Prospective evaluation of screening colonoscopy: who is being screened?

Correlates of Poor Self-Assessed Health Status among Socially Disadvantaged Populations in Poland

Self-assessment of health is recommended as valuable source of information about subjective health status. The present study was performed to evaluate the correlates of self-rated health status among beneficiaries of social care in Poland. This assessment could be crucial for the implementation of targeted preventive measures among this valuable population. The study population consisted of 1710 beneficiaries of social care from the Piotrkowski District. The relationship between self-rated health status and its correlates (sociodemographic, lifestyle factors, and health conditions) was examined using logistic regression, with a poor health rating as the outcome. Overall, 11% of respondents declared poor self-assessed health status. Men more often rated health status as poor (15%) as compared to women (8.5%) (p < 0.001). The odds of a poor assessment of health increased with age, being unemployed or disabled/retired (OR = 2.34 95%CI (1.34–4.19) or OR = 9.07 95%CI (3.68–22.37), respectively), and additionally with poor life satisfaction (OR = 5.14 95% CI (1.94–13.64)). Regarding lifestyle characteristics, only binge drinking was associated with poor health status assessment (OR = 12.62 95%CI (3.71–42.87)). In addition, having any illness or health problems decreased health status (OR = 4.26 95%CI (1.36–13.31)). Socially-disadvantaged populations, especially men who poorly rated their health status, still constituted a large percentage of the population, which is an important public health problem. Increasing knowledge about the correlates of health status will allow greater prevention strategies to be developed for the population.

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

INTRODUCTION

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Delivery of primary health care to persons who are socio-economically disadvantaged: does the organizational delivery model matter?

BACKGROUND

As health systems evolve, it is essential to evaluate their impact on the delivery of health services to socially disadvantaged populations. We evaluated the delivery of primary health services for different socio-economic groups and assessed the performance of different organizational models in terms of equality of health care delivery in Ontario, Canada.

METHODS

Cross sectional study of 5,361 patients receiving care from primary care practices using Capitation, Salaried or Fee-For-Service remuneration models. We assessed self-reported health status of patients, visit duration, number of visits per year, quality of health service delivery, and quality of health promotion. We used multi-level regressions to study service delivery across socio-economic groups and within each delivery model. Identified disparities were further analysed using a t-test to determine the impact of service delivery model on equity.

RESULTS

Low income individuals were more likely to be women, unemployed, recent immigrants, and in poorer health. These individuals were overrepresented in the Salaried model, reported more visits/year across all models, and tended to report longer visits in the Salaried model. Measures of primary care services generally did not differ significantly between low and higher income/education individuals; when they did, the difference favoured better service delivery for at-risk groups. At-risk patients in the Salaried model were somewhat more likely to report health promotion activities than patients from Capitation and Fee-For-Service models. At-risk patients from Capitation models reported a smaller increase in the number of additional clinic visits/year than Fee-For-Service and Salaried models. At-risk patients reported better first contact accessibility than their non-at-risk counterparts in the Fee-For-Service model only.

CONCLUSIONS

Primary care service measures did not differ significantly across socio-economic status or primary care delivery models. In Ontario, capitation-based remuneration is age and sex adjusted only. Patients of low socio-economic status had fewer additional visits compared to those with high socio-economic status under the Capitation model. This raises the concern that Capitation may not support the provision of additional care for more vulnerable groups. Regions undertaking primary care model reforms need to consider the potential impact of the changes on the more vulnerable populations.

Epidemiological study of colorectal adenoma and cancer in symptomatic patients in China between 1990 and 2009

OBJECTIVE

The best cure for colorectal cancer (CRC) lies on its early diagnosis and treatment. We aimed to provide the epidemiological features of advanced colorectal adenoma (A-CRA) and CRC in symptomatic patients and to determine whether the incidences of A-CRA and CRC increased simultaneously in China between 1990 and 2009.

METHODS

A total of 157,943 patients who had undergone a colonoscopy from 1990 to 2009 were enrolled, of which 6,777 patients had A-CRA and 3,503 had CRC. They were compared with controls in a stratified analysis. The detection rates of A-CRA and CRC in the 1990s and 2000s were also compared.

RESULTS

The detection rate of A-CRA increased 1.88-fold over the two decades, while that of CRC increased 0.66-fold. The percentages of patients with A-CRA and CRC who were elder than 50 years were significantly higher in the 2000s than those in the 1990s (P = 0.000). The changes of location of A-CRA and CRC during the two decades indicated a shift of lesions from the distal colon to proximal colon.

CONCLUSION

There was a significant increase in detection rate of A-CRA in the 2000s, but CRC did not increase at a similar speed. Our results indicated that the early detection and removal of colorectal adenoma in symptomatic patients might decrease the incidence of CRC.

Associations of physician supplies with colon cancer care in Ontario and California, 1996 to 2006

BACKGROUND

This study examined the differential effects of physician supplies on colon cancer care in Ontario and California. The associations of physician supplies with colon cancer stage at diagnosis, receipt of surgery and adjuvant chemotherapy, and 5-year survival were observed within each country and compared between-country.

METHODS

Random samples of Ontario and California cancer registries provided 2,461 and 2,200 colon cancer cases that were diagnosed between 1996 and 2000, and followed until 2006. Both registries included data on the stage of disease at the time of diagnosis, receipt of cancer-directed surgery, receipt of adjuvant chemotherapy, and survival. Census tract-level data on low-income prevalence were, respectively, taken from 2001 and 2000 Canadian and United States population censuses. County-level primary care physician and gastroenterologist densities were computed for the same years.

RESULTS

Significant income-adjusted, gastroenterologist density threshold effects (2.0 or more vs. less than 2.0 per 100,000 inhabitants) were observed for early diagnosis (OR = 1.57) and 5-year survival (OR = 1.63) in Ontario, but not in California. Significant incremental threshold effects of primary care physician densities on chemotherapy receipt (8.0 and 9.0 or more per 10,000 inhabitants, respective ORs of 1.79 and 2.37) were also only observed in Ontario.

CONCLUSIONS

These colon cancer care findings support the theory that while personal economic resources are more predictive in America, community-level resources such as physician supplies are more predictive of health care access and effectiveness in Canada.

Effects of socioeconomic status on colon cancer treatment accessibility and survival in Toronto, Ontario, and San Francisco, California, 1996-2006

OBJECTIVES

We examined the differential effects of socioeconomic status on colon cancer care and survival in Toronto, Ontario, Canada, and San Francisco, California.

METHODS

We analyzed registry data for colon cancer patients from Ontario (n = 930) and California (n = 1014), diagnosed between 1996 and 2000 and followed until 2006, on stage, surgery, adjuvant chemotherapy, and survival. We obtained socioeconomic data for individuals' residences from population censuses.

RESULTS

Income was directly associated with lymph node evaluation, chemotherapy, and survival in San Francisco but not in Toronto. High-income persons had better survival rates in San Francisco than in Toronto. After adjustment for stage, survival was better for low-income residents of Toronto than for those of San Francisco. Middle- to low-income patients were more likely to receive indicated chemotherapy in Toronto than in San Francisco.

CONCLUSIONS

Socioeconomic factors appear to mediate colon cancer care in urban areas of the United States but not in Canada. Improvements are needed in screening, diagnostic investigations, and treatment access among low-income Americans.

Colorectal cancer screening practices among obstetrician/gynecologists and nurse practitioners

OBJECTIVE

Obstetrician/gynecologists (Ob/Gyn) and nurse practitioners (NP) are essential providers of primary and preventive care for their female patients. Therefore, colorectal cancer (CRC) screening should be part of their routine preventive practices. The purpose of our study is to evaluate the CRC screening practices of these providers.

METHODS

A self-administered survey was mailed to a national sample of 1130 Ob/Gyns and NPs to assess providers' demographics, current CRC screening practices, and familiarity with CRC guidelines.

RESULTS

Three hundred thirty-six providers (29.7%) returned our survey (54% Ob/Gyns and 46% NPs). Three fourths of providers routinely performed screening for CRC, compared with 95% for breast and cervical cancer. Routine CRC screening was more common among Ob/Gyns (87.2%) than NPs (61.7%) (p < 0.001). Slightly over half of providers correctly identified the recommended age to begin CRC screening for the average-risk patient, with no significant difference between provider types. Overall, Ob/Gyns scored higher than NPs on a series of questions assessing CRC screening (p < 0.03). Several provider factors were found to be significantly associated with screening practices, including practicing >10 years (p < 0.01), practicing in a multispecialty group (2.62 times more likely), and having an older patient population (p < 0.001).

CONCLUSIONS

Ob/Gyns and NPs underuse CRC screening compared with breast and cervical cancer screening and lack knowledge about appropriate use of CRC screening modalities. Opportunities to further educate Ob/Gyns and NPs should be sought to improve compliance with current CRC screening guidelines.

Attitude of the Italian general population towards prevention and screening of the most common tumors, with special emphasis on colorectal malignancies

Screening and early diagnosis of cancer represent relatively recent tools in the long-lasting battle against tumors. If the American public opinion manifests its enthusiasm towards screening, the attitude of European is less well known. The purpose of the present study was to assess the level of knowledge and awareness of cancer screening (with particular emphasis on colorectal neoplasms) among middle-aged individuals. The study group consisted of 945 healthy individuals (489 men, 456 women, average age 57 +/- 12.4 years) who were asked to answer a series of questions about cancer screening and surveillance through a questionnaire presented by trained residents. Each interview lasted 20-30 min. Middle-aged Italians of both sexes seem to be aware of the fact that cancer is a frequent disease; moreover, many of the interviewed subjects believe almost all neoplasms are incurable. Diet, style of life, other environmental factors and familial factors are fully appreciated as relevant risk factors. The exact meaning of prevention was clear to less than half of the subjects. When various cancer sites were analyzed, the existence of preventive measures was well known for breast, cervical and prostate tumors, but their role was less clear for colorectal cancer. Only a fraction of the interviewed individuals were willing to undergo screening; the main reasons for refusal were lack of usefulness and fear of results. Among various tests, ultrasound and endoscopy were usually carried out in the presence of symptoms. Finally, multivariate analysis showed that the two factors significantly associated with the decision to undergo screening procedures were increasing age and level of education. The results of the study suggest that middle-aged Italian individuals, predominantly from Northern regions, have a correct perception of some aspects (frequency, risk factors) of cancer biology, whereas the knowledge of other aspects (outcome, prevention) remains poor or approximate. It follows that one of the main objectives of the Political Class should be to obtain a better education of overage individuals about cancer and the many problems related to this common disease.

Pharmacoepigenomics in colorectal cancer: a step forward in predicting prognosis and treatment response

Despite therapeutic innovations and increasing education on lifestyle to prevent colorectal cancer, it is still one of the most common cancer types, and for men the second cause of cancer-related death. Lately, much attention has been given to identify molecular markers involved in colorectal cancer prognosis and treatment with the aim to develop a more accurate classification system based on (epi)genetic alterations and, in addition, find markers that could potentially enhance management of colorectal cancer by predicting treatment response in advance. Although many genetic markers have been claimed to have prognostic or predictive influence, results are often inconclusive and, with some exception, they are not used in standard practice. Epigenetic alterations have received less attention although they are probably even more interesting as they can potentially be reversed through drug treatment. This review describes the current knowledge on the prognostic and predictive value of epigenetic markers in colorectal cancer.

The impact of socioeconomic status on perceived barriers to colorectal cancer testing

PURPOSE

Colorectal cancer (CRC) screening is effective, but only one-half of age-eligible adults adhere to national guidelines. Lower socioeconomic status (SES) groups are less likely to be screened.

METHODS

Baseline data from a prospective study were, used to examine the associations among CRC screening screening barriers, and SES. A convenience sample of adults (N = 291) aged 40 years and older was recruited from a federally qualified health center. Questionnaires were administered orally and included demographics, health, health behavior, and screening barriers.

RESULTS

In logistic regression, having health insurance was associated with greater odds of screening Bivariate analyses detected few differences in fecal occult blood test (FOBT) barriers, but several endoscopy barriers were more common among the lowest SES groups. For example, fear of injury from endoscopy was more likely among low-income and uninsured participants.

DISCUSSION

The impact of SES on cancer screening is complex, but low-SES participants more often reported certain barriers than their higher-SES counterparts. This was more evident for endoscopy than for FOBT. Programs targeted at low-SES patients may need to focus on barriers that are not fully addressed in traditional promotion efforts.

Regional differences in colorectal cancer incidence, stage, and subsite among American Indians and Alaska Natives, 1999-2004

BACKGROUND

Colorectal cancer (CRC) is a leading cause of cancer morbidity and mortality for American Indians and Alaska Natives (AI/ANs), but misclassification of race causes underestimates of disease burden.

METHODS

The authors compared regional differences in CRC incidence, stage at diagnosis, and anatomic distribution between AI/ANs and non-Hispanic whites (NHWs). To reduce misclassification, data from the National Program of Cancer Registries; the Surveillance, Epidemiology, and End Results Program; and the Indian Health Service (IHS) were linked. The analysis was limited to the 56% of AI/AN who live in IHS Contract Health Service Delivery Areas.

RESULTS

From 1999 to 2004, the overall incidence rate (per 100,000 persons per year) of CRC was 9% lower in the AI/AN population (46.3) than in the NHW population (50.8). However, AI/AN CRC incidence rates varied nearly 5-fold regionally, from 21 in the Southwest to 102.6 in Alaska. Compared with NHW rates, AI/AN rates were significantly higher in Alaska (rate ratio [RR], 2.03), the Northern Plains (RR, 1.39), and the Southern Plains (RR, 1.16) but were lower in the Pacific Coast (RR, 0.80), the East (RR, 0.65), and the Southwest (RR, 0.45). AI/ANs were diagnosed more often with advanced CRC than with localized CRC (RR, 1.92) compared with NHWs (RR, 1.48). Females more often had proximal CRC among both the AI/AN population (females, 40.1%; males, 33.5%) and the NHW population (females, 50.1%; males, 40.3%), although AI/ANs had a higher proportion of distal cancers overall.

CONCLUSIONS

CRC incidence rates in AI/AN populations varied dramatically between regions. Efforts are needed to make CRC screening a priority, overcome barriers to endoscopic screening, and to engage AI/AN communities in culturally appropriate ways to participate in prevention and early detection programs.

Association of demographic and treatment variables in long-term colon cancer survival

The purpose of this study is to examine demographic and treatment variables because they relate to 5-year survival in colon cancer. The study design is analysis of 174 471 patients with colon and rectosigmoid cancer as reported to the American College of Surgeons National Cancer Data Base. Factors associated with a reduced risk of mortality included female gender (hazard ratio = 0.89; 95% confidence interval, 0.87-0.90), education status (hazard ratio = 0.87; 95% confidence interval, 0.85-0.89), increased number of lymph nodes resected (compared with <8, 8-12: hazard ratio = 0.90; 95% confidence interval, 0.89-0.92; >12: hazard ratio = 0.79; 95% confidence interval, 0.77-0.80), and addition of chemotherapy (hazard ratio = 0.69; 95% CI, 0.68-0.71). African American race (hazard ratio = 1.14; 95% confidence interval, 1.11-1.18) and increasing age correlated with an increased hazard risk (61-75 years: hazard ratio = 1.26; 95% confidence interval, 1.23-1.29; >or=76 years: hazard ratio = 2.15; 95% confidence interval, 2.09-2.21, compared with age <60 years). Survival in colon cancer is significantly impacted by patient's age, race, gender, and education status but not by income or area of residence.

Colorectal cancer care knowledge mapping: identifying priorities for knowledge translation research

OBJECTIVE

We do not know the extent and nature of knowledge translation (KT) in oncology. This study examined colorectal cancer (CRC) health services research, and engaged researchers and decision makers in prioritizing KT research gaps.

METHODS

MEDLINE was searched from 1996 to 2006 for CRC health services research in Canada, Australia, the United Kingdom, and United States. Studies were tabulated by indicator, type of research and country to reveal gaps. Researchers and decision makers prioritized gaps via questionnaire, then generated research questions for top-ranked gaps at a one-day workshop.

RESULTS

A total of 132 articles were categorized and 29 individuals attended the workshop. We lack knowledge about factors influencing rates of many indicators. Researchers and decision makers prioritized KT research on factors that could either influence the utilization of screening or enhance the quality of surgical outcomes. They acknowledged lack of research capacity and policy support as barriers, and confusion about the concept of KT.

CONCLUSIONS

Several opportunities were revealed for improving the quality of CRC screening and surgery. Greater coordination of, and support for KT research is required to address these gaps. Further research should evaluate different methods of achieving KT between researchers and decision makers for research planning.

Screening for colorectal cancer in average-risk Chinese population using a mixed strategy with sigmoidoscopy and colonoscopy

PURPOSE

The Chinese population has been shown to have more distal colonic neoplasm and a higher sensitivity of sigmoidoscopic screening strategy for detecting advanced neoplasm compared with Western populations. This study was designed to evaluate the efficacy of the mixed screening strategy with sigmoidoscopy and colonoscopy in the average-risk Chinese population.

METHODS

Consecutive average-risk adults aged >/=50 years who underwent colonoscopy as part of a health checkup were enrolled. Data were analyzed in a hypothetical graded screening strategy using colonoscopy on patients older than a certain cutoff age or those with distal sentinel polyps. The sensitivity in detecting advanced colonic neoplasm and advanced proximal neoplasm as well as the number of colonoscopies reduced were assessed.

RESULTS

Of the 2,106 persons eligible for analysis, 1,193 (56.6 percent) were males and 913 (43.4 percent) were females. If the cutoff ages were 55, 60, and 65 years, and adenoma detected in the distal colon was the indication for subsequent colonoscopy, the detection rate for 1) advanced colonic neoplasm in the entire colon would be 94, 93.1, and 83.6 percent, respectively, and 2) advanced proximal neoplasm would be 84.8, 82.6, and 58.7 percent, respectively. The number of colonoscopic procedures could be reduced by 28, 48, and 65 percent if the cutoff ages were 55, 60, and 65 years, respectively.

CONCLUSIONS

The mixed screening strategy using a cutoff age at 60 years and distal adenoma as the sentinel lesion is an effective screening program in the average-risk Chinese population.

Variations in reconstruction after radical cystectomy

BACKGROUND

Most urologists specializing in the management of patients with bladder cancer consider continent urinary diversion the reconstructive technique that affords the best quality of life after radical cystectomy. The authors sought to evaluate factors that predict reconstructive technique after radical cystectomy.

METHODS

Using linked data from Medicare and the National Cancer Institute's (NCI) Surveillance, Epidemiology, and End Results (SEER) program, 3611 subjects were identified who underwent radical cystectomy for bladder cancer between 1992 and 2000. Multivariate logistic regression was used to identify factors independently associated with utilization of continent reconstruction after radical cystectomy, incorporating patient and provider variables.

RESULTS

In multivariate analysis, the likelihood of continent diversion was inversely associated with older age (odds ratio [OR] < or = 0.68, P <.002), African American race (OR 0.43, P = .003), and higher comorbidity index (OR 0.71, P = .03), and directly associated with male sex (OR 1.45, P = .002), higher education level (OR 1.54, P = .03), and year of surgery (OR > or = 1.56, P < .001 for all year categories vs. 1992-1994). Treatment at academic (OR 1.43, P = .003) and NCI-designated cancer centers (OR 5.50, P <.001) and by high-volume providers (OR 1.49, P <.001) was independently associated with continent reconstruction.

CONCLUSIONS

Disparities in the utilization of continent urinary diversion after radical cystectomy suggest that demographic, socioeconomic, provider-based, and clinical variables predict the likelihood that those undergoing radical cystectomy will receive continent reconstruction. Regionalization of bladder cancer care may ameliorate many of the disparities noted but must be balanced against the risk imposed by a delay in care.