Taishotoyama Symposium Barriers to colorectal cancer screening: economics, capacity and adherence

Validity of APCS score as a risk prediction score for advanced colorectal neoplasia in Chinese asymptomatic subjects: A prospective colonoscopy study

The Asia-Pacific Colorectal Screening (APCS) score is a risk-stratification tool that helps predict the risk for advanced colorectal neoplasia (ACN) in asymptomatic Asian populations, but has not yet been assessed for its validity of use in Mainland China.The aim of the study was to assess the validity of APCS score in asymptomatic Chinese population, and to identify other risk factors associated with ACN.Asymptomatic subjects (N = 1010) who underwent colonoscopy screening between 2012 and 2014 in Beijing were enrolled. APCS scores based on questionnaires were used to stratify subjects into high, moderate, and average-risk tiers. Cochran-Armitage test for trend was used to assess the association between ACN and risk tiers. Univariate and multivariate logistic regression was performed with ACN as the outcome, adjusting for APCS score, body mass index, alcohol consumption, self-reported diabetes, and use of nonsteroidal anti-inflammatory drugs as independent variables.The average age was 53.5 (standard deviation 8.4) years. The prevalence of ACN was 4.1% overall, and in the high, moderate, and average-risk tiers, the prevalence was 8.8%, 2.83%, and 1.55%, respectively (P < 0.001). High-risk tier had 3.3 and 6.1-fold increased risk of ACN as compared with those in the moderate and average-risk tiers, respectively. In univariate analysis, high-risk tier, obesity, diabetes, and alcohol consumption were associated with ACN. In multivariate analysis, only high-risk tier was an independent predictor of ACN.The APCS score can effectively identify a subset of asymptomatic Chinese population at high risk for ACN. Further studies are required to identify other risk factors, and the acceptability of the score to the general population will need to be further examined.

Trends in colorectal cancer admissions and stage at presentation: impact of screening

BACKGROUND

Colorectal cancer (CRC) incidence is rising among patients under age 50. As such, we set out to determine the proportion of CRC-related hospital admissions and distribution of colon cancer by stage in different age groups.

METHODS

The NIS database for 2002-2012 was used to investigate trends of colorectal cancer resection by age, and the ACS NSQIP database for 2012-2013 was used to investigate contemporary stage at diagnosis for colon cancer in different age groups.

RESULTS

A total of 1,198,421 patients were admitted to a hospital with a diagnosis of CRC and captured by the NIS database. Although the number of hospitalized CRC patients decreased from 2002 to 2012, the observed decrease was predominant in patients older than 65 years (P < 0.01) and in colon cancer compared to rectal cancer patients (P < 0.01). The proportion of patients younger than 65 years increased from 32.8 % in 2002 to 41.1 % in 2012, and the proportion of patients under age 50 increased from 9 to 12 %. In the NSQIP database, the age <50 group also had a significantly higher proportion of advanced disease (stage III/IV) compared to patients age 50 and older (62.3 vs. 47.5 %, P < 0.01). In 2012, it was observed that most patients with rectal cancer were younger than 65 years (55.8 %).

CONCLUSION

There was a steady decrease in the number of hospitalized patients with colorectal cancer during the last decade, primarily attributable to a decrease in the older than 65 years age patients and colon cancer patients. The proportion of hospitalized patients age <50 is rising. In addition, patients younger than 50 years were more likely to have advanced disease compared to older patients.

Predicting Non-Adherence with Outpatient Colonoscopy Using a Novel Electronic Tool that Measures Prior Non-Adherence

BACKGROUND

Accurately predicting the risk of no-show for a scheduled colonoscopy can help target interventions to improve compliance with colonoscopy, and thereby reduce the disease burden of colorectal cancer and enhance the utilization of resources within endoscopy units.

OBJECTIVES

We aimed to utilize information available in an electronic medical record (EMR) and endoscopy scheduling system to create a predictive model for no-show risk, and to simultaneously evaluate the role for natural language processing (NLP) in developing such a model.

DESIGN

This was a retrospective observational study using discovery and validation phases to design a colonoscopy non-adherence prediction model. An NLP-derived variable called the Non-Adherence Ratio ("NAR") was developed, validated, and included in the model.

PARTICIPANTS

Patients scheduled for outpatient colonoscopy at an Academic Medical Center (AMC) that is part of a multi-hospital health system, 2009 to 2011, were included in the study.

MAIN MEASURES

Odds ratios for non-adherence were calculated for all variables in the discovery cohort, and an Area Under the Receiver Operating Curve (AUC) was calculated for the final non-adherence prediction model.

KEY RESULTS

The non-adherence model included six variables: 1) gender; 2) history of psychiatric illness, 3) NAR; 4) wait time in months; 5) number of prior missed endoscopies; and 6) education level. The model achieved discrimination in the validation cohort (AUC= =70.2 %). At a threshold non-adherence score of 0.46, the model's sensitivity and specificity were 33 % and 92 %, respectively. Removing the NAR from the model significantly reduced its predictive power (AUC = 64.3 %, difference = 5.9 %, p < 0.001).

CONCLUSIONS

A six-variable model using readily available clinical and demographic information demonstrated accuracy for predicting colonoscopy non-adherence. The NAR, a novel variable developed using NLP technology, significantly strengthened this model's predictive power.

Comparative effectiveness of fecal immunochemical test outreach, colonoscopy outreach, and usual care for boosting colorectal cancer screening among the underserved: a randomized clinical trial

IMPORTANCE

Colorectal cancer (CRC) screening saves lives, but participation rates are low among underserved populations. Knowledge on effective approaches for screening the underserved, including best test type to offer, is limited.

OBJECTIVE

To determine (1) if organized mailed outreach boosts CRC screening compared with usual care and (2) if FIT is superior to colonoscopy outreach for CRC screening participation in an underserved population.

DESIGN, SETTING, AND PARTICIPANTS

We identified uninsured patients, not up to date with CRC screening, age 54 to 64 years, served by the John Peter Smith Health Network, Fort Worth and Tarrant County, Texas, a safety net health system.

INTERVENTIONS

Patients were assigned randomly to 1 of 3 groups. One group was assigned to fecal immunochemical test (FIT) outreach, consisting of mailed invitation to use and return an enclosed no-cost FIT (n = 1593). A second was assigned to colonoscopy outreach, consisting of mailed invitation to schedule a no-cost colonoscopy (n = 479). The third group was assigned to usual care, consisting of opportunistic primary care visit–based screening (n = 3898). In addition, FIT and colonoscopy outreach groups received telephone follow-up to promote test completion.

MAIN OUTCOME MEASURES

Screening participation in any CRC test within 1 year after randomization.

RESULTS

Mean patient age was 59 years; 64% of patients were women. The sample was 41% white, 24% black, 29% Hispanic, and 7% other race/ethnicity. Screening participation was significantly higher for both FIT (40.7%) and colonoscopy outreach (24.6%) than for usual care (12.1%) (P < .001 for both comparisons with usual care). Screening was significantly higher for FIT than for colonoscopy outreach (P < .001). In stratified analyses, screening was higher for FIT and colonoscopy outreach than for usual care, and higher for FIT than for colonoscopy outreach among whites, blacks, and Hispanics (P < .005 for all comparisons). Rates of CRC identification and advanced adenoma detection were 0.4% and 0.8% for FIT outreach, 0.4% and 1.3% for colonoscopy outreach, and 0.2% and 0.4% for usual care, respectively (P < .05 for colonoscopy vs usual care advanced adenoma comparison; P > .05 for all other comparisons). Eleven of 60 patients with abnormal FIT results did not complete colonoscopy. CONCLUSIONS AND REVELANCE: Among underserved patients whose CRC screening was not up to date, mailed outreach invitations resulted in markedly higher CRC screening compared with usual care. Outreach was more effective with FIT than with colonoscopy invitation.

TRIAL REGISTRATION

clinicaltrials.gov Identifier: NCT01191411.

Gender and ethnic differences in colorectal cancer screening embarrassment and physician gender preferences

PURPOSE/OBJECTIVES

To examine colorectal cancer (CRC) screening embarrassment among men and women from three ethnic groups and the associated physician gender preference by patient gender and ethnicity.

DESIGN

Cross-sectional, purposive sampling.

SETTING

Urban community in Brooklyn, NY.

SAMPLE

A purpose-derived, convenience sample of 245 European American, African American, and immigrant Jamaican men and women (aged 45-70 years) living in Brooklyn, NY.

METHODS

Participants provided demographics and completed a comprehensive measure of CRC screening embarrassment.

MAIN RESEARCH VARIABLES

Participant gender and ethnicity, physician gender, and CRC screening embarrassment regarding feces or the rectum and unwanted physical intimacy.

FINDINGS

As predicted, men and women both reported reduced fecal and rectal embarrassment and intimacy concern regarding same-gender physicians. As expected, Jamaicans reported greater embarrassment regarding feces or the rectum compared to European Americans and African Americans; however, in contrast to expectations, women reported less embarrassment than men. Interactions indicated that rectal and fecal embarrassment was particularly high among Jamaican men.

CONCLUSIONS

Men and women have a preference for same-gender physicians, and embarrassment regarding feces and the rectum shows the most consistent ethnic and gender variation.

IMPLICATIONS FOR NURSING

Discussing embarrassment and its causes, as well as providing an opportunity to choose a same-gender physician, may be promising strategies to reduce or manage embarrassment and increase CRC screening attendance.

The many faeces of colorectal cancer screening embarrassment: preliminary psychometric development and links to screening outcome

OBJECTIVES

Although embarrassment may be among the most easily modified discrete emotional barriers to patients seeking health care or testing, work in the area of colorectal cancer (CRC) has been restricted by the absence of suitable instrumentation. The current report describes the development and validation of a self-report instrument assessing two specific aspects of CRC screening embarrassment and their links to screening outcomes.

DESIGN

Convenience sampling was used to recruit 245 European American, African-American, and immigrant Caribbean community-dwelling men and women (aged 45-75 years) living in Brooklyn, New York.

METHODS

Participants completed the measure of CRC screening embarrassment, an array of convergent and divergent validity measures including dispositional embarrassment, general medical embarrassment, neuroticism, trait emotion, social desirability, previous treatment avoidance because of embarrassment, relevant health characteristics, and a brief CRC screening history.

RESULTS

As expected, CRC screening embarrassment was not unidimensional and had two reliable and distinct components, one concentrated on faecal/rectal embarrassment and the other on embarrassment arising from unwanted intimacy during examinations. In addition to demonstrating patterns of convergent and divergent validity consistent with their separation, multivariate analyses indicated that faecal/rectal embarrassment (but not intimacy concerns) predicted CRC screening frequency.

CONCLUSIONS

The current report extends current understanding by identifying the specific sources of embarrassment that may contribute to patients' avoidance of CRC screening. Directions for future study and implications for clinical practice and interventions are discussed.

Barrier-focused intervention to increase colonoscopy attendance among nonadherent high-risk populations

AIM: To increase attendance for colonoscopy among nonadherent high-risk individuals for colorectal cancer (CRC) screening in China.

METHODS: During the first 12 mo without intervention, only 428 of the 2398 high-risk subjects attended a scheduled colonoscopy examination. The 1970 subjects who did not attend for CRC screening were enrolled in the present study. Prior barrier investigation was performed to ascertain the reasons for nonadherence. A barrier-focused intervention program was then established and implemented among eligible nonadherent subjects by telephone interviews and on-site consultations. The completion rates of colonoscopy during the first 12 mo without intervention and the second 12 mo with intervention were compared. Variations in the effect of the intervention on some high-risk factors and barrier characteristics were analyzed using logistic regression.

RESULTS: 540 subjects who were not eligible were excluded from the study. The colonoscopy attendance rate was 23.04% (428/1858) during the first 12 mo without intervention, and 37.69% (539/1430) during the second 12 mo with intervention (P < 0.001). Logistic regression analysis showed that the intervention was more effective among subjects with only objective barriers (OR: 34.590, 95% CI: 23.204-51.563) or subjects with some specific high-risk characteristics: first-degree relatives diagnosed with CRC (OR: 1.778, 95% CI: 1.010-3.131), personal history of intestinal polyps (OR: 3.815, 95% CI: 1.994-7.300) and positive result for immunochemical fecal occult blood testing (OR: 2.718, 95% CI: 1.479-4.996).

CONCLUSION: The barrier-focused telephone or on-site consultation intervention appears to be a feasible means to improve colonoscopy attendance among nonadherent high-risk subjects for CRC screening in China.