Performance measures in three rounds of the English bowel cancer screening pilot

Impact of screening participation on modelled mortality benefits of a multi-cancer early detection test by socioeconomic group in England

BACKGROUND

Cancer burden is higher and cancer screening participation is lower among individuals living in more socioeconomically deprived areas of England, contributing to worse health outcomes and shorter life expectancy. Owing to higher multi-cancer early detection (MCED) test sensitivity for poor-prognosis cancers and greater cancer burden in groups experiencing greater deprivation, MCED screening programmes may have greater relative benefits in these groups. We modelled potential differential benefits of MCED screening between deprivation groups in England at different levels of screening participation.

METHODS

We applied the interception multi-cancer screening model to cancer incidence and survival data made available by the National Cancer Registration and Analysis Service in England to estimate reductions in late-stage diagnoses and cancer mortality from an MCED screening programme by deprivation group across 24 cancer types. We assessed the impact of varying the proportion of people who participated in annual screening in each deprivation group on these estimates.

RESULTS

The modelled benefits of an MCED screening programme were substantial: reductions in late-stage diagnoses were 160 and 274 per 100 000 persons in the least and most deprived groups, respectively. Reductions in cancer mortality were 60 and 99 per 100 000 persons in the least and most deprived groups, respectively. Benefits were greatest in the most deprived group at every participation level and were attenuated with lower screening participation.

CONCLUSIONS

For the greatest possible population benefit and to decrease health inequalities, an MCED implementation strategy should focus on enhancing equitable, informed participation, enabling equal participation across all socioeconomic deprivation groups.

TRIAL REGISTRATION NUMBER

NCT05611632.

Trends in pathology diagnoses during 10 years of a colorectal cancer screening programme

AIMS

We report pathology findings from the first 10 years of the faecal-occult blood-based Northern Ireland Bowel Cancer Screening Programme, presenting summary data and trends in pathology diagnoses and clinicopathological features of screen-detected cancers.

METHODS AND RESULTS

Data were analysed from a comprehensive polyp-level pathology database representing all endoscopy specimens from programme inception in 2010 until 2021. A total of 9800 individuals underwent 13 472 endoscopy procedures, yielding 25 967 pathology specimens and 32 119 diagnoses. Index specimen diagnoses (4.1%) and index colonoscopies (10.4%) yielded a diagnosis of colorectal cancer, representing 1045 cancers from 1020 individuals (25 with synchronous cancers). A further 13 index cancers were identified via computed tomography colonography; 65.3% of cancer diagnoses were in males; 41.7% were stage I, 23.1% stage II, 25.8% stage III and 1.8% stage IV (7.6% unstaged). Of 233 pT1 cancers diagnosed within local excision specimens, 79 (33.9%) had completion surgery. Ten-year trends showed a steady decline in the proportion of index colonoscopies that yielded a diagnosis of cancer (14.7% in year 1; 4.8% in year 11) or advanced colorectal polyp. There was a strong upward trend in diagnoses of sessile serrated lesions, which overtook hyperplastic polyps in proportions of total index diagnoses by the end of the study time-frame (8.7% compared to 8.5%).

CONCLUSIONS

Over the first 10 years of a population colorectal cancer screening programme, 'real world' pathology data demonstrate success in the form of reduced diagnoses of cancer and advanced colorectal polyp with passage of successive screening rounds. Interesting trends with respect to serrated polyp diagnoses are also evident, probably related to pathologist and endoscopist behaviour.

Colorectal cancer incidence trends by tumour location among adults of screening-age in England: a population-based study

AIM

Proximal and distal colorectal cancers (CRCs) exhibit different clinical, molecular and biological patterns. The aim of this study was to determine temporal trends in the age-standardized incidence rates (ASIRs) of proximal and distal CRC following the introduction of the English Bowel Cancer Screening Programme (BCSP) in 2006.

METHOD

The National Cancer Registration and Analysis Service database was used to identify incident cases of CRC among adults of screening age (60-74 years) between 2001 and 2017. ASIRs were calculated using the European Standard Population 2013 and incidence trends analysed by anatomical subsite (proximal, caecum to descending colon; distal, sigmoid to rectum), sex and Index of Multiple Deprivation (IMD) quintile using Joinpoint regression software.

RESULTS

Between 2001 and 2017, 541 515 incident cases of CRC were diagnosed [236 167 proximal (43.6%) and 305 348 distal (56.4%)]. A marginal reduction in the proximal ASIR was noted from 2008 [annual percentage change (APC) -1.4% (95% CI -2.0% to -0.9%)] compared with a greater reduction in distal ASIR from 2011 to 2014 [APC -6.6% (95% CI -11.5% to -1.5%)] which plateaued thereafter [APC -0.5% (95% CI -3.2% to 2.2%)]. Incidence rates decreased more rapidly in men than women. Adults in IMD quintiles 4-5 experienced the greatest reduction in distal tumours [APC -3.5% (95% CI -4.3% to -2.7%)].

CONCLUSION

Following the introduction of the English BCSP, the incidence of CRC has subsequently reduced among adults of screening age, with this trend being most pronounced in distal tumours and in men. There is also evidence of a reduction in the deprivation gap for distal tumour incidence. Strategies to improve the detection of proximal tumours are warranted.

Inequalities in cancer screening, prevention and service engagement between UK ethnic minority groups

More people in the UK are living with cancer than ever before. With an increasingly ethnically diverse population, greater emphasis must be placed on understanding factors influencing cancer outcomes. This review seeks to explore UK-specific variations in engagement with cancer services in minority ethnic groups and describe successful interventions. The authors wish to highlight that, despite improvement to engagement and education strategies, inequalities still persist and work to improve cancer outcomes across our communities still needs to be prioritised. There are many reasons why cancer healthcare inequities exist for minority communities, reported on a spectrum ranging from cultural beliefs and awareness, through to racism. Strategies that successfully enhanced engagement included language support; culturally-sensitive reminders; community-based health workers and targeted outreach. Focusing on the diverse city of Leicester the authors describe how healthcare providers, researchers and community champions have worked collectively, delivering targeted community-based strategies to improve awareness and access to cancer services.

Contextual factors associated with cancer screening uptake: A systematic review of observational studies

We conducted a systematic review of a wide range of contextual factors related to cancer screening uptake that have been studied so far. Studies were identified through PubMed and Web of Science databases. An operational definition of context was proposed, considering as contextual factors: social relations directly aimed at cancer screening, health care provider and facility characteristics, geographical/accessibility measures and aggregated measures at supra-individual level. We included 70 publications on breast, cervical and/or colorectal cancer screening from 42 countries, covering a data period of 24 years. A wide diversity of factors has been investigated in the literature so far. While several of them, as well as many interactions, were robustly associated with screening uptake (family, friends or provider recommendation, provider sex and experience, area-based socio-economic status…), others showed less consistency (ethnicity, urbanicity, travel time, healthcare density …). Screening inequities were not fully explained through adjustment for individual and contextual factors. Context, in its diversity, influences individual screening uptake and lots of contextual inequities in screening are commonly shared worldwide. However, there is a lack of frameworks, standards and definitions that are needed to better understand what context is, how it could modify individual behaviour and the ways of measuring and modifying it.

[Colorectal cancer screening program : Test completion rate and follow-up results after selective mailing of the test kit, based on likelihood of participation]

BACKGROUND

Even though theinterest of a Colorectal-Cancer Screening Program has been amply demonstrated, in French departments the participation rate (PR) seldom reaches 45%. In the absence of mass mailing, a strategy (S-1) consisting in mailing a test kit to people having made a request was implemented in 2015. In 2017, another mailing strategy (S-2), which consisted in sending the test kit only to people likely to take the test, was programmed. This study assesses the respective impact of these two strategies as compared to the standard approach (S-0).

METHODS

The study included 254,113 (S-0), 4,130 (S-1) and 10,887 (S-2) people aged 50-74, targeted during the 2016-2017 campaign in Seine-Saint-Denis (France). S-0 persons received a 2nd reminder without a test-kit, while S-1 persons received, at their request, a mailed test kit. Without having made a request, S-2 persons the mailed test kit according to probability of participation (Proba) which was estimated a priori by the ratio between the sum total of index values (frequency of previous participation, date of most recent participation, age) and a theoretical maximum. Completion rates (test/colonoscopy) were compared 18 months after the last S-2 kit was sent.

RESULTS

PR was highest in S-1 (S-0: 5.8%, S-1: 74.9%, S-2: 31.3%; p < 0.0001). In S-2, PR rose as Proba increased (Proba: ]0-30%], ]30-50%], ]50-75%], ]75-100%]; PR: 21.1%, 23.3%, 36.2%, 52.8% respectively; p < 0.05). Compared to the ≥70 years age-group, the 50-54 years age-group presented a lower PR in S-1 (65.9% vs. 85.1%; p < 0.05) whereas it presented a higher PR in S-0 (4.3% vs. 7.1%; p < 0.05) and in S-2 (23.2% vs. 54.5%; p < 0.05). All in all, colonoscopy completion rates were highest in S-1 (S-0: 62.2%, S-1: 80.0%, S-2: 65.0%; p < 0.001).

CONCLUSION

Test-kit mailing without spontaneous request does not lead to an optimal level of participation, thereby highlighting a need to give thought to new and improved mobilization methods. The relatively pronounced participation of younger persons, who are not favored by present-day testing specifications, underscores the interest of a specific approach addressed to active people, who are less inclined than elderly individuals to regularly consult their attending physicians.

Factors Related to Non-participation in the Basque Country Colorectal Cancer Screening Programme

Background: Despite the high participation rates in the Basque Country, colorectal cancer screening programme (Spain), there is still a part of the population that has never participated. Since it is essential to ensure equal access to health services, it is necessary to identify the determinants of health and socio-economic factors related to non-participation in the screening programme. Methods: Cross sectional descriptive study including all invited population in a complete round between 2015 and the first trimester of 2017. Health risk factors available in medical records and their control have been analyzed using univariate and multivariate analyses. Results: 515,388 people were invited at the programme with a 71.9% of fecal immunochemical test participation rate. Factors that increase the risk of non-participation are: being men (OR = 1.10, 95% CI 1.09-1.12); younger than 60 (OR = 1.18, 95% CI 1.17-1.20); smoker (OR = 1.20, 95% CI 1.18-1.22); hypertensive (OR = 1.14, 95% CI 1.12-1.15) and diabetic (OR = 1.40, 95% CI 1.36-1.43); having severe comorbidity (OR = 2.09, 95% CI 2.00-2.19) and very high deprivation (OR = 1.15, 95% CI 1.12-1.17), as well as making <6 appointments to Primary Care in 3 years (OR = 2.39, 95% CI 2.33-2.45). Still, the area under the curve (AUC) indicates that there are more factors related to non-participation. Conclusions: The participation in the Basque Country colorectal cancer-screening Programme is related to some risk factors controlled by Primary Care among others. Therefore, the involvement of these professionals could improve, not only the adherence to the CRC screening, but also other health styles and preventive interventions.

Cluster randomized controlled trial of volitional and motivational interventions to improve bowel cancer screening uptake: A population-level study

OBJECTIVES

Colorectal cancer (CRC) is a leading cause of cancer death worldwide, although effective uptake of bowel cancer screening is below 60% in England. This trial investigated the influence of volitional and motivational interventions and their combination on increasing guaiac fecal occult blood testing (gFOBT) screening uptake.

METHOD

In total, 34,633 participants were recruited (via North-East of England bowel cancer screening hub) into a 2×2 factorial cluster randomized controlled trial. Social norm-based motivational intervention (SNA); Implementation intention-based Volitional Help Sheet (VHS); Combined intervention (SNA+VHS); Treatment as usual control. Screening rate (gFOBT kit return rate within 8 weeks of invitation) was the primary outcome.

RESULTS

Screening kits were returned by 60% of participants (N=20,847/34,633). A substantial imbalance was observed in participant characteristics, participants in the combined intervention group were younger and more likely to be first time invitees. Adjusted analyses found insufficient evidence that any of the interventions were different to control (Combined: OR = 1.18, 95% CI 0.97-1.44; SNA alone: OR=0.93; 95% CI: 0.76-1.15; VHS alone OR= 0.88; 95% CI: 0.75-1.03). Subgroup analyses demonstrated a significant beneficial effect of the combined intervention in the youngest age group compared to control (OR = 1.27; 95% CI: 1.05-1.54).

CONCLUSIONS

The study did not support any benefit of either VHS or SNA interventions alone on bowel cancer screening uptake. The combined SNA+VHS intervention was significantly different from control only in the youngest age group in adjusted analyses. However, the magnitude of effect in the youngest age group suggests that further testing of VHS plus SNA interventions in carefully targeted populations may be warranted.

Are there ethnic and religious variations in uptake of bowel cancer screening? A retrospective cohort study among 1.7 million people in Scotland

OBJECTIVE

Cancer screening should be equitably accessed by all populations. Uptake of colorectal cancer screening was examined using the Scottish Health and Ethnicity Linkage Study that links the Scottish Census 2001 to health data by individual-level self-reported ethnicity and religion.

SETTING

Data on 1.7 million individuals in two rounds of the Scottish Bowel Cancer Screening Programme (2007-2013) were linked to the 2001 Census using the Scottish Community Health Index number.

MAIN OUTCOME MEASURE

Uptake of colorectal cancer screening, reported as age-adjusted risk ratios (RRs) by ethnic group and religion were calculated for men and women with 95% CI.

RESULTS

In the first, incidence screening round, compared with white Scottish men, Other White British (RR 109.6, 95% CI 108.8 to 110.3) and Chinese (107.2, 95% CI 102.8 to 111.8) men had higher uptake. In contrast, men of all South Asian groups had lower uptake (Indian RR 80.5, 95% CI 76.1 to 85.1; Pakistani RR 65.9, 95% CI 62.7 to 69.3; Bangladeshi RR 76.6, 95% CI 63.9 to 91.9; Other South Asian RR 88.6, 95% CI 81.8 to 96.1). Comparable patterns were seen among women in all ethnic groups, for example, Pakistani (RR 55.5, 95% CI 52.5 to 58.8). Variation in uptake was also observed by religion, with lower rates among Hindu (RR (95%CI): 78.4 (71.8 to 85.6)), Muslim (69.5 (66.7 to 72.3)) and Sikh (73.4 (67.1 to 80.3)) men compared with the reference population (Church of Scotland), with similar variation among women: lower rates were also seen among those who reported being Jewish, Roman Catholic or with no religion.

CONCLUSIONS

There are important variations in uptake of bowel cancer screening by ethnic group and religion in Scotland, for both sexes, that require further research and targeted interventions.

Do we know the effects of colorectal cancer screening? A short communication on selective uptake and differential effects of colorectal cancer screening in Scandinavia

Colorectal cancer (CRC) contributes extensively to the overall cancer burden, with substantial and increasing social inequality in both incidence and survival. In several countries, this social inequality in incidence and survival has been increasing over time, and the increase is expected to continue. To overcome this, it is advised to implement nationwide CRC screening programmes, as these are effective in detecting possible signs of CRC, hence identifying earlier-stage cancer and reducing mortality. However, little is known about the distribution of these effects across population groups. It is possible that the outcomes of CRC screening are not equally distributed among participants, but rather that the screening programme serves some population groups better than others. The aim of this short communication based on published data is to describe the status of selective uptake according to sociodemographic and economic factors in CRC screening in Scandinavia. Furthermore, we raise questions that need to be addressed in future research in order to grasp the full effects of the screening programme and ultimately to ensure high uptake as well as participation in subsequent diagnostic procedures across population groups.

Trends and Predictors for the Uptake of Colon Cancer Screening Using the Fecal Occult Blood Test in Spain from 2011 to 2017

Background: In Spain, colorectal cancer screening using the fecal occult blood test, targeted towards the 50–69 age bracket, was implemented on different dates. We aim to assess the temporal trend of colorectal cancer (CRC) screening uptake according to the year of screening implementation in each region and to identify predictors for the uptake of CRC screening. Methods: A cross-sectional study with 12,657 participants from the Spanish National Health Surveys 2011 and 2017 was used. Uptake rates were analyzed according to the date that the screening program was implemented. Results: For regions with programs implemented before 2011, the uptake rate increased 3.34-fold from 2011 to 2017 (9.8% vs. 32.7%; p < 0.001). For regions that implemented screening within the 2011–2016 period, the uptake rose from 4.3% to 13.2% (3.07-fold; p < 0.001), and for regions that implemented screening after 2016, the uptake increased from 3.4% to 8.8% (2.59-fold; p < 0.001). For the entire Spanish population, the uptake increased 3.21-fold (6.8% vs. 21.8%; p < 0.001). Positive predictors for uptake were older age, Spanish nationality, middle-to-high educational level, suffering chronic diseases, non-smoking and living in regions where screening programs were implemented earlier. Conclusions: The different periods for the implementation of CRC screening as well as sociodemographic and health inequalities may have limited the improvement in the screening uptake from 2011 to 2017 in Spain.

Gender differences in stage at diagnosis and preoperative radiotherapy in patients with rectal cancer

Background

Few studies have examined gender differences in the clinical management of rectal cancer. We examine differences in stage at diagnosis and preoperative radiotherapy in rectal cancer patients.

Methods

A prospective cohort study was conducted in 22 hospitals in Spain including 770 patients undergoing surgery for rectal cancer. Study outcomes were disseminated disease at diagnosis and receiving preoperative radiotherapy. Age, comorbidity, referral from a screening program, diagnostic delay, distance from the anal verge, and tumor depth were considered as factors that might explain gender differences in these outcomes.

Results

Women were more likely to be diagnosed with disseminated disease among those referred from screening (odds ratio, confidence interval 95% (OR, CI = 7.2, 0.9–55.8) and among those with a diagnostic delay greater than 3 months (OR, CI = 5.1, 1.2–21.6). Women were less likely to receive preoperative radiotherapy if they were younger than 65 years of age (OR, CI = 0.6, 0.3–1.0) and if their tumors were cT3 or cT4 (OR, CI = 0.5, 0.4–0.7).

Conclusions

The gender-specific sensitivity of rectal cancer screening tests, gender differences in referrals and clinical reasons for not prescribing preoperative radiotherapy in women should be further examined. If these gender differences are not clinically justifiable, their elimination might enhance survival.

Predictors of overall and test-specific colorectal Cancer screening adherence

This study investigated predictors of overall and test-specific colorectal cancer screening (CRCS). Stool blood test (SBT) and/or colonoscopy screening were offered to primary care patients in two randomized controlled trials which assessed the impact of behavioral interventions on screening. Data were obtained through surveys and electronic medical records. Among 1942 participants, 646 (33%) screened. Exposure to interventions was associated with higher overall CRCS by twofold to threefold; older age, African American race, being married, and having a higher screening decision stage were also associated with higher overall CRCS (odds ratios = 1.30, 1.31, 1.34, and 5.59, respectively). Intervention, older age, female gender, and being married were associated with higher SBT adherence, while preference for colonoscopy was associated with lower SBT adherence. Intervention and higher decision stage were associated with higher colonoscopy adherence, while preference for SBT was associated with lower colonoscopy adherence. Among older individuals, African Americans had higher overall CRCS than whites, but this was not true among younger individuals (interaction p = .041). The higher screening adherence of African Americans over whites was due to stronger screening with a non-preferred test, i.e., higher SBT adherence only among individuals who preferred colonoscopy and higher colonoscopy adherence only among individuals who preferred SBT. Intervention exposure, sociodemographic background, and screening decision stage predicted overall CRCS adherence. Gender and test preference also affected test-specific screening adherence. Interactions involving race and test preference suggest that it is important to provide both colonoscopy and SBT screening options to patients, particularly African Americans.

Market segmentation tools provide insights into demographic variations in bowel cancer screening uptake

Background

The National Health Service Bowel Cancer Screening Programme (NHS BCSP) aims to detect individuals who have precancerous polyps or early stage cancer, when it is easier to treat. To be effective, a screening uptake of at least 52% is required. Variations in uptake by demographic characteristic are reported and the aim of this study was to better understand who participates in the NHS BCSP, to inform action to address inequalities in screening uptake.

Methods

Invitation-level data for the Derbyshire population were supplied by the NHS BCSP Eastern Hub for the period 1 April 2014 to 31 March 2016. Data were linked by postal code to the Mosaic Public Sector Segmentation tool. Descriptive analysis using 14 groups and 61 types within Mosaic was undertaken to offer insight into the demographic, lifestyle and behavioural traits of people living in small geographies against their screening uptake, with a particular focus on identifying population groups with an uptake below 52% and so at risk of health inequalities.

Results

180 176 screening invitations were dispatched with an overall uptake of 60.55%. Six Mosaic groups have an uptake below the 52% acceptable level: urban cohesion, rental hubs, transient renters, family basics, vintage value and municipal tenants. These groups are characterised by high levels of social-rented accommodation, multicultural urban communities and transient populations.

Conclusion

Segmentation tools offer an effective way to generate novel insights into bowel cancer screening uptake and develop tailored strategies for working with identified communities to increase participation.

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.

Postoperative Outcomes of Screen-Detected vs Non-Screen-Detected Colorectal Cancer in the Netherlands

Importance

The nationwide fecal immunochemical test-based screening program has influenced surgical care for patients with colorectal cancer (CRC) in the Netherlands, although these implications have not been studied in much detail so far.

Objective

To compare surgical outcomes of patients diagnosed as having CRC through the fecal immunochemical test-based screening program (screen detected) and patients with non-screen-detected CRC.

Design, Setting, and Participants

This was a population-based comparative cohort study using the Dutch ColoRectal Audit and analyzed all Dutch hospitals performing CRC resections. Patients who underwent elective resection for CRC between January 2011 to December 2016 were included.

Interventions

Colorectal cancer surgery.

Main Outcomes and Measures

Postoperative nonsurgical complications, postoperative surgical complications, postoperative 30-day or in-hospital mortality, and complicated course (postoperative complication resulting in a hospital stay >14 days and/or a reintervention and/or mortality). A risk-stratified comparison was made for different postoperative outcomes based on screening status (screen detected vs not screen detected), cancer stage (I-IV), and for cancer stage I to III also on age (aged ≤70 years and >70 years) and American Society of Anesthesiologists score (I-II and III-IV). To determine any residual case-mix-corrected differences in outcomes between patients with screen-detected and non-screen-detected cancer, univariable and multivariable logistic regression analyses were performed.

Results

In total, 36 242 patients with colon cancer and 17 416 patients with rectal cancer were included for analysis. Compared with patients with non-screen-detected CRC, screen-detected patients were younger (mean [SD] age, 68 [5] vs 70 [11] years), more often men (3777 [60%] vs 13 506 [57%]), and had lower American Society of Anesthesiologists score (American Society of Anesthesiologists score III+: 838 [13%] vs 5529 [23%]). Patients with stage I to III colon cancer who were screen detected had a significantly lower mortality and complicated course rate compared with non-screen-detected patients. For patients with rectal cancer, only a significant difference was found in mortality rate in patients with a cancer stage IV disease, which was higher in the screen-detected group. Compared with non-screen-detected colon cancer, an independent association was found for screen-detected colon cancer on nonsurgical complications (adjusted odds ratio, 0.81; 95% CI, 0.73-0.91), surgical complications (adjusted odds ratio, 0.80; 95% CI, 0.72-0.89), and complicated course (adjusted odds ratio, 0.80; 95% CI, 0.71-0.90). Screen-detected rectal cancer had significantly higher odds on mortality.

Conclusions and Relevance

Postoperative outcomes were significantly better for patients with colon cancer referred through the fecal immunochemical test-based screening program compared with non-screen-detected patients. These differences were not found in patients with rectal cancer. The outcomes of patients with screen-detected colon cancer were still better after an extensive case-mix correction, implying additional underlying factors favoring patients referred for surgery through the screening program.

Scottish Bowel Screening Programme colonoscopy quality - scope for improvement?

AIM

The delivery of the Scottish Bowel Screening Programme (SBoSP) is rooted in the provision of a high quality, effective and participant-centred service. Safe and effective colonoscopy forms an integral part of the process. Additional accreditation as part of a multi-faceted programme for participating colonoscopists, as in England, does not exist in Scotland. This study aimed to describe the quality of colonoscopy in the SBoSP and compare this to the English national screening standards.

METHODS

Data were collected from the SBoSP between 2007 and 2014. End-points for analysis were caecal intubation, cancer, polyp and adenoma detection, and complications. Overall results were compared with 2012 published English national standards for screening and outcomes from 2006 to 2009.

RESULTS

During the study period 53 332 participants attended for colonoscopy. The colonoscopy completion rate was 95.6% overall. The mean cancer detection rate was 7.1%, the polyp detection rate was 45.7% and the adenoma detection rate was 35.5%. The overall complication rate was 0.47%.

CONCLUSION

Colonoscopy quality in the SBoSP has exceeded the standard set for screening colonoscopy in England, despite not adopting a multi-faceted programme for screening colonoscopy. However, the overall adenoma detection rate in Scotland was 9.1% lower than that in England which has implications for colonoscopy quality and may have an impact on cancer prevention rates, a key aim of the SBoSP.

Risk of Oral and Upper Gastrointestinal Cancers in Persons With Positive Results From a Fecal Immunochemical Test in a Colorectal Cancer Screening Program

BACKGROUND & AIMS

European guidelines recommend screening for colorectal cancer (CRC) using the fecal immunochemical test (FIT), with follow-up colonoscopies for individuals with positive test results. However, more than half of participants with positive results from the FIT are not found to have advanced neoplasia in the colonoscopy examination. Fecal occult blood might also come from the upper gastrointestinal (GI) tract, so perhaps we should consider esophagogastroduodenoscopy (EGD), to detect upper GI cancers. We aimed to determine how many individuals are found to have oral or upper GI cancers (oral cavity, throat, esophageal, gastric, or small bowel cancer) within 3 years after a positive or negative result from a FIT in a CRC screening program.

METHODS

We performed a retrospective analysis of data from a pilot study of 3 rounds of biennial FIT-based screening for CRC in 2 regions in the west of the Netherlands, from 2006 through October 2012. Participants who developed oral or upper GI cancers were identified through linkage with the National Cancer Registry. We classified these cancers into 3 groups: those that developed in individuals with a positive result from a FIT but negative findings from colonoscopy (no advanced neoplasia), those that developed in individuals with a positive result from a FIT and a positive finding from colonoscopy (advanced neoplasia), and those that developed in individuals with negative results from a FIT. We compared oral and upper GI cancer incidence among groups.

RESULTS

Among 16,165 screening participants, linkage identified 52 persons who developed an oral or upper GI cancer within 3 years after a FIT. We found no significant difference in incidence values between individuals with a positive vs a negative FIT result: 8 cancers developed in individuals with a positive result from a FIT (0.37%; 95% CI, 0.19-0.76) and 44 developed in individuals with a negative result from a FIT (0.31%; 95% CI, 0.23-0.42) (P = .65). Of the 8 individuals with a positive result from a FIT and an oral or upper GI cancer, 6 were diagnosed after negative findings from colonoscopy and 2 after positive findings from colonoscopy. We found that only 0.14% of all persons with a positive result from a FIT were diagnosed with a gastric or esophageal cancer within 3 years.

CONCLUSION

In a study of individuals in the Netherlands undergoing screening for CRC by FIT, we found fewer than 1% of patients with a positive result from the FIT to receive a diagnosis of upper GI cancers within 3 years. Routine EGD investigation of individuals with positive results from a FIT and negative findings from colonoscopy is therefore not recommended. TrialRegister.nl, Number: NTR5385.

The contribution of a negative colorectal screening test result to symptom appraisal and help-seeking behaviour among patients subsequently diagnosed with an interval colorectal cancer

Background

Colorectal cancer (CRC) screening programmes using a guaiac faecal occult blood test (gFOBt) reduce CRC mortality. Interval cancers are diagnosed between screening rounds: reassurance from a negative gFOBt has the potential to influence the pathway to diagnosis of an interval colorectal cancer.

Methods

Twenty‐six semi‐structured face‐to‐face interviews were carried out in Scotland and England, with individuals diagnosed with an interval colorectal cancer following a negative gFOBt result.

Results

Participants reported they were reassured by a negative gFOBt, interpreting their result as an “all clear”. Therefore, most did not suspect cancer as a possible cause of symptoms and many did not recall their screening result during symptom appraisal. Among those who did consider cancer, and did think about their screening test result, reassurance from a negative gFOBt led some to “downplay” the seriousness of their symptoms with some interviewees explicitly stating that their negative test result contributed to a delayed decision to seek help.

Conclusion

Screening participants need to be informed of the limitations of screening and the ongoing risk of developing colorectal cancer even when in receipt of a negative result: the importance of minimizing delay in seeking medical advice for colorectal symptoms should be emphasized.

Informing future research for carriage of multiresistant Gram-negative bacteria: problems with recruiting to an English stool sample community prevalence study

OBJECTIVES

This study aims to highlight problems with recruiting to an English stool sample community prevalence study. It was part of a larger cross-sectional research to determine the risk factors for the presence of extended-spectrum beta-lactamase and carbapenemase-producing coliforms in stool samples of the asymptomatic general English population.

SETTING

Four National Health Service primary care trusts (PCTs) of England representing a different section of the population of England: Newham PCT; Heart of Birmingham Teaching PCT; Shropshire County PCT; and Southampton City PCT.

PARTICIPANTS

Sixteen general practices across the four PCTs were purposefully selected. After stratification of GP lists by age, ethnicity and antibiotic use, 58 337 randomly selected patients were sent a postal invitation.Patients who had died, moved to a different surgery, were deemed too ill by their General Practitioner or hospitalised at the time of mailing were excluded.

RESULTS

Stool and questionnaire returns varied by area, age, gender and ethnicity; the highest return rate of 27.3% was in Shropshire in the age group of over 60 years; the lowest, 0.6%, was in Birmingham in the age group of 18-39 years. Whereas only 3.9%(2296) returned a completed questionnaire and stool sample, 94.9% of participants gave permission for their sample and data to be used in future research.

CONCLUSION

Researchers should consider the low stool specimen return rate and wide variation by ethnicity and age when planning future studies involving stool specimen collection. This is particularly pertinent if the study has no health benefit to participants. Further research is needed to explore how to improve recruitment in multicultural communities and in younger people.

Possible missed opportunities for diagnosing colorectal cancer in Dutch primary care: a multimethods approach

BACKGROUND

Early detection of colorectal cancer (CRC) is important to achieve better survival. Discriminating symptoms suggestive of CRC from benign conditions is a challenge for GPs because most known 'alarm symptoms' have low predictive values.

AIM

To further understand the diagnostic process of CRC in general practice in terms of healthcare use and by analysing factors related to diagnostic intervals.

DESIGN AND SETTING

A multimethod approach comprising a historical, prospective registry study and qualitative content analysis.

METHOD

Healthcare use in the year before referral for colonoscopy was compared between patients diagnosed with CRC and an age-, sex,- and GP-matched control population. Qualitative content analysis was performed on free texts in electronic patient records from a purposive sample of patients with CRC.

RESULTS

Patients with CRC (n = 287) had 41% (25-59%) more face-to-face contacts and 21% (7-37%) more medication prescriptions than controls (n = 828). Forty-six per cent of patients with CRC had two or more contacts for digestive reasons, compared with 12.2% of controls, more often for symptoms than diagnoses. From qualitative analysis two themes emerged: 'possible missed diagnostic opportunities' and 'improvements in diagnostic process unlikely'. Possible missed diagnostic opportunities were related to patients waiting before presenting symptoms, doctors attributing symptoms to comorbid conditions or medication use, or doctors sticking to an initial diagnosis.

CONCLUSION

Fewer missed diagnostic opportunities might occur if GPs are aware of pitfalls in diagnosing CRC: the assumption that symptoms are caused by comorbid conditions or medication, or relating complaints to pre-existing medical conditions. GPs also need to be aware that repeated digestive complaints warrant rethinking an earlier diagnosis.

Evaluation of a prediction model for colorectal cancer: retrospective analysis of 2.5 million patient records

Earlier detection of colorectal cancer greatly improves prognosis, largely through surgical excision of neoplastic polyps. These include benign adenomas which can transform over time to malignant adenocarcinomas. This progression may be associated with changes in full blood count indices. An existing risk algorithm derived in Israel stratifies individuals according to colorectal cancer risk using full blood count data, but has not been validated in the UK. We undertook a retrospective analysis using the Clinical Practice Research Datalink. Patients aged over 40 with full blood count data were risk‐stratified and followed up for a diagnosis of colorectal cancer over a range of time intervals. The primary outcome was the area under the receiver operating characteristic curve for the 18–24‐month interval. We also undertook a case–control analysis (matching for age, sex, and year of risk score), and a cohort study of patients undergoing full blood count testing during 2012, to estimate predictive values. We included 2,550,119 patients. The area under the curve for the 18–24‐month interval was 0.776 [95% confidence interval (CI): 0.771, 0.781]. Performance improves as the time interval reduces. The area under the curve for the age‐matched case–control analysis was 0.583 [0.574, 0.591]. For the population risk‐scored in 2012, the positive predictive value at 99.5% specificity was 8.8% with negative predictive value 99.6%. The algorithm offers an additional means of identifying risk of colorectal cancer, and could support other approaches to early detection, including screening and active case finding.

Initial participation as a predictor for continuous participation in population-based colorectal cancer screening

Objectives

To assess patterns and probabilities of participation in multiple rounds of colorectal cancer screening.

Methods

All individuals who were invited to participate in population-based colorectal cancer screening in the Stockholm-Gotland region in Sweden between 1 January 2008 and 30 September 2015 were included in the study. Guaiac-based faecal occult blood testing was used. All individuals invited to the three first consecutive screening rounds were included in the analysis.

Results

There were 346,168 individuals eligible for invitation to screening. The average participation rate during the follow-up period was 60%. Eligible individuals could be invited 1–4 times, depending on age at first invitation. Of 48,959 individuals invited to the three first consecutive rounds of screening, 71% participated at least once, and 50% participated in all three rounds. Participation at first invitation was a predictor for participation in subsequent rounds, and the likelihood of continuous participation following participation in the first round was 84%. Of those who attended the first and second rounds, 93% also participated in the third round. Similar patterns of consistency were seen among non-participants. For individuals not participating in the first screening round, the likelihood of consistent non-participation was 71.

Conclusions

Participation in the first round of screening is a strong predictor for participation in subsequent rounds. Therefore, reducing barriers for initial participation is a key for achieving consistent participation over several rounds in organized colorectal cancer screening programmes.

Interval Colorectal Cancer Incidence Among Subjects Undergoing Multiple Rounds of Fecal Immunochemical Testing

BACKGROUND & AIMS

Among subjects screened for colorectal cancer (CRC) by the guaiac fecal occult blood test, interval cancers develop in 48% to 55% of the subjects. Data are limited on how many persons screened by fecal immunochemical tests (FIT), over multiple rounds, develop interval cancers. In the Netherlands, a pilot FIT-based biennial CRC screening program was conducted between 2006 and 2014. We collected and analyzed data from the program on CRCs detected during screening (SD-CRC) and CRCs not detected within the screening program (non-SD-CRC; such as FIT interval cancers, colonoscopy interval cancers, and cancer in nonparticipants).

METHODS

Screenees with a negative FIT result received a letter explaining that no blood had been detected in the stool sample and were re-invited, if eligible, for screening biennially. Screenees with a positive FIT result (hemoglobin concentration of 10 μg Hb/g feces) were invited for consultation and scheduled for colonoscopy; results were collected. After the fourth round of FIT screening, the cohort was linked to the Netherlands Cancer Registry, through March 31, 2015; participant characteristics, data on tumor stage, location (at time of resection), and survival status were collected for all identified CRC cases. A reference group comprised all persons with CRC diagnosed in the Netherlands general population during the same period, in the same age range (50-76 years), who had not been offered CRC screening. The median time between invitations (2.37 years) was used as a cutoff to categorize participants within the FIT interval cancer category. We compared participant characteristics, tumor characteristics, and mortality among subjects with SD-CRC and with non-SD-CRC.

RESULTS

A total of 27,304 eligible individuals were invited for FIT screening, of whom 18,716 (69%) participated at least once. Of these, 3005 (16%) had a positive result from the FIT in 1 of the 4 screening rounds. In total, CRC was detected in 261 participants: 116 SD-CRCs and 145 non-SD-CRCs (27 FIT interval cancers, 9 colonoscopy interval cancers, and 109 CRCs in nonparticipants). The FIT interval cancer proportion after 3 completed screening rounds was 23%. Participants with SD-CRC had more early-stage tumors than participants with non-SD-CRCs (P < .001). Of persons with SD-CRC and FIT interval cancers, significantly higher proportions survived (89% and 81%, respectively) compared with persons with colonoscopy interval cancers (44% survival) and nonparticipants with CRC (60% survival) (P < .001).

CONCLUSIONS

In an analysis of data from a pilot FIT-based biennial screening program, we found that among persons screened by FIT, 23% developed FIT interval cancer. FIT therefore detects CRC with 77% sensitivity. The proportion of FIT interval cancers in FIT screening appears to be lower than that with guaiac fecal occult blood testing. Clinical trial registry: yes, www.trialregister.nl, trial number: NTR5385.

Approaching the Hard-to-Reach in Organized Colorectal Cancer Screening: an Overview of Individual, Provider and System Level Coping Strategies

BACKGROUND

Despite the proven effectiveness of colorectal cancer (CRC) screening on reduction of CRC mortality, the uptake of CRC screening remains low. Participation rate is one of determinants for the success of organized population-based screening program. This review aims to identify those who are hard-to-reach, and summarize the strategies to increase their screening rate from individual, provider and system levels.

METHODS

A systematic search of electronic English databases was conducted on the factors and strategies of uptake in CRC screening for the hard-to-reach population up to May 2017.

DISCUSSION

The coverage rate and participation rate are two indexes to identify the hard-to-reach population in organized CRC screening program. However, the homeless, new immigrants, people with severe mental illness, the jail intimates, and people with characteristics including lower education levels and/or low socioeconomic status, living in rural/remote areas, without insurance, and racial minorities are usually recognized as hard-to-reach populations. For them, organized screening programs offer a better coverage, while novel invitation approaches for eligible individuals and multiple strategies from primary care physicians are still needed to enhance screening rates among subjects who are hard-to-reach. Suggestions implied the effectiveness of interventions at the system level, including linkages to general practice; use of decision making tools; enlisting supports from coalition; and the continuum from screening to diagnosis and treatment.

CONCLUSION

Organized CRC screening offers a system access to approach the hard-to-reach populations. To increase their uptake, multiple and novel strategies from individual, provider and system levels should be applied. For policymakers, public healthcare providers and community stakeholders, it is a test to tailor their potential needs and increase their participation rates through continuous efforts to eliminate disparities and inequity in CRC screening service.

Association between socioeconomic deprivation and colorectal cancer screening outcomes: Low uptake rates among the most and least deprived people

Background

Screening with faecal occult blood tests reduces colorectal cancer-related mortality; however, age, sex and socioeconomic factors affect screening outcomes and could lead to unequal mortality benefits. The aim of this study was to describe the main outcomes of the population-based Barcelona colorectal cancer screening programme (BCRCSP) by deprivation.

Methods

Retrospective study of the eligible population of the first round of the BCRCSP. Participants’ postal addresses were linked with the MEDEA database to obtain the deprivation quintiles (Dq). Chi-squared tests were used to compare proportions across variables and logistic regression was used to estimate the adjusted effects of age, sex and deprivation on uptake, FIT positivity, colonoscopy adherence and advanced neoplasia detection rate.

Results

Overall uptake was 44.7%, higher in Dq2, 3 and 4 (OR 1.251, 1.250 and 1.276, respectively) than in the least deprived quintile (Dq 1), and lowest in Dq5 (OR 0.84). Faecal immunochemical test (FIT) positivity and the percentage of people with detectable faecal haemoglobin below the positivity threshold increased with deprivation. The advanced neoplasia detection rate was highest in Dq4.

Conclusion

Unlike most regions where inequalities are graded along the socioeconomic continuum, inequalities in the uptake of colorectal cancer screening in Spain seem to be concentrated first in the most disadvantaged group and second in the least deprived group. The correlation of deprivation with FIT-positivity and faecal haemoglobin below the positivity threshold is worrying due to its association with colorectal cancer and overall mortality.

CT colonography: role in FOBT-based screening programs for colorectal cancer

Computed tomographic colonography (CTC) is a minimally invasive imaging examination for the colon, and is safe, well tolerated and accurate for the detection of colorectal cancer (CRC) and advanced adenoma. While the role of CTC as a primary test for population screening of CRC is under investigation, the fecal occult blood test (FOBT) has been recommended for population screening of CRC in Europe. Subjects with positive FOBT are invited to undergo total colonoscopy, which has some critical issues, such as suboptimal compliance, contraindications and the possibility of an incomplete exploration of the colon. Based on available data, the integration of CTC in FOBT-based population screening programs for CRC may fall into three scenarios. First, CTC is recommended in FOBT-positive subjects when colonoscopy is refused, incomplete or contraindicated. For these indications CTC should replace double-contrast barium enema. Second, conversely, CTC is not currently recommended as a second-level examination prior to colonoscopy in all FOBT-positive subjects, as this strategy is most probably not cost-effective. Finally, CTC may be considered instead of colonoscopy for surveillance after adenoma removal, but specific studies are needed.

Colorectal and interval cancers of the Colorectal Cancer Screening Program in the Basque Country (Spain)

AIM

To assess proportions, related conditions and survival of interval cancer (IC).

METHODS

The programme has a linkage with different clinical databases and cancer registers to allow suitable evaluation. This evaluation involves the detection of ICs after a negative faecal inmunochemical test (FIT), interval cancer FIT (IC-FIT) prior to a subsequent invitation, and the detection of ICs after a positive FIT and confirmatory diagnosis without colorectal cancer (CRC) detected and before the following recommended colonoscopy, IC-colonoscopy. We conducted a retrospective observational study analyzing from January 2009 to December 2015 1193602 invited people onto the Programme (participation rate of 68.6%).

RESULTS

Two thousand five hundred and eighteen cancers were diagnosed through the programme, 18 cases of IC-colonoscopy were found before the recommended follow-up (43542 colonoscopies performed) and 186 IC-FIT were identified before the following invitation of the 769200 negative FITs. There was no statistically significant relation between the predictor variables of ICs with sex, age and deprivation index, but there was relation between location and stage. Additionally, it was observed that there was less risk when the location was distal rather than proximal (OR = 0.28, 95%CI: 0.20-0.40, P < 0.0001), with no statistical significance when the location was in the rectum as opposed to proximal. When comparing the screen-detected cancers (SCs) with ICs, significant differences in survival were found (P < 0.001); being the 5-years survival for SCs 91.6% and IC-FIT 77.8%.

CONCLUSION

These findings in a Population Based CRC Screening Programme indicate the need of population-based studies that continue analyzing related factors to improve their detection and reducing harm.

Embedded survey study harms colorectal cancer screening attendance: Experiences from Finland 2010 to 2015

Objective We previously found that administering a pre-screening lifestyle questionnaire lowered the subsequent attendance proportion in the first-ever colorectal cancer screening. We sought to determine whether the effect continued in subsequent screening rounds. Methods The eligible survey cohort ( n = 10,375) received a follow-up questionnaire in 2012, and in 2013, they were invited for colorectal cancer screening for the second time. For the third screening round, in 2015, no questionnaires were sent in the previous year. Screening attendance in 2013 and in 2015 was examined in relation to survey mailings. Results The colorectal cancer screening attendance rate in 2013 was 58.4% in the survey population, and 63.9% in those not surveyed ( P < 0.001). In 2015, the screening attendance rate was 61.7% among those who had been sent the questionnaires in 2010 and in 2012, and 66.2% in those not surveyed ( P < 0.001). The reduction in screening attendance was greater at the second (2013) round than at the first (2011). Conclusion The effect of the initial survey seemed to continue even when no questionnaires were being sent. Attendance among those who had been sent questionnaires earlier did not reach the level of the group that was never surveyed.

The relationship between ethnicity, social deprivation and late presentation of colorectal cancer

INTRODUCTION

Tumour staging at time of presentation is an important factor in determining survival in colorectal cancer. The aim of this paper is to investigate the relationship between ethnicity and deprivation in late (Stage IV) presentation of colorectal cancer.

METHODS

Data from the Thames Cancer Registry comprising 77,057 colorectal cancer patients between the years 2000 and 2012 were analysed.

RESULTS

A total of 17,348 patients were identified with complete data, of which 53.9% were male. Patients from a Black Afro/Caribbean background were diagnosed with CRC at a much younger age than the White British group (median age 67 compared with 72, p<0.001). In multiple regression, ethnicity, deprivation and age were positive predictors of presenting with advanced tumour stage at time of diagnosis. Black patients were more likely to present with Stage IV tumours than white patients (OR 1.37, 95% CI 1.18-1.59, p<0.001). Social deprivation was also a predictor of Stage IV cancer presentation, with the most deprived group (Quintile 5) 1.26 times more likely to be diagnosed with Stage IV cancer compared with the most affluent group (CI 1.13-1.40, p<0.001). Sub-group analyses demonstrated that Black & Affluent patients were still at greater risk of Stage IV CRC than their White & Affluent counterparts (OR 1.24, 95% CI 1.11-1.45, p=0.023). Patients with rectal cancer were less likely to present with Stage IV CRC (OR 0.66, 95% CI 0.61-0.71, p<0.001).

CONCLUSION

Racial and age related disparities exist in tumour presentation in the United Kingdom. Patients from black and socially deprived backgrounds as well as the elderly are more likely to present with advanced tumours at time of diagnosis.

Uptake trends in the Scottish Bowel Screening Programme and the influences of age, sex, and deprivation

Objective Age, sex, and deprivation are known factors influencing colorectal (bowel) cancer screening uptake. We investigated the influence of these factors on uptake over time. Methods Data from the Scottish Bowel Screening Programme (SBoSP) were collected between 2007 and 2014. End-points for analysis were uptake, faecal occult blood test positivity, and disease detection, adjusted for age, sex, deprivation, and year of screening. Results From 5,308,336 individual screening episodes documented, uptake gradually increased with increasing age up to 65-69 and was lower in men than women (52.4% vs. 58.7%, respectively). Deprivation had a significant effect on uptake by men and women of all age groups, with the most deprived least likely to complete a screening test. Uptake has increased with time in both sexes and across the deprivation gradient. The number needed to screen to detect significant neoplasia was significantly lower in men than women overall (170 vs. 365), and this held over all age and deprivation groups. The number needed to screen was also lower in the more deprived population. Conclusions Although lower age, male sex, and increased deprivation are associated with lower bowel cancer screening uptake in Scotland, uptake has increased since SBoSP introduction in all age groups, both sexes, and across the deprivation gradient. Despite a lower uptake, the number needed to screen to find significant disease was lower in men and in those with higher levels of deprivation.

The information needs of adult cancer survivors across the cancer continuum: A scoping review

OBJECTIVE

To provide an updated synthesis of the literature that investigates the self-reported information needs of people diagnosed with cancer across the cancer continuum.

METHODS

We conducted a scoping review of the literature published from August 2003 to June 2015 and expanded an existing typology summarizing the information needs of people diagnosed with cancer.

RESULTS

The majority of the included studies (n=104) focused on questions relevant to the diagnosis/active treatment phase of the cancer continuum (52.9%) and thus the most frequently identified information needs related to this phase (33.4%). Information needs varied across the continuum and the results highlight the importance of recognising this fact.

CONCLUSION

People diagnosed with cancer experience discrete information needs at different points from diagnosis to survival. Much of the research conducted in this area has focused on their information needs during the diagnosis and treatment of cancer, and literature relating to information needs following completion of treatment is sparse.

PRACTICE IMPLICATIONS

Further research is needed to discern the specific nature of the treatment concerns and identify the information needs that survivors experience during recurrence of cancer, metastasis or changes in diagnosis, and the end of life phase of the cancer continuum.

Incidence of interval cancers in faecal immunochemical test colorectal screening programmes in Italy

Objective

In Italy, colorectal screening programmes using the faecal immunochemical test from ages 50 to 69 every two years have been in place since 2005. We aimed to measure the incidence of interval cancers in the two years after a negative faecal immunochemical test, and compare this with the pre-screening incidence of colorectal cancer.

Methods

Using data on colorectal cancers diagnosed in Italy from 2000 to 2008 collected by cancer registries in areas with active screening programmes, we identified cases that occurred within 24 months of negative screening tests. We used the number of tests with a negative result as a denominator, grouped by age and sex. Proportional incidence was calculated for the first and second year after screening.

Results

Among 579,176 and 226,738 persons with negative test results followed up at 12 and 24 months, respectively, we identified 100 interval cancers in the first year and 70 in the second year. The proportional incidence was 13% (95% confidence interval 10–15) and 23% (95% confidence interval 18–25), respectively. The estimate for the two-year incidence is 18%, which was slightly higher in females (22%; 95% confidence interval 17–26), and for proximal colon (22%; 95% confidence interval 16–28).

Conclusion

The incidence of interval cancers in the two years after a negative faecal immunochemical test in routine population-based colorectal cancer screening was less than one-fifth of the expected incidence. This is direct evidence that the faecal immunochemical test-based screening programme protocol has high sensitivity for cancers that will become symptomatic.

Interval cancers in a guaiac-based colorectal cancer screening programme: Consequences on sensitivity

Objective

To evaluate interval cancers in the population-based colorectal cancer screening programme of Stockholm/Gotland, Sweden.

Methods

From 2008, individuals aged 60–69 were invited to colorectal cancer screening using biennial guaiac-based faecal occult blood test (Hemoccult®). Interval cancers, defined as colorectal cancer among participants not diagnosed by the screening programme but registered in the Swedish cancer register, were evaluated by cross-checking the screening histories for all cancers in the region 2008–2012.

Results

Of 203,848 individuals from nine different birth cohorts who participated (∼60%), 4530 (2.2%) tested positive. All invited individuals were followed up for 24 months after invitation. The cancer register reported 557 colorectal cancer, 219 (39.3%) screen-detected cancers and 338 (60.7%) interval cancers, generating both test- and episode sensitivities of approximately 40% and an interval cancer-rate of 17.1/10,000 tests. Among individuals with positive tests without colorectal cancer diagnosed at work-up colonoscopy, 37 interval cancers (10.9%) occurred. There was statistically significant lower sensitivity in women, ranging 22.4–32.2%, compared with 43.2–52.0% in men. Age-group and tumour location were not strongly correlated to screen-detected cancer rates. The programme sensitivity increased by year (20.3–25.0%), with successively more colorectal cancers diagnosed within the expanding programme (11.6–16.2%).

Conclusion

Interval cancer is a quality indicator of a screening programme. As the interval cancer-rate determined in a well-organized population-based screening programme was actually higher than the screen-detected cancer rate, a change to a more sensitive screening test is indicated. The lower screen-detected cancers among women, and compliance and quality of work-up colonoscopies also need attention.

Adherence to colorectal cancer screening: four rounds of faecal immunochemical test-based screening

BACKGROUND

The effectiveness of faecal immunochemical test (FIT)-based screening programs is highly dependent on consistent participation over multiple rounds. We evaluated adherence to FIT screening over four rounds and aimed to identify determinants of participation behaviour.

METHODS

A total of 23 339 randomly selected asymptomatic persons aged 50-74 years were invited for biennial FIT-based colorectal cancer screening between 2006 and 2014. All were invited for every consecutive round, except for those who had moved out of the area, passed the upper age limit, or had tested positive in a previous screening round. A reminder letter was sent to non-responders. We calculated participation rates per round, response rates to a reminder letter, and differences in participation between subgroups defined by age, sex, and socioeconomic status (SES).

RESULTS

Over the four rounds, participation rates increased significantly, from 60% (95% CI 60-61), 60% (95% CI 59-60), 62% (95% CI 61-63) to 63% (95% CI 62-64; P for trend<0.001) with significantly higher participation rates in women in all rounds (P<0.001). Of the 17 312 invitees eligible for at least two rounds of FIT screening, 12 455 (72%) participated at least once, whereas 4857 (28%) never participated; 8271 (48%) attended all rounds when eligible. Consistent participation was associated with older age, female sex, and higher SES. Offering a reminder letter after the initial invite in the first round increased uptake with 12%; in subsequent screening rounds this resulted in an additional uptake of up to 10%.

CONCLUSIONS

In four rounds of a pilot biennial FIT-screening program, we observed a consistently high and increasing participation rate, whereas sending reminders remain effective. The substantial proportion of inconsistent participants suggests the existence of incidental barriers to participation, which, if possible, should be identified and removed.

Characteristics of men responding to an invitation to undergo testing for prostate cancer as part of a randomised trial

BACKGROUND

Sociodemographic characteristics are associated with participating in cancer screening and trials. We compared the characteristics of those responding with those not responding to a single invitation for prostate-specific antigen (PSA) testing for prostate cancer as part of the Cluster randomised triAl of PSA testing for Prostate cancer (CAP).

METHODS

Age, rurality and deprivation among 197,763 men from 271 cluster-randomised primary care centres in the UK were compared between those responding (n = 90,300) and those not responding (n = 100,953) to a prostate cancer testing invitation.

RESULTS

There was little difference in age between responders and nonresponders. Responders were slightly more likely to come from urban rather than rural areas and were slightly less deprived than those who did not respond.

CONCLUSION

These data indicate similarities in age and only minor differences in deprivation and urban location between responders and nonresponders. These differences were smaller, but in the same direction as those observed in other screening trials.

TRIAL REGISTRATION

ISRCTN92187251 . Registered on 29 November 2004.

The associations between objective numeracy and colorectal cancer screening knowledge, attitudes and defensive processing in a deprived community sample

We examined associations between numeracy and sociocognitive factors associated with colorectal cancer screening uptake (n = 964). Nearly half (45.7%) of the respondents incorrectly answered a numeracy question (low numeracy). Low numeracy respondents were less knowledgeable about colorectal cancer (p < .001), less positive towards screening (emotional, p < .001 and practical, p = .001) and less likely to intend to participate in screening (p = .001). They also reported greater defensive processing of cancer information (p = .001). Sociocognitive factors fully mediated the relationship between numeracy and screening intention. Addressing numeracy issues may reduce inequalities in CRC screening participation, but communication strategies could be limited by the tendency process cancer information defensively.

Understanding of a negative bowel screening result and potential impact on future symptom appraisal and help-seeking behaviour: a focus group study

Background

Colorectal cancer (CRC) screening using a faecal occult blood test (FOBt) has the potential to reduce cancer‐related mortality. Symptom vigilance remains crucial as a proportion of cancers will be diagnosed between screening rounds. A negative FOBt has the potential to influence how participants respond to future symptoms of CRC.

Objective

To explore (i) understanding of a negative FOBt and (ii) the potential impact of a negative FOBt upon future symptom appraisal and help‐seeking behaviour.

Design

Qualitative methodology utilizing focus groups with participants who received a negative FOBt within the National Bowel Cancer Screening Programme in Coventry and Lothian. Topics explored included: experience of screening participation, interpretation and understanding of a negative result, symptom awareness and attitudes towards help‐seeking.

Results

Four broad themes were identified: (i) emotional response to a negative FOBt, (ii) understanding the limitations of FOBt screening, (iii) symptom knowledge and interpretation and (iv) over‐reassurance from a negative FOBt. Participants were reassured by a negative FOBt, but there was variability in the extent to which the result was interpreted as an “all clear”. Some participants acknowledged the residual risk of cancer and the temporal characteristic of the result, while others were surprised that the result was not a guarantee that they did not have cancer.

Discussion and conclusions

Participants recognized that reassurance from a negative FOBt could lead to a short‐term delay in help‐seeking if symptoms developed. Screening programmes should seek to emphasize the importance of the temporal nature of FOBt results with key messages about symptom recognition and prompt help‐seeking behaviour.

Uptake of Bowel Scope (Flexible Sigmoidoscopy) Screening in the English National Programme: the first 14 months

OBJECTIVE

To examine uptake in the first six pilot centres of the English Bowel Scope Screening (BSS) programme, which began in early 2013 and invites adults aged 55 for a one off Flexible Sigmoidoscopy.

METHODS

Between March 2013 and May 2014 the six pilot centres sent 21,187 invitations. Using multivariate logistic regression analysis, we examined variation in uptake by gender, socioeconomic deprivation (using the Index of Multiple Deprivation), area-based ethnic diversity (proportion of non-white residents), screening centre, and appointment time (routine: daytime vs out-of-hours: evening/weekend).

RESULTS

Uptake was 43.1%. Men were more likely to attend than women (45% vs 42%; OR 1.136, 95% CI 1.076, 1.199, p < 0.001). Combining data across centres, there was a socioeconomic gradient in uptake, ranging from 33% in the most deprived to 53% in the least deprived quintile. Areas with the highest level of ethnic diversity also had lower uptake (39%) than other areas (41-47%) (all p < 0.02), but there was no gradient. Individuals offered a routine appointment were less likely to attend than those offered an out-of-hours appointment (42% vs. 44%; OR 0.931, 95% CI 0.882, 0.983, p = 0.01). Multivariate analyses confirmed independent effects of deprivation, gender, and centre, but not of ethnic diversity or appointment time.

CONCLUSION

Early indications of uptake are encouraging. Future efforts should focus on increasing public awareness of the programme and reducing socioeconomic inequalities.

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.

Implications of polygenic risk for personalised colorectal cancer screening

BACKGROUND

We modelled the utility of applying a personalised screening approach for colorectal cancer (CRC) when compared with standard age-based screening. In this personalised screening approach, eligibility is determined by absolute risk which is calculated from age and polygenic risk score (PRS), where the PRS is relative risk attributable to common genetic variation. In contrast, eligibility in age-based screening is determined only by age.

DESIGN

We calculated absolute risks of CRC from UK population age structure, incidence and mortality rate data, and a PRS distribution which we derived for the 37 known CRC susceptibility variants. We compared the number of CRC cases potentially detectable by personalised and age-based screening. Using Genome-Wide Complex Trait Analysis to calculate the heritability attributable to common variation, we repeated the analysis assuming all common CRC risk variants were known.

RESULTS

Based on the known CRC variants, individuals with a PRS in the top 1% have a 2.9-fold increased CRC risk over the population median. Compared with age-based screening (aged 60: 10-year absolute risk 1.96% in men, 1.19% in women, as per the UK NHS National Bowel Screening Programme), personalised screening of individuals aged 55-69 at the same risk would lead to 16% fewer men and 17% fewer women being eligible for screening with 10% and 8%, respectively, fewer screen-detected cases. If all susceptibility variants were known, individuals with a PRS in the top 1% would have an estimated 7.7-fold increased risk. Personalised screening would then result in 26% fewer men and women being eligible for screening with 7% and 5% fewer screen-detected cases.

CONCLUSION

Personalised screening using PRS has the potential to optimise population screening for CRC and to define those likely to maximally benefit from chemoprevention. There are however significant technical and operational details to be addressed before any such programme is introduced.

Colorectal Cancer Screening Programme in Spain: Results of Key Performance Indicators After Five Rounds (2000-2012)

Effective quality assurance is essential in any screening programme. This article provides a unique insight into key quality indicators of five rounds of the first population-based colorectal cancer screening programme implemented in Spain (2000–2012), providing the results according to the type of screening (prevalent or first screen and incident or subsequent screen) and test (guaiac or immunochemical). The total crude participation rate increased from 17.2% (11,011) in the first round to 35.9% (22,988) in the last one. Rescreening rate was very high (88.6% in the fifth round). Positivity rate was superior with the faecal immunochemical test (6.2%) than with the guaiac-based test (0.7%) (p < 0.0001) and detection rates were also better with the immunochemical test. The most significant rise in detection rate was observed for high risk adenoma in men (45.5 per 1,000 screened). Most cancers were diagnosed at an early stage (61.4%) and there was a statistically significant difference between those detected in first or subsequent screening (52.6% and 70.0% respectively; p = 0.024). The availability of these results substantially improves data comparisons and the exchange of experience between screening programmes.

Factors associated with completion of bowel cancer screening and the potential effects of simplifying the screening test algorithm

Background:

The primary colorectal cancer screening test in England is a guaiac faecal occult blood test (gFOBt). The NHS Bowel Cancer Screening Programme (BCSP) interprets tests on six samples on up to three test kits to determine a definitive positive or negative result. However, the test algorithm fails to achieve a definitive result for a significant number of participants because they do not comply with the programme requirements. This study identifies factors associated with failed compliance and modifications to the screening algorithm that will improve the clinical effectiveness of the screening programme.

Methods:

The BCSP Southern Hub data for screening episodes started in 2006–2012 were analysed for participants aged 60–69 years. The variables included age, sex, level of deprivation, gFOBt results and clinical outcome.

Results:

The data set included 1 409 335 screening episodes; 95.08% of participants had a definitively normal result on kit 1 (no positive spots). Among participants asked to complete a second or third gFOBt, 5.10% and 4.65%, respectively, failed to return a valid kit. Among participants referred for follow up, 13.80% did not comply. Older age was associated with compliance at repeat testing, but non-compliance at follow up. Increasing levels of deprivation were associated with non-compliance at repeat testing and follow up. Modelling a reduction in the threshold for immediate referral led to a small increase in completion of the screening pathway.

Conclusions:

Reducing the number of positive spots required on the first gFOBt kit for referral for follow-up and targeted measures to improve compliance with follow-up may improve completion of the screening pathway.

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.

Social Cognitive Mediators of Sociodemographic Differences in Colorectal Cancer Screening Uptake

Background. This study examined if and how sociodemographic differences in colorectal cancer (CRC) screening uptake can be explained by social cognitive factors. Methods. Face-to-face interviews were conducted with individuals aged 60–70 years (n = 1309) living in England as part of a population-based omnibus survey. Results. There were differences in screening uptake by SES, marital status, ethnicity, and age but not by gender. Perceived barriers (stand. b = −0.40, p < 0.001), social norms (stand. b = 0.33, p < 0.001), and screening knowledge (stand. b = 0.17, p < 0.001) had independent associations with uptake. SES differences in uptake were mediated through knowledge, social norms, and perceived barriers. Ethnic differences were mediated through knowledge. Differences in uptake by marital status were primarily mediated through social norms and to a lesser extent through knowledge. Age differences were largely unmediated, except for a small mediated effect via social norms. Conclusions. Sociodemographic differences in CRC screening uptake were largely mediated through social cognitive factors. Impact. Our findings suggest that multifaceted interventions might be needed to reduce socioeconomic inequalities. Ethnic differences might be reduced through improved screening knowledge. Normative interventions could emphasise screening as an activity endorsed by important others outside the immediate family to appeal to a wider audience.