Colorectal cancer testing among patients cared for by Iowa family physicians

Comparative effectiveness of five fecal immunochemical tests using colonoscopy as the gold standard: study protocol

BACKGROUND

There are nearly 50,000 colorectal cancer (CRC) deaths in the United States each year. CRC is curable if detected in its early stages. Fecal immunochemical tests (FITs) can detect precursor lesions and many can be analyzed at the point-of-care (POC) in physician offices. However, there are few data to guide test selection. Broader use of FITs could make CRC screening more accessible, especially in resource-poor settings.

METHODS

A total of 3600 racially and ethnically diverse individuals aged 50 to 85 years having either a screening or surveillance colonoscopy will be recruited. Each participant will complete five FITs on a single stool sample. Test characteristics for each FIT for advanced colorectal neoplasia (ACN) will be calculated using colonoscopy as the gold standard.

RESULTS

We have complete data from a total of 2990 individuals. Thirty percent are Latino and 5.3% are black/African American. We will present full results once the study is completed.

CONCLUSIONS

Our focus in this study is how well FITs detect ACN, using colonoscopy as the gold standard. Four of the five FITs being used are POC tests. Although FITs have been shown to have acceptable performance, there is little data to guide which ones have the best test characteristics and colonoscopy is the main CRC screening test used in the United States. Use of FITs will allow broader segments of the population to access CRC screening because these tests require no preparation, are inexpensive, and can be collected in the privacy of one's home. Increasing CRC screening uptake will reduce the burden of advanced adenomas and colorectal cancer.

Rural–urban disparities in colorectal cancer screening among military service members and Veterans

Introduction: Little is known about rural–urban disparities in colorectal cancer (CRC) screening rates among the military service member and Veteran (SMV) population in the United States. Given that health care access is a challenge in rural areas, we sought to determine whether rural-dwelling Veterans were less likely to be screened for CRC than urban-dwelling Veterans. Methods: Secondary data for this cross-sectional study were retrieved from the 2016 Behavioral Risk Factor Surveillance System for a national sample of non-institutionalized SMVs ( N = 63,919). The influence of rurality on CRC screening among SMVs was determined using maximum likelihood multiple logistic regression. Results: After controlling for relevant covariates, rurality was independently associated with decreased likelihood of meeting guidelines for CRC screening among SMVs (odds ratio = 0.83, 95% confidence interval, 0.76–0.90). Discussion: Innovative interventions for CRC screening should target SMVs in rural areas because doing so may lower mortality from CRC.

Population-based screening improves histopathological prognostic factors in colorectal cancer

INTRODUCTION

Diagnosis of colorectal cancer (CRC) based on clinical symptoms is usually established in its advanced stages. One strategy for reducing mortality is the early detection and removal of preneoplastic and initial neoplastic lesions, even before the first symptoms appear, by means of population-based screening campaigns. The aim of the present study is to determine whether CRC diagnosed via a screening campaign has more favourable histopathological prognostic factors than when diagnosed in the symptomatic phase.

MATERIAL AND METHODS

The prospective study of all the patients undergoing programmed CRC surgery at the JM Morales Meseguer Hospital (Spain) is between 2004 and 2010. The patients were divided into two groups: one diagnosed from clinical symptoms and one through a screening campaign. The following factors were compared: tumour size; degree of tumour invasion of the wall; lymph node, perineural and lymphovascular involvement; tumour stage; and grade of differentiation.

RESULTS

Compared to the symptomatic group, the screen-detected patients had smaller-sized tumours (lesions of less than 5 cm in 84 vs 69.55%, p < 0.001), a lower degree of colorectal wall invasion (T0-1 in 36 vs 9.02%, p < 0.001), less lymph node involvement (N0 in 72 vs 58.76%, p > 0.05), less vascular invasion (7.20 vs 15.22%, p = 0.79) and less perineural invasion (6.4 vs 20.70%, p < 0.001). The TNM staging in the screening group was lower than in the symptomatic group (stage 0-1 in 50.40 vs 18.58%, p < 0.001).

CONCLUSIONS

CRC diagnosed through a population-based screening programme presents more favourable histopathological characteristics than that diagnosed from the appearance of symptoms.

Free Fecal Immunochemical Test Disbursement in Eight Family Physician Offices

Colorectal cancer (CRC) is the second leading cause of cancer death. CRC screening with a fecal immunochemical test (FIT) is important as occult blood may be detected. To offer Iowa Research Network members in family physician offices the opportunity to provide FITs at no charge to patients in need and determine how many of the tests would be handed out to patients and how many would be returned to the office. Eight family physician offices agreed to participate and 50 two-day FITs were provided, potentially providing 400 patients a CRC screening test. One hundred and eighty (45%) of the 400 FITs were handed out to patients. Of the 92 (51%) patients who returned at least one card, 77 (84%) had negative results, 13 (14%) were positive, and 2 (2 %) were indeterminate. Of 13 patients with a positive result, 11 (85%) had a follow-up colonoscopy. Providing 400 FITs at no charge to the offices was an expensive endeavor. Implementing this forced a change in office routine and the type of fecal occult blood test used. Less than half of the FITs were given out to patients and of those given out, about half of the patients returned a FIT. For those who returned FITs and had positive findings, 85% followed-up with a colonoscopy. Office nurses implementing the CRC screening need to be included in the planning of the type of fecal occult blood test used and receptive to the project.

The cost-effectiveness of training US primary care physicians to conduct colorectal cancer screening in family medicine residency programs

BACKGROUND

Demand for a wide array of colorectal cancer screening strategies continues to outpace supply. One strategy to reduce this deficit is to dramatically increase the number of primary care physicians who are trained and supportive of performing office-based colonoscopies or flexible sigmoidoscopies. This study evaluates the clinical and economic implications of training primary care physicians via family medicine residency programs to offer colorectal cancer screening services as an in-office procedure.

METHODS

Using previously established clinical and economic assumptions from existing literature and budget data from a local grant (2013), incremental cost-effectiveness ratios are calculated that incorporate the costs of a proposed national training program and subsequent improvements in patient compliance. Sensitivity analyses are also conducted.

RESULTS

Baseline assumptions suggest that the intervention would produce 2394 newly trained residents who could perform 71,820 additional colonoscopies or 119,700 additional flexible sigmoidoscopies after ten years. Despite high costs associated with the national training program, incremental cost-effectiveness ratios remain well below standard willingness-to-pay thresholds under base case assumptions. Interestingly, the status quo hierarchy of preferred screening strategies is disrupted by the proposed intervention.

CONCLUSIONS

A national overhaul of family medicine residency programs offering training for colorectal cancer screening yields satisfactory incremental cost-effectiveness ratios. However, the model places high expectations on primary care physicians to improve current compliance levels in the US.

Is Travel Time to Colonoscopy Associated With Late-Stage Colorectal Cancer Among Medicare Beneficiaries in Iowa?

BACKGROUND

Colorectal cancer (CRC) screening has been shown to decrease the incidence of late-stage colorectal cancer, yet a substantial proportion of Americans do not receive screening. Those in rural areas may face barriers to colonoscopy services based on travel time, and previous studies have demonstrated lower screening among rural residents. Our purpose was to assess factors associated with late-stage CRC, and specifically to determine if longer travel time to colonoscopy was associated with late-stage CRC among an insured population in Iowa.

METHODS

SEER-Medicare data were used to identify individuals ages 65 to 84 years old diagnosed with CRC in Iowa from 2002 to 2009. The distance between the centroid of the ZIP code of residence and the ZIP code of colonoscopy was computed for each individual who had continuous Medicare fee-for-service coverage for a 3- to 4-month period prior to diagnosis, and a professional claim for colonoscopy within that time frame. Demographic characteristics and travel times were compared between those diagnosed with early- versus late-stage CRC. Also, demographic differences between those who had colonoscopy claims identified within 3-4 months prior to diagnosis (81%) were compared to patients with no colonoscopy claims identified (19%).

RESULTS

A total of 5,792 subjects met inclusion criteria; 31% were diagnosed with early-stage versus 69% with late-stage CRC. Those divorced or widowed (vs married) were more likely to be diagnosed with late-stage CRC (OR: 1.20, 95% CI: 1.06-1.37). Travel time was not associated with diagnosis of late-stage CRC.

DISCUSSION

Among a Medicare-insured population, there was no relationship between travel time to colonoscopy and disease stage at diagnosis. It is likely that factors other than distance to colonoscopy present more pertinent barriers to screening in this insured population. Additional research should be done to determine reasons for nonadherence to screening among those with access to CRC screening services, given that over two-thirds of these insured individuals were diagnosed with late-stage CRC.

System Strategies for Colorectal Cancer Screening at Federally Qualified Health Centers

Objectives. We assessed the protocols and system processes for colorectal cancer (CRC) screening at federally qualified health centers (FQHCs) in 4 midwestern states. Methods. We identified 49 FQHCs in 4 states. In January 2013, we mailed their medical directors a 49-item questionnaire about policies on CRC screening, use of electronic medical records, types of CRC screening recommended, clinic tracking systems, referrals for colonoscopy, and barriers to providing CRC. Results. Forty-four questionnaires (90%) were returned. Thirty-three of the respondents (75%) estimated the proportion of their patients up-to-date with CRC screening, with a mean of 35%. One major barrier to screening was inability to provide colonoscopy for patients with a positive fecal occult blood test (59%). The correlation of system strategies and estimated percentage of patients up-to-date with CRC screening was 0.43 (P = .01). Conclusions. CRC system strategies were associated with higher CRC screening rates. Implementing system strategies for CRC screening takes time and effort and is important to maintain, to help prevent, or to cure many cases of CRC, the second leading cause of cancer in the United States.

Increasing colorectal cancer screening in an overdue population: participation and cost impacts of adding telephone calls to a FIT mailing program

Many people who live in rural areas face distance barriers to colonoscopy. Our previous study demonstrated the utility of mailing fecal immunochemical tests (FIT) to average risk patients overdue for colorectal cancer (CRC screening). The aims of this study were to determine if introductory and reminder telephone calls would increase the proportion of returned FITs as well as to compare costs. Average risk patients overdue for CRC screening received a high intensity intervention (HII), which included an introductory telephone call to see if they were interested in taking a FIT prior to mailing the test out and reminder phone calls if the FIT was not returned. This HII group was compared to our previous low intensity intervention (LII) where a FIT was mailed to a similar group of veterans with no telephone contact. While a higher proportion of eligible respondents returned FITs in the LII (92 vs. 45 %), there was a much higher proportion of FITs returned out of those mailed in the HII (85 vs. 14 %). The fewer wasted FITs in the HII led to it having lower cost per FIT returned ($27.43 vs. $44.86). Given that either intervention is a feasible approach for patients overdue for CRC screening, health care providers should consider offering FITs using a home-based mailing program along with other evidence-based CRC screening options to average risk patients. Factors such as location, patient population, FIT cost and reimbursement, and personnel costs need to be considered when deciding the most effective way to implement FIT screening.

Test characteristics of faecal immunochemical tests (FIT) compared with optical colonoscopy

BACKGROUND

Faecal occult blood tests are often the initial test in population-based screening. We aimed to: 1) compare the results of single sample faecal immunochemical tests (FITs) with colonoscopy, and 2) calculate the sensitivity for proximal vs. distal adenomatous polyps or cancer.

METHODS

Individuals scheduled for a colonoscopy were invited to complete a FIT prior to their colonoscopy preparation. FIT results were classified as positive, negative, or invalid. Colonoscopy reports were reviewed and abstracted. Because of product issues, four different FIT manufacturers were used. The test characteristics for each FIT manufacturer were calculated for advanced adenomatous polyps or cancer according to broad reason for colonoscopy (screening or surveillance/diagnostic).

RESULTS

Of those invited, 1,026 individuals (43.9%) completed their colonoscopy and had a valid FIT result. The overall sensitivity of the FITs (95% confidence intervals) was 0.18 (0.10 to 0.28) and specificity was 0.90 (0.87 to 0.91) for advanced adenomas or cancer. The sensitivity for distal lesions was 0.23 (0.11 to 0.38) and for proximal lesions was 0.09 (0.02 to 0.25). The odds ratio of an individual with a distal advanced adenoma or cancer testing positive was 2.68 (1.20 to 5.99). The two individuals with colorectal cancer tested negative, as did one individual with high-grade dysplasia.

CONCLUSIONS

The sensitivity of a single-sample FIT for advanced adenomas or cancer was low. Individuals with distal adenomas had a higher odds of testing positive than those with proximal lesions or no lesions.

A comparison of colorectal cancer screening uptake among average-risk insured American Indian/Alaska Native and white women

INTRODUCTION

American Indian and Alaska Native (AI/AN) women have among the lowest rates of colorectal cancer (CRC) screening. Whether screening disparities persist with equal access to health care is unknown.

METHODS

Using administrative data from 1996-2007, we compared CRC screening events for 286 AI/AN and 14,042 White women aged 50 years and older from a health maintenance organization in the Pacific Northwest of the U.S.

RESULTS

The proportion of AI/AN and White women screened for CRC at age 50 was similar (13.3% vs. 14.0%, p =.74). No differences were seen in the type of screening test. Time elapsed to first screening among AI/AN women who were not screened at age 50 did not differ from White women (hazard ratio 1.0, 95% confidence interval 0.8-1.3).

CONCLUSIONS

Uptake for CRC screening was similar among insured AI/AN and White women, suggesting that when access to care is equal, racial disparities in screening diminish.

Colon polyp model use for educating about colorectal cancer screening in the Iowa Research Network

Providing a model of a colon segment with an adenomatous polyp and cancer can help to educate patients about the adenoma to carcinoma sequence and how this sequence can be interrupted with appropriate testing. The purpose of this study was to assess the use of a three-dimensional colon model with polyps and cancer provided to family physicians or nurses in some Iowa Research Network family physician offices. Colon models were provided to 117 family medicine healthcare providers interested in colorectal cancer screening. Using a mailed survey and follow-up telephone calls to non-responders, 81 (69%) questionnaires were returned. Thirty-six (44%) of the respondents reported they had used the model, 33 (41%) reported they used the model for a mean 16% of their patients in a month's time, 31 (38%) reported using the model to teach patients about the colon and polyps prior to a colonoscopy. Other model use described by respondents included educating staff to promote patient willingness for colonoscopies, demonstrating the need for colon cancer screening, and teaching patients about annual fecal occult blood tests. Respondents agreed that anatomical models are helpful for patient education, the design of the colon model was good, and that it facilitated demonstration of colon polyps. Possible recommendations for an office-wide adoption of an anatomical model would be an in-service for all employees and a standard location for finding the model.

Barriers to cervical cancer screening among middle-aged and older rural Appalachian women

Although cervical cancer rates in the United States have declined sharply in recent decades, certain groups of women remain at elevated risk, including middle-aged and older women in central Appalachia. Cross-sectional baseline data from a community-based randomized controlled trial were examined to identify barriers to cervical cancer screening. Questionnaires assessing barriers were administered to 345 Appalachian women aged 40-64, years when Papanicolaou (Pap) testing declines and cervical cancer rates increase. Consistent with the PRECEDE/PROCEED framework, participants identified barriers included predisposing, enabling, and reinforcing factors. Descriptive and bivariate analyses are reported, identifying (a) the most frequently endorsed barriers to screening, and (b) significant associations of barriers with sociodemographic characteristics in the sample. Recommendations are provided to decrease these barriers and, ultimately, improve rates of Pap tests among this traditionally underserved and disproportionately affected group.

Public health and cooperative group partnership: a colorectal cancer intervention

OBJECTIVES

To describe the development of a multi-component colorectal cancer educational tool for female breast cancer survivors through a cooperative group and public health partnership.

DATA SOURCES

PubMed, World Wide Web, guidelines from professional organizations, surveys and focus groups with breast cancer survivors.

CONCLUSION

Collaboration is at the core of cooperative group and public health research. This partnership led to the development of a colorectal cancer educational tool for breast cancer survivors. Focus groups revealed that female breast cancer survivors were receptive to education on colorectal cancer screening.

IMPLICATIONS FOR NURSING PRACTICE

Nurses are instrumental in research collaborations between cooperative groups and public health. The colorectal educational intervention for breast cancer survivors serves as an exemplar of partnerships leading to innovative research planning and implementation outcomes.

Evaluation of a home-based colorectal cancer screening intervention in a rural state

PURPOSE

Distance from health care facilities can be a barrier to colorectal cancer (CRC) screening, especially for colonoscopy. Alternatively, an improved at-home stool-based screening tool, the fecal immunochemical test (FIT), requires only a single sample and has a better sensitivity-specificity balance compared to traditional guaiac fecal occult blood tests. Our objective was to determine if FITs mailed to asymptomatic, average-risk patients overdue for screening resulted in higher screening rates versus mailing educational materials alone or no intervention (ie, usual care).

METHODS

Veterans ages 51-64, asymptomatic, at average risk for CRC, overdue for screening and in a veterans administration (VA) catchment area covering a large rural population were randomly assigned to 3 groups: (1) education only (Ed) group: mailed CRC educational materials and a survey of screening history and preferences (N = 499); (2) FIT group: mailed the FIT, plus educational materials and survey (N = 500); and (3) usual care (UC) group: received no mailings (N = 500).

FINDINGS

At 6 months postintervention, 21% of the FIT group had received CRC screening by any method compared to 6% of the Ed group (and 6% of the UC group) (P < .0001). Of the 105 respondents from the FIT group, 71 (68%) were eligible to take the FIT. Of those, 64 (90%) completed the FIT and 8 (12%) tested positive.

CONCLUSIONS

This low-intensity intervention of mailing FITs to average risk patients overdue for screening resulted in a significantly higher screening rate than educational materials alone or usual care, and may be of particular interest in rural areas.

The "Iowa get screened" colon cancer screening program

OBJECTIVE

To implement a colon cancer screening program for uninsured or underinsured Iowans.

METHODS

All 1995 uninsured patients or patients with Iowa Care insurance aged 50 to 64 years attending the University of Iowa Clinic or the Iowa City Free Medical Clinic were mailed information about the project. Recruitment also took place in person, by having the clinic receptionist hand subjects a research packet, and through community posters. Individuals with colonic symptoms or who were up to date with screening were ineligible. Eligible subjects received a free fecal immunochemical test (FIT), and those with positive FITs were provided with a colonoscopy at no cost to them.

RESULTS

Of 449 individuals who completed eligibility forms (23% of the study population), 297 (66%) were eligible and were provided with an FIT. Two-hundred thirty-five (79%) returned a stool sample, with 49 (21%) testing positive. Thirty of the 49 (61%) individuals had a colonoscopy, and 20 individuals had at least 1 polyp biopsied. Thirteen individuals had at least 1 tubular adenoma; 2 had adenomas more than 1 cm in diameter, with no colon cancers identified. Face-to-face recruitment had the highest rate of returned FITs (72%) compared with handing the subject a research packet (3%) or a mailing only (9%) (Chi-square, P < .001).

CONCLUSION

There was high interest in and compliance with colon cancer screening using a FIT among underinsured individuals. Although the FIT positivity rate was higher than expected, many individuals did not complete recommended follow-up colonoscopies. Population-based strategies for offering FIT could significantly increase colon cancer screening among disadvantaged individuals, but programs will have to develop sustainable mechanisms to include the necessary organization and address substantial costs of providing mass screening, as well as facilitating and providing colonoscopies for those who test positive.

Patients whose physicians recommend colonoscopy and those who follow through

BACKGROUND

More than half of eligible individuals are not up-to-date with colon cancer screening.

PURPOSE

To assess the characteristics of those who received a colonoscopy screening recommendation and those who followed the physician recommendation.

METHODS

Patient self-administered questionnaire and medical record review in 16 private family physician practices.

RESULTS

From 8372 patients invited to participate, 685 were enrolled and had a medical record review; 219 (32%) had a colonoscopy recommendation and 86 (39%) received a colonoscopy. Independent factors associated with having a recommendation for colonoscopy were significantly younger in age (odds ratios [OR] = 1.6), higher incomes (annual income ≥$40 000 vs <$40 000; OR = 1.8), physician or nurse discussion about colon cancer tests (OR = 1.6), physical visit in the preceding 26 months (OR = 1.7), distant relative with colon cancer (OR = 2.4), and a medical diagnosis of hyperlipidemia (OR = 2.1). Independent factors associated with following through on colonoscopy after a recommendation were age ≥65 years (OR = 0.3), male patient (OR = 0.4), and feeling that colon cancer screening is very important (OR = 3.2).

CONCLUSIONS

Socioeconomic factors are associated with receipt of a colonoscopy recommendation. Fewer than one third of patients had documentation of a physician colonoscopy recommendation and of those, less than half followed through.

Physician recommendation and patient adherence for colorectal cancer screening

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

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.

Are physicians' recommendations for colorectal cancer screening guideline-consistent?

BACKGROUND

Many older adults in the U.S. do not receive appropriate colorectal cancer (CRC) screening. Although primary care physicians' recommendations to their patients are central to the screening process, little information is available about their recommendations in relation to guidelines for the menu of CRC screening modalities, including fecal occult blood testing (FOBT), flexible sigmoidoscopy (FS), colonoscopy, and double contrast barium enema (DCBE). The objective of this study was to explore potentially modifiable physician and practice factors associated with guideline-consistent recommendations for the menu of CRC screening modalities.

METHODS

We examined data from a nationally representative sample of 1266 physicians in the U.S. surveyed in 2007. The survey included questions about physician and practice characteristics, perceptions about screening, and recommendations for age of initiation and screening interval for FOBT, FS, colonoscopy and DCBE in average risk adults. Physicians' screening recommendations were classified as guideline consistent for all, some, or none of the CRC screening modalities recommended. Analyses used descriptive statistics and polytomous logit regression models.

RESULTS

Few (19.1%; 95% CI:16.9%, 21.5%) physicians made guideline-consistent recommendations across all CRC screening modalities that they recommended. In multivariate analysis, younger physician age, board certification, north central geographic region, single specialty or multi-specialty practice type, fewer patients per week, higher number of recommended modalities, use of electronic medical records, greater influence of patient preferences for screening, and published clinical evidence were associated with guideline-consistent screening recommendations (p < 0.05).

CONCLUSIONS

Physicians' CRC screening recommendations reflect both overuse and underuse, and few made guideline-consistent CRC screening recommendations across all modalities they recommended. Interventions that focus on potentially modifiable physician and practice factors that influence overuse and underuse and address the menu of recommended screening modalities will be important for improving screening practice.

Race moderates the relationship between obesity and colorectal cancer screening in women

OBJECTIVE

To determine if the relationship between obesity and usage of colorectal cancer (CRC) screening in women varies when stratifying by race.

METHODS

Using nationally representative data from the 2005 National Health Interview Survey, we examined the relationship between obesity and CRC screening for white and African-American women aged 50 and older. Screening usage variables indicated if a woman was up-to-date for any CRC screening test, colonoscopy, or FOBT. We used multivariable logistic regression models that included interaction terms to determine if race moderates the obesity-screening relationship. We also calculated adjusted up-to-date colonoscopy rates using direct standardization to model covariates.

RESULTS

The relationship between obesity and screening differed by race for any CRC screening test (P = 0.04 for interaction) and for colonoscopy (P = 0.01 for interaction), but not for FOBT. Obese white women had a lower adjusted colonoscopy rate (30.2%, 95% CI 25.9-34.8) than non-obese white women (39.1%, 95% CI 36.1-42.2). Obese African-American women, on the other hand, had a higher adjusted colonoscopy rate (41.2%, 95% CI 31.6-51.4) than their non-obese counterparts (35.6%, 95% CI 28.3-43.6). Overall, adjusted colonoscopy rates were lowest among obese white women.

CONCLUSIONS

Obesity is associated with lower CRC screening rates in white, but not African-American women.

Association of health beliefs and colonoscopy use among survivors of colorectal cancer

OBJECTIVES

Clinical practice guidelines recommend ongoing testing (surveillance) for colorectal cancer survivors because they remain at risk for both local recurrences and second primary tumors. However, survivors often do not receive colorectal cancer surveillance. We used the Health Belief Model (HBM) to identify health beliefs that predict intentions to obtain routine colonoscopies among colorectal cancer survivors.

METHODS

We completed telephone interviews with 277 colorectal cancer survivors who were diagnosed 4 years earlier, between 2003 and 2005, in North Carolina. The interview measured health beliefs, past preventive behaviors, and intentions to have a routine colonoscopy in the next 5 years.

RESULTS

In bivariate analyses, most HBM constructs were associated with intentions. In multivariable analyses, greater perceived likelihood of colorectal cancer (OR = 2.00, 95% CI = 1.16-3.44) was associated with greater intention to have a colonoscopy. Survivors who already had a colonoscopy since diagnosis also had greater intentions of having a colonoscopy in the future (OR = 9.47, 95% CI = 2.08-43.16).

CONCLUSIONS

Perceived likelihood of colorectal cancer is an important target for further study and intervention to increase colorectal cancer surveillance among survivors. Other health beliefs were unrelated to intentions, suggesting that the health beliefs of colorectal cancer survivors and asymptomatic adults may differ due to the experience of cancer.

Factors associated with practice of colorectal cancer screening among primary care physicians in a Chinese population: a cross-sectional study

OBJECTIVES

Primary care physicians (PCPs) are influential in colorectal cancer (CRC) screening uptake in the community. This study aims to evaluate the factors associated with PCPs' practice of CRC screening among asymptomatic patients in a Chinese population.

METHODS

A validated postal questionnaire was sent to all practicing PCPs who were members of a community-based network in Hong Kong. Three separate rounds of reminder letters were sent to non-respondents. Binary logistic regression analysis was used with ever-referral for CRC screening in the past 12 months as the outcome variable. Predictor variables include physicians' gender, clinical experience, types of practice, and attitudes towards CRC screening.

RESULTS

Of 428 eligible physicians, 263 (61.4%) responded. A total of 187 physicians (71.1%) had referred patients for CRC screening in the past 1 year. Among all asymptomatic patients aged 50 years or older, physicians reported referring only 3.0% (1.0-10.0%) [median (interquartile range)] of patients. Colonoscopy (57.0%) and fecal occult blood testing (FOBT) (46.4%) were the most commonly recommended tests for these asymptomatic patients. Family history of CRC (58.6%) and patients' concern about CRC (50.2%) were major reasons for referral. PCPs in private practice (adjusted odds ratio [aOR] 2.60, 95% C.I. 1.21-5.59) and those with positive attitude towards CRC screening (aOR 2.27, 95% C.I. 1.15-4.48) were more likely to recommend CRC screening.

CONCLUSIONS

PCPs' attitude towards CRC screening is a significant determinant of its practice. Future studies should identify and strengthen the influencers of PCPs' attitude to enhance CRC screening rates.

Increasing colon cancer testing in rural Colorado: evaluation of the exposure to a community-based awareness campaign

Background

Despite effective prevention and early detection screening methods, colorectal cancer is the second leading cause of cancer death in the United States. Colorectal cancer screening community-based interventions are rare, and the literature lacks information about community-based intervention processes. Using participatory research methods, the High Plains Research Network developed a community-based awareness and educational intervention to increase colorectal cancer screening rates in rural northeastern Colorado. This study describes the program components and implementation and explores whether the target population was exposed to the intervention, the reach of the individual intervention components, and the effect on screening intentions.

Methods

A random digit dial survey was conducted of residents age 40 and older in the first 3 communities to receive the intervention to estimate exposure to the intervention and its effect on colorectal cancer screening intentions.

Results

Exposure to at least intervention component was reported by 68% of respondents (n = 460). As the level of exposure increased, intentions to talk to a doctor about colorectal cancer screening increased significantly more in respondents who had not been tested in the past 5 years than those who had (p = .025). Intentions to get tested increased significantly in both groups at the same rate as level of exposure increased (p < .001).

Conclusion

Using local community members led to the successful implementation of the intervention. Program materials and messages reached a high percentage of the target population and increased colorectal cancer screening intentions.

Patient clock drawing and accuracy of self-report compared with chart review for colorectal cancer (CRC) screening

The purpose of this study was to test the accuracy of patient colorectal cancer (CRC) screening self-report and CRC screening documented in their medical record for those who are cognitively impaired and those who are not based on the clock drawing task. A cross-sectional study where patient survey and medical record information were linked was conducted in 16 primary care offices. Of the 960 patients mailed questionnaires, there were 493 respondents who completed the questionnaire and clock drawing, had a chart review, and had no help in drawing the clock or completing the questionnaire. Chart review was conducted for CRC screening in physician offices. Clock drawings were scored 0-7 according to the Watson method. Accuracy of ever being screened for CRC or being up-to-date for CRC screening was determined by comparing self-report with medical records and calculating sensitivity, specificity, positive and negative predictive values, false positive rate, and false negative rate. Seventy-five clocks were abnormal, scoring 4 or more. Agreement between self-reported colonoscopy and medical record review was higher in subjects with normal clock drawings than those with abnormal clock drawings. When examining predictors of agreement/disagreement for colonoscopy screening, abnormal clock drawing was the single predictor for higher disagreement.

[Results of a study on populational colorectal cancer screening]

INTRODUCTION

As colorectal cancer (CRC) screening based on occult blood detection has been shown to be effective in reducing mortality due to this disease, it is now important to decide on the best methods to obtain the maximum numbers of participants. The aim of the study was to analyse the results from a pilot CRC screening programme in a general population sample in Barcelona. A follow-up of false positive cases was made after five years.

PATIENTS AND METHOD

A cross section of the population aged 50-74 years in one primary health care centre was studied. The screening test consisted of an immunological method for the detection of faecal occult blood which was sent to the homes of the target population.

RESULTS

Participation was 46.6%, 11.7% of the tests were positive, and 79.3% agreed to have a colonoscopy. Eight adenocarcinomas and 32 patients with adenomas >0.4 cm were diagnosed.

CONCLUSIONS

The results obtained on the initial participation and the follow-up at five years suggest the viability of a CCR screening programme in our country.

Influence of primary care use on population delivery of colorectal cancer screening

OBJECTIVE

Colorectal cancer (CRC) screening is commonly initiated during primary care visits. Thus, at the population level, limited primary care attendance may constitute a substantial barrier to CRC screening uptake. Within a defined population, we quantified the percent of CRC screening underuse that is potentially explained by low use of primary care visits.

METHODS

Among 48,712 adults ages 50 to 78 years eligible for CRC screening within a Washington state health plan, we estimated the degree to which a lack of CRC screening in 2002 to 2003 (fecal occult blood testing, sigmoidoscopy, or colonoscopy) was attributable to low primary care use, expressed as the population attributable risk percent (PAR%) associated with 0 to 3 primary care visits during the 2-year period.

RESULTS

In analyses adjusted for age, comorbidity, nonprimary care visit use, and prior preventive service use, low primary care use in 2002 to 2003 was strongly associated with a lack of CRC screening among both women and men. However, a majority of unscreened women and men had > or =4 primary care visits. Thus, whether low primary care use was defined as 0, 0 to 1, 0 to 2, or 0 to 3 primary care visits, the PAR% associated with low primary care use was large in neither women (range, 3.0-6.8%) nor men (range: 5.6-11.5%).

CONCLUSIONS

Health plan outreach efforts to encourage primary care attendance would be unlikely to substantially increase population uptake of CRC screening. In similar settings, resources might be more fruitfully devoted to the optimization of screening delivery during primary care visits that patients already attend.

Having a personal health care provider and receipt of colorectal cancer testing

PURPOSE

We wanted to assess the relationship between having a personal health care provider and receiving colorectal cancer testing.

METHODS

Self-reported data were obtained from the United States 2004 Behavioral Risk Factor Surveillance System. Men and women aged 50 years and older were included, and associations of having a personal health care provider, age, sex, race/ethnicity, education, income, and health insurance status with colorectal cancer testing were examined. Multiple logistic regression was performed on a final sample of 120,221 individuals.

RESULTS

Having at least 1 personal health care provider significantly predicted up-to-date colorectal cancer testing in both the univariate (odds ratio [OR]=3.96; 95% confidence interval [CI] 3.56-4.41) and multiple regression models (OR = 2.91; 95% CI 2.58-3.28). Age, sex, race/ethnicity, education, income, and health insurance were also significantly associated with up-to-date colorectal cancer testing.

CONCLUSIONS

Having a personal health care provider was associated with up-to-date colorectal cancer testing. Efforts to increase and support the primary care workforce are needed to improve up-to-date colorectal cancer screening rates.

Increasing patient/physician communications about colorectal cancer screening in rural primary care practices

BACKGROUND

Rural populations as well as less educated people in the United States are less likely to receive colorectal cancer (CRC) screening than people living in urban areas and more educated people.

METHODS

We tested a computer tablet, Patient/Provider Communication Assistant (PPCA), which collected data, educated patients, and printed personalized notes to patients and providers encouraging conversation about CRC screening. Mixed model analyses using a prepost quasi-experimental design compared patient results during the comparison and intervention periods in 5 rural primary care practices on provider discussion about CRC screening, provider recommendation, and patient intention to be screened. Models including age, education, and literacy measures as covariates were examined.

RESULTS

Providers talked with patients about CRC screening in general, and colonoscopy specifically more frequently after the PPCA than with the comparison group (P values = 0.04 and 0.01, respectively). Providers recommended CRC screening more often to patients in the intervention group than to the comparison group (P = 0.02). Patients planned to be screened, specifically with colonoscopy, more frequently after the intervention than in the comparison group (P = 0.003). There were no interactions between group and any of the covariates. Ninety-five percent of the patients, regardless of age or education, found the PPCA easy to use.

CONCLUSIONS

Results indicated increased provider discussion and recommendation, and patients' intentions to obtain CRC screening, and in particular colonoscopy, for patients exposed to the intervention, regardless of the patients' age or literacy levels. The PPCA is a promising intervention method that is acceptable to rural patients.

Perceptions of Iowa family physicians regarding colorectal cancer screening

BACKGROUND

Fewer than half of Americans have been screened for colorectal cancer (CRC), a largely preventable disease.

METHODS

All physician members (n = 1030) of the Iowa Academy of Family Physicians were mailed a 3-page investigator-developed survey about their attitudes, barriers, and practices regarding CRC screening.

RESULTS

The usable response rate was 29%. Forty-three percent practiced in rural settings. Ninety-five percent felt that they were well informed about American Cancer Society guidelines and 90% tried to follow the guidelines. Most doctors (88%) disagreed with the statement that there was "no time to adequately discuss screening," but they would like more time to discuss screening. Only 40% felt their medical records were organized to easily determine screening status, 40% encouraged office staff to participate in screening, and 16% had a written policy regarding CRC screening. Physicians estimated that they recommend screening to 78% of their patients and that 54% of their patients were actually up-to-date. Discussion of CRC screening was strongly dependent on visit type, with physicians estimating that CRC screening is discussed at 11% of acute visits, 42% of chronic visits, and 87% of health maintenance visits. Several office system factors were associated with a recommendation for screening in a multivariable linear regression model (R = 0.33).

CONCLUSIONS

Although nearly all physicians felt that they were well informed about American Cancer Society guidelines and tried to follow guidelines for CRC screening, few had office systems to facilitate screening. Physicians would like more time to discuss screening. Office systems likely have the most potential to improve CRC screening among patients attending primary care practices.

History of allergy and reduced incidence of colorectal cancer, Iowa Women's Health Study

Previous epidemiologic studies have reported that a history of allergy is associated with reduced risk of colorectal cancer and other malignancies. We studied the association between allergy history and incident colorectal cancer (n=410) prospectively in 21,292 Iowa women followed for 8 years. Allergy was defined from four self-reported questions about physician-diagnosed asthma (a), hay fever (b), eczema or allergy of the skin (c), and other allergic conditions (d). A history of any allergy was inversely associated with incident colorectal cancer: after multivariate adjustment, the hazard ratio (HR) was 0.74 [95% confidence interval (95% CI), 0.59-0.94]. Compared with women with no allergy, women reporting only one of the four types of allergy and women reporting two or more types had HRs of 0.75 (95% CI, 0.56-1.01) and 0.58 (95% CI, 0.37-0.90), respectively (P trend=0.02). The inverse association persisted in analyses restricted to any type of nonasthmatic allergy (HR, 0.73; 95% CI, 0.56-0.95). HRs were similar for rectal and colon cancers as well as for colon subsites: proximal and distal (HRs for any allergy ranged from 0.63 to 0.78 across these end points). Allergy history, which may reflect enhanced immunosurveillance, is associated with a reduced risk of colorectal cancer.

Improving colorectal cancer screening in primary care practice: innovative strategies and future directions

Colorectal cancer (CRC) screening has been supported by strong research evidence and recommended in clinical practice guidelines for more than a decade. Yet screening rates in the United States remain low, especially relative to other preventable diseases such as breast and cervical cancer. To understand the reasons, the National Cancer Institute and Agency for Healthcare Research and Quality sponsored a review of CRC screening implementation in primary care and a program of research funded by these organizations. The evidence base for improving CRC screening supports the value of a New Model of Primary Care Delivery: 1. a team approach, in which responsibility for screening tasks is shared among other members of the practice, would help address physicians' lack of time for preventive care; 2. information systems can identify eligible patients and remind them when screening is due; 3. involving patients in decisions about their own care may enhance screening participation; 4. monitoring practice performance, supported by information systems, can help target patients at increased risk because of family history or social disadvantage; 5. reimbursement for services outside the traditional provider-patient encounter, such as telephone and e-mail contacts, may foster enhanced screening delivery; 6. training opportunities in communication, cultural competence, and use of information technologies would improve provider competence in core elements of screening programs. Improvement in CRC screening rates largely depends on the efforts of primary care practices to implement effective systems and procedures for screening delivery. Active engagement and support of practices are essential for the enormous potential of CRC screening to be realized.

The Green Acres Effect: The Need for a New Colorectal Cancer Screening Campaign Tailored to Rural Audiences

National health communication campaign developers have ignored rural audiences in campaign development and testing, despite the health disparities that exist for this group. Researchers in a rural Midwestern state tested the appropriateness of CDC's national colorectal cancer screening campaign, Screen for Life. Based on focus groups and a quasiexperimental design evaluation, researchers determined that the national campaign did not adequately address the needs of the rural audience. A new print and radio campaign was developed based on previous findings, grounded in social marketing and the health belief model. New tailored campaign materials were refined in focus groups. Final versions were tested in two quasiexperimental designs. Results support the campaign's reach and efficacy. Those in the intervention county were significantly more likely than the unexposed to (a) report recent exposure to ads, (b) plan to seek out information regarding screening, and (c) plan to get screened in the near future.