Adherence to follow-up after a positive fecal occult blood test in an organized colorectal cancer screening program in Korea, 2004-2008

Postponing colonoscopy for 6 months in high-risk population increases colorectal cancer detection in China

BACKGROUND AND AIMS

Colonoscopy is an important colorectal cancer (CRC) screening modality; however, not all high-risk groups identified by fecal immunochemical test (FIT) and/or high-risk factor questionnaire (HRFQ) undergo colonoscopy in time. The impact of delays in colonoscopy on CRC detection among high-risk populations remains poorly understood, warranting further clarification.

METHODS

A retrospective study was conducted among CRC high-risk population identified by Tianjin CRC screening program. According to the colonoscopy results after HRFQ and FIT, patients were classified into CRC, advanced adenoma, non-advanced adenoma, and normal groups. The time interval between CRC screening and colonoscopy was investigated and its relationship with colonoscopy results. Logistic regression was performed to explore the risk factors of CRC detection.

RESULTS

Among the high-risk population without a history of CRC or polyps, 49,810 underwent HRFQ, FIT, and colonoscopy, and a time interval of fewer than 6 months was found for 79.56% of patients (n = 39,630). People with positive FIT were more likely to undergo colonoscopy within 6 months, and detection rates of CRC and/or advanced adenoma were positively related to time intervals. Similar results were found in people with a negative FIT but positive HRFQ. A time interval longer than 6 months was a significant predictor of CRC detection in high-risk populations.

CONCLUSION

For high-risk people identified by CRC screening, especially those with a positive FIT, a time interval of 6 months was associated with an increased probability of CRC detection. Our findings emphasize that populations at high risk should undergo colonoscopy at least within 6 months.

Effectiveness of Colorectal Cancer (CRC) Screening on All-Cause and CRC-Specific Mortality Reduction: A Systematic Review and Meta-Analysis

(1) Background: The aim of this study was to pool and compare all-cause and colorectal cancer (CRC) specific mortality reduction of CRC screening in randomized control trials (RCTs) and simulation models, and to determine factors that influence screening effectiveness. (2) Methods: PubMed, Embase, Web of Science and Cochrane library were searched for eligible studies. Multi-use simulation models or RCTs that compared the mortality of CRC screening with no screening in general population were included. CRC-specific and all-cause mortality rate ratios and 95% confidence intervals were calculated by a bivariate random model. (3) Results: 10 RCTs and 47 model studies were retrieved. The pooled CRC-specific mortality rate ratios in RCTs were 0.88 (0.80, 0.96) and 0.76 (0.68, 0.84) for guaiac-based fecal occult blood tests (gFOBT) and single flexible sigmoidoscopy (FS) screening, respectively. For the model studies, the rate ratios were 0.45 (0.39, 0.51) for biennial fecal immunochemical tests (FIT), 0.31 (0.28, 0.34) for biennial gFOBT, 0.61 (0.53, 0.72) for single FS, 0.27 (0.21, 0.35) for 10-yearly colonoscopy, and 0.35 (0.29, 0.42) for 5-yearly FS. The CRC-specific mortality reduction of gFOBT increased with higher adherence in both studies (RCT: 0.78 (0.68, 0.89) vs. 0.92 (0.87, 0.98), model: 0.30 (0.28, 0.33) vs. 0.92 (0.51, 1.63)). Model studies showed a 0.62-1.1% all-cause mortality reduction with single FS screening. (4) Conclusions: Based on RCTs and model studies, biennial FIT/gFOBT, single and 5-yearly FS, and 10-yearly colonoscopy screening significantly reduces CRC-specific mortality. The model estimates are much higher than in RCTs, because the simulated biennial gFOBT assumes higher adherence. The effectiveness of screening increases at younger screening initiation ages and higher adherences.

Third Asia-Pacific consensus recommendations on colorectal cancer screening and postpolypectomy surveillance

The Asia-Pacific region has the largest number of cases of colorectal cancer (CRC) and one of the highest levels of mortality due to this condition in the world. Since the publishing of two consensus recommendations in 2008 and 2015, significant advancements have been made in our knowledge of epidemiology, pathology and the natural history of the adenoma-carcinoma progression. Based on the most updated epidemiological and clinical studies in this region, considering literature from international studies, and adopting the modified Delphi process, the Asia-Pacific Working Group on Colorectal Cancer Screening has updated and revised their recommendations on (1) screening methods and preferred strategies; (2) age for starting and terminating screening for CRC; (3) screening for individuals with a family history of CRC or advanced adenoma; (4) surveillance for those with adenomas; (5) screening and surveillance for sessile serrated lesions and (6) quality assurance of screening programmes. Thirteen countries/regions in the Asia-Pacific region were represented in this exercise. International advisors from North America and Europe were invited to participate.

Examining the Factors That Affect the Diagnosis of Patients with Positive Fecal Occult Blood Test Results

Due to the threat of colorectal cancer (CRC) to health, Taiwan included the fecal occult blood test (FOBT) under preventive health services in 2010. We examined the factors that affect the diagnosis of people with positive FOBT results. Data were retrospectively collected from the CRC screening database. In the model predicting factors that affect the diagnosis of 89,046 people with positive FOBT results, the risks of disease in the CRC group were lower in medical institutions that conducted follow-up examinations in regions such as Northern Taiwan compared to that in Eastern Taiwan (p = 0.013); they were lower in the age group of 50 to 65 years than those in the age group of 71 to 75 years (p < 0.001, p = 0.016), and lower in the outpatient medical units that conducted follow-up examinations than those in the inpatient medical units by 0.565 times (p < 0.001, 95% CI: 0.493−0.647). Factors affecting the diagnosis of patients with positive FOBT results were gender, the region of the medical institution, medical unit for follow-up examinations, age, screening site, family history, type of follow-up examinations, and follow-up time. Therefore, the identification of characteristics of patients with positive FOBT results and the promotion of follow-up examination are important prevention strategies for CRC.

An Assessment of Physicians’ Recommendations for Colorectal Cancer Screening and International Guidelines Awareness and Adherence: Results From a Thai National Survey

Background

Colorectal cancer (CRC) screening uptake is generally low in the Asia Pacific and physicians’ recommendations affect the screening participation.

Objective

The study aimed to assess Thai physicians’ recommendations for CRC screening, and the awareness of and adherence to international guidelines.

Methods

A survey containing questions assessing physicians’ demographic data, screening recommendations, and awareness of the international CRC screening guidelines assessed by clinical vignettes. Independent predictors of physicians’ recommendations for CRC screening were determined by logistic regression analysis.

Results

Five hundred and eighty-sixth of 1,286 (46%) physicians completed the survey, and 58% of them offered CRC screening. The majority of colorectal surgeons (91%) and gastroenterologists (86%) endorsed screening, whereas 35% of primary care physicians recommended screening. The patient’s age was the only factor influencing the physician’s decision to offer CRC screening (OR, 2.75: 95% CI, 1.61–4.67). Colonoscopy was the most recommended modality among specialists, whereas 60% of primary care physicians offered fecal occult blood tests (FOBTs). The guidelines awareness was noted in 81% of participants, with the highest rates among gastroenterologists and colorectal surgeons. Gastroenterologists were more likely to adhere to the guidelines than surgeons, but both recommended shorter interval surveillance colonoscopy than guidelines recommendations in cases of small hyperplastic rectosigmoid polyps.

Conclusions

Recommendations for CRC screening and awareness of guidelines vary among different specialties. A low proportion of primary care physicians recommended screening and colorectal surgeons and gastroenterologists recommended shorter intervals for surveillance of small hyperplastic polyp than suggested by guidelines.

Adherence to colonoscopy in cascade screening of colorectal cancer: A systematic review and meta-analysis

BACKGROUND AND AIM

This study aims to systematically evaluate adherence to colonoscopy and related factors in cascade screening of colorectal cancer (CRC) among average-risk populations, which is crucial to achieve the effectiveness of CRC screening.

METHODS

We searched PubMed, Embase, Web of Science, and Cochrane Library for studies published in English up to October 16, 2020, and reporting the adherence to colonoscopy following positive results of initial screening tests. A random-effects meta-analysis was applied to estimate pooled adherence and 95% confidence intervals. Subgroup analysis and mixed-effects meta-regression analysis were performed to evaluate heterogeneous factors for adherence level.

RESULTS

A total of 245 observational and 97 experimental studies were included and generated a pooled adherence to colonoscopy of 76.6% (95% confidence interval: 74.1-78.9) and 80.4% (95% confidence interval: 77.2-83.1), respectively. The adherence varied substantially by calendar year of screening, continents, CRC incidence, socioeconomic status, recruitment methods, and type of initial screening tests, with the initial tests as the most modifiable heterogeneous factor for adherence across both observational (Q = 162.6, P < 0.001) and experimental studies (Q = 23.2, P < 0.001). The adherence to colonoscopy was at the highest level when using flexible sigmoidoscopy as an initial test, followed by using guaiac fecal occult blood test, quantitative or qualitative fecal immunochemical test, and risk assessment. The pooled estimate of adherence was positively associated with specificity and positive predictive value of initial screening tests, but negatively with sensitivity and positivity rate.

CONCLUSIONS

Colonoscopy adherence is at a low level and differs by study-level characteristics of programs and populations. Initial screening tests with high specificity or positive predictive value may be followed by a high adherence to colonoscopy.

A global view of adherence to colonoscopy follow-up in cascade screening of colorectal cancer

OBJECTIVE

To overview the colonoscopy adherence in cascade screening of colorectal cancer (CRC) and evaluate potential influence of the initial tests based on an ecological evaluation.

METHODS

The performance of the initial screening tests and adherence to subsequent colonoscopy were extracted from relevant studies published up to 16 October 2020. The age-standardised incidence (ASRi) of CRC in populations in the year of screening was derived from the Cancer Statistics.

RESULTS

One hundred sixty-six observational studies and 60 experimental studies were identified. Most studies applied cascade screening with faecal occult blood tests (FOBTs) as an initial test. The adherence to colonoscopy varied greatly across populations by continents, gross national income and type of initial tests, with a median (interquartile range) of 79.8% (63.1%-87.8%) in observational studies and 82.1% (66.7%-90.4%) in randomised trials. The adherence was positively correlated with the ASRi of CRC (r = 0.145, p = 0.023) and positive predictive value (PPV) of the initial tests (r = 0.206, p = 0.002) in observational studies and correlated with ASRi of CRC (r = 0.309, p = 0.002) and sensitivity of the initial tests (r = -0.704, p = 0.003) in experimental studies.

CONCLUSIONS

Adherence to colonoscopy varies greatly across populations and is related with performance of the initial tests, indicating the importance to select appropriate initial tests.

Machine Learning Models Cannot Replace Screening Colonoscopy for the Prediction of Advanced Colorectal Adenoma

Screening for colorectal cancer (CRC) continues to rely on colonoscopy and/or fecal occult blood testing since other (non-invasive) risk-stratification systems have not yet been implemented into European guidelines. In this study, we evaluate the potential of machine learning (ML) methods to predict advanced adenomas (AAs) in 5862 individuals participating in a screening program for colorectal cancer. Adenomas were diagnosed histologically with an AA being ≥ 1 cm in size or with high-grade dysplasia/villous features being present. Logistic regression (LR) and extreme gradient boosting (XGBoost) algorithms were evaluated for AA prediction. The mean age was 58.7 ± 9.7 years with 2811 males (48.0%), 1404 (24.0%) of whom suffered from obesity (BMI ≥ 30 kg/m²), 871 (14.9%) from diabetes, and 2095 (39.1%) from metabolic syndrome. An adenoma was detected in 1884 (32.1%), as well as AAs in 437 (7.5%). Modelling 36 laboratory parameters, eight clinical parameters, and data on eight food types/dietary patterns, moderate accuracy in predicting AAs with XGBoost and LR (AUC-ROC of 0.65–0.68) could be achieved. Limiting variables to established risk factors for AAs did not significantly improve performance. Moreover, subgroup analyses in subjects without genetic predispositions, in individuals aged 45–80 years, or in gender-specific analyses showed similar results. In conclusion, ML based on point-prevalence laboratory and clinical information does not accurately predict AAs.

Colorectal cancer and potential predictors of never screened for faecal occult blood test: a narrative review

Colorectal cancer (CRC) is a major public health threat. Therefore, CRC screening uptake has been a focus with the established precancerous lesion and the strong association of early detection with staging and survival of the disease. However, CRC screening is relatively low in many countries. This article briefly discussed the current situation of CRC, recommendations, and current uptake of CRC screening in various countries. Besides that, this article also highlights the potential factors that help to predict the CRC screening uptake worldwide. Identification of those factors could guide policymakers to develop an effective strategy to improve the CRC screening uptake and ultimately improve the health outcome of the population.

Implementation and results of a gastrointestinal cancer screening program in an Amazon rainforest village: A descriptive study

Background and study aims  Gastrointestinal cancer is an important cause of death worldwide. Remote populations are especially vulnerable to these conditions due to reduced access to screening and adequate treatment. In this context, the Belterra project was designed as a pilot taskforce to deliver gastrointestinal screening to an underserved Amazonian population and to spread knowledge and practice to local health workers. This study aimed to describe the implementation and present the results of the Belterra Project. Patients and methods  The project took place between October 2014 and December 2017 in Belterra, Pará, Brazil. Public-private partnerships were obtained and were essential for funding. The project required complex logistic solutions to provide gastrointestinal screening to every inhabitant between 50 and 70 years of age, including medical equipment and personal transportation to a remote area. Subjects were asked about their medical history, and received a physical examination, endoscopic examinations, and stool tests. Results  Over the course of 19 expeditions, we screened 2,022 inhabitants of Belterra, aged 50 to 70 years. Five colorectal and six gastric adenocarcinomas were diagnosed, as were several lower-stage lesions. Overall, 26 % of the participants undergoing colonoscopy showed some type of colonic lesion. Conclusions  Notwithstanding the geographical, cultural, and financial barriers, this study suggests that the implementation of a gastrointestinal cancer screening program for remote Brazilian populations is feasible, reaching high adherence. Although logistics is very demanding, such campaigns may be a good strategy to provide mass gastrointestinal cancer screening for underserved populations.

Time to Colonoscopy After Abnormal Stool-Based Screening and Risk for Colorectal Cancer Incidence and Mortality

BACKGROUND AND AIMS

The optimal time interval for diagnostic colonoscopy completion after an abnormal stool-based colorectal cancer (CRC) screening test is uncertain. We examined the association between time to colonoscopy and CRC outcomes among individuals who underwent diagnostic colonoscopy after abnormal stool-based screening.

METHODS

We performed a retrospective cohort study of veterans age 50 to 75 years with an abnormal fecal occult blood test (FOBT) or fecal immunochemical test (FIT) between 1999 and 2010. We used multivariable Cox proportional hazards to generate CRC-specific incidence and mortality hazard ratios (HRs) and 95% confidence intervals (CI) for 3-month colonoscopy intervals, with 1 to 3 months as the reference group. Association of time to colonoscopy with late-stage CRC diagnosis was also examined.

RESULTS

Our cohort included 204,733 patients. Mean age was 61 years (SD 6.9). Compared with patients who received a colonoscopy at 1 to 3 months, there was an increased CRC risk for patients who received a colonoscopy at 13 to 15 months (HR 1.13; 95% CI 1.00-1.27), 16 to 18 months (HR 1.25; 95% CI 1.10-1.43), 19 to 21 months (HR 1.28; 95% CI: 1.11-1.48), and 22 to 24 months (HR 1.26; 95% CI 1.07-1.47). Compared with patients who received a colonoscopy at 1 to 3 months, mortality risk was higher in groups who received a colonoscopy at 19 to 21 months (HR 1.52; 95% CI 1.51-1.99) and 22 to 24 months (HR 1.39; 95% CI 1.03-1.88). Odds for late-stage CRC increased at 16 months.

CONCLUSIONS

Increased time to colonoscopy is associated with higher risk of CRC incidence, death, and late-stage CRC after abnormal FIT/FOBT. Interventions to improve CRC outcomes should emphasize diagnostic follow-up within 1 year of an abnormal FIT/FOBT result.

Adherence to follow-up examination after positive fecal occult blood test results affects colorectal cancer mortality: A Korea population-based cohort study

BACKGROUND

The impact of adherence to follow-up examination after a fecal occult blood test (FOBT) remains ill-defined.

AIM

To evaluate the impact of adherence to the follow-up examination on clinical outcomes in individuals with positive FOBT results.

METHODS

This was a retrospective cohort study involving Korean individuals aged 50 years or older who participated in the National Cancer Screening Program for CRC from 2009 to 2010. Individuals who underwent a confirmative examination within a year after positive FOBT results were included in compliant group, and those who did not were included in non-compliant group. The incidence and stage of CRC, and 5-year survival were compared between two groups.

RESULTS

5,914 were diagnosed with CRC in the compliant group and 2,973 in the non-compliant group. The proportion of advanced-stage CRC was significantly higher in the non-compliant group (localized CRC 44.6% vs. 36.7% and distant CRC 8.7% vs. 12.5%, p< 0.0001). The survival probability within 5 years was 71.0% in the non-compliant group and 85.9% in the compliant group (hazard ratio 1.70, 95% CI, 1.52-1.90, p< 0.001).

CONCLUSION

Individuals who underwent follow-up examination 1 year or more after positive FOBT had a lower survival rate compared with that in those who underwent examination within 1 year.

Barriers to completing colonoscopy after a positive fecal occult blood test

Background

Colorectal cancer leads to significant morbidity and mortality. Early detection and treatment are essential. Screening using fecal occult blood tests has increased significantly, but adherence to colonoscopy follow-up is suboptimal, increasing CRC mortality risk.

The aim of this study was to identify barriers to colonoscopy following a positive FOBT at the level of the patient, physician, organization and policymakers.

Methods

This mixed methods study was conducted at two health care organizations in Israel. The study included retrospective analyses of 45,281 50–74 year-old members with positive fecal immunochemical tests from 2010 to 2014, and a survey of 772 patients with a positive test during 2015, with and without follow-up. The qualitative part of the study included focus groups with primary physicians and gastroenterologists and in-depth interviews with opinion leaders in healthcare.

Results

Patient lack of comprehension regarding the test was the strongest predictor of non-adherence to follow-up. Older age, Arab ethnicity, and lower socio economic status significantly reduced adherence. We found no correlation with gender, marital status, patient activation, waiting time for appointments or distance from gastroenterology clinics. Primary care physicians underestimate non-adherence rates. They feel responsible for patient follow-up, but express lack of time and skills that will allow them to ensure adherence among their patients. Gastroenterologists do not consider fecal occult blood an effective tool for CRC detection, and believe that all patients should undergo colonoscopy. Opinion leaders in the healthcare field do not prioritize the issue of follow-up after a positive screening test for colorectal cancer, although they understand the importance.

Conclusions

We identified important barriers that need to be addressed to improve the effectiveness of the screening program. Targeted interventions for populations at risk for non-adherence, specifically for those with low literacy levels, and better explanation of the need for follow-up as a routine need to be set in place. Lack of agreement between screening recommendations and gastroenterologist opinion, and lack of awareness among healthcare authority figures negatively impact the screening program need to be addressed at the organizational and national level.

Trial registration

This study was approved by the IRB in both participating organizations (Meuhedet Health Care Institutional Review Board #02–2–5-15, Maccabi Healthcare Institutional Review Board BBI-0025-16). Participant consent was waived by both IRB’s.

To do or not to do - a survey study on factors associated with participating in the Danish screening program for colorectal cancer

Background

Screening programs for colorectal cancer (CRC) exist in many countries, and with varying participation rates. The present study aimed at identifying socio-demographic factors for accepting a cost-free screening offer for CRC in Denmark, and to study if more people would accept the screening offer if the present fecal test was replaced by a blood test.

Methods

We used a cross-sectional survey design based on a representative group of 6807 Danish citizens aged 50–80 years returning a fully answered web-based questionnaire with socio-demographic data added from national registries. Data were analyzed in STATA and based on bivariate analyses followed by regression models.

Results

Danes in general have a high level of lifetime participation (+ 80%) in the national CRC screening program. The results of the stepwise logistic regression model to predict CRC screening participation demonstrated that female gender, higher age, higher income, and moderate alcohol intake were positively associated with screening participation, whereas a negative association was observed for higher educational attainment, obesity, being a smoker, and higher willingness to take health risks. Of the 1026 respondents not accepting the screening offer, 61% were willing to reconsider their initial negative response if the fecal sampling procedure were replaced by blood sampling.

Conclusion

The CRC screening program intends to include the entire population within a certain at-risk age group. However, individual factors (e.g. sex, age obesity, smoking, risk aversity) appear to significantly affect willingness to participate in the screening program. From a preventive perspective, our findings indicate the need for a more targeted approach trying to reach these groups.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-020-06023-6.

Factors of Never Screened with Faecal Occult Blood Test in Public Primary Care Facilities

BACKGROUND

Colorectal cancer (CRC) is still a major public health threat. In the effort to reduce CRC incidence and mortality, faecal occult blood test (FOBT) is currently the screening tools used for early detection of CRC. However, the uptake of FOBT screening is less than promising. This study aims to identify the prevalence and predictors of Never Screened with FOBT (NS-FOBT).

METHODS

A cross sectional study was conducted in five health clinics under Kota Kinabalu district, Sabah, Malaysia Borneo involving 162 attendees with age of 50 years old and above. A validated self-administered questionnaire was used to collect the data. Multiple logistic regression analysis was used to determine the predictors of NS-FOBT.

RESULTS

The prevalence of NS-FOBT was 85.8% (n=139). Important predictors of NS-FOBT were age (aOR: 0.922; 95% CI: 0.855, 0.995; p=0.035), Bumiputera ethnicity (vs Non Bumiputera; aOR: 4.285; 95% CI: 1.384, 13.263; p=0.012), knowledge score (aOR: 0.921; 95% CI: 0.856, 0.99; p=0.027), and attitude score (aOR: 0.801; 95% CI: 0.702, 0.913; p=0.001).

CONCLUSION

There is high prevalence of NS-FOBT. Age, ethnicity, knowledge, and attitude were important predictors of NS-FOBT. Strategies are needed to improve FOBT screening rate among the public. Socio-culturally tailored health promotion strategies as well as strengthening the communication, collaboration, and education to enhance the role of family physician is vital in improving the CRC prevention and care.

Determinants of non-participation in colon examination following positive stool sample in colorectal cancer screening

BACKGROUND

Social inequalities has been shown for participation in colorectal cancer screening and recently in the initial stool sample blood test. If these differences persist at follow-up colon examination after a positive stool test, it would suggest that social inequality in screening may be greater than the inequality observed in initial stool sample blood test.

METHODS

All data were derived from national registers. Using logistic regression analyses, odds of non-participation for follow-up colon examination were estimated based on age group, educational level, income quartile, immigration status and marital status in men and in women, who had participated in initial stool sample test for blood with a positive result.

RESULTS

Among 20 849 men and 16 565 women invited for follow-up colonoscopy in the period 2014-15, 10.63 and 11.37%, respectively, did not attend. In men, odds of non-participation were higher in the eldest, those with lower income and lower educational level, in immigrants and in singles. Odds ratio (OR) in males of highest income quartile was 0.54 [95% confidence interval (CI) 0.46; 0.63] compared with lowest income quartile. In women, the differences were not as large. OR in females of highest income quartile was 0.73 (95% CI 0.61; 0.87) compared with lowest income quartile.

CONCLUSION

Sociodemographic differences in odds of non-participation exist in follow-up colon examination in the Danish colorectal cancer screening. Differences were evident in all subgroups of the male population. The same patterns were seen in women. Social inequalities in participation for follow-up colon examination can increase overall social inequality and consequently, lead to health disparities.

Implementing a multilevel intervention to accelerate colorectal cancer screening and follow-up in federally qualified health centers using a stepped wedge design: a study protocol

Background

Screening for colorectal cancer (CRC) not only detects disease early when treatment is more effective but also prevents cancer by finding and removing precancerous polyps. Because many of our nation’s most disadvantaged and vulnerable individuals obtain health care at federally qualified health centers, these centers play a significant role in increasing CRC screening among the most vulnerable populations. Furthermore, the full benefits of cancer screenings must include timely and appropriate follow-up of abnormal results. Thus, the purpose of this study is to implement a multilevel intervention to increase rates of CRC screening, follow-up, and referral-to-care in federally qualified health centers, as well as simultaneously to observe and to gather information on the implementation process to improve the adoption, implementation, and sustainment of the intervention. The multilevel intervention will target three different levels of influences: organization, provider, and individual. It will have multiple components, including provider and staff education, provider reminder, provider assessment and feedback, patient reminder, and patient navigation.

Methods

This study is a multilevel, three-phase, stepped wedge cluster randomized trial with four clusters of clinics from four different FQHC systems. In the first phase, there will be a 3-month waiting period during which no intervention components will be implemented. After the 3-month waiting period, we will randomize two clusters to cross from the control to the intervention and the remaining two clusters to follow 3 months later. All clusters will stay at the same phase for 9 months, followed by a 3-month transition period, and then cross over to the next phase.

Discussion

There is a pressing need to reduce disparities in CRC outcomes, especially among racial/ethnic minority populations and among populations who live in poverty. Single-level interventions are often insufficient to lead to sustainable changes. Multilevel interventions, which target two or more levels of changes, are needed to address multilevel contextual influences simultaneously. Multilevel interventions with multiple components will affect not only the desired outcomes but also each other. How to take advantage of multilevel interventions and how to implement such interventions and evaluate their effectiveness are the ultimate goals of this study.

Trial registration

This protocol is registered at clinicaltrials.gov (NCT04514341) on 14 August 2020.

Adherence to national guidelines for colorectal cancer screening in Israel: Comprehensive multi-year assessment based on electronic medical records

OBJECTIVES

To assess time trends in colorectal cancer screening uptake, time-to-colonoscopy completion following a positive fecal occult blood test and associated patient factors, and the extent and predictors of longitudinal screening adherence in Israel.

SETTING

Nation-wide population-based study using data collected from four health maintenance organizations for the Quality Indicators in Community Healthcare Program.

METHODS

Screening uptake for the eligible population (aged 50-74) was recorded 2003-2018 using aggregate data. For a subcohort (2008-2012, N = 1,342,617), time-to-colonoscopy following a positive fecal occult blood test and longitudinal adherence to screening guidelines were measured using individual-level data, and associated factors assessed in multivariate models.

RESULTS

The annual proportion screened rose for both sexes from 11 to 65%, increasing five-fold for age group 60-74 and >six-fold for 50-59 year olds, respectively. From 2008 to 2012, 67,314 adults had a positive fecal occult blood test, of whom 71% eventually performed a colonoscopy after a median interval of 122 (95% confidence interval 110.2-113.7) days. Factors associated with time-to-colonoscopy included age, socioeconomic status, and comorbidities. Only 25.5% of the population demonstrated full longitudinal screening adherence, mainly attributable to colonoscopy in the past 10 years rather than annual fecal occult blood test performance (83% versus 17%, respectively). Smoking, diabetes, lower socioeconomic status, cardiovascular disease, and hypertension were associated with decreased adherence. Performance of other cancer screening tests and frequent primary care visits were strongly associated with adherence.

CONCLUSIONS

Despite substantial improvement in colorectal cancer screening uptake on a population level, individual-level data uncovered gaps in colonoscopy completion after a positive fecal occult blood test and in longitudinal adherence to screening, which should be addressed using focused interventions.

Clinical Factors Associated with Adherence to the Follow-Up Examination after Positive Fecal Occult Blood Test in National Colorectal Cancer Screening

Background: The compliance with the follow-up examination after a positive fecal occult blood test (FOBT) is lower than expected. We aimed to evaluate the adherence rate to the follow-up examination in patients with a positive FOBT and to identify the clinical factors associated with this adherence.

METHODS

The study population comprised adults aged ≥50 years who participated in the National Cancer Screening Program for colorectal cancer (CRC) in 2013. Compliance was defined as undergoing follow-up examination within 1 year of a positive FOBT.

RESULTS

From 214,131 individuals with a positive FOBT, 120,911 (56.5%) were in the compliance group and 93,220 (43.5%) were in the non-compliance group. On multivariate analysis, good compliance was associated with men (odds ratio (OR) = 1.12, 95% confidence interval (CI) (1.09-1.15)), younger ages (70-79 years, OR = 2.19 (2.09-2.31); 60-69 years, OR = 3.29 (3.13-3.46); 50-59 years, OR = 3.57 (3.39-3.75) vs. >80 years), previous experience of CRC screening (a negative FOBT, OR = 1.18 (1.15-1.21); a positive FOBT, OR = 2.42 (2.31-2.54)), absent previous experience of colonoscopy or barium enema (OR = 2.06 (1.99-2.13)), higher economic income (quartile, 75%, OR = 1.14 (1.11-1.17); 100%, OR = 1.22 (1.19-1.25)), current smokers (OR = 1.12 (1.09-1.15)), alcohol intake (OR = 1.03 (1.01-1.05)), active physical activity (≥3 times/week, OR = 1.13 (1.11-1.15)), depression (OR = 1.11 (1.08-1.14)), and present comorbidities (Charlson Comorbidity Index, ≥1).

CONCLUSION

This study identified clinical factors, namely, male, younger ages, prior experience of fecal test, absent history of colonoscopy or double-contrast barium enema (DCBE) within 5 years, and high socioeconomic status to be associated with good adherence to the follow-up examination after a positive FOBT.

Do socioeconomic factors play a role in nonadherence to follow-up colonoscopy after a positive faecal immunochemical test in the Flemish colorectal cancer screening programme?

OBJECTIVE

In Flanders (Belgium), a population-based colorectal cancer (CRC) screening programme was started in 2013, coordinated by the Centre for Cancer Detection (CCD) in cooperation with the Belgian Cancer Registry (BCR). The CCD offers a biennial faecal immunochemical test (FIT) to Flemish citizens aged 56-74 years and recommends a colonoscopy when screened positive by FIT. The study objective is to investigate sociodemographic differences in follow-up colonoscopy adherence after a positive FIT.

METHODS

Characteristics of the study population were derived by linkage of data from the CCD and BCR, linked with data of the Intermutualistic Agency and the Crossroads Bank for Social Security, resulting in aggregated tables to ensure anonymity. A total of 37 834 men and women aged 56-74 years with a positive FIT in 2013-2014 were included. Adherence to follow-up colonoscopy was calculated for age, sex, work intensity at household level, preferential reimbursement status, and first and current nationality. Descriptive analyses and logistic regressions were performed.

RESULTS

Nonadherence to follow-up colonoscopy was associated with increasing age, and was significantly higher in men [odds ratio (OR), 1.08], participants with a preferential reimbursement status (OR, 1.34), very low work intensity (OR, 1.41), no payed work (OR, 1.38) and other than Belgian nationality by birth (OR, 1.6-4.66).

CONCLUSION

Adherence to follow-up colonoscopy after a positive FIT differs according to sociodemographic variables. Additional research is needed to explore reasons for nonadherence to colonoscopy and tackle barriers by exploring interventions to increase colonoscopy follow-up adherence after a positive FIT in the Flemish colorectal cancer screening programme.

The Rise of Colorectal Cancer in Asia: Epidemiology, Screening, and Management

PURPOSE OF REVIEW

Colorectal cancer (CRC) remains the third most commonly diagnosed cancer globally, and its incidence and mortality rates have been on the rise in Asia. In this paper, we summarize the recent trends and screening challenges of CRC in this region.

RECENT FINDINGS

In 2018, Asia had the highest proportions of both incident (51.8%) and mortality (52.4%) CRC cases (all genders and ages) per 100,000 population in the world. In addition, there has been a rising trend of this disease across Asia with some regional geographic variations. This rise in CRC can be attributed to westernized dietary lifestyle, increasing population aging, smoking, physical inactivity, and other risk factors. In curbing the rising trend, Japan, South Korea, Singapore, and Taiwan have launched nationwide population-based screening programs. CRC screening across this region has been found to be effective and cost-effective compared with no screening at all. The emergence of new therapies has caused a reduction in case fatality; however, these new options have had a limited impact on cure rates and long-term survival due to the great disparity in treatment capacity/resources and screening infrastructures among Asian countries with different degrees of economic development. CRC is still rising in Asia, and implementation of screening is necessary for moderate- to high-incidence countries and construction of treatment capacity is the priority task in low-incidence and low-income countries. Unless countries in Asia implement CRC screening, the incidence and mortality rates of this disease will continue to rise especially with the rapidly rising population growth, economic development, westernized lifestyle, and increasing aging.

Disparities in the Participation Rate of Colorectal Cancer Screening by Fecal Occult Blood Test among People with Disabilities: A National Database Study in South Korea

PURPOSE

Implementation of screening program may lead to increased health disparity within the population if participation differs by socioeconomic status. In Korea, colorectal cancer screening is provided at no or minimal cost to all people over 50 by National Cancer Screening Program. We investigated colorectal cancer screening participation rate and its trend over the last 10 years in relation to disabilities.

Materials and Methods

We linked national disability registration data with National Cancer Screening Program data. Age, sex-standardized participation rates were analyzed by type and severity of disability for each year, and factors associated with colorectal cancer screening participation were examined by multivariate logistic regression.

RESULTS

Age, sex-standardized participation rate in people without disability increased from 16.2 to 33.9% (change, +17.7), but it increased from 12.7% to 27.2% (change, +14.5) among people with severe disability. People with severe disabilities showed a markedly lower colorectal cancer screening participation rate than people without disability (adjusted odds ratio [aOR], 0.714; 95% confidence interval, 0.713 to 0.720). People with autism (aOR, 0.468), renal failure (aOR, 0.498), brain injury (aOR, 0.581), ostomy (aOR, 0.602), and intellectual disability (aOR, 0.610) showed the lowest participation rates.

CONCLUSION

Despite the availability of a National Cancer Screening Program and overall increase of its usage in the Korean population, a significant disparity was found in colorectal cancer screening participation, especially in people with severe disabilities and or several specific types of disabilities. Greater effort is needed to identify the barriers faced by these particularly vulnerable groups and develop targeted interventions to reduce inequality.

The compliance rate for the second diagnostic evaluation after a positive fecal occult blood test: A systematic review and meta-analysis

Introduction

Only a minority of patients with a positive fecal occult blood test (FOBT) undergo a follow-up second diagnostic procedure, thus minimizing its contribution for colorectal cancer (CRC) prevention. We aimed to obtain a precise estimation of this problem and also assess the diagnostic yield of CRC and adenomas by colonoscopy in these patients.

Methods

Literature searches were conducted for "compliance" OR "adherence" AND "fecal occult blood test" OR "fecal immunohistochemical test" AND "colonoscopy." Comprehensive meta-analysis software was used.

Results

The search resulted in 42 studies (512,496 patients with positive FOBT), published through December 31, 2017. A funnel plot demonstrates a moderate publication bias. Compliance with any second procedure, colonoscopy, or combination of double-contrast barium enema with or without sigmoidoscopy in patients with a positive FOBT was 0.725 with 95% confidence interval (CI) 0.649-0.790 (p = 0.000), 0.804 with 95% CI 0.740-0.856 (p = 0.000) and 0.197 with 95% CI 0.096-0.361 (p = 0.000), respectively. The diagnostic yield for CRC, advanced adenoma and simple adenoma was 0.058 with 95% CI 0.050-0.068 (p = 0.000), 0.242 with 95% CI 0.188-0.306 (p = 0.000) and 0.147 with 95% CI 0.116-0.184 (p < 0.001), respectively.

Discussion

Compliance with diagnostic evaluation after a positive FOBT is still suboptimal. Therefore, measures to increase compliance need to be taken given the increased risk of CRC in these patients.

The gap between knowledge and undergoing colorectal cancer screening using the Health Belief Model: A national survey

BACKGROUND/AIMS

Colorectal cancer (CRC) is a public health issue, and before the initiation of a national cancer screening program, there is a need to examine the acceptance of the public to undergo CRC screening and explore potential barriers.

MATERIALS AND METHODS

A nationwide survey was conducted using an electronic platform to collect demographic variables and using the Health Belief Model to assess attitudes and behavior of participants as well as the knowledge about and intent to undergo CRC screening. At the end of the survey, participants from Riyadh were invited to get screened for CRC.

RESULTS

Responses from 5720 individuals covering all the 13 jurisdictions of Saudi Arabia were collected. Males represented 71.53% of the respondents; the mean age was 43.28 years and 15.24% had already undergone CRC screening using various methods, mostly colonoscopy (72.73%). The mean knowledge score was 11.05 (standard deviation 4.4, range 1-23), with no difference between genders, jurisdictions of the Kingdom, between those who expressed interest in screening and those who did not, and between those who accepted the invitation to undergo CRC screening and those who did not. Participants displayed positive attitudes toward both CRC screening and colonoscopy as a screening tool, and 73% expressed willingness to undergo screening. On multivariate analysis, male gender was the only factor associated with a higher probability of accepting screening, whereas neither knowledge nor willingness to undergo screening predicted accepting the invitation to screening.

CONCLUSION

Although the majority of participants were willing to undergo screening, no significant correlation between knowledge and willingness to undergo screening were predictors of screening uptake. Other areas that could be targeted in the promotion of CRC screening uptake to bridge the gap between "knowing" and "doing" should be explored.

Is the patient activation measure associated with adherence to colonoscopy after a positive fecal occult blood test result?

BACKGROUND

Colorectal cancer (CRC) is a major cause of morbidity and mortality worldwide, but these can be reduced significantly with population screening using annual fecal occult blood tests (FOBT)A positive FOBT requires timely follow-up with colonoscopy to maximize screening benefits.. Several barriers to follow-up have been identified, with patient health behaviors and choices comprising a significant part of these. The Patient Activation Measure (PAM) assesses knowledge, skills, beliefs, and confidence in managing health. Increased patient activation is related to positive health outcomes. The aim of this study is to examine the association between patient empowerment, as reflected in the PAM, and follow-up colonoscopy within 90 days of a positive FOBT result.

METHODS

This case-control study included 429 patients with a positive FOBT, 174 who had a colonoscopy within 90 days, and 255 who did not.. Participants completed a PAM telephone questionnaire (Cronbach's α = 0.785). We used both univariate and multivariate analyses to examine the effect of the PAM score as on the likelihood of undergoing colonoscopy, after adjusting for the independent variables.

RESULTS

In this study we did not find a significant association between PAM and adherence to colonoscopy, using both univariate and multivariate analyses (p = .334 and p = .697, whether PAM was defined as a continuous or as categorical, respectively).

CONCLUSIONS

This study was the first to examine the association between patient empowerment, as reflected in the patient activation measure, and adherence to colonoscopy after a positive FOBT. The findings did not support such an association. Further examination is required to clarify the relation between patient empowerment and activation and personal healthcare in general, and in the Israeli population in particular. Future policy should include specific, technical interventions to improve FOBT follow-up among all groups, until the patient-related barriers are better understood.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT02534142 https://clinicaltrials.gov/ct2/show/NCT02534142.

Budget Impact of the Accreditation Program for Clinical Laboratories on Colorectal Cancer Screening via Fecal Immunochemical Testing: Results from the National Cancer Screening Program in Korea

Background

False-positive fecal immunochemical test (FIT) results in the National Cancer Screening Program (NCSP) for colorectal cancer may lead to unnecessary procedures, such as colonoscopies, increasing the medical costs. We estimated reductions in the cost of National Health Insurance according to the accreditation status of screening facilities participating in the NCSP for colorectal cancer.

Methods

We used data collected between 2007 and 2010 from NCSP and the Korea Central Cancer Registry to identify patients with colorectal cancer. We also ascertained the history of the accreditation of each facility by the Korean Laboratory Accreditation Program (KLAP). Budget impact was defined as a reduction in medical costs achieved when the false-positive rate of the non-accredited facilities decreased relative to that of the accredited facilities.

Results

A total of 3,285 screening facilities participated in the NCSP. Of these, 196 were accredited by the KLAP. The false-positive rate of the accredited facilities was 2.47%, and that of the non-accredited facilities was 6.83%. Medical costs were estimated to be reduced by approximately 19 million US dollars (USD), and the cost of detecting one case of colorectal cancer was estimated to decrease from 9,212 USD to 7,332 USD if the false-positive rate of non-accredited facilities were decreased to that of the accredited facilities. Clinics were estimated to have the largest associated cost reduction.

Conclusions

Quality assurance in clinical laboratories could lower false-positive rates and prevent the use of unnecessary procedures, ensuring patient safety and increasing the cost-effectiveness of FIT screening in the NCSP for colorectal cancer.

Timeliness of Colonoscopy After Abnormal Fecal Test Results in a Safety Net Practice

Fecal testing can only reduce colorectal cancer mortality if patients with an abnormal test result receive a follow-up colonoscopy. As part of the Strategies and Opportunities to STOP Colon Cancer in Priority Populations (STOP CRC) project, we examined factors associated with adherence to follow-up colonoscopy among patients with abnormal fecal test results. As part of STOP CRC outreach, Virginia Garcia Memorial Health Center staff distributed 1753 fecal immunochemical tests (FIT), of which 677 (39 %) were completed, and 56 had an abnormal result (8 %). Project staff used logistic regression analyses to examine factors associated with colonoscopy referral and completion. Of the 56 patients with abnormal FIT results; 45 (80 %) had evidence of a referral for colonoscopy, 32 (57 %) had evidence of a completed colonoscopy within 18 months, and 14 (25 %) within 60 days of an abnormal fecal test result. In adjusted analysis, Hispanics had lower odds of completing follow-up colonoscopy within 60 days than non-Hispanic whites (adjusted OR 0.20; 95 % CI 0.04, 0.92). Colonoscopy within 60 days trended lower for women than for men (adjusted OR 0.25; 95 % CI 0.06-1.04). Among the 24 patients lacking medical record evidence of a colonoscopy, 19 (79 %) had a documented reason, including clinician did not pursue, patient refused, and colonoscopy not indicated. No reason was found for 21 %. Improvements are needed to increase rates of follow-up colonoscopy completion, especially among female and Hispanic patients.

Screening of colorectal cancer: present and future

INTRODUCTION

Colorectal cancer (CRC) is the third most common cancer in males and second in females, and the fourth most common cause of cancer death worldwide. Currently, about 60-70% of diagnosed cases in symptomatic patients are detected at an advanced stage of disease. Earlier stage detection through the use of screening strategies would allow for better outcomes in terms of reducing the disease burden. Areas covered: The aim of this paper is to review the current published evidence from literature which assesses the performance and effectiveness of different screening tests for the early detection of CRC. Expert commentary: Adequate screening strategies can reduce CRC incidence and mortality. In the last few decades, several tests have been proposed for CRC screening. To date, there is still insufficient evidence to identify which approach is definitively superior, and no screening strategy for CRC can therefore be defined as universally ideal. The best strategy would be the one that can be economically viable and to which the patient can adhere best to over time. The latest guidelines suggest colonoscopy every 10 years or annual fecal immuno-chemical test (FIT) for people with normal risk, while for individuals with high risk or hereditary syndromes specific recommendations are provided.

Interventions to Improve Follow-up of Positive Results on Fecal Blood Tests: A Systematic Review

BACKGROUND

Fecal immunochemical testing is the most commonly used method for colorectal cancer screening worldwide. However, its effectiveness is frequently undermined by failure to obtain follow-up colonoscopy after positive test results.

PURPOSE

To evaluate interventions to improve rates of follow-up colonoscopy for adults after a positive result on a fecal test (guaiac or immunochemical).

DATA SOURCES

English-language studies from the Cochrane Central Register of Controlled Trials, PubMed, and Embase from database inception through June 2017.

STUDY SELECTION

Randomized and nonrandomized studies reporting an intervention for colonoscopy follow-up of asymptomatic adults with positive fecal test results.

DATA EXTRACTION

Two reviewers independently extracted data and ranked study quality; 2 rated overall strength of evidence for each category of study type.

DATA SYNTHESIS

Twenty-three studies were eligible for analysis, including 7 randomized and 16 nonrandomized studies. Three were at low risk of bias. Eleven studies described patient-level interventions (changes to invitation, provision of results or follow-up appointments, and patient navigators), 5 provider-level interventions (reminders or performance data), and 7 system-level interventions (automated referral, precolonoscopy telephone calls, patient registries, and quality improvement efforts). Moderate evidence supported patient navigators and provider reminders or performance data. Evidence for system-level interventions was low. Seventeen studies reported the proportion of test-positive patients who completed colonoscopy compared with a control population, with absolute differences of -7.4 percentage points (95% CI, -19 to 4.3 percentage points) to 25 percentage points (CI, 14 to 35 percentage points).

LIMITATION

More than half of studies were at high or very high risk of bias; heterogeneous study designs and characteristics precluded meta-analysis.

CONCLUSION

Patient navigators and giving providers reminders or performance data may help improve colonoscopy rates of asymptomatic adults with positive fecal blood test results. Current evidence about useful system-level interventions is scant and insufficient.

PRIMARY FUNDING SOURCE

National Cancer Institute. (PROSPERO: CRD42016048286).

Colonoscopy and sigmoidoscopy use among older adults in different countries: A systematic review

Screening for colorectal cancer (CRC) by colonoscopy and sigmoidoscopy has been demonstrated to be effective in reducing CRC incidence and mortality, and they are increasingly employed as screening tests and for diagnostic purposes in many countries. We conducted a systematic review to provide up-to-date estimates on the utilization of lower gastrointestinal endoscopy (colonoscopy and sigmoidoscopy) in the general average-risk population in different countries. PubMed and Web of Science were searched for relevant articles published between 1 September 2008 and 31 October 2016. A total of 23 studies from the US and 20 studies from other countries were included in this review. Estimates from the US were highest, continued to increase over the past decade and reached 62% for colonoscopy use within 10years in people aged 50-75years in 2012. Endoscopy use in other countries was substantially lower (12-44% for lifetime colonoscopy use and 13-30% for recent colonoscopy use), except for Germany, where 55% of the screening-eligible population reported colonoscopy utilization within the previous 10years in 2008-2011. Both lifetime and recent endoscopy use increased with age and peaked at approximately 70-75years. Although several European and Asian countries have started to collect endoscopy utilization data through periodic national health surveys, more data are still much needed from non-US countries. With the implementation of CRC screening programs in an increasing number of countries, especially European countries, an increase in endoscopy use and subsequent reduction in CRC incidence and mortality in the years to come might be expected in those countries.

Colorectal Cancer Screening in Asia

PURPOSE OF REVIEW

Colorectal cancer (CRC) is increasing in Asia, especially in regions with higher levels of economic development. Several Asian countries have launched population CRC screening programs to combat this devastating disease because previous studies have demonstrated that either fecal occult blood test or lower gastrointestinal endoscopy can effectively reduce CRC mortality.

RECENT FINDINGS

Screening includes engaging the population, testing, administering a confirmation examination, and treating screening-detected neoplasms; thus, monitoring the whole process using measurable indicators over time is of utmost importance. Only when the quality of every step is secured can the effectiveness of CRC screening be maximized. Screening and verification examination rates remain low in Asian countries, and important infrastructure, including cancer or death registry systems, colonoscopy capacity, and reasonable subsidization for screening, is lacking or insufficient. Future research should identify potential local barriers to screening. Good communication and dialog among screening organizers, clinicians, professional societies, and public health workers are indispensible for successful screening programs.

Fecal Occult Blood Test Results of the National Colorectal Cancer Screening Program in South Korea (2006-2013)

There has been controversy regarding the clinical utility of fecal occult blood test (FOBT) as a screening tool for colorectal cancer (CRC) in the general population. The purpose of this study was to examine the results of Korea national CRC screening using FOBT from 2006 to 2013 and to evaluate the implementation of the program. We analyzed the results of FOBT, colonoscopy, and the side effects during colonoscopy for the subjects (n = 20,609,909) from the Korea National Health Insurance Cancer Screening database. For evaluation of Korea national CRC screening program implementation over the 8-year period, we calculated uptake rate, FOBT positivity rate, and subsequent test compliance rate. The overall uptake rate was 30.1%, with an increasing pattern from 2006 to 2011. A relatively higher FOBT positivity rate (6.4%) and lower subsequent test compliance rate (46.6%) were observed in comparison to the results previously reported in Western countries. Side effects reported within 3 months period after colonoscopy accounted for 0.17% of all procedures, with bleeding being the most prevalent type. Although the implementation of CRC screening program using FOBT in Korea seems successful, trends in key indicators for Korea national CRC screening program should be monitored continuously.

Colorectal cancer population screening programs worldwide in 2016: An update

Colorectal cancer (CRC) is the third most commonly diagnosed cancer in the world. The incidence and mortality show wide geographical variations. Screening is recommended to reduce both incidence and mortality. However, there are significant differences among studies in implementation strategies and detection. This review aimed to present the results and strategies of different screening programs worldwide. We reviewed the literature on national and international screening programs published in PubMed, on web pages, and in clinical guidelines. CRC Screening programs are currently underway in most European countries, Canada, specific regions in North and South America, Asia, and Oceania. The most extensive screening strategies were based on fecal occult blood testing, and more recently, the fecal immunochemical test (FIT). Participation in screening has varied greatly among different programs. The Netherlands showed the highest participation rate (68.2%) and some areas of Canada showed the lowest (16%). Participation rates were highest among women and in programs that used the FIT test. Men exhibited the greatest number of positive results. The FIT test has been the most widely used screening program worldwide. The advent of this test has increased participation rates and the detection of positive results.

Contribution of patient, physician, and environmental factors to demographic and health variation in colonoscopy follow-up for abnormal colorectal cancer screening test results

BACKGROUND

Patient, physician, and environmental factors were identified, and the authors examined the contribution of these factors to demographic and health variation in colonoscopy follow-up after a positive fecal occult blood test/fecal immunochemical test (FOBT/FIT) screening.

METHODS

In total, 76,243 FOBT/FIT-positive patients were identified from 120 Veterans Health Administration (VHA) facilities between August 16, 2009 and March 20, 2011 and were followed for 6 months. Patient demographic (race/ethnicity, sex, age, marital status) and health characteristics (comorbidities), physician characteristics (training level, whether primary care provider) and behaviors (inappropriate FOBT/FIT screening), and environmental factors (geographic access, facility type) were identified from VHA administrative records. Patient behaviors (refusal, private sector colonoscopy use) were estimated with statistical text mining conducted on clinic notes, and follow-up predictors and adjusted rates were estimated using hierarchical logistic regression.

RESULTS

Roughly 50% of individuals completed a colonoscopy at a VHA facility within 6 months. Age and comorbidity score were negatively associated with follow-up. Blacks were more likely to receive follow-up than whites. Environmental factors attenuated but did not fully account for these differences. Patient behaviors (refusal, private sector colonoscopy use) and physician behaviors (inappropriate screening) fully accounted for the small reverse race disparity and attenuated variation by age and comorbidity score. Patient behaviors (refusal and private sector colonoscopy use) contributed more to variation in follow-up rates than physician behaviors (inappropriate screening).

CONCLUSIONS

In the VHA, blacks are more likely to receive colonoscopy follow-up for positive FOBT/FIT results than whites, and follow-up rates markedly decline with advancing age and comorbidity burden. Patient and physician behaviors explain race variation in follow-up rates and contribute to variation by age and comorbidity burden. Cancer 2017;123:3502-12. Published 2017. This article is a US Government work and is in the public domain in the USA.

Association Between Time to Colonoscopy After a Positive Fecal Test Result and Risk of Colorectal Cancer and Cancer Stage at Diagnosis

IMPORTANCE

The fecal immunochemical test (FIT) is commonly used for colorectal cancer screening and positive test results require follow-up colonoscopy. However, follow-up intervals vary, which may result in neoplastic progression.

OBJECTIVE

To evaluate time to colonoscopy after a positive FIT result and its association with risk of colorectal cancer and advanced-stage disease at diagnosis.

DESIGN, SETTING, AND PARTICIPANTS

Retrospective cohort study (January 1, 2010-December 31, 2014) within Kaiser Permanente Northern and Southern California. Participants were 70 124 patients aged 50 through 70 years eligible for colorectal cancer screening with a positive FIT result who had a follow-up colonoscopy.

EXPOSURES

Time (days) to colonoscopy after a positive FIT result.

MAIN OUTCOMES AND MEASURES

Risk of any colorectal cancer and advanced-stage disease (defined as stage III and IV cancer). Odds ratios (ORs) and 95% CIs were adjusted for patient demographics and baseline risk factors.

RESULTS

Of the 70 124 patients with positive FIT results (median age, 61 years [IQR, 55-67 years]; men, 52.7%), there were 2191 cases of any colorectal cancer and 601 cases of advanced-stage disease diagnosed. Compared with colonoscopy follow-up within 8 to 30 days (n = 27 176), there were no significant differences between follow-up at 2 months (n = 24 644), 3 months (n = 8666), 4 to 6 months (n = 5251), or 7 to 9 months (n = 1335) for risk of any colorectal cancer (cases per 1000 patients: 8-30 days, 30; 2 months, 28; 3 months, 31; 4-6 months, 31; and 7-9 months, 43) or advanced-stage disease (cases per 1000 patients: 8-30 days, 8; 2 months, 7; 3 months, 7; 4-6 months, 9; and 7-9 months, 13). Risks were significantly higher for examinations at 10 to 12 months (n = 748) for any colorectal cancer (OR, 1.48 [95% CI, 1.05-2.08]; 49 cases per 1000 patients) and advanced-stage disease (OR, 1.97 [95% CI, 1.14-3.42]; 19 cases per 1000 patients) and more than 12 months (n = 747) for any colorectal cancer (OR, 2.25 [95% CI, 1.89-2.68]; 76 cases per 1000 patients) and advanced-stage disease (OR, 3.22 [95% CI, 2.44-4.25]; 31 cases per 1000 patients).

CONCLUSIONS AND RELEVANCE

Among patients with a positive fecal immunochemical test result, compared with follow-up colonoscopy at 8 to 30 days, follow-up after 10 months was associated with a higher risk of colorectal cancer and more advanced-stage disease at the time of diagnosis. Further research is needed to assess whether this relationship is causal.

Colorectal cancer-global burden, trends, and geographical variations

BACKGROUND

The aim of this study is to describe the trends and variations in the global burden of colorectal cancer (CRC).

METHODS

Data (2012-2030) relating to CRC was extracted from GLOBOCAN 2012 database and analyzed.

RESULTS

The results of our study demonstrate a rising global burden of colorectal cancer which persists until the year 2035 and likely beyond. The rise in the global burden is not uniform with significant variations influenced by geographic location, socio-economic status, age, and gender. Although the EURO region has the highest burden, Asia as a continent continues to bear the heaviest brunt of the disease. Although the burden of disease is higher in more developed regions, mortality is considerably higher in less developed regions and this gap widens over the next two decades. The disease predominantly affects the male gender across all regions of the world. Age has a complex relation with the burden of CRC and is affected by the cross-influences relating to socio-economic status.

CONCLUSIONS

The results of our study demonstrate a rising global burden of CRC with some unique variations. Knowledge of this data can increase awareness and help strategic targeting of efforts and resources.

Time to Colonoscopy after Positive Fecal Blood Test in Four U.S. Health Care Systems

BACKGROUND

To reduce colorectal cancer mortality, positive fecal blood tests must be followed by colonoscopy.

METHODS

We identified 62,384 individuals ages 50 to 89 years with a positive fecal blood test between January 1, 2011 and December 31, 2012 in four health care systems within the Population-Based Research Optimizing Screening through Personalized Regimens (PROSPR) consortium. We estimated the probability of follow-up colonoscopy and 95% confidence intervals (CI) using the Kaplan-Meier method. Overall differences in cumulative incidence of follow-up across health care systems were assessed with the log-rank test. HRs and 95% CIs were estimated from multivariate Cox proportional hazards models.

RESULTS

Most patients who received a colonoscopy did so within 6 months of their positive fecal blood test, although follow-up rates varied across health care systems (P <0.001). Median days to colonoscopy ranged from 41 (95% CI, 40-41) to 174 (95% CI, 123-343); percent followed-up by 12 months ranged from 58.1% (95% CI, 51.6%-63.7%) to 83.8% (95% CI, 83.4%-84.3%) and differences across health care systems were also observed at 1, 2, 3, and 6 months. Increasing age and comorbidity score were associated with lower follow-up rates.

CONCLUSION

Individual characteristics and health care system were associated with colonoscopy after positive fecal blood tests. Patterns were consistent across health care systems, but proportions of patients receiving follow-up varied. These findings suggest that there is room to improve follow-up of positive colorectal cancer screening tests.

IMPACT

Understanding the timing of colonoscopy after positive fecal blood tests and characteristics associated with lack of follow-up may inform future efforts to improve follow-up.

Outreach and Inreach Organized Service Screening Programs for Colorectal Cancer

BACKGROUND

Outreach (i.e., to invite those who do not use, or who under use screening services) and inreach (i.e., to invite an existing population who have already accessed the medical system) approaches may influence people to increase their use of screening test; however, whether their outcomes would be equivalent remains unclear.

METHODS

A total of 3,363,896 subjects, 50-69 years of age, participated in a colorectal cancer (CRC) screening program using biennial fecal immunochemical tests; 34.5% participated during 2004-2009 when the outreach approach alone was used, and 65.5% participated from 2010-2013 when outreach was integrated with an inreach approach. We compared the outcomes of the two approaches in delivery of screening services.

RESULTS

Coverage rates increased from 21.4% to 36.9% and the positivity rate increased from 4.0% to 7.9%, while referral for confirmatory diagnostic examinations declined from 80.0% to 53.3%. The first period detected CRC in 0.20% of subjects screened, with a positive predictive value (PPV) of 6.1%, and the second detected CRC in 0.34% of subjects, with a PPV of 8.0%. After adjusting for confounders, differences were observed in the PPV for CRC (adjusted relative risk, 1.50; 95% confidence interval [CI], 1.41-1.60), cancer detection rate (1.20; 95% CI, 1.13-1.27), and interval cancer rate (0.72; 95% CI, 0.65-0.80). When we focused on the comparison between two approaches during the same study period of 2010-2013, the positivity rate of fecal testing (8.2% vs. 7.6%) and the PPV for CRC detection remained higher (1.07; 95% CI, 1.01-1.12) in subjects who were recruited from the inreach approach.

CONCLUSIONS

Outcomes of screening were equivalent or better after integration of outreach and inreach approaches.

IMPACT

The results will encourage makers of health-care policy to adopt the integration approach to deliver screening services.

Preferences and acceptance of colorectal cancer screening in Thailand

Colorectal cancer (CRC) is now common in Thailand with an increase in incidence over time. Health authorities are planning to implement a nationwide CRC screening program using fecal immunochemical test (FIT) as a primary screening tool. This study aimed to estimate preferences and acceptance of FIT and colonoscopy, explore factors influencing the acceptance, and investigate reasons behind choosing and rejecting to screen before the program was implemented. Patients aged 50-69, visiting the primary care unit during the study period, were invited to join this study. Patients with a history of cancer or past CRC screening were excluded. Face-to-face interviews were conducted. Subjects were informed about CRC and the screening tests: FIT and colonoscopy. Then, they were asked for their opinions regarding the screening. The total number of subjects was 437 (86.7% response rate). Fifty-eight percent were females. The median age was 58 years. FIT was accepted by 74.1% of subjects compared to 55.6% for colonoscopy. The acceptance of colonoscopy was associated with perceived susceptibility to CRC and family history of cancer. No symptoms, unwilling to screen, healthy, too busy and anxious about diagnosis were reasons for refusing to screen. FIT was preferred for its simplicity and non-invasiveness compared with colonoscopy. Those rejecting FIT expressed a strong preference for colonoscopy. Subjects chose colonoscopy because of its accuracy; it was refused for the process and complications. If the screening program is implemented for the entire target population in Thailand, we estimate that 106,546 will have a positive FIT, between 8,618 and 12,749 identified with advanced adenoma and between 2,645 and 3,912 identified with CRC in the first round of the program.

Colorectal cancer screening: a global overview of existing programmes

Colorectal cancer (CRC) ranks third among the most commonly diagnosed cancers worldwide, with wide geographical variation in incidence and mortality across the world. Despite proof that screening can decrease CRC incidence and mortality, CRC screening is only offered to a small proportion of the target population worldwide. Throughout the world there are widespread differences in CRC screening implementation status and strategy. Differences can be attributed to geographical variation in CRC incidence, economic resources, healthcare structure and infrastructure to support screening such as the ability to identify the target population at risk and cancer registry availability. This review highlights issues to consider when implementing a CRC screening programme and gives a worldwide overview of CRC burden and the current status of screening programmes, with focus on international differences.

Lack of follow-up colonoscopy after positive FOBT in an organized colorectal cancer screening program is associated with modifiable health care practices

BACKGROUND

ColonCancerCheck (CCC), Ontario's organized colorectal cancer (CRC) screening program, uses guaiac fecal occult blood testing (gFOBT). To reduce CRC-related mortality, persons with a positive gFOBT must have colonoscopy. We identified factors associated with failure to have colonoscopy within 6months of a positive gFOBT.

METHODS

Population-based, retrospective cohort analysis of CCC participants with positive gFOBT (April 2008 to December 2009) using health administrative data. Patient, physician and health care utilization factors associated with a lack of follow-up colonoscopy were identified using descriptive and multivariate analyses.

RESULTS

There were 21,839 participants with a positive gFOBT; 14,091 (64%) had colonoscopy within 6months. The strongest factors associated with failure to follow-up were recent colonoscopy (in 2years prior vs. >10years or never, OR: 4.31, 95% C.I.: 3.82, 4.86), as well as repeat gFOBT (OR: 6.08, 95% C.I.: 5.46, 6.78) and hospital admission (OR: 4.35, 95% C.I.: 3.57, 5.26) in the follow-up period.

CONCLUSION

In the first 18months of the CCC Program, 1/3 of those with a positive gFOBT did not have colonoscopy within 6months. Identification of potentially modifiable factors associated with failure to follow up lay the groundwork for interventions to address this critical quality gap.

Organizational predictors of colonoscopy follow-up for positive fecal occult blood test results: an observational study

BACKGROUND

This study assessed the contribution of organizational structures and processes identified from facility surveys to follow-up for positive fecal occult blood tests [FOBT-positive (FOBT(+))].

METHODS

We identified 74,104 patients with FOBT(+) results from 98 Veterans Health Administration (VHA) facilities between August 16, 2009 and March 20, 2011, and followed them until September 30, 2011, for completion of colonoscopy. We identified patient characteristics from VHA administrative records, and organizational factors from facility surveys completed by primary care and gastroenterology chiefs. We estimated predictors of colonoscopy completion within 60 days and six months using hierarchical logistic regression models.

RESULTS

Thirty percent of patients with FOBT(+) results received colonoscopy within 60 days and 49% within six months. Having gastroenterology or laboratory staff notify gastroenterology providers directly about FOBT(+) cases was a significant predictor of 60-day [odds ratio (OR), 1.85; P = 0.01] and six-month follow-up (OR, 1.25; P = 0.008). Additional predictors of 60-day follow-up included adequacy of colonoscopy appointment availability (OR, 1.43; P = 0.01) and frequent individual feedback to primary care providers about FOBT(+) referral timeliness (OR, 1.79; P = 0.04). Additional predictors of six-month follow-up included using guideline-concordant surveillance intervals for low-risk adenomas (OR, 1.57; P = 0.01) and using group appointments and combined verbal-written methods for colonoscopy preparation instruction (OR, 1.48; P = 0.0001).

CONCLUSION

Directly notifying gastroenterology providers about FOBT(+) results, using guideline-concordant adenoma surveillance intervals, and using colonoscopy preparations instruction methods that provide both verbal and written information may increase overall follow-up rates. Enhancing follow-up within 60 days may require increased colonoscopy capacity and feedback to primary care providers.

IMPACT

These findings may inform organizational-level interventions to improve FOBT(+) follow-up.

Cancer control programs in East Asia: evidence from the international literature

Cancer is a major cause of mortality and morbidity throughout the world, including the countries of North-East and South-East Asia. Assessment of burden through cancer registration, determination of risk and protective factors, early detection and screening, clinical practice, interventions for example in vaccination, tobacco cessation efforts and palliative care all should be included in comprehensive cancer control programs. The degree to which this is possible naturally depends on the resources available at local, national and international levels. The present review concerns elements of cancer control programs established in China, Taiwan, Korea, and Japan in North-East Asia, Viet Nam, Thailand, Malaysia, and Indonesia as representative larger countries of South-East Asia for comparison, using the published literature as a guide. While major advances have been made, there are still areas which need more attention, especially in South-East Asia, and international cooperation is essential if standard guidelines are to be generated to allow effective cancer control efforts throughout the Far East.

Cancer is a major cause of mortality and morbidity throughout the world, including the countries of North-East and South-East Asia. Assessment of burden through cancer registration, determination of risk and protective factors, early detection and screening, clinical practice, interventions for example in vaccination, tobacco cessation efforts and palliative care all should be included in comprehensive cancer control programs. The degree to which this is possible naturally depends on the resources available at local, national and international levels. The present review concerns elements of cancer control programs established in China, Taiwan, Korea, and Japan in North-East Asia, Viet Nam, Thailand, Malaysia, and Indonesia as representative larger countries of South-East Asia for comparison, using the published literature as a guide. While major advances have been made, there are still areas which need more attention, especially in South-East Asia, and international cooperation is essential if standard guidelines are to be generated to allow effective cancer control efforts throughout the Far East.

Diagnostic performance of guaiac-based fecal occult blood test in routine screening: state-wide analysis from Bavaria, Germany

OBJECTIVES

Randomized trials have shown that annual or biannual screening by guaiac-based fecal occult blood tests (gFOBTs) reduces colorectal cancer (CRC) mortality. Few clinical studies have evaluated diagnostic performance of gFOBT through validation by colonoscopy in all participants. We aimed for a comprehensive evaluation of diagnostic performance of gFOBT by age and sex under routine screening conditions.

METHODS

Our analysis is based on 20,884 colonoscopies following up a positive gFOBT and 182,956 primary screening colonoscopies documented in a state-wide quality assurance program in Bavaria, Germany, in 2007-2009. Positive likelihood ratios (LR+), which represent an integrative measure of diagnostic performance, were derived, by age groups (55-59, 60-64, 65-69, 70-74 years) and sex, from a joint and comparative analysis of prevalences of colorectal neoplasms in both groups.

RESULTS

Overall LR+ (95% confidence intervals) were 1.11 (1.06-1.15), 1.80 (1.72-1.88), and 5.04 (4.64-5.47) for non-advanced adenoma, advanced adenoma, and cancer, respectively. Assuming a specificity of gFOBT of 95.2%, as recently observed in a German study among 2,235 participants of screening colonoscopy, these LR+ would translate to sensitivities of 5.3%, 8.6%, and 24.2% for the three outcomes, respectively. Diagnostic performance was similarly poor among women and men and across age groups.

CONCLUSIONS

The performance of gFOBT under routine screening conditions is even worse than previously estimated from clinical studies. In routine screening application, gFOBTs are expected to miss more than 9 out of 10 advanced adenomas and 3 out of 4 cancers. These results underline the need and the potential for better noninvasive CRC screening tests.