Colorectal Cancer Screening Initiation After Age 50 Years in an Organized Program

Colorectal cancer screening participation in First Nations populations worldwide: a systematic review and data synthesis

Background

First Nations populations have poorer colorectal cancer (CRC) survival compared to non-First Nations populations. Whilst First Nations populations across the world are distinct, shared experiences of discrimination and oppression contribute to persistent health inequities. CRC screening improves survival, however screening rates in First Nations populations are poorly described. This study seeks to define participation rates in CRC screening in First Nations populations worldwide.

Methods

A systematic literature search was conducted of PubMed, Embase, Cochrane Library, CINAHL, MEDLINE, grey literature, national registries and ClinicalTrials.gov. All sources were searched from their inception date to 18 February 2024. Studies were included if they reported CRC screening rates in adult (≥18 years) First Nations populations. We aimed to undertake a meta-analysis if there were sufficient data. Quality of papers were assessed using the Joanna Briggs Institute (JBI) appraisal tool. The study was registered with PROSPERO, CRD42020210181.

Findings

The literature search identified 1723 potentially eligible published studies. After review, 57 studies were included, 50 from the United States (US), with the remaining studies from Australia, Aotearoa New Zealand (NZ), Canada, Dominica and Guatemala. Additionally, eleven non-indexed reports from national programs in Australia and NZ were included. There were insufficient data to undertake meta-analysis, therefore a systematic review and narrative synthesis were conducted. CRC screening definitions varied, and included stool-based screening, sigmoidoscopy and colonoscopy. US First Nations screening rates ranged between 4.0 and 79.2%, Australia reported 10.6-35.2%, NZ 18.4-49%, Canada 22.4-53.4%, Guatemala 2.2% and Dominica 4.2%. Fifty-five studies were assessed as moderate or high quality and two as low quality.

Interpretation

Our findings suggested that there is wide variation in CRC screening participation rates across First Nations populations. Screening data are lacking in direct comparator groups and longitudinal outcomes. Disaggregation of screening data are required to better understand and address First Nations CRC outcome inequities.

Funding

None.

The impact of cumulative colorectal cancer screening delays: A simulation study

OBJECTIVE

Annual fecal immunochemical tests can reduce colorectal cancer incidence and mortality. However, screening is a multi-step process and most patients do not perfectly adhere to guideline-recommended screening schedules. Our objective was to compare the reduction in colorectal cancer incidence and life-years gained based on US guideline-concordant fecal immunochemical test screening to scenarios with a range of delays.

METHOD

The Colorectal Cancer Simulated Population model for Incidence and Natural history (CRC-SPIN) microsimulation model was used to estimate the effect of systematic departures from fecal immunochemical test screening guidelines on lifetime screening benefit.

RESULTS

The combined effect of consistent modest delays in screening initiation (1 year), repeated fecal immunochemical test screening (3 months), and receipt of follow-up or surveillance colonoscopy (3 months) resulted in up to 1.3 additional colorectal cancer cases per 10,000, 0.4 additional late-stage colorectal cancer cases per 10,000 and 154.7 fewer life-years gained per 10,000. A 5-year delay in screening initiation had a larger impact on screening effectiveness than consistent small delays in repeated fecal immunochemical test screening or receipt of follow-up colonoscopy after an abnormal fecal immunochemical test. The combined effect of consistent large delays in screening initiation (5 years), repeated fecal immunochemical test screening (6 months), and receipt of follow-up or surveillance colonoscopy (6 months) resulted in up to 3.7 additional colorectal cancer cases per 10,000, 1.5 additional late-stage colorectal cancer cases per 10,000 and 612.3 fewer life-years gained per 10,000.

CONCLUSIONS

Systematic delays across the screening process can result in meaningful reductions in colorectal cancer screening effectiveness, especially for longer delays. Screening delays could drive differences in colorectal cancer incidence across patient groups with differential access to screening.

Colorectal Cancer Screening: A Quality Improvement Initiative Using a Bilingual Patient Navigator, Mobile Technology, and Fecal Immunochemical Testing to Engage Hispanic Adults

BACKGROUND

Fecal immunochemical tests (FITs) are an effective screening method to detect and prevent colorectal cancer (CRC) when done in appropriate intervals. The use of bilingual patient navigators (PNs) and secure short message service (SMS) has been demonstrated to increase CRC screening rates among Hispanic adults.

OBJECTIVES

The purpose of this quality improvement project is to increase CRC screening rates among Hispanic adults in a family clinic by 25% in the post-project implementation period using an unlicensed bilingual PN, secure SMS, and at-home FITs.

METHODS

A retrospective chart review was used. Spanish-translated educational videos were delivered using SMS, and instructional screening guidance was provided via telephone in Spanish by the PN. Participants were surveyed to determine satisfaction with the support received from the PN.

FINDINGS

Findings showed a 35% increase in the clinic's FIT rates. Findings also showed that having a PN's support influenced the decision to complete FIT as compared to the use of secure SMS.

Selection of patients for large mailed fecal immunochemical test colorectal cancer screening outreach programs: A systematic review

OBJECTIVE

Digital health care offers an opportunity to scale and personalize cancer screening programs, such as mailed outreach for colorectal cancer (CRC) screening. However, studies that describe the patient selection strategy and process for CRC screening are limited. Our objective was to evaluate implementation strategies for selecting patients for CRC screening programs in large health care systems.

METHODS

We conducted a systematic review of 30 studies along with key informant surveys and interviews to describe programmatic implementation strategies for selecting patients for CRC screening. PubMed and Embase were searched since inception through December 2018, and hand searches were performed of the retrieved reference lists but none were incorporated (n = 0). No language exclusions were applied.

RESULTS

Common criteria for outreach exclusion included: being up-to-date with routine CRC screening (n = 22), comorbidities (n = 20), and personal history (n = 22) or family history of cancer (n = 9). Key informant surveys and interviews were performed (n = 28) to understand data sources and practices for patient outreach selection, and found that 13 studies leveraged electronic medical care records, 10 studies leveraged a population registry (national, municipal, community, health), 4 studies required patient opt-in, and 1 study required primary care provider referral. Broad ranges in fecal immunochemical test completion were observed in community clinic (n = 8, 31.0-59.6%), integrated health system (n = 5, 21.2-82.7%), and national regional CRC screening programs (n = 17, 23.0-64.7%). Six studies used technical codes, and four studies required patient self-reporting from a questionnaire to participate.

CONCLUSION

This systematic review provides health systems with the diverse outreach practices and technical tools to support efforts to automate patient selection for CRC screening outreach.

Comparative Access to and Use of Digital Breast Tomosynthesis Screening by Women's Race/Ethnicity and Socioeconomic Status

Importance

Digital breast tomosynthesis (DBT) has reduced recall and increased cancer detection compared with digital mammography (DM), depending on women's age and breast density. Whether DBT screening access and use are equitable across groups of women based on race/ethnicity and socioeconomic characteristics is uncertain.

Objective

To determine women's access to and use of DBT screening based on race/ethnicity, educational attainment, and income.

Design, Setting, and Participants

This cross-sectional study included 92 geographically diverse imaging facilities across 5 US states, at which a total of 2 313 118 screening examinations were performed among women aged 40 to 89 years from January 1, 2011, to December 31, 2017. Data were analyzed from June 13, 2019, to August 18, 2020.

Exposures

Women's race/ethnicity, educational level, and community-level household income.

Main Outcomes and Measures

Access to DBT (on-site access) at time of screening by examination year and actual use of DBT vs DM screening by years since facility-level DBT adoption (≤5 years).

Results

Among the 2 313 118 screening examinations included in the analysis, the proportion of women who had DBT access at the time of their screening appointment increased from 11 558 of 354 107 (3.3%) in 2011 to 194 842 of 235 972 (82.6%) in 2017. In 2012, compared with White women, Black (relative risk [RR], 0.05; 95% CI, 0.03-0.11), Asian American (RR, 0.28; 95% CI, 0.11-0.75), and Hispanic (RR, 0.38; 95% CI, 0.18-0.80) women had significantly less DBT access, and women with less than a high school education had lower DBT access compared with college graduates (RR, 0.18; 95% CI, 0.10-0.32). Among women attending facilities with both DM and DBT available at the time of screening, Black women experienced lower DBT use compared with White women attending the same facility (RRs, 0.83 [95% CI, 0.82-0.85] to 0.98 [95% CI, 0.97-0.99]); women with lower educational level experienced lower DBT use (RRs, 0.79 [95% CI, 0.74-0.84] to 0.88 [95% CI, 0.85-0.91] for non-high school graduates and 0.90 [95% CI, 0.89-0.92] to 0.96 [95% CI, 0.93-0.99] for high school graduates vs college graduates); and women within the lowest income quartile experienced lower DBT use vs women in the highest income quartile (RRs, 0.89 [95% CI, 0.87-0.91] to 0.99 [95% CI, 0.98-1.00]) regardless of the number of years after facility-level DBT adoption.

Conclusions and Relevance

In this cross-sectional study, women of minority race/ethnicity and lower socioeconomic status experienced lower DBT access during the early adoption period and persistently lower DBT use when available over time. Future efforts should address racial/ethnic, educational, and financial barriers to DBT screening.

Predictors of Colorectal Cancer Screening Modality Among Newly Age-Eligible Medicaid Enrollees

INTRODUCTION

This study examines individual- and practice-level predictors of screening modality among 1,484 Medicaid enrollees who initiated colorectal cancer screening (fecal immunochemical test/fecal occult blood tests or colonoscopy) within a year of turning age 50 years. Understanding screening modality patterns for patients and health systems can help optimize colorectal cancer screening initiatives that will lead to high screening completion rates.

METHODS

Multivariable logistic regression was conducted in 2019 to analyze Medicaid claims data (January 2013-June 2015) to explore predictors of colonoscopy screening (versus fecal testing).

RESULTS

Overall, 64% of enrollees received a colonoscopy and 36% received a fecal immunochemical test/fecal occult blood test. Male (OR=1.21, 95% CI=1.08, 1.37) compared with female enrollees and those with 4-6 (OR=1.57, 95% CI=1.15, 2.15), 7-10 (OR=2.23, 95% CI=1.64, 3.03), and ≥11 (OR=1.79, 95% CI=1.22, 2.65) primary care visits compared with 0-3 visits had higher odds of colonoscopy screening. Non-White, non-Hispanic enrollees (OR=0.71, 95% CI=0.58, 0.87) compared with White, non-Hispanics Whites had lower odds of colonoscopy screening. Practices with an endoscopy facility within their ZIP code (OR=1.50, 95% CI=1.08, 2.08) compared with practices without a nearby endoscopy facility had higher odds of colonoscopy screening.

CONCLUSIONS

Among newly age-eligible Medicaid enrollees who received colorectal cancer screening, non-White, non-Hispanic individuals were less likely and male enrollees and those with ≥4 primary care visits were more likely to undergo colonoscopy versus fecal immunochemical test/fecal occult blood test. Colonoscopy also was the more common modality among adults whose primary care clinic had an endoscopy facility in the same ZIP code. Future research is needed to fully understand patient, provider, and practice preferences regarding screening modality.

Variation in Colorectal Cancer Stage and Mortality across Large Community-Based Populations: PORTAL Colorectal Cancer Cohort

INTRODUCTION

Colorectal cancer (CRC) incidence and mortality can be reduced by effective screening and/or treatment. However, the influence of health care systems on disparities among insured patients is largely unexplored.

METHODS

To evaluate insured patients with CRC diagnosed between 2010 and 2014 across 6 diverse US health care systems in the Patient-Centered Outcomes Research Institute (PCORI) Patient Outcomes Research To Advance Learning (PORTAL) CRC cohort, we contrasted CRC stage; CRC mortality; all-cause mortality; and influences of demographics, stage, comorbidities, and treatment between health systems.

RESULTS

Among 16,211 patients with CRC, there were significant differences between health care systems in CRC stage at diagnosis, CRC-specific mortality, and all-cause mortality. The unadjusted risk of CRC mortality varied from 27% lower to 21% higher than the reference system (hazard ratio [HR] = 0.73, 95% confidence interval = 0.66-0.80 to HR = 1.21, 95% confidence interval = 1.05-1.40; p < 0.01 across systems). Significant differences persisted after adjustment for demographics and comorbidities (p < 0.01); however, adjustment for stage eliminated significant differences (p = 0.24). All-cause mortality among patients with CRC differed approximately 30% between health care systems (HR = 0.89-1.17; p < 0.01). Adjustment for age eliminated significant differences (p = 0.48).

DISCUSSION

Differences in CRC survival between health care systems were largely explained by stage at diagnosis, not demographics, comorbidity, or treatment. Given that stage is strongly related to early detection, these results suggest that variation in CRC screening systems represents a modifiable systems-level factor for reducing disparities in CRC survival.

Advanced Notification Calls Prior to Mailed Fecal Immunochemical Test in Previously Screened Patients: a Randomized Controlled Trial

BACKGROUND

Phone calls as part of multimodal fecal immunochemical test (FIT) outreach are effective but resource-intensive. Previous studies of advanced notification calls before FIT mailing have not differentiated patients' prior screening status.

OBJECTIVE

To determine the effectiveness of a phone call preceding mailing of a FIT kit on test completion rate for patients who have completed a prior FIT.

DESIGN

Randomized controlled trial nested within a larger study. All patients were assigned to receive organized mailed FIT outreach in the larger study.

PARTICIPANTS

Patients in a safety-net health setting ages 50-75 years old with a previously negative FIT.

INTERVENTIONS

Patients were assigned to either receive an advanced notification phone call or no phone call preceding a mailed FIT kit. Both groups received an informational postcard prior to the mailed FIT.

MAIN MEASURES

The primary outcome was FIT completion rate at 1 year. The secondary outcomes were FIT completion rates at 60, 90, and 180 days, rates stratified by demographic subgroups, and rates according to outcome of the phone call.

KEY RESULTS

A total of 1645 patients were assigned to advanced notification calls and 1595 were assigned to no call preceding the FIT mailing. Although FIT completion rate was higher at day 60 (55.5% vs. 50.8%, p < 0.01), an advanced notification call did not significantly improve FIT completion at 1 year (70.9% vs. 69.9%, p = 0.52). Of the patients assigned to receive an advanced notification call, 90.5% were spoken with or left a voicemail; patients who were spoken with were more likely to complete a FIT at 1 year compared with patients who were only left a voicemail or could not be left a voicemail (79.9% vs. 69.2% vs. 49.6%, p < 0.01).

CONCLUSIONS

Advanced notification phone calls prior to FIT mailing did not improve rates at 1 year for patients with a previously negative FIT.

Colorectal Cancer Screening in People With and Without HIV in an Integrated Health Care Setting

BACKGROUND

As people with HIV (PWH) live longer, age-appropriate colorectal cancer (CRC) screening is increasingly important. Limited data exist on CRC screening and outcomes comparing PWH and persons without HIV.

SETTING

Large integrated health care system.

METHODS

This study included PWH and demographically matched persons without HIV who were aged 50-75 years during 2005-2016 and had no previous CRC screening. We evaluated time to first CRC screening (fecal test, sigmoidoscopy, or colonoscopy). We also assessed detection of adenoma and CRC with sigmoidoscopy or colonoscopy by HIV status, accounting for CRC risk factors including sex, age, race/ethnicity, number of outpatient visits, smoking, body mass index, type-2 diabetes, and inflammatory bowel disease. Among PWH, we evaluated whether CD4 count (<200/200-499/≥500 cells/µL) was associated with adenoma and CRC.

RESULTS

Among 3177 PWH and 29,219 persons without HIV, PWH were more likely to be screened (85.6% vs. 79.1% within 5 years, P < 0.001). Among those with sigmoidoscopy or colonoscopy, adenoma was detected in 161 (19.6%) PWH and 1498 (22.6%) persons without HIV, and CRC was detected in 4 (0.5%) PWH and 69 (1.0%) persons without HIV. In adjusted analyses, we found no difference in prevalence of either adenoma or CRC by HIV status (adjusted prevalence ratio = 0.97, 95% confidence interval: 0.83 to 1.12). Lower CD4 count did not increase likelihood of adenoma or CRC.

CONCLUSIONS

Within an integrated health care system with an organized CRC screening program, we found no disparities in CRC screening uptake or outcomes among people with and without HIV, and CD4 count did not influence CRC risk among PWH.

Initiation of Colorectal Cancer Screening Among Medicaid Enrollees

INTRODUCTION

Few studies have explored how individual- and practice-level factors influence colorectal cancer screening initiation among Medicaid enrollees newly age eligible for colorectal cancer screening (i.e., turning 50 years). This study explored colorectal cancer screening initiation among newly age-eligible Medicaid enrollees in Oregon.

METHODS

Medicaid claims data (January 2013 to June 2015) were used to conduct multivariable logistic regression (in 2018 and 2019) to explore individual- and practice-level factors associated with colorectal cancer screening initiation among 9,032 Medicaid enrollees.

RESULTS

A total of 17% of Medicaid enrollees initiated colorectal cancer screening; of these, 64% received a colonoscopy (versus fecal testing). Colorectal cancer screening initiation was positively associated with turning 50 years in 2014 (versus 2013; OR=1.21), being Hispanic (versus non-Hispanic white; OR=1.41), urban residence (versus rural; OR=1.23), and having 4 to 7 (OR=1.90) and 8 or more (OR=2.64) primary care visits compared with 1 to 3 visits in the year after turning 50 years. Having 3 or more comorbidities was inversely associated with initiation (OR=0.75). The odds of screening initiation were also higher for practices with 3 to 4 (OR=1.26) and 8 or more (OR=1.34) providers compared with 1 to 2 providers, and negatively associated with percentage of Medicaid panel age eligible for colorectal cancer screening (OR=0.92).

CONCLUSIONS

Both individual- and practice-level factors are associated with disparities in colorectal cancer screening initiation among Oregon Medicaid enrollees. Future work promoting colorectal cancer screening might focus on additional barriers to the timely initiation of colorectal cancer screening and explore the effect of practice in-reach and population outreach strategies.

Time to fecal immunochemical test completion for colorectal cancer screening

OBJECTIVES

Fecal immunochemical tests (FITs) can efficiently screen for colorectal cancer (CRC), but little is known on the timing to their completion. We investigate the time to return of a FIT following an order and describe patient characteristics associated with FIT return.

STUDY DESIGN

Retrospective cohort study.

METHODS

We identified 63,478 members of Kaiser Permanente Washington, aged 50 to 74 years, who received a FIT order from 2011 through 2012. Patient characteristics were ascertained through administrative and electronic health record data sources. We compared time from FIT order to return by patient characteristics using Kaplan-Meier and Cox regression methods.

RESULTS

About half (53.7%) of members completed a FIT. Median time from order to return was 13 days (mean, 44.5 days; interquartile range, 6-42 days). There was higher completion of FITs among Asian patients (hazard ratio [HR], 1.43; 95% CI, 1.38-1.48), black patients (HR, 1.13; 95% CI, 1.08-1.19), and Hispanic patients (HR, 1.10; 95% CI, 1.04-1.16) compared with white patients; among patients with recent CRC testing (vs no testing in past 2 years; HR, 1.90; 95% CI, 1.86-1.95); and among patients with Medicare insurance (vs commercial; HR, 1.30; 95% CI, 1.24-1.37). Factors associated with decreased FIT completion included younger age (50-54 years vs 70-74 years; HR, 0.87; 95% CI, 0.82-0.92), obesity (vs normal body mass index; HR, 0.88; 95% CI, 0.86-0.91), and higher Charlson Comorbidity Index score (≥3 vs 0; HR, 0.82; 95% CI, 0.79-0.87).

CONCLUSIONS

Time to return of FIT varies by patient characteristics. We observed greater FIT completion among people of color, suggesting that racial disparities in CRC may not be due to patient completion of the test after an order is received.

Does a transition to accountable care in Medicaid shift the modality of colorectal cancer testing?

BACKGROUND

Health care reform is changing preventive services delivery. This study explored trajectories in colorectal cancer (CRC) testing over a 5-year period that included implementation of 16 Medicaid Accountable Care Organizations (ACOs, 2012) and Medicaid expansion (2014) - two provisions of the Affordable Care Act (ACA) - within the state of Oregon, USA.

METHODS

Retrospective analysis of Oregon's Medicaid claims for enrollee's eligible for CRC screening (50-64 years) spanning January 2010 through December 2014. Our analysis was conducted and refined April 2016 through June 2018. The analysis assessed the annual probability of patients receiving CRC testing and the modality used (e.g., colonoscopy, fecal testing) relative to a baseline year (2010). We hypothesized that CRC testing would increase following Medicaid ACO formation - called Coordinated Care Organizations (CCOs).

RESULTS

A total of 132,424 unique Medicaid enrollees (representing 255,192 person-years) met inclusion criteria over the 5-year study. Controlling for demographic and regional factors, the predicted probability of CRC testing was significantly higher in 2014 (+ 1.4 percentage points, p < 0.001) compared to the 2010 baseline but not in 2012 or 2013. Increased fecal testing using Fecal Occult Blood Tests (FOBT) or Fecal Immunochemical Tests (FIT) played a prominent role in 2014. The uptick in statewide fecal testing appears driven primarily by a subset of CCOs.

CONCLUSIONS

Observed CRC testing did not immediately increase following the transition to CCOs in 2012. However increased testing in 2014, may reflect a delay in implementation of interventions to increase CRC screening and/or a strong desire by newly insured Medicaid CCO members to receive preventive care.