in the medical laboratory

Guaiac-based faecal occult blood tests (gFOBT) are still used in asymptomatic population bowel screening programmes but are being replaced by faecal immunochemical tests (FIT) for haemoglobin. gFOBT have many well-documented disadvantages and there is little evidence for their use in assessment of the symptomatic. Many laboratories have eliminated gFOBT from their approved repertoires by invoking the authoritative published guidelines. Data continue to accumulate that gFOBT are obsolete. FIT are available in two formats, qualitative and quantitative, the latter having advantages that the faecal haemoglobin concentrations are measured and cut-off concentrations that stimulate further investigation can be user-defined. There is growing evidence that FIT would be useful in a spectrum of clinical settings in addition to screening. All laboratories should have FIT in their existing repertoire. For some uses, qualitative FIT would be adequate. However, much evidence has accumulated that measurements of faecal haemoglobin concentrations are beneficial for the assessment of both disease severity and the future risk of colorectal neoplasia. Interpretation requires appreciation that faecal haemoglobin concentrations are higher in men than women and rise with age. It might well be that risk scoring systems that take gender and age into account, possibly with other factors including symptoms, will benefit individuals. Laboratories should consider how quantitative faecal haemoglobin measurements could be brought into routine practice and included in their forward planning. External quality assessment is needed. Specialists in laboratory medicine are urged to play a significant role in the research and development still required to make this a truly mature investigation.

Screening colonoscopy in the US: attitudes and practices of primary care physicians

BACKGROUND

Rising colorectal cancer (CRC) screening rates in the last decade are attributable almost entirely to increased colonoscopy use. Little is known about factors driving the increase, but primary care physicians (PCPs) play a central role in CRC screening delivery.

OBJECTIVE

Explore PCP attitudes toward screening colonoscopy and their associations with CRC screening practice patterns.

DESIGN

Cross-sectional analysis of data from a nationally representative survey conducted in 2006-2007.

PARTICIPANTS

1,266 family physicians, general practitioners, general internists, and obstetrician-gynecologists.

MAIN MEASURES

Physician-reported changes in the volume of screening tests ordered, performed or supervised in the past 3 years, attitudes toward colonoscopy, the influence of evidence and perceived norms on their recommendations, challenges to screening, and practice characteristics.

RESULTS

The cooperation rate (excludes physicians without valid contact information) was 75%; 28% reported their volume of FOBT ordering had increased substantially or somewhat, and the majority (53%) reported their sigmoidoscopy volume decreased either substantially or somewhat. A majority (73%) reported that colonoscopy volume increased somewhat or substantially. The majority (86%) strongly agreed that colonoscopy was the best of the available CRC screening tests; 69% thought it was readily available for their patients; 59% strongly or somewhat agreed that they might be sued if they did not offer colonoscopy to their patients. All three attitudes were significantly related to substantial increases in colonoscopy ordering.

CONCLUSIONS

PCPs report greatly increased colonoscopy recommendation relative to other screening tests, and highly favorable attitudes about colonoscopy. Greater emphasis is needed on informed decision-making with patients about preferences for test options.

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

OBJECTIVE

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

DATA SOURCES

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

STUDY ELIGIBILITY CRITERIA, PARTICIPANTS, AND INTERVENTIONS

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

RESULTS

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

LIMITATIONS

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

CONCLUSIONS AND IMPLICATIONS OF KEY FINDINGS

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

Patterns of colorectal cancer test use, including CT colonography, in the 2010 National Health Interview Survey

BACKGROUND

Recommended colorectal cancer (CRC) screening tests for adults ages 50 to 75 years include home fecal occult blood tests (FOBT), sigmoidoscopy with FOBT, and colonoscopy. A newer test, computed tomographic (CT) colonography, has been recommended by some, but not all, national organizations.

METHODS

We analyzed 2010 National Health Interview Survey data, including new CT colonography questions, from respondents ages 50 to 75 years (N = 8,952). We (i) assessed prevalence of CRC test use overall, by test type, and by sociodemographic and health care access factors and (ii) assessed reported reasons for not having a CRC test.

RESULTS

The age-standardized percentage of respondents reporting FOBT, sigmoidoscopy, or colonoscopy within recommended time intervals was 58.3% [95% confidence interval (CI), 57.0-59.6]. Colonoscopy was the most commonly reported test [within past 10 years: 54.6% (95% CI, 53.2-55.9)]. Home FOBT and sigmoidoscopy with FOBT were less frequently used [FOBT within past year: 8.8% (95% CI, 8.1-9.6); sigmoidoscopy within past 5 years with FOBT within past 3 years: 1.3% (95% CI, 1.0-1.6)]. CT colonography was rare: 1.3% (95% CI, 1.0-1.7). Increasing age, education, income, having health care insurance, and having a usual source of health care were associated with higher CRC test use. Test use within recommended time intervals was particularly low among individuals ages 50 to 64 years without health care insurance [21.2% (95% CI, 18.3-24.4)]. The most common reason for nonuse was "no reason or never thought about it."

CONCLUSIONS

About 40% of Americans ages 50 to 75 years do not meet the recommendations for having CRC screening tests.

IMPACT

Expanded health care coverage and greater awareness of CRC screening are needed to further decrease CRC mortality.

The Need for Office Systems to Improve Colorectal Cancer Screening

Patients generally access colorectal cancer (CRC) screening through primary care physicians. National guidelines recommend CRC screening for adults beginning at age 50, yet one-third of Americans are not up to date. Methods: A self-administered questionnaire was administered to family physicians from 16 practices in a Midwestern state who attended an information session for a randomized study to improve CRC screening. The questionnaire assessed CRC screening practices, knowledge of CRC screening guidelines, and office strategies for improving screening. Results: Of 131 health care providers, 85 (65%) completed the questionnaire. Two-thirds were aware of the CRC screening guidelines; 91% knew that the follow-up interval for screening depends on the test chosen. Twenty-five percent incorrectly stated that a single-sample in-office fecal occult blood test is an acceptable screening test. Only 8% had a written policy regarding CRC screening; 18% had offices that used chart reminders; and 32% had charts organized to easily identify patient screening status. Regarding perceptions, those who agreed that they encourage their office staff to participate in screening estimated that they offer screening to more patients than those who disagreed (82.8% vs 70.2%, P < .0001); in addition, those who agreed with and tried to follow the guidelines estimated that they offer screening to more patients than those who disagreed (77.4% vs 60.5%, P = .004). Conclusion: Although physicians were knowledgeable about CRC screening guidelines, 25% mistakenly believed that single-sample in-office fecal testing was appropriate. There was a striking lack of office systems for identifying eligible patients and facilitating CRC screening.

Cancer screening in the United States, 2011: A review of current American Cancer Society guidelines and issues in cancer screening

Each year the American Cancer Society (ACS) publishes a summary of its recommendations for early cancer detection, a report on data and trends in cancer screening rates, and select issues related to cancer screening. This article summarizes the current ACS guidelines, describes the anticipated impact of new health care reform legislation on cancer screening, and discusses recent public debates over the comparative effectiveness of different colorectal cancer screening tests. The latest data on the utilization of cancer screening from the National Health Interview Survey is described, as well as several recent reports on the role of health care professionals in adult utilization of cancer screening.

Community contextual predictors of endoscopic colorectal cancer screening in the USA: spatial multilevel regression analysis

Background

Colorectal cancer (CRC) is the second leading cause of cancer death in the United States, and endoscopic screening can both detect and prevent cancer, but utilization is suboptimal and varies across geographic regions. We use multilevel regression to examine the various predictors of individuals' decisions to utilize endoscopic CRC screening. Study subjects are a 100% population cohort of Medicare beneficiaries identified in 2001 and followed through 2005. The outcome variable is a binary indicator of any sigmoidoscopy or colonoscopy use over this period. We analyze each state separately and map the findings for all states together to reveal patterns in the observed heterogeneity across states.

Results

We estimate a fully adjusted model for each state, based on a comprehensive socio-ecological model. We focus the discussion on the independent contributions of each of three community contextual variables that are amenable to policy intervention. Prevalence of Medicare managed care in one's neighborhood was associated with lower probability of screening in 12 states and higher probability in 19 states. Prevalence of poor English language ability among elders in one's neighborhood was associated with lower probability of screening in 15 states and higher probability in 6 states. Prevalence of poverty in one's neighborhood was associated with lower probability of screening in 36 states and higher probability in 5 states.

Conclusions

There are considerable differences across states in the socio-ecological context of CRC screening by endoscopy, suggesting that the current decentralized configuration of state-specific comprehensive cancer control programs is well suited to respond to the observed heterogeneity. We find that interventions to mediate language barriers are more critically needed in some states than in others. Medicare managed care penetration, hypothesized to affect information about and diffusion of new endoscopic technologies, has a positive association in only a minority of states. This suggests that managed care plans' promotion of this cost-increasing technology has been rather limited. Area poverty has a negative impact in the vast majority of states, but is positive in five states, suggesting there are some effective cancer control policies in place targeting the poor with supplemental resources promoting CRC screening.