Acceptance of screening for colorectal cancer by flexible sigmoidoscopy

The effect of primary care physician counseling on participation rate and use of sedation in colonoscopy-based colorectal cancer screening program--a randomized controlled study

OBJECTIVES

Physician recommendation is a strong predictor of colorectal cancer (CRC) screening adherence, but there are no sufficient data specific to primary colonoscopy screening programs. The primary objective was to compare the effect of primary care physician's (PCP) counseling with information leaflet about CRC screening on participation rate in opportunistic primary colonoscopy screening program. Secondary objective was to determine the impact of this counseling on a decision to choose unsedated colonoscopy.

MATERIAL AND METHODS

Six hundred consecutive subjects 50-65 years of age visiting PCP group practice for routine medical consultation were randomly assigned in a 1:1 ratio either to discuss CRC screening with PCP or to receive an information leaflet on CRC screening only. The outcome measures were the participation rate and the proportion of unsedated colonoscopies assessed on subjects' self-reports collected six months after the intervention. Multivariate logistic regression model with backward selection was used to investigate the association between independent covariates and binary endpoints.

RESULTS

Participation rate was 47.0% (141 subjects) in the counseling group and 13.7% (41 patients) in the information leaflet group. The rates of unsedated colonoscopies were 77.0% and 39.0%, respectively. In a multivariate analyses, PCP's counseling was associated with higher participation in CRC screening (adjusted odds ratio [OR] 5.33, 95% confidence intervals [95% CI] 3.55-8.00) and higher rate of unsedated colonoscopies (OR 7.75, 95% CI 2.94-20.45).

CONCLUSION

In opportunistic primary colonoscopy screening, PCP's counseling significantly increases participation rate and decreases demand for sedation compared to recruitment with information materials only. NCT01688817.

Non-compliance in surveillance for patients with previous resection of large (≥ 1 cm) colorectal adenomas

AIM: To assess the extent and reasons of non-compliance in surveillance for patients undergoing polypectomy of large (≥ 1 cm) colorectal adenomas.

METHODS: Between 1995 and 2002, colorectal adenomas ≥ 1 cm were diagnosed in 210 patients and subsequently documented at the Erlangen Registry of Colorectal Polyps. One hundred and fifty-eight patients (75.2%) could be contacted by telephone and agreed to be interviewed. Additionally, records were obtained from the treating physicians.

RESULTS: Fifty-four out of 158 patients (34.2%) neglected any surveillance. Reasons for non-compliance included lack of knowledge concerning surveillance intervals (45.8%), no symptoms (29.2%), fear of examination (18.8%) or old age/severe illness (6.3%). In a multivariate analysis, the factors including female gender (P = 0.036) and age > 62 years (P = 0.016) proved to be significantly associated with non-compliance in surveillance.

CONCLUSION: Efforts to increase compliance in surveillance are of utmost importance. This applies particularly to women’s compliance. Effective strategies for avoiding metachronous colorectal adenoma and cancer should focus on both the improvement in awareness and knowledge of patients and information about physicians for surveillance.

Colorectal cancer screening in average risk individuals

Colorectal cancer is the third leading type of cancer, and the second leading cause of cancer-related death in the United States. Prevention of colorectal cancer should be achievable by screening programs that detect adenomas in asymptomatic patients and lead to their removal. In this manuscript, we review the major screening modalities, the advantages and disadvantages of each approach, the data supporting their use, and various issues affecting the implementation of each test. Screening guidelines will be reviewed, and future techniques for colorectal cancer screening examined.

Selecting patients for flexible sigmoidoscopy. Determinants of incomplete depth of insertion

BACKGROUND

Flexible sigmoidoscopy (FS) is an effective method to prevent and reduce mortality from colorectal carcinoma (CRC). Incomplete depth of insertion (IDI) during FS may result in missed polyps and carcinomas. To determine whether it is possible to predict IDI, the authors analyzed factors that affected the depth of insertion in FS.

METHODS

For the current study, FS results were recorded prospectively over a 5-year period. A questionnaire was administered to the patient by the investigator prior to FS to collect data, including age, gender, weight, comorbid illnesses, history of prior abdominal and pelvic surgeries, family history of colon carcinoma or polyps, and prior FS or colonoscopies. The depth of insertion of the flexible sigmoidoscope from the anal verge, which was defined as the reading on the outside of the instrument at its maximal insertion, was measured in centimeters. IDI was defined as a depth of insertion < 50 cm. Classification and regression tree analysis was used to develop a model that included variables predictive of IDI.

RESULTS

The best classification tree included gender, age < 69 years (in women), and a history of hysterectomy. Men had a < 5% risk of an IDI and women age < 69 years without a hysterectomy fared as well (6.6%). Older women and younger women who underwent hysterectomy had higher rates of IDI (29.2% and 22.3%, respectively.)

CONCLUSIONS

The authors developed a model based on age, gender, and hysterectomy status that, after further validation, may be useful for predicting which patients likely will have an incomplete examination. In those patients who have a high probability of IDI, the choice can be made to offer colonoscopy or perform FS under sedation, with analgesia, or with the help of distraction techniques.

Colonoscopy screening for colorectal cancer: the outcomes of two recruitment methods

OBJECTIVES

To determine the response to colorectal cancer (CRC) screening by colonoscopy, through direct invitation or through invitation by general practitioners.

DESIGN AND SETTING

Two-way comparison of randomised population sampling versus cluster sampling of a representative general practice population in the Australian Capital Territory, May 2002 to January 2004.

INTERVENTION

Invitation to screen, assessment for eligibility, interview, and colonoscopy.

SUBJECTS

881 subjects aged 55-74 years were invited to screen: 520 from the electoral roll (ER) sample and 361 from the general practice (GP) cluster sample.

MAIN OUTCOME MEASURES

Response rate, participation rate, and rate of adenomatous polyps in the screened group.

RESULTS

Participation was similar in the ER arm (35.1%; 95% CI, 30.2%-40.3%) and the GP arm (40.1%; 95% CI, 29.2%-51.0%) after correcting for ineligibility, which was higher in the ER arm. Superior eligibility in the GP arm was offset by the labour of manual record review. Response rates after two invitations were similar for the two groups (ER arm: 78.8%; 95% CI, 75.1%-82.1%; GP arm: 81.7%; 95% CI, 73.8%-89.6%). Overall, 53.4% ineligibility arose from having a colonoscopy in the past 10 years (ER arm, 98/178; GP arm, 42/84). Of 231 colonoscopies performed, 229 were complete, with 32% of subjects screened having adenomatous polyps.

CONCLUSIONS

Colonoscopy-based CRC screening yields similar response and participation rates with either random population sampling or general practice cluster sampling, with population sampling through the electoral roll providing greater ease of recruitment.

Value of Fentanyl in Flexible Sigmoidoscopy

Studies have recorded significant patient discomfort during flexible sigmoidoscopy when it is performed without sedation/analgesia. This study observed whether a single dose of 50 mcg intravenous fentanyl reduces pain, improving compliance, acceptability, and completion rates. In a prospective study, 109 consecutive patients were offered the option of 50 mcg intravenous fentanyl or no analgesia. Patient's pre-procedure expectations, objective pain scores, and willingness to undergo a subsequent procedure using the same technique were recorded. Endoscopist recorded the success, complications, and objective pain scores for each patient. Of the 46 patients (42%) choosing fentanyl, 9 (20%) experienced moderate/severe pain as against 26 (41%) of the 63 patients (58%) opting for no analgesia (p < 0.05). Further, 52% receiving fentanyl had a significantly better experience compared to their pre-procedure expectations as against 33% who received no analgesia (p < 0.05). No patient receiving fentanyl expressed unwillingness to undergo the procedure again using the same technique, whereas 16 (25%) of those receiving no analgesia indicated they would not (p < 0.01). Endoscopists recorded moderate/severe pain in 13 patients (12%), whereas 35 patients (32%) recorded moderate/severe pain (p < 0.001). Analgesia for endoscopy should involve patient choice. However, a single dose of 50 mcg fentanyl reduced patient discomfort and improved satisfaction. It appeared safe and likely to improve patient compliance and acceptability for flexible sigmoidoscopy.

Evaluation of TENS during screening flexible sigmoidoscopy

The expectation of pain is a statistically significant factor negatively affecting patient compliance with current screening flexible sigmoidoscopy recommendations. Numerous pain reduction modalities have been studied with limited success. Transcutaneous electrical nerve stimulation (TENS) has been used to treat pain of various origins. The purpose of this pilot study was to determine the efficacy of TENS in reducing discomfort experienced during screening flexible sigmoidoscopy.A double-blind study was conducted in which 90 subjects were randomized to receive TENS, sham TENS, or control (standard care). The same pulse frequency and intensity were used for all subjects in the TENS group. Subjects completed preprocedural and postprocedural questionnaires, and the endoscopist completed a postprocedural questionnaire. A slight, but statistically insignificant (p =.526) reduction in the mean pain score reported by the TENS group was noted when compared with the sham TENS and control groups (2.00, 2.27, and 2.23 respectively). In light of the fact that only one pulse frequency and intensity of the TENS intervention were used in this study, further study with this safe and cost-effective modality is warranted.

Colorectal cancer screening with flexible sigmoidoscopy—participants' experiences and technical feasibility

AIM

To evaluate tolerability and technical feasibility of colorectal cancer screening with flexible sigmoidoscopy.

METHODS

One thousand men and women aged 59-61 years, randomly selected from the population register of Uppsala, Sweden, were invited by mail. After random allocation, half of them were called up by a nurse (group 1), while the other half were asked to call themselves (group 2) to book a sigmoidoscopy. After the examination, the participants anonymously answered a questionnaire about their subjective experiences. Endoscopists and their assisting nurse filled out structured forms documenting various technical aspects including an estimation of the subjects' discomfort.

RESULTS

Four hundred and sixty-nine subjects participated. Mean intubation depth was 59 cm (range 28-60) and mean duration 5.8 min (range 2-23). On average, participants reported low degrees of discomfort and feeling of exposure, but 19 and 27% rated pain and distension, respectively, on the upper half of a visual analogue scale (VAS). Most subjects found the duration acceptable. Patient discomfort, as appraised by the endoscopists, was lower in men than in women, positively linked to duration of the procedure, but inversely associated with intubation distance. However, the overall differences between strata of participants were small. Among self-reported variables, group 1 and 2 differed significantly only with regard to 'other discomfort'. All but six subjects would accept a repeat examination. Failures, resulting in incomplete examinations, occurred in 14 subjects.

CONCLUSIONS

Flexible sigmoidoscopy is generally well tolerated and technically feasible in screening for colorectal cancer. A more personalised invitation did not have any important effects on the subjective experience.

Compliance and findings in a Swedish population screened for colorectal cancer with sigmoidoscopy

AIM

The aim of this study was to evaluate the patterns of compliance and the frequency of adenomas and neoplasms in a Swedish population.

METHODS

In 1996, 2000 men and women born in 1935 or 1936 were selected at random from the population registers of Uppsala and Malmö/Lund. All subjects were invited by mail to participate. In a randomised study design, subjects were either called up by a nurse to schedule the appointment for sigmoidoscopy or instructed to call themselves. At sigmoidoscopy subjects with a cancer, an adenoma (neoplastic polyp) or more than three hyperplastic polyps were scheduled for a complete colonoscopy.

RESULTS

Thirty-nine percent (770/1988) of all the invited subjects had a sigmoidoscopy. The participation differed between the two centres, 47% at the Uppsala centre and 30% at the Malmö/Lund centre (P<0.01). There was no statistically significant difference between the two different invitation groups. In all, 98 subjects (13%) were planned for colonoscopy. Thirty-one (35%) of the subjects having a colonoscopy were women and 57 (65%) were men. Fifty-five true adenomas were found in 46 subjects. All together, six subjects had proximal adenomas. Five adenocarcinomas were diagnosed, all within the reach of the sigmoidoscope.

CONCLUSIONS

The compliance was lower and the adenomas were fewer than expected. To increase compliance it is necessary with rigorously controlled invitation routines.

Psychosocial influences on older adults' interest in participating in bowel cancer screening

BACKGROUND

As part of a multicenter, randomized controlled trial of the efficacy of flexible sigmoidoscopy for the prevention of bowel cancer, an investigation of the predictors of screening interest was carried out in a subsample of older adults.

METHOD

The aim of the study was to establish the predictive power of the Health Belief Model (HBM) and to evaluate the contribution of HBM elements in mediating the effect of other demographic and health variables which have been found to be associated with screening interest and participation. A total of 5,099 participants were sent a postal questionnaire which examined screening interest, attitudes toward screen ing (benefits and barriers), perceived bowel cancer risk, bowel cancer worry, bowel symptoms, health status, state anxiety, and optimism. A total of 3,648 questionnaires were returned completed, giving a response rate of 71.5%.

RESULTS

The results showed that threat, barriers, and benefits explained 47% of the variance in interest. Demographic and health variables were also associated with screening interest, although most of their effect was mediated by the HBM constructs.

DISCUSSION

This community study in older adults showed a high level of interest in participating in screening. The large sample size provided the opportunity to test the value of the HBM model and to examine mediation of demographic and health variables. The HBM proved to be a good model of screening interest. These results further our understanding of the decision processes in participating in cancer screening and point to directions to increase the level of participation in community samples.

Inhaled patient-administered nitrous oxide/oxygen mixture does not impair driving ability when used as analgesia during screening flexible sigmoidoscopy

BACKGROUND

Entonox (nitrous oxide/oxygen mixture) has an analgesic effect, but its use is currently contraindicated in patients who plan to drive after its administration. We assessed the effect on driving ability of Entonox used as analgesia in patients undergoing screening flexible sigmoidoscopy.

METHODS

Forty men and 40 women scheduled for screening flexible sigmoidoscopy who had not driven to the examination site were recruited together with a matched control subject from the same list. Before the examination complex motor skills were assessed in both groups using an adaptive tracking task, previously demonstrated to be the most sensitive test for detecting impairment of driving ability due to drugs. During the examination Entonox analgesia was available to the study group only, and after the screening examination complex motor function was retested on the same computer.

RESULTS

Both groups improved their computer score on repeat testing, by 0.53 (range -1.9 to 4.6) in the study group and by 0.44 (range -0.6 to 2.5) in the control group.

CONCLUSIONS

These data strongly support the view that Entonox analgesia does not impair driving ability. In the context of screening flexible sigmoidoscopy its use may lead to an increase in compliance.

Australian general practitioners' views and use of colorectal cancer screening tests

OBJECTIVES

To determine general practitioners' (GPs) current beliefs, knowledge and self-reported practices of screening for colorectal cancer.

DESIGN AND SETTING

Postal survey of national random sample of 1271 GPs in 1996.

OUTCOME MEASURES

GP views on effectiveness of faecal occult blood testing (FOBT) and flexible sigmoidoscopy in reducing premature death from colorectal cancer in "average-risk" patients (asymptomatic with no family history); views on frequency of tests and target group; use of these tests; and independent predictors of views and use.

RESULTS

Response rate was 67%. FOBT and flexible sigmoidoscopy were said to be effective as screening tests by 38% and 61% of GPs, respectively, but 30% and 25% were unsure. Independent predictors of belief in screening effectiveness were State of practice (for FOBT), male sex and awareness of Gut Foundation guidelines (for flexible sigmoidoscopy) and increasing age (for both). Most often chosen screening frequencies were every year for FOBT (29%), and five-yearly for flexible sigmoidoscopy (24%), although 19% and 26%, respectively, were unsure of the appropriate screening interval. Most often cited target group was people aged over 40 years with first-degree relatives with colorectal cancer: 63% of GPs would offer FOBT and 74%, flexible sigmoidoscopy. Fewer than 3% of GPs were likely to adopt an opportunistic approach to screening, yet 15% would be highly likely to recommend FOBT during a dedicated health check-up for a 58-year-old male patient, and 9% for a female patient.

CONCLUSION

The absence to date of a coherent national policy on colorectal cancer screening is associated with wide variations in views and practice that are inconsistent with the available evidence. If GPs are to be involved in implementing population screening, national policy must be widely and effectively promulgated.

Colorectal cancer screening: discussions with first degree relatives

Screening by faecal occult blood test and colonoscopy is recommended for first degree relatives of people with colorectal cancer. While it is known that screening participation among relatives is low, relatives' beliefs and attitudes towards screening have not been explored at an in-depth level. In this study, four focus group discussions with first degree relatives of people with colorectal cancer were held. Discussions were audio-taped, transcribed verbatim and the data were independently coded and analysed by the authors. Three main themes were identified: risk, understanding, and screening. Perceived risk was determined by family history, age and gender. Of concern, there was limited understanding of the asymptomatic nature of screening with most relatives initially 'screened' after consulting a doctor with colorectal symptoms. These findings need to be considered in screening programs.

Sublingual hyoscyamine for patient comfort during screening sigmoidoscopy: a randomized, double-blind, placebo-controlled clinical trial

BACKGROUND

Screening sigmoidoscopy is an underutilized method for detecting early colorectal cancer, and patient discomfort is one reason for poor compliance in the general population. The possible benefit of a well-tolerated, low-cost antispasmodic medication, sublingual hyoscyamine, used before flexible sigmoidoscopy was assessed in a randomized, double-blinded, placebo-controlled trial.

METHODS

One hundred fifty patients were enrolled and randomized to receive two sublingual hyoscyamine tablets (0.125 mg/tablet) or the placebo 10 minutes before sigmoidoscopy. Patient comfort and the endoscopist's perception of the ease of insertion were measured using a 100 mm visual analog scale. The depth of sigmoidoscope insertion was measured in centimeters, and complications were recorded.

RESULTS

The median age was 55 years (range 25 to 83 years). There were 100 men (66.7%) and 50 women (33.3%). Approximately half (n = 76, 50.7%) had a prior sigmoidoscopy or colonoscopy. No statistical differences were found between treatment group means for age, gender, pain score, ease of insertion, or depth of insertion. The hyoscyamine group tended to have lower mean pain (32.4 vs. 37.7, p = 0.18) and difficulty (29.9 vs. 33.7, p = 0.31) scores and greater depth of sigmoidoscope insertion (51.3 vs. 47.7, p = 0.07); however, the differences were not statistically significant. The treatment groups differed with a higher percentage of the hyoscyamine group having a previous endoscopy (60.0% vs. 41.3%, p = 0.02); however, no significant differences were detected between mean pain scores as related to treatment when controlling for previous experience with endoscopy (p = 0.31).

CONCLUSIONS

In this study, hyoscyamine administered in the sublingual route did not significantly improve patient comfort, ease of insertion, or the depth of sigmoidoscope insertion during screening sigmoidoscopy. The search for alternative methods to improve patient comfort during screening endoscopy should continue.

Overview of the epidemiology of colorectal cancer

INTRODUCTION

The epidemiology of colorectal cancer has generated more interest recently, because recent developments in genetics, molecular biology, and genetic epidemiology have increased our understanding of the role of genes in the etiology of colorectal cancer. Interactions between genetic susceptibility and environmental factors in the etiology of cancer may be easier to define.

EPIDEMIOLOGY

Colorectal cancer is common in the Western world and is rare in developing countries. A sharp increase is seen in Eastern Europe and Japan.

ETIOLOGY

Molecular genetics has shown that accumulation of genetic changes is important in the development of colorectal cancer. Mutations in at least four to five genes are required for the formation of a malignant tumor. Environmental mutagenic factors may determine which susceptible individuals grow carcinomas. Environmental risk factors for colorectal cancer are found in a western diet, rich in fat, meat, and animal protein and low in fiber, fruit, and vegetables. The complex interrelations between food components make it difficult to define the precise role of specific food factors.

PREVENTION

Conclusive evidence of the effectiveness of primary prevention of colorectal cancer via dietary measures or nonsteroidal anti-inflammatory drugs is lacking. Secondary prevention by interrupting the adenoma carcinoma sequence is an actual possibility, its effectiveness, however, needs to be determined. Molecular genetics holds a promise for identifying populations at high risk for colorectal cancer, therefore, targeting the screening to make it more cost-effective.

Screening for colorectal cancer by once only sigmoidoscopy: a feasibility study in Turin, Italy

OBJECTIVES

To assess the impact on compliance of three invitation methods, as well as the acceptability and efficacy of two bowel preparation regimens, for endoscopic screening in the general population.

METHODS

1170 subjects (men and women aged 55 to 59, in the rosters of a sample of general practitioners (GPs) in Turin), were randomly allocated to one of three invitation groups (A: personal letter, signed by GP, with a pre-fixed appointment; B: same as for A + letter supporting the study by a well known scientist; C: letter signed by the study coordinator, NS) and two preparation regimens (i: one enema, self administered at home two hours before the test; ii: two enemas, administered the night before and two hours before the test). A postal reminder was mailed to non-attenders. A sample of non-responders was contacted for a telephone interview by a trained nurse. Written consent was obtained from all subjects undergoing the test.

RESULTS

A total of 278 subjects attended for sigmoidoscopic screening. An invitation from the GP alone produced the highest response rate (compliance: A = 29.3%; B = 24.9%; C = 26.8%). A single enema was as effective as two enemas in achieving satisfactory preparation for the test: the proportion of subjects invited to repeat the test was 8.1% in the single enema group, and 9.6% in the group receiving two enemas.

CONCLUSIONS

Compliance with this screening procedure tends to be low. One enema, self administered two hours before sigmoidoscopy, can ensure a satisfactory bowel preparation.