Interventions to ensure follow-up of positive fecal immunochemical tests: An international survey of screening programs

Explaining the Correlates of the Multi-Theory Model (MTM) of Health Behavior Change in Visual (Structural) Colorectal Cancer Screening Examinations

Colorectal cancer (CRC) ranks third in terms of global cancer prevalence and is the second most common cause of cancer-related mortality. Although CRC rates are decreasing in the United States, inequalities still exist despite the effectiveness of invasive screening methods, such as colonoscopy, flexible sigmoidoscopy, and computed tomography (CT) colonography in detecting colorectal cancer. Many current interventions promoting CRC screening do not utilize a modern theory-based approach, which has led to the low utilization of these screening methods. This cross-sectional study aims to address the lack of theory-based treatments for promoting visual CRC screening examinations by applying the multi-theory model (MTM) of health behavior change to explicate the health-related factors for individuals to seek visual colorectal cancer screening examinations for CRC screening. A 57-item validated questionnaire assessing MTM constructs and CRC screening was administered online. The survey questionnaire was administered to a sample of 640 adults from the United States. The participants were between the ages of 45 and 75 years. Hierarchical multiple regression was used to assess the relationship between MTM constructs with the initiation and sustenance of CRC screening behaviors. Out of the total participants in this nationwide sample, 71.4% (n = 457) reported that they had undergone a visual CRC screening examination. MTM subscales, specifically participatory dialogue, changes in the physical environment along with age, recommendation for CRC screening from a healthcare provider, and previous experience with colonoscopy, were found to be significant factors in predicting the initiation of visual CRC screening behavior. These factors accounted for 22% of the variation in initiation among this group (R2 = 0.222, F = 3.521, p < 0.001). The MTM can be a valuable framework for designing educational media, information media, social media platforms, and clinical interventions to promote visual colorectal cancer screening examinations.

Effectiveness of behavior change techniques to address barriers to follow-up colonoscopy: results from an online survey and randomized factorial experiment

BACKGROUND

Nonattendance at colonoscopy is associated with reduced colorectal cancer (CRC) survival.

PURPOSE

The aim of this research was to quantify barriers to colonoscopy and test the effectiveness of behavior change techniques (BCTs) to address them.

METHODS

Two studies were conducted. In the first study, participants were asked to imagine their next CRC screening result was abnormal, and were presented with the standard abnormal result letter used in the English CRC Screening Programme. Participants then completed a short survey. Multivariate regression tested associations between perceived barriers and intentions. In the second study, participants were randomly presented with a modified version of the abnormal results letter, which incorporated one or more BCTs, designed to target barriers identified in study 1, using a 28 factorial design. Participants then completed the same survey used in study 1. Multivariate regression tested the effectiveness of the BCTs to modify target barriers and intentions.

RESULTS

In study 1, 5 items were associated with intentions, namely "Lack of understanding that CRC can be asymptomatic," "Perceived importance of screening," "Transport/travel," "Shared decision making and family influenced participation," and "Fear of pain and discomfort" (all P's < .05). In study 2, the inclusion of a social support message, targeting "shared decision-making and family influenced participation," facilitated independent decision making and increased intentions (both P's < .05). There was no evidence to support the remaining 7 BCTs to modify barriers or intentions (all P's < .05).

CONCLUSIONS

Inclusion of a social support message facilitated independent decision-making and improved intentions.

Barriers and facilitators to colonoscopy for cancer detection: patient and practitioner perspectives

OBJECTIVE

To further understand the barriers and facilitators to attending colonoscopy examination following a positive routinely offered stool test result, from the perspective of patients and Specialist Screening Practitioners (SSPs).

METHODS

Qualitative semi-structured interviews were conducted. Participants (N = 32) were patients (n = 20) who, as part of the Bowel Cancer Screening Programme (BCSP) in England, were invited to attend a colonoscopy examination, and SSPs (n = 12), who worked for the BCSP in England. Framework analysis included inductive and deductive coding.

RESULTS

Anxiety was as a key barrier cited by patients and SSPs, arising from the moment the patient received the invitation letter. Notably, procedural-related anxieties centred upon the fear of pain and discomfort and test invasiveness. The role of family, friends and the SSP were recognised by patients and SSPs to facilitate participation. Many patients, yet not SSPs, emphasised an obligation to attend all medical test invitations.

CONCLUSION

Practically orientated strategies suggested by patients and SSPs address the patient barriers identified. These include earlier information to patients on the option of sedation for pain relief, earlier notification of potential financial support for patients unable to fund their own travel costs, and fewer uses of the term cancer within written materials.

Racial/ethnic and socioeconomic disparities in colorectal cancer screening in a large organization with universal insurance before and during the coronavirus disease 2019 pandemic

OBJECTIVES

Israel is regarded as a country with a developed economy and a moderate income inequality index. In this population-based study, we aimed to measure the inequalities in colorectal cancer screening within Clalit Health, an organization with universal insurance, before and during the coronavirus disease 2019 pandemic.

SETTING

Retrospective analysis within Clalit Health Services, Israel.

METHODS

We evaluated the rate of being up to date with screening (having a colonoscopy within 10 years or a fecal occult blood test within 1 year) and the colonoscopy completion rate (having a colonoscopy within 6 months of a positive fecal occult blood test) among subjects aged 50-75 in 2019-2021.

RESULTS

In 2019, out of 918,135 subjects, 61.3% were up to date with screening; high socioeconomic status: 65.9% (referent), medium-socioeconomic status: 60.1% (odds ratio 0.81, 95% confidence interval 0.80-0.82), low-socioeconomic status: 59.0% (odds ratio 0.75, 95% confidence interval 0.74-0.75); Jews: 61.9% (referent), Arabs: 59.7% (odds ratio 0.91, 95% confidence interval 0.90-0.92), Ultraorthodox-Jews: 51.7% (odds ratio 0.77, 95% confidence interval 0.75-0.78). Out of 21,308 with a positive fecal occult blood test, the colonoscopy completion rate was 51.8%; high-socioeconomic status: 59.8% (referent), medium-socioeconomic status: 54.1% (odds ratio 0.79, 95% confidence interval 0.73-0.86), low-socioeconomic status: 45.5% (odds ratio 0.60, 95% confidence interval 0.56-0.65); Jews: 54.7% (referent), Ultraorthodox-Jews: 51.4% (odds ratio 0.91, 95% confidence interval 0.90-0.92), Arabs: 44.7% (odds ratio 0.77, 95% confidence interval 0.75-0.78). In 2020-2021, there was a slight drop in the rate of being up to date with screening, while most of the discrepancies were kept or slightly increased with time.

CONCLUSIONS

We report significant inequalities in colorectal cancer screening before and during the coronavirus disease 2019 pandemic in Israel, despite a declared policy of equality and universal insurance.

Effects of a modified invitation letter to follow-up colonoscopy for bowel cancer detection

OBJECTIVE

To investigate whether modifications made to the current National Health Service (NHS) invitation letter for follow-up colonoscopy examination affect participant state anxiety and behavioural intentions to attend.

METHODS

Five hundred and thirty-eight adults of bowel cancer-eligible screening age (56-74) were randomized to receive the current NHS invitation letter or the modified version of the letter as a hypothetical scenario. Modifications to the letter included fewer uses of the term cancer and awareness of alternative screening options. The history of the colonoscopy invitation, anticipated state anxiety, behavioural intention to attend the nurse appointment, and colonoscopy concerns upon reading the letter were measured.

RESULTS

Behavioural intentions were high in both conditions; however, participants reading the current letter reported significantly higher behavioural intentions compared to the modified letter. There was no main effect of previous invite status or interaction between previous invite status and letter condition on behavioural intentions. However, the effect of the letter on levels of anxiety depended on the participant's invitation history. Those never invited for a colonoscopy were more anxious when reading the modified letter compared to the current letter. Conversely, previous colonoscopy invitees were less anxious following reading the modified letter than those reading the current letter. Those never invited for a colonoscopy were more concerned about embarrassment and test invasiveness. All findings remained the same when controlling for age and education.

CONCLUSION

Modifications to the invitation letter were not beneficial to levels of screening intention or anxiety.

Blood Test Increases Colorectal Cancer Screening in Persons Who Declined Colonoscopy and Fecal Immunochemical Test: A Randomized Controlled Trial

BACKGROUND & AIMS

The septin 9 blood test is indicated for colorectal cancer screening in individuals who decline first-line tests, but participation in this context is unclear. We conducted a randomized controlled trial to compare reoffering colonoscopy and fecal immunochemical test (FIT) alone versus also offering the blood test among individuals who declined colonoscopy and FIT.

METHODS

Screen-eligible Veterans aged 50-75 years who declined colonoscopy and FIT within the previous 6 months were randomized to letter and telephone outreach to reoffer screening with colonoscopy/FIT only (control), or additionally offering the blood test as a second-line option (intervention). The primary outcome was completion of any screening test within 6 months. The secondary outcome was completion of a full screening strategy within 6 months, including colonoscopy for those with a positive noninvasive test.

RESULTS

Of 359 participants who completed follow-up, 9.6% in the control group and 17.1% in the intervention group completed any screening (7.5% difference; P = .035). Uptake of colonoscopy and FIT was similar in the 2 groups. The full screening strategy was completed in 9.0% and 14.9% in the control and intervention groups, respectively (5.9% difference; P = .084).

CONCLUSIONS

Among individuals who previously declined colonoscopy and FIT, offering a blood test as a secondary option increased screening by 7.5% without decreasing uptake of first-line screening options. However, completion of a full screening strategy did not increase. These findings indicate that a blood test is a promising method to improve colorectal cancer screening, but obtaining a timely colonoscopy after a positive noninvasive test remains a challenge (ClincialTrials.gov number, NCT03598166).

Rationale for organized Colorectal cancer screening programs

Colorectal cancer (CRC) is a major health problem and it is expected that the number of persons diagnosed with CRC and CRC-related deaths will continue to increase. However, recent years have shown reductions in CRC incidence and mortality particularly among individuals aged 50 years and older which can be attributed to screening, improvements in patients' management, closer adherence to treatment guideline recommendations and a higher utilization of curative surgery, chemotherapy and radiotherapy. The International Agency for Research on Cancer has concluded that there has been sufficient evidence that biennially screening using a stool-test or once-only endoscopy screening reduces CRC-related mortality. In Europe, between 2008 and 2018, nine countries have successfully implemented a population-based organized program and another six are in the roll-out phase. Population-based organized programs show higher screening participation rates and lower lack of compliance to follow-up testing after a positive screen test compared to opportunistic screening. Moreover, organized programs aim to provide high quality screening thereby reducing the risk of the harms of screening, including over-screening, and complications of screening, and poor follow-up of those who test positive. We describe how population-based organized CRC screening programs are preferred, since they reflect a more appropriate utilization of available resources, reduce inequities in access, and can integrate interventions addressing barriers to screening at the individual and health system levels.

Reach and effectiveness of a centralized navigation program for patients with positive fecal immunochemical tests requiring follow-up colonoscopy

Completion rates for follow-up colonoscopies after an abnormal fecal immunochemical test (FIT) are suboptimal in federally qualified health center (FQHC) settings. We implemented a screening intervention that included mailed FIT outreach to North Carolina FQHC patients from June 2020 to September 2021 and centralized patient navigation to support patients with abnormal FITs in completing follow-up colonoscopy. We evaluated the reach and effectiveness of navigation using electronic medical record data and navigator call logs detailing interactions with patients. Reach assessments included the proportion of patients successfully contacted by phone and who agreed to participate in navigation, intensity of navigation provided (including types of barriers to colonoscopy identified and total navigation time), and differences in these measures by socio-demographic characteristics. Effectiveness outcomes included colonoscopy completion, timeliness of follow-up colonoscopy (i.e., within 9 months), and bowel prep adequacy. Among 514 patients who completed a mailed FIT, 38 patients had an abnormal result and were eligible for navigation. Of these, 26 (68%) accepted navigation, 7 (18%) declined, and 5 (13%) could not be contacted. Among navigated patients, 81% had informational needs, 38% had emotional barriers, 35% had financial barriers, 12% had transportation barriers, and 42% had multiple barriers to colonoscopy. Median navigation time was 48.5 min (range: 24-277 min). Colonoscopy completion differed across groups - 92% of those accepting navigation completed colonoscopy within 9 months, versus 43% for those declining navigation. We found that centralized navigation was widely accepted in FQHC patients with abnormal FIT, and was an effective strategy, resulting in high colonoscopy completion rates.

Trends of Cancer Screenings, Diagnoses, and Mortalities During the COVID-19 Pandemic: Implications and Future Recommendations

INTRODUCTION

The impact of the COVID-19 pandemic on cancer screenings and care has yet to be determined. This study aims to investigate the screening, diagnosis, and mortality rates of the top five leading causes of cancer mortality in the United States from 2019 to 2021 to determine the potential impact of the COVID-19 pandemic on cancer care.

METHODS

A retrospective cohort study investigating the impact of the COVID-19 pandemic on screening, diagnoses, and mortality rates of the top five leading causes of cancer death (lung/bronchus, colon/rectum, pancreas, breast, and prostate), as determined by the National Institute of Health (NIH) utilizing The United States Healthcare Cost Institute and American Cancer Society databases from 2019 to 2021.

RESULTS

Screenings decreased by 24.98% for colorectal cancer and 16.01% for breast cancer from 2019 to 2020. Compared to 2019, there was a .29% increase in lung/bronchus, 19.72% increase in colorectal, 1.46% increase in pancreatic, 2.89% increase in breast, and 144.50% increase in prostate cancer diagnoses in 2020 (all P < .01). There was an increase in the total number of deaths from colorectal, pancreatic, breast, and prostate cancers from 2019 to 2021.

CONCLUSION

There was a decrease in the screening rates for breast and colorectal cancer, along with an increase in the estimated incidence and mortality rate among the five leading causes of cancer deaths from 2019 to 2021. The findings suggest that the COVID-19 pandemic is associated with impaired cancer screening, diagnosis, and care, and further emphasizes the need for proactive screening and follow-up to prevent subsequent cancer morbidity and mortality.

Barriers to colonoscopy in UK colorectal cancer screening programmes: Qualitative interviews with ethnic minority groups

OBJECTIVE

People from ethnic minority backgrounds are less likely to attend colonoscopy, following faecal immunochemical test screening, and are more likely to be diagnosed with colorectal cancer at an advanced stage as a result. The aim of this research was to explore the barriers and facilitators to attending colonoscopy, perceived by ethnic minority groups living in the United Kingdom.

METHODS

Semi-structured online and telephone interviews were conducted with thirty men and women of Black-African (n = 5), Black-Caribbean (n = 5), South Asian (n = 10) and White British (n = 10) descent. Participants were eligible for screening, but had not necessarily been invited for colonoscopy. All interviews were conducted in the participant's first language and were assessed using Framework-analysis, in line with a conceptual framework developed from previous interviews with healthcare professionals.

RESULTS

Five thematic groups of barriers and facilitators were developed: 'Locus of control', 'Cultural attitudes and beliefs', 'Individual beliefs, knowledge and personal experiences with colonoscopy and cancer', 'Reliance on family and friends' and 'Health concerns'. Differences were observed, between ethnic groups, for: 'Locus of control', 'Cultural attitudes and beliefs' and 'Reliance on family and friends'. Black and South Asian participants frequently described the decision to attend colonoscopy as lying with 'God' (Muslims, specifically), 'the doctor', or 'family' (Locus of control). Black and South Asian participants also reported relying on friends and family for 'language, transport and emotional support' (Reliance on family and friends). Black-African participants, specifically, described cancer as 'socially taboo' (Cultural attitudes and beliefs).

CONCLUSIONS

The results highlight several targets for culturally-tailored interventions to make colonoscopy more equitable.

Robotic, self-propelled, self-steerable, and disposable colonoscopes: Reality or pipe dream? A state of the art review

Robotic colonoscopes could potentially provide a comfortable, less painful and safer alternative to standard colonoscopy. Recent exciting developments in this field are pushing the boundaries to what is possible in the future. This article provides a comprehensive review of the current work in robotic colonoscopes including self-propelled, steerable and disposable endoscopes that could be alternatives to standard colonoscopy. We discuss the advantages and disadvantages of these systems currently in development and highlight the technical readiness of each system to help the reader understand where and when such systems may be available for routine clinical use and get an idea of where and in which situation they can best be deployed.

Reduced Cancer Screening Due to Lockdowns of the COVID-19 Pandemic: Reviewing Impacts and Ways to Counteract the Impacts

The COVID-19 pandemic has created disruptions in health services in general and cancer screening and diagnostic services in particular, leading to diminished cancer screening participation rates. This paper aims to seek insights into impacts that the pandemic has had on cancer screening, impacts that reduced cancer screening may have in the long run, and how to address such impacts. The paper demonstrates that reduced cancer screening in the pandemic is likely to result in enhanced demands for cancer screening in the new normal, enhanced demands for resources to address such demands, and poor prognosis due to stage migration of cancer diseases. Some measures are recommended for counteracting these impacts.

Barriers and facilitators to colonoscopy following fecal immunochemical test screening for colorectal cancer: A key informant interview study

OBJECTIVES

People who are referred for colonoscopy, following an abnormal colorectal cancer (CRC) screening result, are at increased risk of CRC. Despite this, many individuals decline the procedure. The aim of this study was to investigate why.

METHODS

As little is currently known about non-attendance at follow-up colonoscopy, and follow-up of abnormal screening results is a nurse-led process, we decided to conduct key informant interviews with Specialist Screening Practitioners ([SSPs] nurses working in the English Bowel Cancer Screening Program). Interviews were conducted online. Transcripts were assessed using inductive and deductive coding techniques.

RESULTS

21 SSPs participated in an interview. Five main types of barriers and facilitators to colonoscopy were described, namely: Sociocultural, Practical, Psychological, Health-related and COVID-related. Key psychological and sociocultural factors included: 'Fear of pain and discomfort associated with the procedure' and 'Lack of support from family and friends'. Key practical, health-related and COVID-related factors included: 'Family and work commitments', 'Existing health conditions as competing priorities' and 'Fear of getting COVID-19 at the hospital'.

CONCLUSIONS

A range of barriers and facilitators to follow-up colonoscopy exist. Future studies conducted with patients are needed to further explore barriers to colonoscopy.

PRACTICE IMPLICATIONS

Strategies to reduce non-attendance should adopt a multifaceted approach.

Timely Colonoscopy After Positive Fecal Immunochemical Tests in the Veterans Health Administration: A Qualitative Assessment of Current Practice and Perceived Barriers

INTRODUCTION

The Veterans Health Administration introduced a clinical reminder system in 2018 to help address process gaps in colorectal cancer screening, including the diagnostic evaluation of positive fecal immunochemical test (FIT) results. We conducted a qualitative study to explore the differences between facilities who performed in the top vs bottom decile for follow-up colonoscopy.

METHODS

Seventeen semistructured interviews with gastroenterology (GI) providers and staff were conducted at 9 high-performing and 8 low-performing sites.

RESULTS

We identified 2 domains, current practices and perceived barriers, and most findings were described by both high- and low-performing sites. Findings exclusive to 1 group mainly pertained to current practices, especially arranging colonoscopy for FIT-positive patients. We observed only 1 difference in the perceived barriers domain, which pertained to primary care providers.

DISCUSSION

These results suggest that what primarily distinguishes high- and low-performing sites is not a difference in barriers but rather in the GI clinical care process. Developing and disseminating patient education materials about the importance of diagnostic colonoscopy, eliminating in-person precolonoscopy visits when clinically appropriate, and involving GI in missed colonoscopy appointments and outside referrals should all be considered to increase follow-up colonoscopy rates. Our study illustrates the challenges of performing a timely colonoscopy after a positive FIT result and provides insights on improving the clinical care process for patients who are at substantially increased risk for colorectal cancer.