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Smith DH, O'Keeffe Rosetti M, Mosen DM, Rosales AG, Keast E, Perrin N, Feldstein AC, Levin TR, Liles EG. Balancing Adherence and Expense: The Cost-Effectiveness of Two-Sample vs One-Sample Fecal Immunochemical Test. Popul Health Manag 2018; 22:83-89. [PMID: 29927702 DOI: 10.1089/pop.2018.0008] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Colorectal cancer (CRC) causes more than 50,000 deaths each year in the United States but early detection through screening yields survival gains; those diagnosed with early stage disease have a 5-year survival greater than 90%, compared to 12% for those diagnosed with late stage disease. Using data from a large integrated health system, this study evaluates the cost-effectiveness of fecal immunochemical testing (FIT), a common CRC screening tool. A probabilistic decision-analytic model was used to examine the costs and outcomes of positive test results from a 1-FIT regimen compared with a 2-FIT regimen. The authors compared 5 diagnostic cutoffs of hemoglobin concentration for each test (for a total of 10 screening options). The principal outcome from the analysis was the cost per additional advanced neoplasia (AN) detected. The authors also estimated the number of cancers detected and life-years gained from detecting AN. The following costs were included: program management of the screening program, patient identification, FIT kits and their processing, and diagnostic colonoscopy following a positive FIT. Per-person costs ranged from $33 (1-FIT at 150ng/ml) to $92 (2-FIT at 50ng/ml) across screening options. Depending on willingness to pay, the 1-FIT 50 ng/ml and the 2-FIT 50 ng/ml are the dominant strategies with cost-effectiveness of $11,198 and $28,389, respectively, for an additional AN detected. The estimates of cancers avoided per 1000 screens ranged from 1.46 to 4.86, depending on the strategy and the assumptions of AN to cancer progression.
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Affiliation(s)
- David H Smith
- 1 Center for Health Research , Kaiser Permanente Northwest, Portland, Oregon
| | | | - David M Mosen
- 1 Center for Health Research , Kaiser Permanente Northwest, Portland, Oregon
| | - A Gabriela Rosales
- 1 Center for Health Research , Kaiser Permanente Northwest, Portland, Oregon
| | - Erin Keast
- 1 Center for Health Research , Kaiser Permanente Northwest, Portland, Oregon
| | - Nancy Perrin
- 1 Center for Health Research , Kaiser Permanente Northwest, Portland, Oregon
| | - Adrianne C Feldstein
- 1 Center for Health Research , Kaiser Permanente Northwest, Portland, Oregon.,2 Northwest Permanente, Kaiser Permanente Northwest , Portland, Oregon
| | | | - Elizabeth G Liles
- 1 Center for Health Research , Kaiser Permanente Northwest, Portland, Oregon.,2 Northwest Permanente, Kaiser Permanente Northwest , Portland, Oregon
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Performance of a quantitative fecal immunochemical test for detecting advanced colorectal neoplasia: a prospective cohort study. BMC Cancer 2018; 18:509. [PMID: 29720130 PMCID: PMC5932873 DOI: 10.1186/s12885-018-4402-x] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2017] [Accepted: 04/18/2018] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND The fecal immunochemical test (FIT) is easier to use and more sensitive than the guaiac fecal occult blood test, but it is unclear how to optimize FIT performance. We compared the sensitivity and specificity for detecting advanced colorectal neoplasia between single-sample (1-FIT) and two-sample (2-FIT) FIT protocols at a range of hemoglobin concentration cutoffs for a positive test. METHODS We recruited 2,761 average-risk men and women ages 49-75 referred for colonoscopy within a large nonprofit, group-model health maintenance organization (HMO), and asked them to complete two separate single-sample FITs. We generated receiver-operating characteristic (ROC) curves to compare sensitivity and specificity estimates for 1-FIT and 2-FIT protocols among those who completed both FIT kits and colonoscopy. We similarly compared sensitivity and specificity between hemoglobin concentration cutoffs for a single-sample FIT. RESULTS Differences in sensitivity and specificity between the 1-FIT and 2-FIT protocols were not statistically significant at any of the pre-specified hemoglobin concentration cutoffs (10, 15, 20, 25, and 30 μg/g). There was a significant difference in test performance of the one-sample FIT between 50 ng/ml (10 μg/g) and each of the higher pre-specified cutoffs. Disease prevalence was low. CONCLUSIONS A two-sample FIT is not superior to a one-sample FIT in detection of advanced adenomas; the one-sample FIT at a hemoglobin concentration cutoff of 50 ng/ml (10 μg/g) is significantly more sensitive for advanced adenomas than at higher cutoffs. These findings apply to a population of younger, average-risk patients in a U.S. integrated care system with high rates of prior screening.
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Davis TC, Morris J, Rademaker A, Ferguson LA, Arnold CL. Barriers and Facilitators to Colorectal Cancer Screening Among Rural Women in Community Clinics by Heath Literacy. JOURNAL OF WOMEN'S HEALTH, ISSUES & CARE 2017; 6:1000292. [PMID: 29568788 PMCID: PMC5858715 DOI: 10.4172/2325-9795.1000292] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
BACKGROUND Rural women lag rural men and urban women in colon cancer (CRC) screening completion. OBJECTIVE To identify rural female patients' knowledge, beliefs barriers, self-efficacy, prior recommendation and completion of CRC screening using an FOBT and to compare these factors by health literacy (HL) level. METHODS This descriptive study was conducted between 2015 and 2016 in 4 rural community clinics in south Louisiana. Patients overdue for screening were given a structured interview by a research assistant. RESULTS 339 women were enrolled, mean age 58.5, 32% had limited HL, 66% were African American. Most (91.7%) had heard of CRC, yet only 71% knew of any CRC screening tests. Women with adequate HL had greater knowledge of specific tests than those with limited HL (78.4% vs 56.6%, p<0.001). Only 25.7% had been given information on CRC testing; those with adequate HL were more likely to have received information (30.1% vs 16.8%; p=0.017). Most women (93.2%) indicated they would want to know if they had CRC, while 72.2% reported a provider had recommended CRC screening. Only 24.9% said a healthcare provider had ever given them an FOBT or that they had ever completed an FOBT (22.7%). There were no differences in women's report of recommendation or completion by HL level.Self-efficacy for completing an FOBT was high; over 90% indicated they could get an FOBT, complete it and mail results to the lab. Level of confidence did not vary by literacy. Three of the four barrier items varied by HL with women with low HL being more likely to fear doing an FOBT because they thought FOBT instructions would be confusing (p=0.002), doing the test would be embarrassing (p=0.025) or messy (p=0.057). CONCLUSIONS Rural women are receptive to CRC screening and view FOBTs as effective. Rural community clinics need to provide low cost FOBTs with literacy, gender and culturally appropriate information.
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Affiliation(s)
- Terry C. Davis
- Department of Medicine, Louisiana State University Health Sciences Center, Shreveport, LA
| | - James Morris
- Department of Medicine, Louisiana State University Health Sciences Center, Shreveport, LA
| | - Alfred Rademaker
- Department of Preventive Medicine and the Robert H. Lurie Comprehensive Cancer Center, Northwestern University, Chicago, IL
| | | | - Connie L. Arnold
- Department of Medicine, Louisiana State University Health Sciences Center, Shreveport, LA
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Chen CH, Wen CP, Tsai MK. Fecal immunochemical test for colorectal cancer from a prospective cohort with 513,283 individuals: Providing detailed number needed to scope (NNS) before colonoscopy. Medicine (Baltimore) 2016; 95:e4414. [PMID: 27603337 PMCID: PMC5023859 DOI: 10.1097/md.0000000000004414] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/29/2023] Open
Abstract
The fecal immunochemical test (FIT) is underutilized, in part, because its benefits have not been fully understood. We assessed the relationship of FIT values with cancer incidence and mortality, and explored how repeated administrations of FIT could aid clinicians. A cohort with 513,283 adults in Taiwan participated in a screening program between 1994 and the end of 2007. Colorectal cancer was identified from National Cancer Registry and not from colonoscopy. Positive FIT was FIT ≥ 100 ng/mL. Number needed to scope (NNS) to identify 1 cancer by different FIT values was calculated for the study time. Only 4% of subjects had FIT ≥ 100 ng/mL but contributed 40% of cancer cases, leading to a NNS of 25 for finding 1 in this group. However, within the same FIT ≥ 100 ng/mL, NNS was different by age: 10 for age 60 to 69 years, 42 for age 40 to 49 years, and 156 for age 20 to 39 years. Furthermore, within the same age, NNS was different by FIT values, for instance, 66 for FIT 100 to 199 ng/mL and 12 for FIT 600 to 799 ng/mL, a difference of 5-fold for age 50 to 59 years. The dose-response relationship of FIT can facilitate consultation regarding the need for colonoscopy by providing a quantitative NNS for cancer risk, an index easily understood by patients. Our conclusion made use of (a) age-dependent and (b) quantitative interpretation of FIT values. This single cutpoint practice obliterates a large amount of valuable cancer risk information available to patients.
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Affiliation(s)
- Chien Hua Chen
- Digestive Disease Center, Show-Chwan Memorial Hospital, Changhua
- Chung Chou University of Science and Technology, Changhua
- Hungkuang University, Taichung
| | - Chi Pang Wen
- Institute of Population Health Sciences, National Health Research Institutes, Zhunan
- China Medical University, Taichung, Taiwan
- Correspondence: Chi Pang Wen, China Medical University Hospital, 91 Hsueh-Shih Road Taichung 40402, Taiwan and Institute of Population Health Sciences, National Health Research Institutes, 35 Keyan Road, Zhunan Town, Miaoli County 35053, Taiwan (e-mail: )
| | - Min Kuang Tsai
- Institute of Population Health Sciences, National Health Research Institutes, Zhunan
- China Medical University, Taichung, Taiwan
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Jones JJ, Wilcox BE, Benz RW, Babbar N, Boragine G, Burrell T, Christie EB, Croner LJ, Cun P, Dillon R, Kairs SN, Kao A, Preston R, Schreckengaust SR, Skor H, Smith WF, You J, Hillis WD, Agus DB, Blume JE. A Plasma-Based Protein Marker Panel for Colorectal Cancer Detection Identified by Multiplex Targeted Mass Spectrometry. Clin Colorectal Cancer 2016; 15:186-194.e13. [PMID: 27237338 PMCID: PMC8961700 DOI: 10.1016/j.clcc.2016.02.004] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2015] [Accepted: 02/03/2016] [Indexed: 02/06/2023]
Abstract
Combining potential diagnostics markers might be necessary to achieve sufficient diagnostic test performance in a complex state such as cancer. Applying this philosophy, we have identified a 13-protein, blood-based classifier for the detection of colorectal cancer. Using mass spectrometry, we evaluated 187 proteins in a case-control study design with 274 samples and achieved a validation of 0.91 receiver operating characteristic area under the curve.
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Affiliation(s)
| | | | | | | | | | | | | | | | - Phong Cun
- Applied Proteomics, Inc., San Diego, CA
| | | | | | - Athit Kao
- Applied Proteomics, Inc., San Diego, CA
| | | | | | | | | | - Jia You
- Applied Proteomics, Inc., San Diego, CA
| | | | - David B Agus
- USC Norris Westside Cancer Center and USC Center for Applied Molecular Medicine, Beverly Hills, CA
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Daly JM, Bay CP, Xu Y, Levy BT. Effect of Ambient Temperature Variations on Positivity of Manual Fecal Immunochemical Tests. J Prim Care Community Health 2015; 6:243-9. [PMID: 26022208 DOI: 10.1177/2150131915588738] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
INTRODUCTION In the United States, many fecal occult blood tests are mailed by patients to a laboratory for analysis. Hemoglobin is not stable in feces and can be affected by the heat. Effects of season and ambient temperature on fecal immunochemical tests (FITs) have demonstrated a decrease in positivity rates during the hottest season. OBJECTIVE To investigate the potential effect of the average of 4-day ambient maximum temperature variations on the positivity of a single sample, one-time Clinical Laboratory Improvement Amendments (CLIA)-waived FIT. SETTING Midwestern tertiary care hospital. METHODS Individuals scheduled for a colonoscopy were invited to complete a qualitative FIT prior to their colonoscopy in 2010 and 2011. FITs were read as positive or negative. RESULTS Valid FITs were received from 1026 individuals over 25 months. The positivity rate was 10.9%. The mean 4-day average of daily maximum ambient temperatures was calculated including the day of receipt for each sample. Fahrenheit temperatures ranged from 16.0 to 96.8. Based on the odds ratio of 1.04 with a confidence interval of 0.94 to 1.14 for a 10°F increase in temperature, there was no statistically significant evidence of an effect of the preceding maximum average 4-day ambient temperature on FIT positivity. CONCLUSION No evidence was found that ambient temperature had an effect on positivity rate over a 25-month period using 4 different qualitative FIT products. Further analysis on effect of ambient temperatures is warranted for the automated FITs and CLIA-waived FITs, including liquid-vial and dry-slide FITs. Primary care providers need to be aware of potential adverse effects of FITs.
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Affiliation(s)
| | | | - Yinghui Xu
- The University of Iowa, Iowa City, IA, USA
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Xu Y, Levy BT, Daly JM, Bergus GR, Dunkelberg JC. Comparison of patient preferences for fecal immunochemical test or colonoscopy using the analytic hierarchy process. BMC Health Serv Res 2015; 15:175. [PMID: 25902770 PMCID: PMC4411789 DOI: 10.1186/s12913-015-0841-0] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2014] [Accepted: 04/10/2015] [Indexed: 12/24/2022] Open
Abstract
Background In average-risk individuals aged 50 to 75 years, there is no difference in life-years gained when comparing colonoscopy every 10 years vs. annual fecal immunochemical testing (FIT) for colorectal cancer screening. Little is known about the preferences of patients when they have experienced both tests. Methods The study was conducted with 954 patients from the University of Iowa Hospital and Clinics during 2010 to 2011. Patients scheduled for a colonoscopy were asked to complete a FIT before the colonoscopy preparation. Following both tests, patients completed a questionnaire which was based on an analytic hierarchy process (AHP) decision-making model. Results In the AHP analysis, the test accuracy was given the highest priority (0.457), followed by complications (0.321), and test preparation (0.223). Patients preferred colonoscopy (0.599) compared with FIT (0.401) when considering accuracy; preferred FIT (0.589) compared with colonoscopy (0.411) when considering avoiding complications; and preferred FIT (0.650) compared with colonoscopy (0.350) when considering test preparation. The overall aggregated priorities were 0.517 for FIT, and 0.483 for colonoscopy, indicating patients slightly preferred FIT over colonoscopy. Patients’ preferences were significantly different before and after provision of detailed information on test features (p < 0.0001). Conclusions AHP analysis showed that patients slightly preferred FIT over colonoscopy. The information provided to patients strongly affected patient preference. Patients’ test preferences should be considered when ordering a colorectal cancer screening test.
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Affiliation(s)
- Yinghui Xu
- Department of Family Medicine, Roy J. and Lucille A. Carver College of Medicine, University of Iowa, Iowa City, IA, 52242, USA.
| | - Barcey T Levy
- Department of Family Medicine, Roy J. and Lucille A. Carver College of Medicine, University of Iowa, Iowa City, IA, 52242, USA. .,Department of Epidemiology, College of Public Health, University of Iowa, Iowa City, IA, 52242, USA.
| | - Jeanette M Daly
- Department of Family Medicine, Roy J. and Lucille A. Carver College of Medicine, University of Iowa, Iowa City, IA, 52242, USA.
| | - George R Bergus
- Department of Family Medicine, Roy J. and Lucille A. Carver College of Medicine, University of Iowa, Iowa City, IA, 52242, USA.
| | - Jeffrey C Dunkelberg
- Department of Internal Medicine, Roy J. and Lucille A. Carver College of Medicine, University of Iowa, Iowa City, IA, 52242, USA.
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Levy BT, Bay C, Xu Y, Daly JM, Bergus G, Dunkelberg J, Moss C. Test characteristics of faecal immunochemical tests (FIT) compared with optical colonoscopy. J Med Screen 2014; 21:133-43. [PMID: 24958730 DOI: 10.1177/0969141314541109] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND Faecal occult blood tests are often the initial test in population-based screening. We aimed to: 1) compare the results of single sample faecal immunochemical tests (FITs) with colonoscopy, and 2) calculate the sensitivity for proximal vs. distal adenomatous polyps or cancer. METHODS Individuals scheduled for a colonoscopy were invited to complete a FIT prior to their colonoscopy preparation. FIT results were classified as positive, negative, or invalid. Colonoscopy reports were reviewed and abstracted. Because of product issues, four different FIT manufacturers were used. The test characteristics for each FIT manufacturer were calculated for advanced adenomatous polyps or cancer according to broad reason for colonoscopy (screening or surveillance/diagnostic). RESULTS Of those invited, 1,026 individuals (43.9%) completed their colonoscopy and had a valid FIT result. The overall sensitivity of the FITs (95% confidence intervals) was 0.18 (0.10 to 0.28) and specificity was 0.90 (0.87 to 0.91) for advanced adenomas or cancer. The sensitivity for distal lesions was 0.23 (0.11 to 0.38) and for proximal lesions was 0.09 (0.02 to 0.25). The odds ratio of an individual with a distal advanced adenoma or cancer testing positive was 2.68 (1.20 to 5.99). The two individuals with colorectal cancer tested negative, as did one individual with high-grade dysplasia. CONCLUSIONS The sensitivity of a single-sample FIT for advanced adenomas or cancer was low. Individuals with distal adenomas had a higher odds of testing positive than those with proximal lesions or no lesions.
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Affiliation(s)
- Barcey T Levy
- Department of Family Medicine, Carver College of Medicine, University of Iowa, Iowa City, IA 52242 Department of Epidemiology, College of Public Health, University of Iowa, Iowa City, IA 52242
| | - Camden Bay
- Department of Family Medicine, Carver College of Medicine, University of Iowa, Iowa City, IA 52242 Department of Epidemiology, College of Public Health, University of Iowa, Iowa City, IA 52242
| | - Yinghui Xu
- Department of Family Medicine, Carver College of Medicine, University of Iowa, Iowa City, IA 52242
| | - Jeanette M Daly
- Department of Family Medicine, Carver College of Medicine, University of Iowa, Iowa City, IA 52242
| | - George Bergus
- Department of Family Medicine, Carver College of Medicine, University of Iowa, Iowa City, IA 52242
| | - Jeffrey Dunkelberg
- Department of Internal Medicine, Division of Gastroenterology, Carver College of Medicine, Iowa City, IA 52242
| | - Carol Moss
- Department of Family Medicine, Carver College of Medicine, University of Iowa, Iowa City, IA 52242
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Smith RA, Brooks D, Cokkinides V, Saslow D, Brawley OW. Cancer screening in the United States, 2013: a review of current American Cancer Society guidelines, current issues in cancer screening, and new guidance on cervical cancer screening and lung cancer screening. CA Cancer J Clin 2013; 63:88-105. [PMID: 23378235 DOI: 10.3322/caac.21174] [Citation(s) in RCA: 177] [Impact Index Per Article: 16.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Each year the American Cancer Society (ACS) publishes a summary of its recommendations for early cancer detection, a report on data and trends in cancer screening rates, and select issues related to cancer screening. In this issue of the journal, current ACS cancer screening guidelines are summarized, as are updated guidelines on cervical cancer screening and lung cancer screening with low-dose helical computed tomography. The latest data on the use of cancer screening from the National Health Interview Survey also are described, as are several issues related to screening coverage under the Patient Protection and Affordable Care Act of 2010.
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Affiliation(s)
- Robert A Smith
- Cancer Control Science Department, American Cancer Society, Atlanta, GA 30303, USA.
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Robinson CM, Cassells AN, Greene MA, Beach ML, Tobin JN, Dietrich AJ. Barriers to colorectal cancer screening among publicly insured urban women: no knowledge of tests and no clinician recommendation. J Natl Med Assoc 2011; 103:746-53. [PMID: 22046852 DOI: 10.1016/s0027-9684(15)30414-4] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
OBJECTIVES To assess barriers to colorectal cancer screening among urban publicly insured women and to evaluate how barriers among underscreened urban women have changed between 2001 and 2007-2008. METHODS Eligible women were selected using Medicaid Managed Care Organization (MMCO) administrative data. MMCO outreach staff interviewed women by phone between October 2007 and February 2008, and assessed their barriers to colorectal cancer screening. We compared the results of these interviews with interviews conducted in 2001 with women in community health center waiting rooms. RESULTS Thirty percent of overdue women had never heard of either colonoscopy or sigmoidoscopy, and 55% had never heard of home fecal occult blood testing (FOBT). Among overdue women who had heard of colonoscopy or sigmoidoscopy, 33% reported misconceptions and 28% reported worry as a barrier. No clinician recommendation was the most commonly reported barrier to home FOBT (44%) and was also reported as a barrier to endoscopy by 22% of women. Between 2001 and 2007-2008, the proportion of women reporting that they had not received a clinician's recommendation for endoscopy or home FOBT increased significantly. CONCLUSIONS A lack of information, no clinician recommendation, misconceptions, and worry persist as barriers to colon cancer screening among this underscreened urban population. An increased focus on clinician recommendation and patient education about stool-based as well as endoscopic screening methods could lead to greater screening compliance.
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Affiliation(s)
- Christina M Robinson
- Department of Community and Family Medicine, Dartmouth Medical School, Lebanon, NH 03756, USA.
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