A randomized trial of two print interventions to increase colon cancer screening among first-degree relatives

Effects of health education on screening rate of first-degree relatives of cancer patients: A systematic review and meta-analysis

OBJECTIVE

To synthesize the effects of educational intervention on the screening rate of first-degree relatives of cancer patients.

METHODS

A total of eight Chinese and English databases were searched (PubMed, Embase, Cochrane Library, CINAHL, Web of Science, Scopus, Medline and China Biology Medicine disc) from the time of library establishment to June 2023, for randomized controlled trials investigating the effects of educational intervention on screening rate of first-degree relatives of cancer patients. Two researchers independently screened and evaluated the quality of studies. RevMan 5.3 software was used to calculate the pooled effect size.

RESULTS

Thirteen studies involving 5628 participants were chosen to include in the meta-analysis. The results revealed that health education can increase screening rate of first-degree relatives of cancer patients (RR = 1.39, 95% CI = 1.16-1.65, P = 0.0002). The effect shown after short-term follow-up (≤6 months) was insignificant in terms of improving screening rate (RR = 1.46, 95% CI = 0.94-2.26, P = 0.09), but after long-term follow-up (＞6 months) the improvement was greater (RR = 1.37, 95% CI = 1.13-1.65, P = 0.002).

CONCLUSION

Health education is effective in increasing the screening rate of first-degree relatives of cancer patients. The effect is more evident after long-term than short-term follow-up.

Communication quality predicts patients' colorectal cancer screening behavior

The purpose of the present study was to investigate the quality of patient/clinician communication as one potential factor that impacts colorectal cancer screening behavior. As part of a larger randomized controlled trial conducted between 2011 and 2016 in the setting of community and academic family medicine or internal medicine practices in Michigan, USA, patients completed a pre-encounter survey, completed their regularly scheduled visit with their primary care clinician (which was audio-recorded), completed a post-encounter survey, and allowed 6-month follow-up chart audit. We trained 10 coders to rate 216 of the audio-recorded conversations between 216 patients and their primary care physicians for 6 specific features of communication quality (using 7-point scales), including the extent to which participants enacted attention to medical content, engagement, emotional expression, relationships, face, and accommodation. At least 3 coders rated each conversation, and intraclass correlations (i.e., reliability assessment) were in the good to excellent range. We found that patient and clinician attention to face (an identity goal) was a significant predictor of colorectal cancer screening at 6 months follow up. Measuring communication in terms of attention to multiple goals reveals unexpected findings about the aspects of communication that impact colorectal cancer screening behavior. The focus of many interventions to improve colorectal cancer screening rates is on the content (i.e., task goals) of clinicians' communication (such as presenting the different options for screening), yet the content of communication was not a significant predictor of screening in the present study. Rather, clinicians' and patients' attention to identity goals predicted screening behavior, which suggests that interventions may not need to be overly complex and that simply improving the quality of attention to identity goals in clinician communication might be one of the most straightforward yet impactful ways to improve colorectal cancer screening uptake among patients.

Patient Navigation Plus Tailored Digital Video Disc Increases Colorectal Cancer Screening Among Low-Income and Minority Patients Who Did Not Attend a Scheduled Screening Colonoscopy: A Randomized Trial

BACKGROUND

Up to 50% of people scheduled for screening colonoscopy do not complete this test and no studies have focused on minority and low-income populations. Interventions are needed to improve colorectal cancer (CRC) screening knowledge, reduce barriers, and provide alternative screening options. Patient navigation (PN) and tailored interventions increase CRC screening uptake, however there is limited information comparing their effectiveness or the effect of combining them.

PURPOSE

Compare the effectiveness of two interventions to increase CRC screening among minority and low-income individuals who did not attend their screening colonoscopy appointment-a mailed tailored digital video disc (DVD) alone versus the mailed DVD plus telephone-based PN compared to usual care.

METHODS

Patients (n = 371) aged 45-75 years at average risk for CRC who did not attend a screening colonoscopy appointment were enrolled and were randomized to: (i) a mailed tailored DVD; (ii) the mailed DVD plus phone-based PN; or (iii) usual care. CRC screening outcomes were from electronic medical records at 12 months. Multivariable logistic regression analyses were used to study intervention effects.

RESULTS

Participants randomized to tailored DVD plus PN were four times more likely to complete CRC screening compared to usual care and almost two and a half times more likely than those who were sent the DVD alone.

CONCLUSIONS

Combining telephone-based PN with a mailed, tailored DVD increased CRC screening among low-income and minority patients who did not attend their screening colonoscopy appointments and has potential for wide dissemination.

Impact of a Personal Health Record Intervention Upon Surveillance Among Colorectal Cancer Survivors: Feasibility Study

BACKGROUND

There are currently an estimated 1.5 million individuals living in the United States with colorectal cancer (CRC), and although the 5-year survival rate has increased, survivors are at risk for recurrence, particularly within the first 2-3 years after treatment. National guidelines recommend continued surveillance after resection to identify recurrence early on. Adherence among survivors ranges from 23% to 94%. Novel interventions are needed to increase CRC survivors' knowledge and confidence in managing their cancer and thus to increase adherence to follow-up surveillance.

OBJECTIVE

The objective of this study is to develop and test the feasibility and efficacy of a stand-alone, web-based personal health record (PHR) to increase surveillance adherence among CRC survivors, with patient beliefs about surveillance as secondary outcomes.

METHODS

A pre- and postintervention feasibility trial was conducted testing the efficacy of the colorectal cancer survivor (CRCS)-PHR, which had been previously developed using an iterative, user-centered design approach.

RESULTS

The average age of the sample was 58 (SD 9.9) years, with 57% (16/28) male and the majority married (20/28, 71%) and employed full-time (15/28, 54%). We observed a significant increase in adherence to colonoscopy (before: 11/21, 52% vs after: 18/21, 86%; P=.005) and CEA (14/21, 67% vs 20/21, 95%; P=.01), as well as a slight increase in CT scans (14/21, 67% vs 18/21, 86%; P=.10). The only significant impact on secondary outcome (patient beliefs) was benefits of CEA test (P=.04), as most of the beliefs were high at baseline.

CONCLUSIONS

This feasibility study lays the groundwork for continued development of the CRCS-PHR to increase CRC surveillance. Patient-centered technologies, such as the CRCS-PHR, represent an important potential approach to improving the receipt of guideline-concordant care and follow-up surveillance, and not just for CRC survivors. Researchers should continue to develop patient-centered health technologies with clinician implementation in mind to increase patient self-efficacy and surveillance adherence.

Effectiveness of a tailored communication intervention on colonoscopy uptake for firstdegree relatives of colorectal cancer patients: A randomised controlled trial

Objective

To evaluate the effect of a WeChat tailored communication intervention on colonoscopy uptake and health beliefs in Chinese first-degree relatives (FDRs) of colorectal cancer patients.

Methods

This study employed a single-blinded randomized controlled trial. A total of 188 eligible FDRs were recruited and randomly assigned to the tailored intervention group or control group. Health beliefs were assessed at 1 (T1) and 3 months (T2) postintervention. The colonoscopy uptake was verified by medical records at T2. Data were analyzed using binary logistic regression and generalized estimating equation models.

Results

Compared with the participants in the control group, those in the intervention group had a significant improvement in terms of colonoscopy uptake (OR = 2.752, 95% CI: 1.428–5.303, P ​< ​0.01), perceived susceptibility (T1: β ​= ​0.298, 95% CI: ​0.052–0.402, P ​< ​0.05; T2: β ​= ​0.251, 95% CI: ​0.078–0.424, P ​< ​0.001) and cues to action (T1: β ​= ​0.0.264, 95% CI: ​0.138–0.389, P ​< ​0.001; T2: β ​= ​0.327, 95% CI: ​0.195–0.459, P ​< ​0.001) and a significant reduction in perceived barriers (T1: β ​= ​−0.237, 95% CI: ​−0.360−0.115, P ​< ​0.01; T2: β ​= ​−0.196, 95% CI: ​−0.331−0.062, P ​< ​0.01).

Conclusions

This study broadens the application of tailored communication using novel channels in the context of screening in the at-risk Chinese population. The results provide insights on how to improve the intervention by modifying its components and communication channels.

Colorectal cancer patients advocating screening to their siblings: a randomized behavioral intervention

BACKGROUND AND AIMS

Siblings of colorectal cancer (CRC) patients are at increased risk of developing CRC, but screening rates remain low. Through a randomized behavioral intervention, this study aimed to determine whether patients can advocate screening to their siblings using a tailored educational package.

METHODS

CRC survivors were recruited and randomized into relaying either tailored materials (intervention group) or existing national screening guidelines (control group) to their siblings. Siblings could respond to the study team if they were interested in learning about CRC screening. Study outcomes were patient advocacy rates (number of patients who had successfully contacted at least 1 eligible sibling) between groups and the proportion of eligible siblings who responded.

RESULTS

Between May 2017 and March 2021, 219 CRC patients were randomized to the intervention (n = 110) and control (n = 109) groups. Patient advocacy rates were high and did not differ significantly between groups. However, only 14.3% of eligible siblings (n = 85) responded to the study team. Siblings of patients from the intervention group were more likely to respond (adjusted odds ratio, 1.8; 95% confidence interval, 1.1-3.0; P < .05). Moreover, after controlling for potential confounders, siblings aged ≥60 years were significantly less likely to respond (adjusted odds ratio, .3; 95% confidence interval, .1-.7; P < .01).

CONCLUSIONS

CRC patients are willing advocates of screening, and siblings contacted by patients from the intervention group were also more likely to reach out to the study team. However, overall sibling response rates were low despite advocacy, suggesting that patient-led advocacy should at best be used as an adjunct to other, multipronged CRC screening promotion modalities.

Two randomized controlled trials for colorectal cancer screening invitations developed using a behavioral science approach

The effectiveness of behaviorally informed, targeted invitations to standard invitations and to no invitation (control arm, primary analysis) were compared in the context of an organized colorectal cancer (CRC) screening program. Two multi-arm, pragmatic randomized controlled trials in men (arms: male-specific, unisex, standard invitation, or no invitation) and in women (arms: unisex, standard invitation, or no invitation), were conducted in Ontario, Canada. Eligible persons aged 50-74, due for CRC screening, were randomized. Primary and secondary outcomes were completion of the guaiac fecal occult blood test (gFOBT) and uptake of any colorectal test, respectively, within 5 months of mailing. Impact of invitation type was assessed using logistic regression. Letters were mailed to 75,810 men and women; 38,673 males and 34,453 females were included in the analyses. Men who received the male-specific letter were most likely to screen with gFOBT compared to controls (odds ratio (OR) 7·24, 95% CI: 5·77, 9·09), followed by those receiving the unisex letter (OR 6·75, 95% CI: 5·37, 8·47) and the standard letter (OR 5·99, 95% CI: 4·76, 7·53). Women who received the unisex letter were most likely to be screened with gFOBT compared to controls (OR 7·07, 95% CI: 5·83, 8·59), followed by those receiving the standard letter (OR 6·76, 95% CI: 5·56, 8·21). In both trials, the findings were similar for the secondary outcome. Mailed invitations were effective for both men and women. With greater targeting using the behaviorally informed invitations, the magnitude of benefit relative to no invitation appeared to increase. (ClinicalTrials.gov, NCT02364895).

Mapping psychosocial interventions in familial colorectal cancer: a rapid systematic review

Background

Approximately 5% of colorectal cancer (CRC) cases are part of a well-defined inherited genetic syndrome and up to approximately 30% of these cases have a clinically defined familial basis. Psychosocial interventions in familial colorectal cancer address aspects mainly focused on affective, cognitive and behavioural outcomes. The present review aims to systematically map out the available psychosocial interventions for individuals with a family history of CRC and describe the current state of the research.

Methods

An extensive electronic search was conducted to investigate the literature published until June 2020. Inclusion criteria consisted of quantitative studies published in English that explored the impact of psychosocial interventions for familial CRC, clearly defined the psychosocial intervention offered and included participants with a family history of CRC.

Results

The analysis included 52 articles. Genetic counselling, educational interventions, psychological interventions and multimodal interventions were identified across the studies. In terms of diagnoses, Lynch Syndrome, Familial Adenomatous Polyposis, Familial Colorectal Cancer were the main conditions included in the studies. Affective, cognitive, behavioural aspects and quality of life emerged as the most frequently explored outcomes. The studies included individuals with both personal and familial history of CRC or family history alone.

Conclusions

Our rapid review provides an overview of the literature exploring the impact of psychosocial interventions for familial CRC. The psychosocial interventions identified had an overwhelmingly positive impact across all types of outcomes measured. Genetic counselling appeared to be most beneficial, and this is expected as it is purposively designed to address genetic conditions. Further quantitative analysis of primary empirical research is needed to determine the efficacy and effectiveness of psychosocial interventions as well as the mechanisms through which they exert their effect.

Development and feasibility of an evidence-based and theory-driven tailored mHealth communication intervention to increase colonoscopy screening rate in first-degree relatives of people with colorectal cancer

PURPOSE

To develop and investigate the feasibility of an evidence-based and theory-driven tailored communication to increase colonoscopy screening rates amongst first-degree relatives of colorectal cancer patients.

METHOD

Based on the tailoring process and identified evidence from the systematic review conducted by the research team, the tailored communication was developed from four aspects: (1) tailoring variables (e.g., demographic, behavioural, and psychosocial characteristics), (2) decision rules, (3) tailored messages and (4) delivery plan. Expert (n = 5) and layman review (n = 5) were conducted to ensure the content validity of decision rules and tailored messages. A single-blinded, family-based cluster randomised controlled trial (n = 21) tested the feasibility and acceptability of the intervention.

RESULTS

A three-session mobile-based tailored intervention with clear decision rules and 27 tailored messages were developed. In the feasibility study, the recruitment rate was 34.4%. The response rate at 1-month post-intervention was 61.9%. After a voice call was added for nonresponders, the response rate at the 3-month post-intervention increased to 81%. All participants were satisfied with the intervention and agreed that the intervention helped them understand the risks and appropriate screening recommendations.

CONCLUSION

The development of a three-session mobile-based tailored intervention with an integrated tailoring decision and message system was reported in this study. Given its remote nature, the mobile-based tailored intervention may encounter challenges in family recruitment and online assessment. Suggestions on (1) study design to avoid contamination, (2) recruitment approaches and (3) strategies to promote response to online questionnaires were made for a future definitive trial.

Partnering to Increase Colorectal Cancer Screening: Perspectives of Community Advisory Board Members

The Patient-Centered Outcomes Research Institute (PCORI) defines engagement in research as the meaningful involvement of patients, caregivers, clinicians, insurers, and others throughout the entire research process-from planning to conducting the study to disseminating study results. The purposes of this paper are to (a) describe methods used to engage community members across the various phases of a PCORI-funded comparative effectiveness trial to increase colorectal cancer screening; and (b) report results of qualitative and quantitative evaluations of community advisory board members' experiences on this project. Decisions to join and stay engaged with the study included feeling valued and appreciated, being compensated, the opportunity to contribute to research based on their skills and expertise, and being committed to colon cancer prevention efforts. Challenges identified by advisory board members included the significant time commitment, transportation, and meeting location. Lessons learned and guidance for researchers committed to patient and community engagement are described.

Systematic Review of Interventions to Increase Stool Blood Colorectal Cancer Screening in African Americans

African Americans experience colorectal cancer (CRC) related disparities compared to other racial groups in the United States. African Americans are frequently diagnosed with CRC at a later stage, screening is underutilized, and mortality rates are highest in this group. This systematic review focused on intervention studies using stool blood CRC screening among African Americans in primary care and community settings. Given wide accessibility, low cost, and ease of dissemination of stool-based CRC screening tests, this review aims to determine effective interventions to improve participation rates. This systematic review included intervention studies published between January 1, 2000 and March 16, 2019. After reviewing an initial search of 650 studies, 11 studies were eventually included in this review. The included studies were studies conducted in community and clinical settings, using both inreach and outreach strategies to increase CRC screening. For each study, an unadjusted odds ratio (OR) for the CRC screening intervention compared to the control arm was calculated based on the data in each study to report effectiveness. The eleven studies together recruited a total of 3334 participants. The five studies using two-arm experimental designs ranged in effectiveness with ORs ranging from 1.1 to 13.0 using interventions such as mailed reminders, patient navigation, and tailored educational materials. Effective strategies to increase stool blood testing included mailed stool blood tests augmented by patient navigation, tailored educational materials, and follow-up calls or mailings to increase trust in the patient-provider relationship. More studies are needed on stool blood testing interventions to determine effectiveness in this population.

Validity and Reliability of the Instruments to Measure Colorectal Cancer Screening Benefits and Barriers-Turkish Version

BACKGROUND

Perceptions of benefits and barriers are important determinants in understanding colorectal cancer screening (CRCS) behaviors. There is a need for standardized Turkish tools that measure the benefits and barriers of fecal occult blood test (FOBT) and colonoscopy (COL).

OBJECTIVE

The aim of this study was to assess the validity and reliability of the Turkish version of the "Instruments to Measure CRCS Benefits and Barriers."

METHODS

This methodological study was carried out in 2 stages in primary care and in 394 adults between the ages of 50 and 70 years. In the first stage, some items of the scales demonstrated low/unacceptable corrected item-total and factor loadings, and in the second stage, it was decided to add emoji-based facial scales, which include emoji expressions.

RESULTS

Results with the emoji-based facial scales included internal consistency coefficients of 0.85 for FOBT benefits, 0.79 for FOBT barriers, 0.84 for COL benefits, and 0.86 for COL barriers; the item-total correlations of FOBT varied between 0.39 and 0.73, whereas those of COL varied between 0.38 and 0.76. The factor loadings of all items were higher than 0.40.

CONCLUSIONS

The emoji-based facial scale for CRC Screening Benefits and Barriers is a valid and reliable tool for measuring the benefits and barriers perceptions of 50- to 70-year-old Turkish adults.

IMPLICATIONS FOR PRACTICE

The Instruments to Measure CRCS Benefits and Barriers-Turkish version can provide insights for nurses and healthcare professionals to understand individuals' perceived FOBT and COL benefits and barriers and to develop effective interventions to increase CRCS rates.

Hereditary colorectal cancer screening: A 10-year longitudinal cohort study following an educational intervention

Family history (FH) of a first-degree relative with colorectal cancer (CRC) is associated with two to fourfold increased risk, yet screening uptake is suboptimal despite proven mortality reduction. We developed a FH-based CRC Risk Triage/Management tool for family physicians (FPs), and educational booklet for patients with CRC FH. This report describes physician referral and patient screening behavior 5 and 10 years post-educational intervention, and factors associated with screening. Longitudinal cohort study. FPs/patients in Ontario and Newfoundland, Canada were sent questionnaires at baseline (2005), 5 and 10 years (2015) following tool/booklet receipt. FPs were asked about CRC screening, patients about FH, screening type and timing. "Correct" screening was concordance with tool recommendations. Results reported for 29/121 (24%) FPs and 98/297 (33%) patients who completed all 3 questionnaires. Over 10 years 2/3 patients received the correct CRC screening test at appropriate timing (baseline 75%, 5-year 62%, 10-year 65%). About half reported their FP recommended CRC screening (5-year 51%, 10-year 63%). Fewer than half the patients correctly assessed their CRC risk (44%, 40%, 41%). Patients were less likely to have correct screening timing if female (RR 0.78; 95% CI 0.61, 0.99; p = 0.045). Patients were less likely to have both correct test and timing if moderate/high CRC risk (RR 0.66; 95% CI 0.47, 0.93; p = 0.017) and more likely if their physician recommended screening (RR1.69; 95% CI 1.15, 2.49; p = 0.007). Physician discussion of CRC risk and screening can positively impact patient screening behavior. Efforts are particularly needed for women and patients at moderate/high CRC risk.

Colorectal cancer patients can be advocates for colorectal cancer screening for their siblings: A study on siblings' perspectives

OBJECTIVE

This study was performed to explore in-depth, the issues and barriers pertaining to colorectal cancer (CRC) screening amongst the siblings of CRC patients in view of their higher risk of developing CRC.

METHODS

A qualitative study of siblings of CRC patients was performed from August 2017 to October 2018. Semi-structured interviewed were performed until data saturation was achieved. The data was then thematically analysed.

RESULTS

A total of 36 siblings of CRC patients, with a median age of 59 (range 39-78) years old completed the interviews. All the interviews were conducted alone with the participants. Each interview lasted between 30 and 45 minutes. None of the participants has undergone screening colonoscopy prior to the interviews. After thematic analysis, five themes were identified. These include: (i) Misunderstanding their own risk of developing colorectal cancer; (ii) Misperceptions of the role of "screening" for colorectal cancer.; (iii) Misconception of the CRC screening modality for FDRs; (iv) Barriers and facilitators of undergoing screening; (v) Misperceptions of national healthcare policies.

CONCLUSIONS

Identifying and addressing the identified barriers for these siblings to undergo screening colonoscopy is easily attainable. A multi-pronged approach should also be adopted to address the various concerns so as to reduce the incidence of CRC amongst these higher risk individuals.

Comparative Effectiveness of Two Interventions to Increase Colorectal Cancer Screening for Those at Increased Risk Based on Family History: Results of a Randomized Trial

BACKGROUND

First-degree relatives (FDR) of patients with colorectal cancer are at risk for colorectal cancer, but may not be up to date with colorectal cancer screening. We sought to determine whether a one-time recommendation about needing colorectal cancer screening using patient navigation (PN) was better than just receiving the recommendation only.

METHODS

Participants were FDRs of patients with Lynch syndrome-negative colorectal cancer from participating Ohio hospitals. FDRs from 259 families were randomized to a website intervention (528 individuals), which included a survey and personal colorectal cancer screening recommendation, while those from 254 families were randomized to the website plus telephonic PN intervention (515 individuals). Primary outcome was adherence to the personal screening recommendation (to get screened or not to get screened) received from the website. Secondary outcomes examined who benefited from adding PN.

RESULTS

At the end of the 14-month follow-up, 78.6% of participants were adherent to their recommendation for colorectal cancer screening with adherence similar between arms (P = 0.14). Among those who received a recommendation to have a colonoscopy immediately, the website plus PN intervention significantly increased the odds of receiving screening, compared with the website intervention (OR: 2.98; 95% confidence interval, 1.68-5.28).

CONCLUSIONS

Addition of PN to a website intervention did not improve adherence to a colorectal cancer screening recommendation overall; however, the addition of PN was more effective in increasing adherence among FDRs who needed screening immediately.

IMPACT

These findings provide important information as to when the additional costs of PN are needed to assure colorectal cancer screening among those at high risk for colorectal cancer.

The effect of knowledge and health beliefs about colorectal cancer on screening behaviour

AIMS AND OBJECTIVES

To determine the effect of the knowledge and health beliefs of individuals about colorectal cancer on their screening behaviour.

BACKGROUND

Colorectal cancer ranks third among the most common cancers both worldwide and in Turkey. Colorectal cancer plays an important role in cancer mortality but can be prevented by promoting healthy behaviour and participation in early screening programmes.

DESIGN

This descriptive study was completed with 114 women and 121 men.

METHODS

The study data were collected using the 'Data collection form' and 'Health Belief Model Scale for Protection from Colorectal Cancer'. Potential risk factors were investigated using logistic regression analyses. The AGREE checklist was completed.

RESULTS

The colorectal cancer screening tests were known by 23.0% of the subjects and 17% had undergone one of these tests. The score medians obtained from the confidence-benefit subscale of Health Belief Model Scale for Protection from Colorectal Cancer were found to be significantly higher in those who had undergone colorectal cancer screening. Logistic regression analysis revealed that having knowledge of the relevant tests was associated with undergoing colorectal cancer screening.

CONCLUSIONS

Having knowledge on colorectal cancer screening tests increases the relevant confidence-benefit perception regarding the tests and the behaviour of participating in screening programmes. Regular training on colorectal cancer and early diagnosis should therefore be provided by healthcare professionals to both women and men aged 50-70 years to increase the rate of undergoing early screening tests.

RELEVANCE TO CLINICAL PRACTICE

Increasing the rate of early screening is among the responsibilities of health workers working in primary health centres. Therefore, problems that prevent individuals from participating in these programmes need to be identified. In this way, health workers will develop suggestions and initiatives that change the individual's health beliefs and increase motivation.

Invitation to Screening Colonoscopy in the Population at Familial Risk for Colorectal Cancer

BACKGROUND

Screening colonoscopy can lower the incidence of colorectal cancer (CRC), yet participation rates are low even in groups at high risk. The goal of this study was to double the rate of participation in screening colonoscopy among persons at familial risk and then to determine the frequency of neoplasia in this risk group.

METHODS

In a nationwide, cluster-randomized, multicenter study, first-degree relatives (FDR) of patients with CRC across Germany received written informational materials concerning the familial risk of CRC, along with an invitation to undergo colonoscopy. Participants in the intervention group were additionally counseled by nurses over the telephone. The primary endpoint of the study was colonoscopy uptake within 30 days.

RESULTS

The participants' mean age was 50.8 years. The colonoscopy uptake rates were 99/125 (79%) in the intervention group and 97/136 (71%) in the control group (RR = 1.11; 95% confidence interval [0.97; 1.28]). A polypectomy was performed in 72 of 196 asymptomatic persons (37%). In 13 cases (7%), an advanced neoplasia was detected; two of these persons had colon cancer (stages T0 and T1). 42% of the participants expressed barriers against colonoscopy. 22 reported mild side effects; there were no serious side effects.

CONCLUSION

Additional counseling by nurses over the telephone does not increase the participation rate. Approaching patients who have CRC is an opportunity to increase the participation of their first-degree relatives in screening colonoscopy. The frequency of neoplasia that was found in this study underscores the need to screen relatives even before they reach the usual age threshold for screening.

Telephone versus in-person colorectal cancer risk and screening intervention for first-degree relatives: A randomized controlled trial

BACKGROUND

Having a first-degree relative (FDR) with colorectal cancer (CRC) is a significant risk factor for CRC. Counseling for FDRs regarding CRC risk factors and personalized risk is important to improve knowledge and screening compliance.

METHODS

A 3-arm randomized controlled trial compared tailored in-person and telephone CRC counseling interventions with controls among FDRs who were not mutation carriers for known hereditary cancer syndromes, but who were considered to be at an increased risk based on family history. It was hypothesized that both telephone and in-person approaches would increase CRC knowledge, screening adherence, perceived risk accuracy, and psychosocial functioning compared with controls. The authors anticipated greater satisfaction with the in-person approach. CRC knowledge, risk perception, psychosocial functioning, and intention to screen were assessed at baseline and at 2-week and 2-month follow-ups (primary endpoint).

RESULTS

A total of 278 FDRs (mean age, 47.4 years, standard deviation, 11.38 years) participated. At baseline, participants reported low to moderate CRC knowledge and overestimations of risk. Screening adherence was 73.7%. At 2 months, participants in the in-person arm and telephone arm demonstrated improvements in knowledge and perceived risk and were not found to be statistically different from each other. However, when comparing each intervention with controls, knowledge in the in-person arm was found to be statistically significantly higher, but the difference between the telephone and control arms was not. Cancer-related stress reduced over time in all groups. Intervention benefits were maintained at 1 year. Baseline screening intent/adherence were high, and therefore did not reach statistically significant improvement.

CONCLUSIONS

Tailored in-person or telephone formats for providing CRC risk counseling, incorporating behavioral interventions, appear to improve knowledge and risk perceptions, with high client satisfaction.

Colorectal Cancer Awareness for Women via Facebook: A Pilot Study

Colorectal cancer is the third leading cause of cancer death among U.S. women. Women report being screened for colorectal cancer less often than men, and if colorectal cancer screening guidelines were routinely followed, approximately 60% of colorectal cancer deaths could be prevented. Many colorectal cancer screening interventions have not used Facebook, which is the most popular social media site among women. Little is known about engaging women in colorectal cancer screening and risk reduction information using Facebook. The "Colorectal Cancer Screening Awareness for Women" Facebook page was created to promote colorectal cancer screening and risk reduction awareness among women. Facebook posts targeted women aged 45-64 years and highlighted colorectal cancer screening methods, guidelines, and colorectal cancer risk reduction strategies. Demographics and data about the women's interactions with the page were collected using Facebook analytics and analyzed. The majority of the 391 users of the Colorectal Cancer Screening Awareness for Women Facebook page were women aged 45-54 years (56.5%). The most "liked" posts were related to colorectal cancer risk reduction behaviors. In an effort to increase routine colorectal cancer screening and colorectal cancer risk reduction behaviors, gastroenterology nurses and practices should consider Facebook as a good method to regularly engage women in colorectal cancer screening and colorectal cancer risk reduction information.

Processes of Change for Colonoscopy: Limited Support for Use Among Navigated Latinos

This study assessed the role of the processes of change (POC), a construct of the transtheoretical model, in colorectal cancer (CRC) screening among Latinos. Latinos participate in CRC screening less often and are diagnosed with CRC at a later stage than whites. POC items were administered to 344 English- and Spanish-speaking Latinos at average risk for CRC who had not had a colonoscopy in the past 5 years and received a colonoscopy referral. POC were measured at three timepoints: following informed consent (T1) at time of referral, 2 weeks prior to scheduled colonoscopy (T2), and 1 month after scheduled colonoscopy (T3). Participants received patient navigation as part of a randomized controlled trial to promote screening colonoscopy. POC scores were examined for changes during the course of the intervention, and logistic regression models assessed the relationship between POC scores and CRC screening adherence. Total POC scores decreased between T1 and T2 (p = 0.03) but were unchanged between T1 and T3. CRC screening adherence was not significantly associated with POC scores or change in POC scores over time. The POC instrument was not found useful for predicting colonoscopy adherence among Latinos in conjunction with patient navigation. Total POC scores did not increase during a patient navigation intervention despite high colonoscopy completion rates.

Can a print-based intervention increase screening for first degree relatives of people with colorectal cancer? A randomised controlled trial

Objective: To test the effectiveness of a targeted print‐based intervention to improve screening adherence in first degree relatives of people with colorectal cancer (CRC).

Methods: People with CRC and their adult first degree relatives were identified through a population‐based cancer registry and randomly allocated as a family unit to the intervention or control condition. The control group received general information about CRC screening. The intervention group received printed advice regarding screening that was targeted to their risk level. Screening adherence was assessed at baseline and at 12 months via self report.

Results: 752 (25%) index cases and 574 (34%) eligible first degree relatives consented to take part in the trial and completed baseline interviews. At 12 months, 58% of first degree relatives in the control group and 61% in the intervention group were adherent to screening guidelines (mixed effects logistic regression group by time interaction effect =2.7; 95%CI=1.2–5.9; P=0.013). Subgroup analysis indicated that the intervention was only effective for those with the lowest risk.

Conclusions: Provision of personalised risk information may have a modest effect on adherence to CRC screening recommendations among first degree relatives of people diagnosed with CRC.

Implications: Improved strategies for identifying and engaging first degree relatives are needed to maximise the population impact of the intervention.

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

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

Sociocultural and health correlates related to colorectal cancer screening adherence among urban African Americans

BACKGROUND

Colorectal cancer (CRC) incidence and mortality are highest among African Americans. African Americans lag behind whites in CRC screening rates. Research has examined the role of CRC screening knowledge and beliefs and their relationship to CRC screening adherence. However, studies have not examined the effect cultural identity, social support, CRC beliefs, an informed decision, and having a chronic disease has on CRC screening among African Americans.

OBJECTIVES

This study examined CRC screening adherence among African Americans within the context of sociocultural variables, an informed decision, and health factors.

METHODS

A secondary data analysis was performed on survey data collected from 129 African American men and women.

RESULTS

Social support and family influence were related to having a colonoscopy. Having diabetes was negatively related to having a colonoscopy. There was no relationship between having a primary care provider and making an informed decision about CRC screening. Religiosity and having a primary care provider predicted colonoscopy.

CONCLUSIONS

The results indicate that certain sociocultural variables are related to colonoscopy. However, those same variables may not be related to or predictive of fecal occult blood test adherence. The diagnosis of diabetes may present a challenge to CRC screening adherence.

IMPLICATIONS FOR PRACTICE

The results of the study suggest that social support and family influence concerning CRC screening be assessed to provide additional support to colonoscopy adherence. The results also suggest that diabetic patients may require additional intervention to increase colonoscopy adherence rates.

Colonoscopy uptake for high-risk individuals with a family history of colorectal neoplasia: A multicenter, randomized trial of tailored counseling versus standard information

BACKGROUND

Colonoscopic screening is recommended for first-degree relatives of patients diagnosed with colorectal cancer (CRC) or colorectal adenomatous polyps (CAP) before the age of 60 years. This has the potential to reduce CRC-related morbidity and mortality, but uptake is currently inadequate.

METHODS

The aim of the study was to compare the effectiveness of standard information versus a nurse-led tailored intervention designed to promote uptake of colonoscopy screening by siblings of CRC or CAP patients. A randomized controlled trial was conducted. Digestive surgeons and gastroenterologists recruited index patients who developed CRC or CAP before the age of 60 years. All index patients received standard screening information for their siblings, in keeping with current guidelines. Centrally computerized randomization of index patients resulted in allocating all their siblings to the same group, intervention or control. The tailored intervention targeted the index patient first, to help them convey information to their siblings. The nurse then provided the siblings with tailored information based on their answers to a self-questionnaire which explored health behaviors, derived from psychosocial models of prevention. Then the siblings were given a personalized information leaflet to hand to their regular physician. The primary endpoint was the rate of documented colonoscopy performed in siblings within 1 year after diagnosis of the index patient. The intent-to-treat analysis included siblings who refused to participate in the study. Statistical analysis was adjusted for intrafamilial correlation.

RESULTS

A total of 304 siblings of 125 index patients were included: 160 in the intervention group and 144 in the control group. The rate of colonoscopy uptake among siblings was 56.3% in the intervention group and 35.4% in the control group (P = 0.0027). The respective rates after exclusion of refusals were 69.2% and 37.0% (P < 0.0001). More lesions were detected in the intervention group (1 invasive cancer and 11 advanced adenomas vs 5 advanced adenomas; P = 0.022).

CONCLUSIONS

This study demonstrates the effectiveness of a nurse-led tailored intervention designed to promote colonoscopy screening uptake by siblings of patients diagnosed with CRC or CAP before age 60 years. Such tailored interventions that also involve physicians should help to reduce CRC-related mortality.

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

BACKGROUND

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

IMPLICATIONS FOR PRACTICE

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

Predictors of stage of adoption for colorectal cancer screening among African American primary care patients

BACKGROUND

Compared with other racial groups, African Americans have the highest colorectal cancer (CRC) incidence and mortality rates coupled with lower screening rates.

OBJECTIVE

Our study examined the predictors of stage of adoption for fecal occult blood testing (FOBT) and colonoscopy among African American primary care patients who were nonadherent to published screening guidelines.

METHODS

Baseline data (N = 815) in a randomized clinical trial were analyzed. Participants were categorized into precontemplation, contemplation, and preparation stages for FOBT and colonoscopy. Predictor variables were demographics, clinical variables, CRC health beliefs and knowledge, and social support. Hierarchical modeling was to identify significant predictors of stage of adoption.

RESULTS

Older, male, Veterans Affairs participants and those with higher perceived self-efficacy, family/friend encouragement, and a provider recommendation had higher odds of being at a more advanced stage of adoption for FOBT. Patients with a history of cancer and higher perceived barriers had higher odds of being at an earlier stage of adoption for FOBT. Predictors of more advanced stage of adoption for colonoscopy included higher perceived benefits, higher perceived self-efficacy, family/friend encouragement, and a provider recommendation for colonoscopy. Higher income (>30 000 vs <15 000) was predictive of earlier stage of adoption for colonoscopy.

CONCLUSIONS

Enhancing self-efficacy, encouragement from family and friends, and provider recommendations are important components of interventions to promote CRC screening.

IMPLICATIONS FOR PRACTICE

Nurses can use knowledge of the characteristics associated with stage of adoption to educate and motivate their African American primary care patients to complete CRC screening tests.

Structuring Health in Colorectal Cancer Screening Conversations: An Analysis of Intersecting Activity Systems

This study used structurating activity theory to analyze 21 conversations between genetic counselors and individuals at increased risk for familial colorectal cancer (CRC). The qualitative analysis revealed ways elements of family, primary healthcare, cancer prevention and treatment, and other systems emerged in intervention conversations as shaping CRC screening attitudes and behaviors. Results indicate that family stories, norms, and roles are resources for enacting health practices in families and that the authority of healthcare providers is a resource for making screening decisions. Conclusions include practical implications for using findings in clinical applications as well as future research directions to build on this exploratory study.

Efficacy of a Telehealth Intervention on Colonoscopy Uptake When Cost Is a Barrier: The Family CARE Cluster Randomized Controlled Trial

BACKGROUND

We tested the efficacy of a remote tailored intervention Tele-Cancer Risk Assessment and Evaluation (TeleCARE) compared with a mailed educational brochure for improving colonoscopy uptake among at-risk relatives of colorectal cancer patients and examined subgroup differences based on participant reported cost barriers.

METHODS

Family members of colorectal cancer patients who were not up-to-date with colonoscopy were randomly assigned as family units to TeleCARE (N = 232) or an educational brochure (N = 249). At the 9-month follow-up, a cost resource letter listing resources for free or reduced-cost colonoscopy was mailed to participants who had reported cost barriers and remained nonadherent. Rates of medically verified colonoscopy at the 15-month follow-up were compared on the basis of group assignment and within group stratification by cost barriers.

RESULTS

In intent-to-treat analysis, 42.7% of participants in TeleCARE and 24.1% of participants in the educational brochure group had a medically verified colonoscopy [OR, 2.37; 95% confidence interval (CI) 1.59-3.52]. Cost was identified as a barrier in both groups (TeleCARE = 62.5%; educational brochure = 57.0%). When cost was not a barrier, the TeleCARE group was almost four times as likely as the comparison to have a colonoscopy (OR, 3.66; 95% CI, 1.85-7.24). The intervention was efficacious among those who reported cost barriers; the TeleCARE group was nearly twice as likely to have a colonoscopy (OR, 1.99; 95% CI, 1.12-3.52).

CONCLUSIONS

TeleCARE increased colonoscopy regardless of cost barriers.

IMPACT

Remote interventions may bolster screening colonoscopy regardless of cost barriers and be more efficacious when cost barriers are absent.

Randomized trial to increase colorectal cancer screening in an ethnically diverse sample of first-degree relatives

BACKGROUND

Ethnic minorities, especially African Americans and Latinos, bear a disproportionate burden of colorectal cancer (CRC), as reflected in incidence, cancer stage, and mortality statistics. In all ethnic groups, first-degree relatives (FDRs) of CRC cases are at an elevated disease risk. However, underuse of CRC screening persists and is particularly evident among minority groups. The current study tested a stepped intervention to increase CRC screening among an ethnically diverse sample of FDRs of CRC cases.

METHODS

A statewide cancer registry was used to recruit CRC cases and through them their FDRs. Relatives who were not current on CRC screening were randomized to intervention or usual-care control arms. The stepped intervention consisted of ethnically targeted and individually tailored print materials followed by telephone counseling for those unscreened at 6 months.

RESULTS

The study sample of 1280 individuals consisted of 403 Latino, 284 African American, 242 Asian, and 351 white FDRs. Statistically significant effects were observed for the cumulative print plus telephone intervention at 12 months (26% in the intervention vs 18% in the control group) and the print intervention alone at 6 months (15% in the intervention vs 10% in the control group). The effect of the print intervention alone versus the cumulative interventions was not statistically significantly different. Stratified analyses indicated that the intervention was effective among white, Latino, and Asian individuals, but not among African-Americans.

CONCLUSIONS

Overall, the intervention was effective in increasing screening rates. Oversampling racial/ethnic minorities allowed for the examination of effects within subgroups, revealing no effect among African American individuals. This finding illustrates the importance of including sufficient numbers of participants from diverse ethnic subgroups in intervention research to enable such stratified analyses.

Socio-psychological factors in the Expanded Health Belief Model and subsequent colorectal cancer screening

OBJECTIVE

CRC screening interventions tailored to the Expanded Health Belief Model (EHBM) socio-psychological factors have been developed, but the contributions of individual factors to screening outcomes are unclear.

METHODS

In observational analyses of data from a randomized intervention trial, we examined the independent associations of five EHBM factors - CRC screening knowledge, self-efficacy, stage of readiness, barriers, and discussion with a provider - with objectively measured CRC screening after one year.

RESULTS

When all five factors were added simultaneously to a base model including other patient and visit characteristics, three of the factors were associated with CRC screening: self-efficacy (OR=1.32, p=0.001), readiness (OR=2.72, p<0.001), and discussion of screening with a provider (OR=1.59, p=0.009). Knowledge and barriers were not independently associated with screening. Adding the five socio-psychological factors to the base model improved prediction of CRC screening (area under the curve) by 7.7%.

CONCLUSION

Patient CRC screening self-efficacy, readiness, and discussion with a provider each independently predicted subsequent screening.

PRACTICE IMPLICATIONS

Self-efficacy and readiness measures might be helpful in parsimoniously predicting which patients are most likely to engage in CRC screening. The importance of screening discussion with a provider suggests the potential value of augmenting patient-focused EHBM-tailored interventions with provider-focused elements.

From observation to intervention: development of a psychoeducational intervention to increase uptake of BRCA genetic counseling among high-risk breast cancer survivors

We describe the development of a psychoeducational intervention (PEI) to increase uptake of genetic counseling targeted to high-risk breast cancer survivors. Based on previous research, scientific literature, and a review of cancer education websites, we identified potential PEI content. We then assessed the initial acceptability and preference of two booklets of identical content but different layouts, by presenting the booklets to individuals with a personal or family history of breast cancer (n = 57). The preferred booklet was evaluated by two focus groups of ten breast cancer patients who had not attended genetic counseling. The booklet was refined based on participants' feedback at each stage. Focus group participants generally found the booklet visually appealing, informative, and helpful, but some thought that it was too long. Final changes were made based on learner verification principles of attraction, comprehension, cultural acceptability, and persuasion. This project produced an interventional tool to present key constructs that may facilitate decision making about risk-appropriate genetic counseling uptake among high-risk breast cancer survivors. The process described for creating, testing, and adapting materials from a patient perspective can be used for developing other PEIs. This newly developed, unique PEI can be used in many clinical settings.

Communication preference moderates the effect of a tailored intervention to increase colorectal cancer screening among African Americans

OBJECTIVE

Test the impact of tailoring CRC screening messages for African Americans (AAs) using novel theoretical variables and to examine moderating effect of communication preferences.

METHODS

Participants were randomized to receive two minimally tailored or two enhanced tailored print newsletters addressing CRC. The enhanced intervention was tailored on Self-Determination Theory and other novel psychological constructs. Minimal tailoring only used information available in the patient's EHR. The primary outcome was CRC screening based on EHR. Participants were AA members aged 50-74 of an integrated health care delivery system not up to date on CRC screening.

RESULTS

We enrolled 881 participants. CRC screening participation rates at 1-year follow up were 20.5% and 21.5% in the minimally and enhanced tailored groups, respectively. Communication preferences moderated the impact of the intervention. Specifically, among those with an autonomous communication preference, screening rates in the minimally and enhanced tailored groups were 17.1% and 25.9%, respectively, while no intervention effect was evident among those with a directive preference.

CONCLUSION

Future research is needed to explore the impact of communication preference tailoring for other health behaviors and among other populations.

PRACTICE IMPLICATIONS

Tailored communications should consider communication style preference to help guide the content and tone of messages.

Sociopsychological tailoring to address colorectal cancer screening disparities: a randomized controlled trial

PURPOSE

Interventions tailored to sociopsychological factors associated with health behaviors have promise for reducing colorectal cancer screening disparities, but limited research has assessed their impact in multiethnic populations. We examined whether an interactive multimedia computer program (IMCP) tailored to expanded health belief model sociopsychological factors could promote colorectal cancer screening in a multiethnic sample.

METHODS

We undertook a randomized controlled trial, comparing an IMCP tailored to colorectal cancer screening self-efficacy, knowledge, barriers, readiness, test preference, and experiences with a nontailored informational program, both delivered before office visits. The primary outcome was record-documented colorectal cancer screening during a 12-month follow-up period. Secondary outcomes included postvisit sociopsychological factor status and discussion, as well as clinician recommendation of screening during office visits. We enrolled 1,164 patients stratified by ethnicity and language (49.3% non-Hispanic, 27.2% Hispanic/English, 23.4% Hispanic/Spanish) from 26 offices around 5 centers (Sacramento, California; Rochester and the Bronx, New York; Denver, Colorado; and San Antonio, Texas).

RESULTS

Adjusting for ethnicity/language, study center, and the previsit value of the dependent variable, compared with control patients, the IMCP led to significantly greater colorectal cancer screening knowledge, self-efficacy, readiness, test preference specificity, discussion, and recommendation. During the followup period, 132 (23%) IMCP and 123 (22%) control patients received screening (adjusted difference = 0.5 percentage points, 95% CI -4.3 to 5.3). IMCP effects did not differ significantly by ethnicity/language.

CONCLUSIONS

Sociopsychological factor tailoring was no more effective than nontailored information in encouraging colorectal cancer screening in a multiethnic sample, despite enhancing sociopsychological factors and visit behaviors associated with screening. The utility of sociopsychological tailoring in addressing screening disparities remains uncertain.

A randomized trial to increase colonoscopy screening in members of high-risk families in the colorectal cancer family registry and cancer genetics network

BACKGROUND

Individuals with a strong family history of colorectal cancer have significant risk for colorectal cancer, although adherence to colonoscopy screening in these groups remains low. This study assessed whether a tailored telephone counseling intervention can increase adherence to colonoscopy in members of high-risk families in a randomized, controlled trial.

METHODS

Eligible participants were recruited from two national cancer registries if they had a first-degree relative with colorectal cancer under age 60 or multiple affected family members, which included families that met the Amsterdam criteria for hereditary non-polyposis colon cancer (HNPCC), and if they were due for colonoscopy within 24 months. Participants were randomized to receive a tailored telephone intervention grounded in behavioral theory or a mailed packet with general information about screening. Colonoscopy status was assessed through follow-up surveys and endoscopy reports. Cox proportional hazards models were used to assess intervention effect.

RESULTS

Of the 632 participants (ages 25-80), 60% were female, the majority were White, non-Hispanic, educated, and had health insurance. Colonoscopy adherence increased 11 percentage points in the tailored telephone intervention group, compared with no significant change in the mailed group. The telephone intervention was associated with a 32% increase in screening adherence compared with the mailed intervention (HR, 1.32; P = 0.01).

CONCLUSIONS

A tailored telephone intervention can effectively increase colonoscopy adherence in high-risk persons. This intervention has the potential for broad dissemination to healthcare organizations or other high-risk populations.

IMPACT

Increasing adherence to colonoscopy among persons with increased colorectal cancer risk could effectively reduce incidence and mortality from this disease.

Telehealth personalized cancer risk communication to motivate colonoscopy in relatives of patients with colorectal cancer: the family CARE Randomized controlled trial

PURPOSE

The rate of adherence to regular colonoscopy screening in individuals at increased familial risk of colorectal cancer (CRC) is suboptimal, especially among rural and other geographically underserved populations. Remote interventions may overcome geographic and system-level barriers. We compared the efficacy of a telehealth-based personalized risk assessment and communication intervention with a mailed educational brochure for improving colonoscopy screening among at-risk relatives of patients with CRC.

METHODS

Eligible individuals age 30 to 74 years who were not up-to-date with risk-appropriate screening and were not candidates for genetic testing were recruited after contacting patients with CRC or their next of kin in five states. Enrollees were randomly assigned as family units to either an active, personalized intervention that incorporated evidence-based risk communication and behavior change techniques, or a mailed educational brochure. The primary outcome was medically verified colonoscopy within 9 months of the intervention.

RESULTS

Of the 481 eligible and randomly assigned at-risk relatives, 79.8% completed the outcome assessments within 9 months; 35.4% of those in the personalized intervention group and 15.7% of those in the comparison group obtained a colonoscopy. In an intent-to-treat analysis, the telehealth group was almost three times as likely to get screened as the low-intensity comparison group (odds ratio, 2.83; 95% CI, 1.87 to 4.28; P < .001). Persons residing in rural areas and those with lower incomes benefitted at the same level as did urban residents.

CONCLUSION

Remote personalized interventions that consider family history and incorporate evidence-based risk communication and behavior change strategies may promote risk-appropriate screening in close relatives of patients with CRC.

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.

Comparing tailored and narrative worksite interventions at increasing colonoscopy adherence in adults 50-75: a randomized controlled trial

Research has identified several communication strategies that could increase adherence to colorectal cancer screening recommendations. Two promising strategies are tailoring and narrative-based approaches. Tailoring is the personalization of information based on individual characteristics. Narrative-based approaches use stories about similar others to counter perceived barriers and cultivate self-efficacy. To compare these two approaches, a randomized controlled trial was carried out at 8 worksites in Indiana. Adults 50-75 (N = 209) received one of four messages about colorectal cancer screening: stock, narrative, tailored, tailored narrative. The primary outcome was whether participants filed a colonoscopy claim in the 18 months following the intervention. Individuals receiving narrative messages were 4 times more likely to screen than those not receiving narrative messages. Tailoring did not increase screening behavior overall. However, individuals with higher cancer information overload were 8 times more likely to screen if they received tailored messages. The results suggest that narrative-based approaches are more effective than tailoring at increasing colorectal cancer screening in worksite interventions. Tailoring may be valuable as a strategy for reaching individuals with high overload, perhaps as a follow-up effort to a larger communication campaign.

A feces collection paper does not enhance participation in a fecal immunochemical test-based colorectal cancer screening program: randomized clinical trial

Discomfort with the collection of a stool sample is a frequently cited barrier for participation in fecal test-based colorectal cancer screening. The objective was to evaluate whether a feces collection paper enhances participation in a fecal immunochemical test (FIT)-based colorectal cancer screening program. Randomized clinical trial. Second round of a biannual Dutch FIT-based colorectal cancer screening program pilot. A random sample of 10 265 individuals from the general population, men and women aged 50-75 years at an average risk for colorectal cancer, was eligible for participation. Invitees were randomized to an FIT-only group (n=5136) or an FIT in combination with a feces collection paper group (n=5129). The main outcome measure was participation in screening. Overall, 5367 tests of 10 265 were returned (52%). In the FIT-only group, 2694 tests were returned [52%; 95% confidence interval (CI): 51-54%] versus 2673 tests in the collection paper group (52%; 95% CI: 51-54%). This difference in the participation rate was not significant (relative risk: 0.99; 95% CI: 0.97-1.04). A feces collection paper does not increase participation rates in FIT-based colorectal cancer screening. Future studies should explore other ways of facilitating participation in colorectal cancer screening programs.

Personalised risk communication for informed decision making about taking screening tests

BACKGROUND

There is a trend towards greater patient involvement in healthcare decisions. Although screening is usually perceived as good for the health of the population, there are risks associated with the tests involved. Achieving both adequate involvement of consumers and informed decision making are now seen as important goals for screening programmes. Personalised risk estimates have been shown to be effective methods of risk communication.

OBJECTIVES

To assess the effects of personalised risk communication on informed decision making by individuals taking screening tests. We also assess individual components that constitute informed decisions.

SEARCH METHODS

Two authors searched the Cochrane Central Register of Controlled Trials (CENTRAL, The Cochrane Library, Issue 3, 2012), MEDLINE (OvidSP), EMBASE (OvidSP), CINAHL (EbscoHOST) and PsycINFO (OvidSP) without language restrictions. We searched from 2006 to March 2012. The date ranges for the previous searches were from 1989 to December 2005 for PsycINFO and from 1985 to December 2005 for other databases. For the original version of this review, we also searched CancerLit  and Science Citation Index (March 2001). We also reviewed the reference lists and conducted citation searches of included studies and other systematic reviews in the field, to identify any studies missed during the initial search.

SELECTION CRITERIA

Randomised controlled trials incorporating an intervention with a 'personalised risk communication element' for individuals undergoing screening procedures, and reporting measures of informed decisions and also cognitive, affective, or behavioural outcomes addressing the decision by such individuals, of whether or not to undergo screening.

DATA COLLECTION AND ANALYSIS

Two authors independently assessed each included trial for risk of bias, and extracted data. We extracted data about the nature and setting of interventions, and relevant outcome data. We used standard statistical methods to combine data using RevMan version 5, including analysis according to different levels of detail of personalised risk communication, different conditions for screening, and studies based only on high-risk participants rather than people at 'average' risk. 

MAIN RESULTS

We included 41 studies involving 28,700 people. Nineteen new studies were identified in this update, adding to the 22 studies included in the previous two iterations of the review. Three studies measured informed decision with regard to the uptake of screening following personalised risk communication as a part of their intervention. All of these three studies were at low risk of bias and there was strong evidence that the interventions enhanced informed decision making, although with heterogeneous results. Overall 45.2% (592/1309) of participants who received personalised risk information made informed choices, compared to 20.2% (229/1135) of participants who received generic risk information. The overall odds ratios (ORs) for informed decision were 4.48 (95% confidence interval (CI) 3.62 to 5.53 for fixed effect) and 3.65 (95% CI 2.13 to 6.23 for random effects). Nine studies measured increase in knowledge, using different scales. All of these studies showed an increase in knowledge with personalised risk communication. In three studies the interventions showed a trend towards more accurate risk perception, but the evidence was of poor quality. Four out of six studies reported non-significant changes in anxiety following personalised risk communication to the participants. Overall there was a small non-significant decrease in the anxiety scores. Most studies (32/41) measured the uptake of screening tests following interventions. Our results (OR 1.15 (95% CI 1.02 to 1.29)) constitute low quality evidence, consistent with a small effect, that personalised risk communication in which a risk score was provided (6 studies) or the participants were given their categorised risk (6 studies), increases uptake of screening tests. 

AUTHORS' CONCLUSIONS

There is strong evidence from three trials that personalised risk estimates incorporated within communication interventions for screening programmes enhance informed choices. However the evidence for increasing the uptake of such screening tests with similar interventions is weak, and it is not clear if this increase is associated with informed choices. Studies included a diverse range of screening programmes. Therefore, data from this review do not allow us to draw conclusions about the best interventions to deliver personalised risk communication for enhancing informed decisions. The results are dominated by findings from the topic area of mammography and colorectal cancer. Caution is therefore required in generalising from these results, and particularly for clinical topics other than mammography and colorectal cancer screening.

Effects of tailored knowledge enhancement on colorectal cancer screening preference across ethnic and language groups

OBJECTIVE

Tailoring to psychological constructs (e.g. self-efficacy, readiness) motivates behavior change, but whether knowledge tailoring alone changes healthcare preferences--a precursor of behavior change in some studies--is unknown. We examined this issue in secondary analyses from a randomized controlled trial of a tailored colorectal cancer (CRC) screening intervention, stratified by ethnicity/language subgroups (Hispanic/Spanish, Hispanic/English, non-Hispanic/English).

METHODS

Logistic regressions compared effects of a CRC screening knowledge-tailored intervention versus a non-tailored control on preferences for specific test options (fecal occult blood or colonoscopy), in the entire sample (N=1164) and the three ethnicity/language subgroups.

RESULTS

Pre-intervention, preferences for specific tests did not differ significantly between study groups (experimental, 64.5%; control 62.6%). Post-intervention, more experimental participants (78.6%) than control participants (67.7%) preferred specific tests (P<0.001). Adjusting for pre-intervention preferences, more experimental group participants than control group participants preferred specific tests post-intervention [average marginal effect (AME)=9.5%, 95% CI 5.3-13.6; P<0.001]. AMEs were similar across ethnicity/language subgroups.

CONCLUSION

Knowledge tailoring increased preferences for specific CRC screening tests across ethnic and language groups.

PRACTICE IMPLICATIONS

If the observed preference changes are found to translate into behavior changes, then knowledge tailoring alone may enhance healthy behaviors.

Quality improvement in gastroenterology clinical practice

An emphasis on quality improvement (QI) is vital to the cost-effective provision of evidence-based health care. QI projects in gastroenterology have typically focused on endoscopy to minimize or eliminate procedure-related complications or errors. However, a significant component of gastroenterology care is based on the management of chronic disease. Patients with chronic diseases are seen in many different outpatient practices in the community and academia. In an attempt to ensure that every patient receives high-quality care, major gastrointestinal societies have published guidelines on the management of common gastrointestinal complaints. However, adherence to these guidelines varies. We discuss common outpatient gastrointestinal illnesses with established guidelines for management that could benefit from active QI projects; these would ensure a consistently high standard of care for every patient.

The lL-8 and IL-13 gene polymorphisms in inflammatory bowel disease and colorectal cancer

Inflammatory bowel diseases (IBD) and colorectal cancer (CRC) are disorders that originate from immune disturbances. In our study, we evaluated the association between the -251 T/A interleukin (IL)-8 and the -1112 C/T IL-13 polymorphisms, the risk of IBD, and CRC development. Genotypes were determined by PCR-restriction fragment length polymorphism in 191 patients with CRC, 150 subjects with IBD, and 205 healthy controls. We found an association between CRC and the presence of the -251 TA genotype and A allele of the IL-8 gene (odds ratios [ORs] 2.28 and 1.65). A similar relationship was observed between these polymorphic variants and ulcerative colitis (OR 2.05 for the -251 TA genotype and OR 1.47 for the -251 A allele) as well as Crohn's disease (ORs 3.11 and 1.56, respectively). Our research also revealed that the CT and TT genotypes of the IL-13 -1112 C/T polymorphism may be connected with a higher risk of CRC (ORs 2.28 and 1.65). The same genotypes affected the susceptibility of IBD (ORs 2.26 and 3.72). Our data showed that the IL-8 -251 T/A and IL-13 -1112 C/T polymorphisms might be associated with the IBD and CRC occurrence and might be used as predictive factors of these diseases in a Polish population.

Optimizing educational video through comparative trials in clinical environments

Although video is increasingly used in public health education, studies generally do not implement randomized trials of multiple video segments in clinical environments. Therefore, the specific configurations of educational videos that will have the greatest impact on outcome measures ranging from increased knowledge of important public health issues, to acceptance of a voluntary HIV test, remain largely unknown. Interventions can be developed to run on affordable handheld computers, including inexpensive tablets or netbooks that each patient can use individually, and to integrate video delivery with automated data collection. These video interventions can then be used not only to educate patients who otherwise might not be reached, but to examine how content can be optimized for greater effectiveness as measured by cognitive and behavioral outcomes. This approach may prove especially valuable in high volume urban facilities, such as hospital emergency departments, that provide points of contact for lower income, lower literacy, and high-risk populations who may not otherwise interact with healthcare providers or researchers. This article describes the development and evaluation of an intervention that educates emergency department patients about HIV prevention and testing while comparatively examining a set of videos, each based upon competing educational theories. The computer-based video intervention and methodology are both highly replicable and can be applied to subject areas and settings far beyond HIV or the emergency department.

Knowledge and practice of iranians toward colorectal cancer, and barriers to screening

BACKGROUND

Colorectal cancer (CRC) is the third most common malignancy in Iran. Limited data are available on knowledge and barriers in regard to CRC and screening tests in Iran. The aim of the study was to characterize knowledge, practice, and barriers toward CRC and its screening tests among an Iranian at-risk population.

METHODS

This cross-sectional study was conducted with participation of 200 individuals of both genders aged 50 years or older in a teaching hospital in Tehran, Iran. Data were collected via face-to-face interviews. A questionnaire containing demographics; knowledge about CRC and screening tests; screening practice; and reasons for not being screened was administered. The reliability alpha for knowledge items was 0.52.

RESULTS

The age of the participants ranged from 50 to 83 years (mean 60.13). Overall, 11% of the respondents reported prior screening by either fecal occult blood test (6.5%) or colonoscopy (4.5%). The majority of individuals had poor knowledge although respondents with prior screening obtained slightly higher score in comparison with nonparticipants in screening (26.74 vs. 23.24; P<0.05). Four commonly cited reasons for not having CRC tests were "doctor did not recommend the test," "did not think it was needed," "never think of the test," and "no symptoms/problems" which were reported by 29%, 26%, 20%, and 17% of the participants, respectively.

CONCLUSION

It is necessary to design appropriate educational interventions to increase the general population's knowledge about CRC and screening before implementing preventive programs in Iran.

Natural language processing improves identification of colorectal cancer testing in the electronic medical record

BACKGROUND

Difficulty identifying patients in need of colorectal cancer (CRC) screening contributes to low screening rates.

OBJECTIVE

To use Electronic Health Record (EHR) data to identify patients with prior CRC testing.

DESIGN

A clinical natural language processing (NLP) system was modified to identify 4 CRC tests (colonoscopy, flexible sigmoidoscopy, fecal occult blood testing, and double contrast barium enema) within electronic clinical documentation. Text phrases in clinical notes referencing CRC tests were interpreted by the system to determine whether testing was planned or completed and to estimate the date of completed tests.

SETTING

Large academic medical center.

PATIENTS

200 patients ≥ 50 years old who had completed ≥ 2 non-acute primary care visits within a 1-year period.

MEASURES

Recall and precision of the NLP system, billing records, and human chart review were compared to a reference standard of human review of all available information sources.

RESULTS

For identification of all CRC tests, recall and precision were as follows: NLP system (recall 93%, precision 94%), chart review (74%, 98%), and billing records review (44%, 83%). Recall and precision for identification of patients in need of screening were: NLP system (recall 95%, precision 88%), chart review (99%, 82%), and billing records (99%, 67%).

LIMITATIONS

Small sample size and requirement for a robust EHR.

CONCLUSIONS

Applying NLP to EHR records detected more CRC tests than either manual chart review or billing records review alone. NLP had better precision but marginally lower recall to identify patients who were due for CRC screening than billing record review.