A systematic review of the psychological impact of false-positive colorectal cancer screening: What is the role of the general practitioner?

National screening for colorectal cancer is associated with stage shift to earlier diagnosis

BACKGROUND

Australia's National Bowel Cancer Screening Program consists of an immunohistochemical faecal occult blood test, targeting adults aged 50-74. Existing literature supports the principle of early detection of colorectal cancer (CRC) via national screening, but little is known about the association between colonoscopy or polypectomy rates and CRC stage over time. The aim of this study is to identify the longitudinal change to colonoscopy and polypectomy rates, and any stage shift associated with this screening program.

METHODS

A retrospective data-linkage study was performed using the Australian national health database (Medicare) to obtain colonoscopy and polypectomy rates between 1998 and 2017. A second prospective database of CRC resection specimens was analysed for this period. The cohort was divided based on time intervals related to the National Bowel Cancer Screening Program: pre-commencement 1998-2006 (Period A), immediately post-commencement 2007-2011 (Period B), and subsequent years 2012-2017 (Period C). Linear regression was used to test relation between annualized predictor and response variables.

RESULTS

Annual colonoscopy rates doubled, and polypectomy rates tripled during the study (P < 0.001). Annual colonoscopy rate correlated to a lower T-stage (P = 0.038) and lower N-stage (P = 0.026), and there was a 7% increase in early CRC (stage I-II) in Period C (P < 0.001). Across the study period there was also a significant increase in right-sided tumours, and concurrent MMR deficiency and BRAF mutation.

CONCLUSION

Polypectomy and colonoscopy rates increased after the introduction of the National Bowel Cancer screening program. There was a clinically significant shift to earlier CRC stage which manifested 5 years after its implementation.

Perceptions and beliefs of general practitioners on their role in the cancer screening programmes in the Netherlands: a mixed-methods study

BACKGROUND

In the Netherlands, population-based cancer screening programmes (CSPs) are organized aiming at cervical, breast and colorectal cancer. For a CSP to be effective, high participation rates are essential; however, there is an alarming downward trend, including wide regional variation in screening uptake. General practitioner (GP) involvement can have a stimulating effect on screening participation. Current GP involvement is however, limited, varies between the programmes and has changed over time. Unexplored is what GPs think of their role(s) in the CSPs. The aim of this study was therefore to map the perceptions and beliefs of GPs regarding their current and future role in the Dutch CSPs.

METHODS

A mixed-methods sequential explanatory study was conducted in the Leiden/The Hague area of the Netherlands, between the end of 2021 and 2022. A questionnaire was developed and distributed among 110 GPs. The aggregated results obtained from the questionnaires served as starting points for conducting semi-structured interviews, with purposefully selected GPs. With this sequential approach we aimed to further enhance the understanding of the questionnaire data, and delved into the topics that emerged from the questionnaire responses.

RESULTS

In total, 46 GPs completed the online questionnaire (response rate 42%). Subsequent five semi-structured comprehensive interviews were conducted. GPs indicated that they frequently encounter the CSP in their daily practice and consider it important. They also emphasised it is important that GPs remain closely involved with the CSPs in the future. Nevertheless, GPs also repeatedly mentioned that they are not eager to take on more logistical/organizational tasks. They are however willing to empower CSPs in a positive manner.

CONCLUSION

GPs were generally positive about the CSPs and their current role within these programmes. Nevertheless, several options have been proposed to improve the CSPs, especially to increase screening uptake for populations in a socioeconomically disadvantaged position. Since it is of utmost importance to screen those who are most at risk of developing the screening-specific tumours, efforts should be made to achieve this goal.

Evaluating the Psychometric Properties and Clinical Utility of a Digital Psychosocial Self-Screening Tool (HEARTSMAP-U) for Postsecondary Students: Prospective Cohort Study

BACKGROUND

Existing screening tools for mental health issues among postsecondary students have several challenges, including a lack of standardization and codevelopment by students. HEARTSMAP-U was adapted to address these issues.

OBJECTIVE

This study aimed to evaluate the suitability of HEARTSMAP-U as a self-screening tool for psychosocial issues among postsecondary students by evaluating its validity evidence and clinical utility.

METHODS

A prospective cohort study was conducted with University of British Columbia Vancouver students to evaluate HEARTSMAP-U's predictive validity and convergent validity. Participating students completed baseline and 3-month follow-up assessments via HEARTSMAP-U and a clinician-administered interview.

RESULTS

In a diverse student sample (n=100), HEARTSMAP-U demonstrated high sensitivity (95%-100%) in identifying any psychiatric concerns that were flagged by a research clinician, with lower specificity (21%-25%). Strong convergent validity (r=0.54-0.68) was demonstrated when relevant domains and sections of HEARTSMAP-U were compared with those of other conceptually similar instruments.

CONCLUSIONS

This preliminary evaluation suggests that HEARTSMAP-U may be suitable for screening in the postsecondary educational setting. However, a larger-scale evaluation is necessary to confirm and expand on these findings.

Evaluating the Harms of Cancer Testing-A Systematic Review of the Adverse Psychological Correlates of Testing for Cancer and the Effectiveness of Interventions to Mitigate These

(1) Background: Several studies have described the psychological harms of testing for cancer. However, most were conducted in asymptomatic subjects and in cancers with a well-established screening programme. We sought to establish cancers in which the literature is deficient, and identify variables associated with psychological morbidity and interventions to mitigate their effect. (2) Methods: Electronic bibliographic databases were searched up to December 2020. We included quantitative studies reporting on variables associated with psychological morbidity associated with cancer testing and primary studies describing interventions to mitigate these. (3) Results: Twenty-six studies described individual, testing-related, and organisational variables. Thirteen randomised controlled trials on interventions were included, and these were categorised into five groups, namely the use of information aids, music therapy, the use of real-time videos, patient navigators and one-stop clinics, and pharmacological or homeopathic therapies. (4) Conclusions: The contribution of some factors to anxiety in cancer testing and their specificity of effect remains inconclusive and warrants further research in homogenous populations and testing contexts. Targeting young, unemployed patients with low levels of educational attainment may offer a means to mitigate anxiety. A limited body of research suggests that one-stop clinics and patient navigators may be beneficial in patients attending for diagnostic cancer testing.

Methodological Quality of PROMs in Psychosocial Consequences of Colorectal Cancer Screening: A Systematic Review

Objective

This systematic review aimed to assess the adequacy of measurement properties in Patient-Reported Outcome Measures (PROMs) used to quantify psychosocial consequences of colorectal cancer screening among adults at average risk.

Methods

We searched four databases for eligible studies: MEDLINE, CINAHL, PsycINFO, and Embase. Our approach was inclusive and encompassed all empirical studies that quantified aspects of psychosocial consequences of colorectal cancer screening. We assessed the adequacy of PROM development and measurement properties for content validity using The COnsensus-based Standards for the selection of health Measurement INstruments (COSMIN) risk of bias checklist.

Results

We included 33 studies that all together used 30 different outcome measures. Two PROMs (6.7%) were developed in a colorectal cancer screening context. COSMIN rating for PROM development was inadequate for 29 out of 30 PROMs (97%). PROMs lacked proper cognitive interviews and pilot studies and therefore had no proven content validity. According to the COSMIN checklist, 27 out of 30 PROMs (90%) had inadequate measurement properties for content validity.

Discussion

The majority of included PROMs had inadequate development and measurement properties. These findings shed light on the trustworthiness of the included studies' findings and call for reevaluation of existing evidence on the psychosocial consequences of colorectal cancer screening. To provide trustworthy evidence about the psychosocial consequences of colorectal cancer screening, editors could require that studies provide evidence of the methodological quality of the PROM. Alternatively, authors should transparently disclose their studies' methodological limitations in measuring psychosocial consequences of screening validly.

Short and long-term psychosocial consequences of participating in a colorectal cancer screening programme: a matched longitudinal study

OBJECTIVES

To investigate the psychosocial consequences of receiving a false-positive (no abnormalities) result or being diagnosed with polyps compared with receiving a negative result in a colorectal cancer (CRC) screening programme.

DESIGN AND SETTING

This was a longitudinal study nested in the roll-out of the Danish CRC screening programme that targets all individuals aged 50-74 years.

PARTICIPANTS

In the inclusion period (April-September 2017), all positive screenees (n=1854) were consecutively enrolled and matched 2:1:1 on sex, age (±2 years), municipality and screening date with negative screenees (n=933) and individuals not yet invited to screening (n=933).Questionnaires were sent by mail to all eligible participants in Region Zealand, Denmark, after the screening result, 2 months and 12 months after the final result.Positive screenees who did not receive the follow-up procedure were excluded.

MAIN OUTCOME MEASURES

The primary outcomes were psychosocial consequences. Outcomes were measured with the CRC screening-specific questionnaire Consequences of screening in CRC with 11 outcomes after the screening result and with 21 outcomes at the two later assessments.

RESULTS

After receiving the screening result, individuals with no abnormalities, low-risk and medium-risk and high-risk polyps scored significantly worse on 8 of 11 outcomes compared with the negative screenee group. At the 12-month follow-up, the differences were still significant in 8 of 21 outcomes (no abnormalities), 4 of 21 outcomes (low-risk polyps) and 10 of 21 outcomes (medium-risk and high-risk polyps). The negative screenee group and the group not yet invited to screening differed psychosocially on 5 of 11 outcomes after the screening result, but on none of the 21 outcomes at the 2 months and 12 months follow-up.

CONCLUSIONS

The study showed that there are both short-term and long-term psychosocial consequences associated with receiving a no abnormalities result or being diagnosed with polyps. The consequences were worst for individuals diagnosed with medium-risk and high-risk polyps.

Psychological distress and quality of life following positive fecal occult blood testing in colorectal cancer screening

OBJECTIVE

This study aimed to assess psychological functioning, quality of life, and regret about screening after a positive fecal immunochemical test (FIT) and subsequent colonoscopy, and to evaluate changes over time.

METHODS

This is a prospective cohort study. Individuals aged 55 to 75 with a positive FIT that were referred for colonoscopy between July 2017 and November 2018, were invited to complete questionnaires related to psychological distress and health-related quality of life at three predefined time points: before colonoscopy, after histopathology result notification, and after 6 months. Four questionnaires were used: the Psychological Consequences Questionnaire (PCQ), the six-item Cancer Worry Scale (CWS), the Decision Regret Scale (DRS), and the 36-item Short-Form (SF-36).

RESULTS

A total of 1066 participants out of 2151 eligible individuals were included. Patients with cancer showed a significant increase in psychological dysfunction (P = .01) and cancer worry (P = .008) after colonoscopy result notification, and a decline to pre-colonoscopy measurements after 6 months. In the no-cancer groups, psychological dysfunction and cancer worry significantly decreased over time (P < .05) but there was no ongoing decline. After 6 months, 17% of participants with no cancer experienced high level of cancer worry (CWS ≥ 10). Yet, only 5% reported high level of regret about screening participation (DRS > 25). A good global quality of life was reported in participants with no cancer.

CONCLUSION

Some psychological distress remains up to 6 months after colonoscopy in participants who tested false-positive in the Dutch bowel cancer screening program.

The diagnostic value of a change in bowel habit for colorectal cancer within different age groups

BACKGROUND

Change in bowel habit as a sole alarm symptom for colorectal cancer is disputed.

OBJECTIVE

We investigated the diagnostic value of change in bowel habit for colorectal cancer, particularly as a single symptom and within different age groups.

METHODS

This retrospective cohort study examined colorectal cancer fast track referrals and outcomes across four Swedish hospitals (April 2016-May 2017). Entry criteria constituted one or more of three alarm features: anaemia, visible rectal bleeding, or change in bowel habit for more than 4 weeks in patients over 40 years of age. Patients were grouped as having only change in bowel habit, change in bowel habit plus anaemia/bleeding or anaemia/bleeding only.

RESULTS

Of 628 patients, 22% were diagnosed with colorectal cancer. There were no cases of colorectal cancer in the only change in bowel habit group under 55 years, while this was 6% for 55-64 years, 8% for 65-74 years and 14% for 75 years and older. Among subjects under 55 years, 2% with anaemia/bleeding had colorectal cancer, this increased to 34% for 55 years and older (P < 0.0001). Change in bowel habit plus anaemia/bleeding gave a colorectal cancer prevalence of 16% in under 55 years and increased to 30% for 55 years and older (P = 0.07).

CONCLUSION

Change in bowel habit as the only alarm feature has a low diagnostic yield for colorectal cancer in patients under 55 years.

Participant-Related Risk Factors for False-Positive and False-Negative Fecal Immunochemical Tests in Colorectal Cancer Screening: Systematic Review and Meta-Analysis

OBJECTIVES

Colorectal cancer (CRC) screening using fecal immunochemical tests (FIT) may reduce CRC-related mortality but its effectiveness is influenced by the limited accuracy of FIT. Identifying individuals at increased risk of a false FIT result could improve screening, but the available evidence is conflicting. We performed a systematic review and meta-analysis on risk factors for false-positive and false-negative FIT results in CRC screening.

METHODS

A systematic search in MEDLINE, EMBASE, and Cochrane Library identified publications (before 29 January 2017) on risk factors (known at time of FIT invitation) associated with false FIT results (presence/absence of advanced neoplasia) in a CRC screening setting. Risk of bias was assessed using QUIPS. In meta-analysis, summary relative risk ratios and corresponding 95% confidence intervals were calculated for each risk factor.

RESULTS

Of 518 records identified, 14 studies with 54,499 participants in total were included for analysis. In meta-analysis, male sex was associated with a significantly lower risk of false-positivity (RR 0.84, CI 0.74-0.94), whereas participants using non-steroidal anti-inflammatory drugs (NSAIDs) had a higher risk (RR 1.16, CI 1.06-1.27). The use of anticoagulants was most frequently studied, without a significant effect on FIT positivity. Males (RR 1.83, CI 1.53-2.19), participants with a family history for CRC (RR 1.61, CI 1.19-2.15), hyperglycemia (RR 1.29, CI 1.02-1.65), hypertension (RR 1.50, CI 1.14-1.98), obesity (RR 1.38, CI 1.11-1.71), and (former) smokers (RR 1.93, CI 1.52-2.45) were all at significantly higher risk for false-negative results. Age was not found to have a systematic effect on either FIT false-positivity or false-negativity in meta-analysis.

CONCLUSIONS

Multiple risk factors, known at time of FIT invitation, are associated with false FIT results in CRC screening. This information can be used to identify populations risking false reassurance after a negative result or unnecessary colonoscopy after a positive result, and to further optimize CRC screening effectiveness.