Other primary malignancies in breast cancer patients treated with breast conserving surgery and radiation therapy

Prognostic Factors Affecting Survival of Patients With Single Primary Breast Cancer vs Patients With Multiple Primary Cancers in Lifetime, One of Which is Breast Cancer

PURPOSE

The aim of this study was to investigate the demographic and molecular characteristics, overall survival (OS), cancer-specific survival (CSS), and prognostic factors affecting the survival of patients with single primary breast cancer (SPBC) and patients with multiple primary cancers in their life time in which one of them is breast cancer (MPC).

METHODS

Using data from SEER 17 Research Plus, patients with breast cancer diagnosed between 2010 and 2019 were included in this study. Race, marital status, laterality, tumor size, molecular subtype, grade, stage, radiotherapy-chemotherapy treatment, and surgery data were analyzed in the data obtained after excluding patients with missing values. Kaplan-Meier survival analysis was used for survival analysis, and Cox regression analysis was used to evaluate the prognostic factors.

RESULTS

573175 patients were included in the study. The mean age of MPC patients was significantly higher than SPBC patients (65.99 ± 12.68, 60.33 ± 13.47, P < .001, respectively). Patients with SPBC had significantly more hormone receptor (HR)-positive/Her2 positive, HR-negative/Her2-negative, and HR-negative/Her2-positive molecular subtypes; patients with MPC had more HR-positive/Her2-negative subtypes (P < .001). Grade 3 tumor status, locoregional spread, and distant metastasis were significantly higher in SPBC patients (P < .001). Overall survival and CSS rates were significantly higher in SPBC patients (P < .001). In MPC patients, overall hazard ratio was 1.631 times higher than SPBC, and the cancer-specific hazard ratio was 1.096 times higher (95% CI [1.606-1.656], 95% CI [1.071-1.121], respectively).

CONCLUSION

Although patients with SPBC have worse prognostic tumor characteristics, OS and CSS rates are better than patients with MPC.

Increased risk of subsequent primary lung cancer among female hormone-related cancer patients: A meta-analysis based on over four million cases

BACKGROUND

The incidence rate of lung cancer in women has significantly increased over the past decade, and previous evidence has indicated a significant relationship between the elevated levels of sex hormones and the risk of lung cancer. Therefore, we hypothesized that female hormone-related cancer (FHRC) patients, including breast, endometrial, cervical, and ovarian cancer patients, may experience a higher risk of developing subsequent lung cancer. This meta-analysis aimed to identify the risk of lung cancer among FHRC patients compared to the general population.

METHODS

The PubMed, Web of Science, EMBASE, Cochrane Library, and CNKI databases were searched up to May 11, 2022. Standardized incidence ratios (SIRs) with 95% confidence intervals (CIs) were used to identify the risk of subsequent lung cancer after FHRC. Subgroup analyses based on the follow-up time and tumor type were also conducted.

RESULTS

A total of 58 retrospective cohort studies involving 4,360,723 FHRC participants were included. The pooled results demonstrated that FHRC patients had a significantly increased risk of developing subsequent primary lung cancer (SIR = 1.61, 95% CI: 1.48-1.76, P <0.001). Subgroup analysis revealed an obvious trend of increasing lung cancer risk over time (SIRs for <5 years, ≥5 years, ≥10 years, ≥20 years, and ≥30 years after FHRC: 1.32, 1.59, 1.57, 1.68, and 1.95, respectively). In addition, subgroup analysis stratified by tumor type indicated an increased risk of developing subsequent lung cancer after breast (SIR = 1.25, P <0.001), endometrial (SIR = 1.40, P = 0.019), cervical (SIR = 2.56, P <0.001), and ovarian cancer (SIR = 1.50, P = 0.010).

CONCLUSION

FHRC patients are more likely to develop lung cancer than the general population. Furthermore, the increased risk of subsequent primary lung cancer is more obvious with a longer survival time and is observed in all types of hormone-related cancer.

REGISTRATION

International Platform of Registered Systematic Review and Meta-analysis Protocols: No. INPLASY202270044; https://inplasy.com/.

Outcomes of non-angiosarcoma radiation-associated soft tissue sarcomas of the chest

BACKGROUND

Radiation-associated soft tissue sarcomas (RA-STS) are rare complications of patients receiving radiation therapy (RT) and are generally associated with a poor prognosis. Most of the literature surrounding RA-STS of the chest is centered on angiosarcoma. Therefore, we aim to document the management and outcome of patients with non-angiosarcoma RA-STS of the chest.

METHODS

We reviewed 17 patients (all female, median age 65 years) diagnosed with RA-STS. The most common primary malignancy was breast carcinoma (n = 15), with a median RT dose of 57.9 Gy. All patients underwent surgical resection; five patients (29%) received radiotherapy; and five patients (29%) received peri-operative chemotherapy.

RESULTS

The 5-year local recurrence and metastatic-free survival were 61% and 60%, while the 5-year disease-specific survival was 53%. Local recurrence was associated with death due to disease (HR 9.06, p = 0.01). Complications occurred in nine of patients, most commonly due to a wound complication (n = 7). At the most recent follow-up, the median Musculoskeletal Tumor Society Score was 63%.

CONCLUSION

RA-STS involving the chest wall are aggressive tumors with a high risk of local relapse and death due to disease. Local recurrence was associated with death due to disease; as such, we recommend aggressive surgical management with evaluation for adjuvant therapies.

Epidemiology and risk factors for ovarian cancer

Ovarian cancer is a complex disease, mostly observed in postmenopausal women, and is associated with poor survival rates. It is the sixth most common cancer and the fifth most common cause of death due to cancer among women in developed countries. Thus, despite representing less than one third of all gynaecologic cancers, deaths due to ovarian cancer account for more than two thirds of deaths due to gynaecologic cancers. Its prevalence is higher in Western Europe and Northern America than Asia and Africa. In sub-Saharan Africa, there is a considerably lower prevalence of ovarian cancer than other parts of Africa. Ovarian cancer is multifaceted, involving many factors, complex biological processes and unpredictable consequences. Unlike other female cancers that have early warning symptoms, ovarian cancer's symptoms are non-specific. As a result, ovarian cancers are normally undetected until advanced stages (III or IV). The major risk factors for ovarian cancer include older age, genetics, family history, hormone replacement therapy, nulliparity, and dietary fat. Controversial factors include obesity, infertility, talc powder, radiation exposure, fertility medications and in vitro fertilization. The current review discusses the aetiology, epidemiology and risk factors for ovarian cancer. Nevertheless, identification of the main risk factors for ovarian cancer may increase the awareness among women of the general population. This should help to decrease the incidence rate of ovarian cancer and increase the five-year survival rate.

Clinical and sociodemographic risk factors associated with the development of second primary cancers among postmenopausal breast cancer survivors

BACKGROUND

Advancement in breast cancer (BC) diagnosis and treatment have increased the number of long-term survivors. Consequently, primary BC survivors are at a greater risk of developing second primary cancers (SPCs). The risk factors for SPCs among BC survivors including sociodemographic characteristics, cancer treatment, comorbidities, and concurrent medications have not been comprehensively examined. The purpose of this study is to assess the incidence and clinicopathologic factors associated with risk of SPCs in BC survivors.

METHODS

We analyzed 171, 311 women with early-stage primary BC diagnosed between January 2000 and December 2015 from the Medicare-linked Surveillance Epidemiology and End Results (SEER-Medicare) database. SPC was defined as any diagnosis of malignancy occurring within the study period and at least 6 months after primary BC diagnosis. Univariate analyses compared baseline characteristics between those who developed a SPC and those who did not. We evaluated the cause-specific hazard of developing a SPC in the presence of death as a competing risk.

RESULTS

Of the study cohort, 21,510 (13%) of BC survivors developed a SPC and BC was the most common SPC type (28%). The median time to SPC was 44 months. Women who were white, older, and with fewer comorbidities were more likely to develop a SPC. While statins [hazard ratio (HR) 1.066 (1.023-1.110)] and anti-hypertensives [HR 1.569 (1.512-1.627)] increased the hazard of developing a SPC, aromatase inhibitor therapy [HR 0.620 (0.573-0.671)] and bisphosphonates [HR 0.905 (0.857-0.956)] were associated with a decreased hazard of developing any SPC, including non-breast SPCs.

CONCLUSION

Our study shows that specific clinical factors including type of cancer treatment, medications, and comorbidities are associated with increased risk of developing SPCs among older BC survivors. These results can increase patient and clinician awareness, target cancer screening among BC survivors, as well as developing risk-adapted management strategies.

Other Primary Malignancies in Patients with Breast Cancer Who Undergo Germline Panel Testing

BACKGROUND

Women with a history of breast cancer (BC) more commonly have a diagnosis of other primary malignancies (OPMs) than the general population. This study sought to evaluate OPMs among patients with BC who underwent germline testing with a hereditary BC gene panel.

METHODS

The study identified women 18 years of age or older with a history of unilateral BC who underwent multi-gene panel testing between January 2014 and August 2019 at the authors' institution. Patient, tumor, and treatment factors for BC and OPM diagnoses were collected for descriptive, univariate, and overall survival (OS) analyses.

RESULTS

Among 1163 patients, 330 (28.4%) had an OPM. The median follow-up period was 4.1 years from BC diagnosis. Of the 1163 patients, 209 (18%) had a BRCA pathogenic variant (PV), 306 (26.4%) had a non-BRCA PV, and 648 (55.7%) had no PV. Development of an OPM varied according to germline testing result, with an OPM developing for 18.6% (39/209) of the patients with a BRCA PV, 31.8% (204/648) of the patients with no PV, and 28.4% (87/306) of the patients with a non-BRCA PV (p < 0.0001). The most common OPMs were ovarian (n = 60), uterine (n = 44), sarcoma (n = 36), melanoma (n = 27), colorectal (n = 22), and lymphoma (n = 20) malignancies. The 5-year OS was 96%. The patients with an OPM 5 years after BC diagnosis had a shorter OS than those who did not (93.4% vs 97.5%; p = 0.002).

CONCLUSION

More than 25% of women with BC who underwent germline panel testing had an OPM diagnosed during the short-term follow-up period, and the diagnosis of an OPM was associated with reduced OS. These data have implications for counseling BC patients who undergo germline testing regarding future cancer screening.

Common Multiple Primary Cancers Associated With Breast and Gynecologic Cancers and Their Risk Factors, Pathogenesis, Treatment and Prognosis: A Review

The mammary gland is closely related to the female reproductive system in many aspects, affecting the whole gynecological system. Breast cancer (BC) is the most common malignancy in women and associated with considerable negative effects. Due to various factors including co-pathogenic genetic mutations, environment factors, lifestyle, behavioral factors, treatment regimens and in-creased survival of patients with BC, there is an increased probability of developing additional primary gynecologic cancers such as ovarian cancer (OC), endometrial cancer (EC), and cervical cancer (CC). More and more studies have been conducted in recent years. Multiple primary cancers (MPCs), also known as multiple primary malignancies, refers to two or more different primary cancers in the same patient occurring in the same or different organs or tissues. The pathogenesis of multiple primary cancers is complex and has a negative effect on the prognosis and survival of patients. This review discusses the common types of BC-associated MPCs, namely, BC associated with OC, BC associated with EC and BC associated with CC, as well as risk factors, pathogenesis, treatment, and prognosis of MPCs associated with breast and gynecologic cancers. It provides new intervention and treatment ideas for patients with BC-associated MPCs to improve quality of life and prognosis.

Synchronous Malignancies Identified by PET-CT Scan in Breast Cancer Patients

Breast cancer is a common malignancy and a common cause of cancer-related mortality in women. Pre-treatment workup of breast cancer does not routinely include positron emission tomography scans. We aimed to review cases of women with breast cancer and a synchronous second primary malignancy. We present three cases of women with non-metastatic cancer in whom a synchronous second primary malignancy was found. Synchronous, second primary malignancies which were identified included rectal cancer, gastrointestinal stromal tumor, and non-small cell lung cancer. All second primary malignancies were identified by a PET-CT scan. In conclusion, PET-CT may be used for detection of secondary primary malignancies in select breast cancer patients.

Primary Lung Cancer After Treatment for Breast Cancer

Breast cancer is the most common malignancy in women and the second most common cause of cancer-related death. Due to advances in the diagnosis and treatment technologies for breast cancer, patients with breast cancer are living longer than before, resulting in an increased risk of developing subsequent malignancies, among which lung cancer is the most common. This review presents the current evidence about the risk, influencing factors and prognostic factors of developing primary lung cancer after treatment for breast cancer. The aim is to help clinicians improve their understanding, diagnosis and treatment of lung cancer after breast cancer.

Primary synchronous malignancies of the breast and the kidney

Synchronous primary malignancies are most frequently seen with cancers of the stomach and oesophagus, mainly attributed to the similar genetic mutations. Most of these multiple malignancies turn out to be metastatic or metachronous lesions. Multiple synchronous malignancies are rarer than metachronous ones. Primary synchronous breast and renal cancer is even rare. These patients require extensive workup to exclude all possible metastases. The nature of the primary tumours must also be confirmed, prior to any treatment strategy. We report the case of a healthy, middle-aged woman who initially presented with a lesion suspicious for breast carcinoma, and further workup revealed the presence of an asymptomatic, synchronous primary renal cell cancer, which is a very rare presentation.

Risk and Influencing Factors for Subsequent Primary Lung Cancer After Treatment of Breast Cancer: A Systematic Review and Two Meta-Analyses Based on Four Million Cases

INTRODUCTION

To compare the risk of developing lung cancer between patients with breast cancer and the general population and explore the risk factors for the development of primary lung cancer after treatment for breast cancer.

METHODS

The PubMed, EMBASE, and Web of Science databases were searched from the establishment date to October 11, 2020. Two separate meta-analyses were performed: one focused on studies reporting the risk of subsequent lung cancer after breast cancer and one focused on studies exploring the risk factors for subsequent lung cancer in patients with breast cancer. The standardized incidence ratios with 95% confidence intervals were combined to compare the risk of developing lung cancer between patients with breast cancer and the general population. The relative risks (RRs) or ORs with 95% confidence intervals were combined to assess the association of clinicopathological parameters with the risk of developing lung cancer after breast cancer. All statistical analyses were conducted by STATA 12.0.

RESULTS

A total of 15 studies involving 1,161,979 patients were eventually included in the first meta-analysis, and the pooled results indicated that female patients with breast cancer revealed a significantly higher risk of developing subsequent lung cancer (standardized incidence ratio = 1.25, p < 0.001). In addition, a total of 22 articles involving 3,090,620 patients were included in the second meta-analysis. The pooled results indicated that smoking (OR = 9.73, p < 0.001) and radiotherapy (RR = 1.40, p < 0.001) were risk factors for developing subsequent lung cancer in patients with breast cancer, and chemotherapy (RR = 0.69, p = 0.002), positive estrogen receptor status (RR = 0.93, p = 0.014) and positive progesterone receptor status (RR = 0.86, p < 0.001) were protective factors. Meanwhile, subgroup analysis based on the relative position of the breast and lung cancers (ipsilateral versus contralateral) was conducted, which indicated that radiotherapy only increased the risk of ipsilateral lung cancer in patients with breast cancer (RR = 1.27, p = 0.001).

CONCLUSIONS

Patients with breast cancer are more likely to develop lung cancer than the general population, and the risk of developing primary lung cancer after breast cancer is affected by smoking, radiotherapy, chemotherapy, estrogen receptor status and progesterone receptor status.

"Radiotherapy for older women (ROW)": A risk calculator for women with early-stage breast cancer

OBJECTIVE

Among older adult women with early-stage breast cancer who undergo lumpectomy, the benefits of radiotherapy vary according to tumor characteristics and life expectancy. We aimed to develop a risk calculator to predict individualized probability of long-term survival and local recurrence, accounting for these factors.

METHODS

We developed a simulation model to estimate an individual patient's risk of local recurrence and all-cause mortality according to age, comorbidities, functional status, tumor characteristics, and radiotherapy status. We integrated two existing prediction models, the Early Breast Cancer Trialist's Collaborative Group prediction model for breast cancer specific outcomes and ePrognosis for life expectancy. An online risk calculator "Radiotherapy for Older Women (ROW)" was developed through an iterative multi-stage process, that included individual consultation and group meetings with an advisory committee (AC) comprised of patients, advocates, clinicians, and researchers.

RESULTS

We developed the tool over 40 months and had 15 group meetings. The risk calculator developed as a simulation model with 16 factors (5 tumor-related, 3 demographic, 4 comorbidities, and 4 functional statuses). Across 56,700 simulated scenarios, the benefit of RT in terms of absolute 10-year local recurrence reduction, ranged from 0% to 34%, depending on individual characteristics. Based on feedback from the AC, overall survival and local recurrence were chosen as the output for ROW, with these outcomes displayed numerically (percentages and natural frequencies) and graphically (pictographs).

CONCLUSIONS

This tool "ROW" could facilitate shared decision making regarding receipt of radiotherapy for older women with early breast cancer. Additional studies to examine usability testing are underway.

Incidence of second primary malignancy after breast cancer and related risk factors-Is breast-conserving surgery safe? A nested case-control study

Risk of second primary malignancy (SPM) is increasing. We aimed to assess the incidence and related risk factors of SPM among breast cancer (BC) patients from this nested case-control study using the SEER database. BC patients with SPM were identified as the case group and SPM-free patients were defined as the control group. Propensity score matching of cases with controls by the year of the first primary BC diagnosis was conducted at the ratio of 1:5, and 97,242 BC patients were enrolled from 1998 to 2013 after the matching. The incidence of SPM in BC patients stratified by age groups and cancer sites was compared to the general population using the adjusted standardized incidence ratio (SIR) and the risk factors for SPM were examined using Cox proportional hazard regressions. Our study showed BC patients had excess risk for SPM than the general population (adjusted SIR for all cancer sites = 12.94, p < 0.001) and the incidence of SPM among them decreased with age. The risk of SPM was significantly related to the following demographical and clinical variables: age (40-59 vs. 18-39, HR = 1.33; 60-79 vs. 18-39, HR = 2.39; ≥80 vs. 18-39, HR = 2.84), race (black vs. white, HR = 1.12), histological type (lobular BC vs. ductal BC, HR = 1.15), radiotherapy (HR = 1.33), marital status (married vs. single, HR = 0.88) and estrogen receptor status (positive vs. negative, HR = 0.85). Consistent results were found in subgroup analysis stratified by contralateral-breast SPMs and nonbreast SPMs.

Association between breast cancer and thyroid cancer: A study based on 13 978 patients with breast cancer

BACKGROUND

Thyroid cancer (TC) is one of the most commonly seen secondary malignancy in breast cancer (BC) survivors.

MATERIALS AND METHODS

A retrospective study was conducted in BC patients in our center from 1999 to 2013. Patients were divided into BC-TC group and BC-alone group.

RESULTS

In total, 13 978 BC patients were identified, among whom 247 (1.8%) had TC. The standardized incidence ratio (SIR) of TC was 4.48 compared with Chinese females, and up to 98.0% of cases were thyroid papillary carcinomas. A family history of malignancy was the only independent risk factor (odds ratio = 1.457, P = 0.025) for development of TC in patients with BC. We also identified inferior survival in patients with synchronous versus metachronous BC-TC (P = 0.016). Synchronous BC-TC (risk ratio = 5.597, P = 0.018) was an independent prognostic factor for inferior RFS.

CONCLUSIONS

We observed high co-occurrence of TC in patients with BC. There might be different mechanisms behind synchronous and metachronous BC-TC.

Characteristics and survival of patients with metachronous or synchronous double primary malignancies: breast and thyroid cancer

BACKGROUND

Clinical experiences suggest that breast cancer (BC) and thyroid cancer (TC) occur metachronously or synchronously in a patient more frequently than it would by chance. This study was conducted to investigate the clinicopathological characteristics and survival of these double primary malignancies.

METHODS

18732 patients with first primary BC and 12877 female patients with first primary TC were performed in this retrospective case-controlled study. The control groups were matched with both age at diagnosis and time of surgery (±2 years). The clinicopathological factors, Overall survival (OS), and HRs were evaluated by SPSS.

RESULTS

There were 91(0.49%) BC patients developed metachronous second primary TC (B-T group), and 117 (0.91%) TC patients developed metachronous second primary BC (T-B group).The expression of estrogen and progesterone receptors, and the value of Ki-67, were significantly higher in the B-T group than control. The median value of thyroid globulin antibody (TGAb) and thyroid peroxidase antibody (TPOAb) were higher in T-B group than control (p <0.05). The duration before second primary cancer was shorter for the B-T group than the T-B group (4.09 years vs. 5.82 years, p<0.001). B-T group patients showed poorer survival than BC only patients (p=0.044).

CONCLUSIONS

In general, the overall risk of the occurrence of a second primary TC or BC elevated highly in patients with BC or TC. Detailed mechanisms need to be studied to explore the association between these two cancers. Early detection and effective prevention for the first primary BC or TC patients are necessities for reducing the incidence of the second primary cancer and improving the OS.

Association between breast cancer and the risk of colorectal cancer

BACKGROUND

The literature to date has suggested a potential increase in colorectal cancer (CRC) among patients with breast cancer.

METHODS

We performed a systematic review of the literature and included 37 retrospective cohort studies and 8 case-control studies. The primary aim was to determine the prevalence of CRC. Secondary aims included analysis of adenomatous polyps and analysis of CRC prevalence by age. We calculated pooled prevalence rates and odds ratios (ORs) using random effects models with 95% confidence intervals (CI).

RESULTS

We identified 1,055,917 individuals with breast cancer among whom 9097 cases of CRC were detected. The pooled event rate for CRC was 0.7% (95% CI, 0.6%-0.9%; I²=97%). Four case-control studies reported prevalence of CRC (N=17,873 patients with breast cancer and 70,366 controls), including 46 cases of CRC in the patients with breast cancer, and 272 CRC in the controls (OR, 1.2; 95% CI, 0.4%-3.7%; P = .7). Six studies reported prevalence of advanced adenomas in patients with breast cancer (N=1087) compared with controls (N=1356) with 62 cases of advanced adenomas in patients compared with 47 in the controls (OR, 1.5; 95% CI, 0.97-2.2; P = .07). In patients with breast cancer <50 years old (4 studies, N=64,706), the pooled OR was increased (OR, 2.5; 95% CI, 1.7-3.5; P =.001). In 3 studies of women <45 years old (N=92,594), the risk was increased (OR, 2.3; 95% CI, 1.7-2.6; P < .001).

CONCLUSIONS

Patients with breast cancer should not undergo CRC screening at intervals different from the general population. In patients with breast cancer <50 years old, CRC screening should be considered at age 45 years.

Characteristics and Survival of Breast Cancer Patients with Multiple Synchronous or Metachronous Primary Cancers

PURPOSE

Newly developed extra-mammary multiple primary cancers (MPCs) are an issue of concern when considering the management of breast cancer survivors. This study aimed to investigate the prevalence of MPCs and to evaluate the implications of MPCs on the survival of breast cancer patients.

MATERIALS AND METHODS

A total of 8204 patients who underwent surgery at Severance Hospital between 1990 and 2012 were retrospectively selected. Clinicopathologic features and survival over follow-up periods of ≤5 and >5 years were investigated using univariate and multivariate analyses.

RESULTS

During a mean follow-up of 67.3 months, 962 MPCs in 858 patients (10.5%) were detected. Synchronous and metachronous MPCs were identified in 23.8% and 79.0% of patients, respectively. Thyroid cancer was the most prevalent, and the second most common was gynecologic cancer. At ≤5 years, patients with MPCs were older and demonstrated significantly worse survival despite a higher proportion of patients with lower-stage MPCs. Nevertheless, an increased risk of death in patients with MPCs did not reach statistical significance at >5 years. The causes of death in many of the patients with MPCs were not related to breast cancer. Stage-matched analysis revealed that the implications of MPCs on survival were more evident in the early stages of breast disease.

CONCLUSION

Breast cancer patients with MPCs showed worse survival, especially when early-stage disease was identified. Therefore, it is necessary to follow screening programs in breast cancer survivors and to establish guidelines for improving prognosis and quality of life.

Breast Cancer Survivorship Care: Targeting a Colorectal Cancer Education Intervention

Breast cancer survivors are at risk of developing a second primary cancer. Colorectal cancer (CRC) is one of the leading second primary cancers, and it is often preventable. We developed a multi-component educational tool to inform and encourage women breast cancer survivors to engage in CRC screening. To assess the strengths and weakness of the tool and to improve the relevancy to the target audience, we convened four focus groups of women breast cancer survivors in Missouri. We also assessed the potential impact of the tool on the knowledge, attitudes, and beliefs regarding CRC and collected information on the barriers to CRC screening through pre- and post-focus groups' questionnaires. A total of 43 women breast cancer survivors participated and provided very valuable suggestions on design and content to update the tool. Through the process and comparing pre- and post-focus group assessments, a significantly higher proportion of breast cancer survivors strongly agreed or agreed that CRC is preventable (78.6% vs. 96.9%, p = 0.02) and became aware that they were at a slightly increased risk for CRC (18.6% vs. 51.7%, p = 0.003). The most cited barrier was the complexity of preparation for colonoscopy.