Colorectal Cancer Screening in Switzerland: Cross-Sectional Trends (2007-2012) in Socioeconomic Disparities

Inequalities in patients' experiences with cancer care: the role of economic and health literacy determinants

BACKGROUND

Patients with fewer socioeconomic and health literacy resources are disadvantaged in their access and use of healthcare, which may give rise to worse experiences with care and thus inequalities in patient experiences. However, only a limited number of studies have examined how socioeconomic and health literacy factors shape inequalities in patients' experiences with cancer care.

OBJECTIVE

To examine whether patients' experiences with cancer care differ according to their economic status and health literacy.

METHODS

Secondary analysis of data on 2789 adult patients diagnosed with cancer from the Swiss Cancer Patient Experiences-2 (SCAPE-2) study, a cross-sectional survey conducted in eight hospitals across Switzerland from September 2021 to February 2022. Regression analysis was applied to examine the independent effect of patients' economic status and health literacy on various outcomes of experiences with cancer care, covering eight different dimensions of patient-centred care, controlling for confounding factors.

RESULTS

Adjusted regression analysis showed that patients with lower economic status reported significantly worse experiences with cancer care in 12 out of 29 specific care experiences, especially in the dimensions of 'respect for patients' preferences' and 'physical comfort' where all items of experiences were associated with economic status. Additionally, lower health literacy was associated with worse patient experiences in 23 specific care experiences. All items in the dimensions of 'respect for patients' preferences', 'physical comfort' and 'emotional support' were associated with health literacy.

DISCUSSION

This study revealed significant inequalities in experiences with cancer care shaped by the economic status and health literacy of patients across different dimensions of patient-centred care. It is essential to address the needs of more disadvantaged patients who face obstacles in their access and use of the healthcare system, not only to mitigate inequalities in cancer care but also to avoid inequalities in health outcomes.

Lack of social support, gender and colorectal cancer screening participation across Europe: How do screening programmes mitigate the effect of social support for men and women?

This study investigates how a lack of social support differentially affects men and women's colorectal cancer (CRC) screening participation, considering different screening strategies implemented across European countries. Although health sociology has stressed gender differences in social support and its effects on health behaviours, this was overlooked by cancer screening research. Using a data set of 65,961 women and 55,602 men in 31 European countries, we analysed the effect of social support variables on CRC screening uptake. We found that living alone and lower perceived social support were associated with lower screening uptake for both men and women. These effects were, however, stronger among men. Population-based screening programmes mitigated these effects, particularly for women, but not for men living alone. In countries with opportunistic screening programmes, social support variables remained associated with screening uptake. We conclude that cancer screening interventions should pay attention to social support and its gender-differentiated effects.

Bakar A, Hj Jobli NM, Sararaks S. Study protocol for a mixed methods approach to optimize colorectal cancer screening in Malaysia: Integrating stakeholders insights and knowledge-to-action framework

INTRODUCTION

Colorectal cancer is a growing global health concern and the number of reported cases has increased over the years. Early detection through screening is critical to improve outcomes for patients with colorectal cancer. In Malaysia, there is an urgent need to optimize the colorectal cancer screening program as uptake is limited by multiple challenges. This study aims to systematically identify and address gaps in screening service delivery to optimize the Malaysian colorectal cancer screening program.

METHODS

This study uses a mixed methods design. It focuses primarily on qualitative data to understand processes and strategies and to identify specific areas that can be improved through stakeholder engagement in the screening program. Quantitative data play a dual role in supporting the selection of participants for the qualitative study based on program monitoring data and assessing inequalities in screening and program implementation in healthcare facilities in Malaysia. Meanwhile, literature review identifies existing strategies to improve colorectal cancer screening. Additionally, the knowledge-to-action framework is integrated to ensure that the research findings lead to practical improvements to the colorectal cancer screening program.

DISCUSSION

Through this complex mix of qualitative and quantitative methods, this study will explore the complex interplay of population- and systems-level factors that influence screening rates. It involves identifying barriers to effective colorectal cancer screening in Malaysia, comparing current strategies with international best practices, and providing evidence-based recommendations to improve the local screening program.

Colorectal Cancer Screening in the Middle East: What, Why, Who, When, and How?

The incidence of colorectal cancer (CRC) in the Middle East is increasing, especially among those younger than 50 years. Risk factors including obesity, sedentary lifestyle, and dietary changes are associated with the epidemiologic shift and are a result of socioeconomic changes happening in the region. Worldwide, CRC screening is associated with decreased incidence and mortality of CRC, but screening uptake is still low in the Middle East because of cultural barriers and lack of awareness; in addition, most countries do not have national screening programs. Knowledge of CRC screening and participation rates vary among different countries, but overall they are low. Both primary and secondary prevention approaches are needed in the Middle East, and cost-effectiveness is important in choosing screening modalities. Although colonoscopy is considered the most robust screening method, stool-based testing may be an acceptable screening strategy in resource-limited settings, and focusing on high-risk individuals such as those with hereditary CRC might be the most cost-effective strategy. In addition to financial limitations in many countries in the Middle East, human displacement places an extra toll on cancer control strategies in the region.

Does the socioeconomic status predict health service utilization in persons with enhanced health care needs? Results from a population-based survey in persons with spinal cord lesions from Switzerland

Background

Evidence suggests that the socioeconomic status (SES) affects individuals’ health service utilization. Spinal cord injury is a condition that often leads to physical impairments and enhanced health care needs. It therefore presents an informative and yet under-researched case in point to investigate social inequalities in health service utilization. This study aims to describe associations between SES and health service utilization in adults with spinal cord injury from Switzerland.

Methods

We use cross-sectional data from 1,294 participants of the Swiss Spinal Cord Injury Cohort Study community survey 2017. SES was operationalized with education, household income, perceived financial hardship, subjective status, and granting of supplementary financial benefits. Health service utilization was assessed with information on visits to 13 different health care providers and four health care institutions (inpatient stays, outpatient clinics, emergency departments, specialized spinal cord centers) during the past 12 months. The dichotomized outcomes on service utilization (visited vs. not visited) were regressed on SES indicators, including adjustments for sociodemographics, lesion characteristics, and health status.

Results

Persons with higher SES reported higher likelihood for specialist, dentist, and dental hygienist visits and reported utilizing a larger number of different care providers. Further, specific SES indicators were associated with certain care provider visits (i.e., higher education and subjective status: higher odds for pharmacist visits; higher income: higher odds for natural healer visits; higher subjective status: higher odds for chiropractor visits; supplementary benefit granting: higher odds for general practitioner and home care service visits). We found statistically non-significant trends towards lower likelihood for inpatient stays, outpatient clinic and emergency department visits and enhanced likelihood for specialized spinal cord-center visits in higher SES groups.

Conclusions

This study generally supports the claim that basic health care provision is guaranteed for all patients with spinal cord injury in Switzerland, independently of their SES. However, social inequalities were still observed for the utilization of specific providers, such as oral health care providers. Given that oral health is key for health maintenance in persons with spinal cord injury, specific interventions to enhance regular dental check-ups in lower SES groups are highly recommended.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12939-022-01693-6.

Ten-year changes in colorectal cancer screening in Switzerland: The Swiss Health Interview Survey 2007, 2012 and 2017

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Colorectal Cancer testing rate increased in Switzerland from 2007 to 2017.

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Colonoscopies are the first screening methods used in Switzerland.

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Low CRC screening rate is associated with age 50–59, high-deductible and basic insurance coverage.

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There is regional disparities in CRC screening rate in Switzerland.

Recent recommendations for colorectal cancer (CRC) screening suggest fecal occult blood test (FOBT) or colonoscopy. Since 2013, mandatory health insurance in Switzerland reimburse CRC screening. We set out to determine if CRC testing rate and type of CRC screening changed in Switzerland from 2007 to 2017 and between the three main language regions. We extracted data on 50–75-year-olds from the Swiss Health Interview Survey (SHIS) 2007, 2012 and 2017 to determine rates of self-reported testing with FOBT within last 2 years and colonoscopy within last 10 years. We estimated prevalence ratio (PR) in multivariate-adjusted logistic regression models and compared rates in German-, French- and Italian-speaking regions, adjusting for sociodemographic, self-rated health and insurance variables. Overall testing rates (FOBT or colonoscopy) increased in all regions from 2007 to 2017 (German-speaking 33.6% to 48.3%; French-speaking 30.8% to 48.8%; Italian-speaking 37.9% to 46.8%), mainly because of an increase in colonoscopy rate for screening reasons (p < 0.001 in all regions). Rates of FOBT testing fell significantly in the German-speaking region (11.9% to 4.4%, p < 0.001), but not in the Italian- (13.9% to 8.5%, p = 0.052) and French-speaking regions (7.6% to 7.4%, p = 0.138). Overall CRC testing rate rose from 33.2% in 2007 to 48.4% in 2017, mainly because of an increase of colonoscopy rate for screening reasons. Coverage remains below the 65% target of European guidelines. Organized screening programs encouraging FOBT screening could contribute to further increasing the CRC testing rate.

Gender inequality and mammography screening: Does living with a partner improve women's mammography uptake?

Macrolevel gender inequality is defined as the unequal distribution of power and resources between men and women shaped by macrolevel social structures and institutions. An emerging line of health research is emphasising its negative consequences on women's health and healthcare access. The present study examines how gender inequality contexts affect women's mammography screening uptake. It adopts a macrosociological and institutionalist approach on preventive healthcare use and compares women who live with a partner with those who do not. This is the first study to test the effect of macrolevel gender inequality on mammography uptake across the 26 Swiss cantons (i.e. regions). The Swiss cantons' autonomy to manage their political and healthcare systems, as provided by the federal system, offers an ideal setting for the comparative analysis of macrolevel factors. Data on 9724 women aged 50-70 from the Swiss Health Interview Survey (waves 2007, 2012 and 2017) is analysed. Multilevel logistic models estimate two canton-level indicators of gender inequality, the gender gaps in time use and full-time employment, and their association with mammography uptake, controlling for women's socioeconomic and demographic characteristics, health status and healthcare use. Cross-level interactions assess how these indicators moderate the mammography uptake of women living with and without a partner. Results show that in cantons with higher gender inequality, women have a lower probability of mammography uptake. Women who live with a partner have a higher mammography uptake than those who do not. However, this advantage is moderated by canton-level gender inequality, namely, women who live with a partner in more gender unequal cantons have a lower mammography uptake than their counterparts who reside in more gender equal cantons. Results support the hypothesis that macrolevel gender inequality moderates women's preventive healthcare uptake, from an institutionalist approach.

Revisiting the Effects of Organized Mammography Programs on Inequalities in Breast Screening Uptake: A Multilevel Analysis of Nationwide Data From 1997 to 2017

This study revisits the effects of mammography screening programs on inequalities in breast screening uptake in Switzerland. The progressive introduction of regional mammography programs by 12 out of the 26 Swiss cantons (regions) since 1999 offers an opportunity to perform an ecological quasi-experimental study. We examine absolute income and marital status inequalities in mammography uptake, and whether the cantons' implementation of mammography programs moderate these inequalities, as previous research has devoted little attention to this. We use five waves of the Swiss Health Interview Survey covering the 1997-2017 period and comprising data on 14,267 women aged 50-70. Both up-to-date and ever-screening outcomes are analyzed with multilevel models which assess the mammography programs' within-canton effect. Findings show that higher income women and married women (compared to unmarried women) had significantly higher mammography uptake probabilities. Mammography programs did not moderate absolute income differences in up-to-date screening; however, they were associated with smaller absolute income differences in ever-screening uptake. Mammography programs related to higher screening uptake for married women, more than for unmarried women. In conclusion, we showed absolute income inequalities in mammography uptake which were not revealed by previous studies using relative inequality measures. Mammography programs may have contributed to reducing income inequalities in ever-screening, yet this was not observed for up-to-date screening. This study has implication for preventive health interventions-e.g., cancer screening promotion should pay attention to women's marital status since screening programs may widen the screening gap between married and unmarried women.

Socioeconomic Disparity Trends in Cancer Screening Among Women After Introduction of National Quality Indicators

PURPOSE

Primary care physicians have an important role in encouraging adequate cancer screening. Disparities in cancer screening by socioeconomic status (SES) may affect presentation stage and cancer survival. This study aimed to examine whether breast, colorectal, and cervical cancer screening rates in women differed by SES and age, and whether screening rates and SES disparities changed after introduction of a primary care-based national quality indicator program.

METHODS

This repeated cross-sectional study spanning 2002-2017 included all female Israeli residents in age ranges appropriate for each cancer screening assessed. SES was measured both as an individual-level variable based on exemption from copayments and as an area-level variable using census data.

RESULTS

In 2017, the most recent year in the study period, screening rates among 1,529,233 women were highest for breast cancer (70.5%), followed by colorectal cancer (64.3%) and cervical cancer (49.6%). Women in the highest area-level SES were more likely to undergo cervical cancer screening compared with those in the lowest (odds ratio = 3.56; 99.9% CI, 3.47-3.65). Temporal trends showed that after introduction of quality indicators for breast and colorectal cancer screening in 2004 and 2005, respectively, rates of screening for these cancers increased, with greater reductions in disparities for the former. The quality indicator for cervical cancer screening was introduced in 2015, and no substantial changes have occurred yet for this screening.

CONCLUSIONS

We found increased uptake and reduced socioeconomic disparities after introduction of cancer screening indicators. Recent introduction of a cervical cancer screening indicator may increase participation and reduce disparities, as has occurred for breast and colorectal cancer screening. These findings related to Israel's quality indicators program highlight the importance of primary care clinicians in increasing cancer screening rates to improve outcomes and reduce disparities.

Impact of comorbidities at diagnosis on the 10-year colorectal cancer net survival: A population-based study

BACKGROUND

It is established that comorbidities negatively influence colorectal cancer (CRC)-specific survival. Only few studies have used the relative survival (RS) setting to estimate this association, although RS has been proven particularly useful considering the inaccuracy in death certification. This study aimed to investigate the impact of non-cancer comorbidities at CRC diagnosis on net survival, using cancer registry data.

METHODS

We included 1076 CRC patients diagnosed between 2000 and 2001 in the canton of Zurich. The number and severity of comorbidities was expressed using the Charlson Comorbidity Index (CCI). Multiple imputation was performed to account for missing information and 10-year net survival was estimated by modeling the excess hazards of death due to CRC, using flexible parametric models.

RESULTS

After imputation, approximately 35 % of the patients were affected by comorbidities. These appeared to decrease the 10-year net survival; the estimated excess hazard ratio for patients with one mild comorbidity was 2.14 (95 % CI 1.60-2.86), and for patients with one more severe or more than one comorbidity was 2.43 (95 % CI 1.77-3.34), compared to patients without comorbidities.

CONCLUSIONS

Our analysis suggested that non-cancer comorbidities at CRC diagnosis significantly decrease the 10-year net survival. Future studies should estimate net survival of CRC including comorbidities as prognostic factor and use a RS framework to overcome the uncertainty in death certification.

Temporal trends and regional disparities in cancer screening utilization: an observational Swiss claims-based study

Background

We examined colorectal, breast, and prostate cancer screening utilization in eligible populations within three data cross-sections, and identified factors potentially modifying cancer screening utilization in Swiss adults.

Methods

The study is based on health insurance claims data of the Helsana Group. The Helsana Group is one of the largest health insurers in Switzerland, insuring approximately 15% of the entire Swiss population across all regions and age groups. We assessed proportions of the eligible populations receiving colonoscopy/fecal occult blood testing (FOBT), mammography, or prostate-specific antigen (PSA) testing in the years 2014, 2016, and 2018, and calculated average marginal effects of individual, temporal, regional, insurance-, supply-, and system-related variables on testing utilization using logistic regression.

Results

Overall, 8.3% of the eligible population received colonoscopy/FOBT in 2014, 8.9% in 2016, and 9.2% in 2018. In these years, 20.9, 21.2, and 20.4% of the eligible female population received mammography, and 30.5, 31.1, and 31.8% of the eligible male population had PSA testing. Adjusted testing utilization varied little between 2014 and 2018; there was an increasing trend of 0.8% (0.6–1.0%) for colonoscopy/FOBT and of 0.5% (0.2–0.8%) for PSA testing, while mammography use decreased by 1.5% (1.2–1.7%). Generally, testing utilization was higher in French-speaking and Italian-speaking compared to German-speaking region for all screening types. Cantonal programs for breast cancer screening were associated with an increase of 7.1% in mammography utilization. In contrast, a high density of relevant specialist physicians showed null or even negative associations with screening utilization.

Conclusions

Variation in cancer screening utilization was modest over time, but considerable between regions. Regional variation was highest for mammography use where recommendations are debated most controversially, and the implementation of programs differed the most.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-020-10079-8.

Does the Flemish colorectal cancer screening programme reach equity in FIT uptake?

BACKGROUND

To investigate colorectal cancer (CRC) screening rates by the faecal immunochemical test (FIT) according to sociodemographic characteristics and nationality.

METHODS

Men and women, aged 56-74, invited to participate in the Flemish CRC screening programme in 2013 and 2014 were included in this study. We analysed the association between CRC screening uptake and sex, age, (first and current) nationality and several proxies for socio-economic status (SES). The statistical analysis was based on descriptive analyses and logistic regression models.

RESULTS

A total of 1 184 426 persons were included in our analysis. The overall screening uptake was 52.3%, uptake varied by sex, age, nationality and SES. Lower participation rates were associated with the youngest and oldest age categories (56-60 and 70-74) and being male. All nationalities other than Belgian or Dutch were significantly less screened. Lower uptake of screening was also associated with several proxy's for low SES, such as having an allowance for being disabled, not being able to work, being an extended minor and having a social allowance/minimum wage. The descriptive analysis showed a 27% difference in CRC screening uptake between the (early) retired and the people entitled to a minimum wage.

CONCLUSIONS

There is a significant difference between screening uptake and demographic and socio-economic variables in the first 2 years of the population-based screening programme in Flanders. Based on the study results, implementing strategies to improve participation in those subgroups is needed.

Evolving perspectives on stool testing for colorectal cancer: a qualitative systematic review

OBJECTIVES

Colorectal cancer is one of the leading causes of cancer-related deaths globally. A multitude of screening methods has been devised for early diagnosis, including the faecal immunochemical test (FIT). This qualitative review aims to discover the barriers and facilitators to the utility of the FIT from the general population's perspective.

METHODS

Authors searched five electronic bases (Medline, Embase, CINAHL, PsycINFO and Web of Science) till December 2019. The search was conducted using key search terms and qualitative and mixed-method studies were included. Two independent reviewers screened articles and conducted quality appraisal. Data were synthesised thematically.

RESULTS

A total of 11 articles that reported users' views on FIT kits were included. Three themes were generated from the included articles: FIT kit factors, patients' perception of colorectal cancer screening, and social health support system. The nature of the test and the supplementary information was found to affect the utilisation of the test. User's awareness and perspectives towards cancer and screening were found to have impacted the adoption of the FIT kit. Social support and local healthcare systems were also found to have influenced the use of FIT.

CONCLUSION

This systematic review focuses on addressing and understanding the perception of FIT from first-hand accounts. Since its inception, FIT screening has increased colorectal cancer screening uptake due to its increased reliability and the simplicity of the test. However, there is a need to increase the uptake of FIT kits through increasing accessibility of the screening process and considering the holistic patient experience.

Association between colorectal cancer testing and insurance type: Evidence from the Swiss Health Interview Survey 2012

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Colonoscopy and FOBT are both recommended for colorectal cancer screening.

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Colonoscopy costs much more, so test choice might be linked to insurance type.

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Private insurance and low deductibles were associated with more colonoscopies.

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FOBT, which is cheap, was not associated with private insurance.

Both colonoscopy and fecal occult blood test (FOBT) are commonly used for colorectal cancer (CRC) screening, but colonoscopy costs much more than FOBT. Swiss insurance offers high or low deductibles and choice of basic or private insurance. We hypothesized that high deductibles and basic insurance discourage colonoscopy, but do not change FOBT rates.

We determined the proportion of patients tested for CRC in Switzerland (colonoscopy within 10 years, FOBT within 2 years), and determined associations with health insurance type.

We extracted data on 50–75-year-olds from the Swiss Health Interview Surveys of 2012 to determine colonoscopy and FOBT testing rates (n = 7335). Multivariate logistic regression models estimated prevalence ratios (PRs) of CRC testing associated with health insurance type (deductible and private insurance), adjusted for socio-demographic factors (age, gender, education, income) and self-rated health.

The weighted proportion of individuals tested for CRC within recommended intervals was 39.5%. Testing with colonoscopy was significantly associated with private insurance (PR 1.85, 95% CI: 1.46–2.35) and low deductible (PR 2.00, 95% CI: 1.56–2.57). Testing with FOBT was significantly associated with deductible (PR 1.71, 95%CI:1.09–2.68) but not with private insurance.

About 60% of the Swiss population was not current with CRC testing. After adjusting for covariates, private insurance and low deductible was significantly associated with higher prevalence of CRC testing, indicating that waiving the deductible could increase CRC screening uptake and reduce health inequality.

The impact of socioeconomic deprivation on the uptake of colorectal cancer screening in London

OBJECTIVE

Screening programmes based on the faecal occult blood test (FOBT) can reduce mortality from colorectal cancer (CRC). However, a significant variation exists in uptake of the test within the UK. Disproportionate uptake risks increasing inequity during staging at diagnosis and survival from CRC. This study aims to evaluate the impact of socioeconomic deprivation on the uptake of CRC screening (FOBT) in London.

METHODS

A retrospective review of the "Vanguard RM Informatics" database was performed to identify eligible individuals for CRC screening across all general practices across London over 30 months (2014-2017). The postcodes of the general practices were used to obtain the deprivation data via the "Indices of Deprivation" database. A Spearman's rho correlation was performed to quantify the impact of the deprivation variables on FOBT uptake.

RESULTS

Overall, 697,402 individuals were eligible for screening across 1359 London general practices, within 5 Clinical Commissioning Groups (CCGs); 48.4% (range: 13%-74%) participated in CRC screening with the lowest participation rates in North West (46%) and North East (47%) London CCGs. All indices of deprivation had a significant correlation with the uptake of FOBT (p < 0.01).

CONCLUSION

This is the largest study across London to date demonstrating a significant positive correlation between deprivation indices and FOBT uptake, highlighting areas of particular risk. Further studies are imperative to quantify the impact of deprivation on CRC morbidity and mortality, together with focused strategies to reduce socioeconomic inequalities in screening in these high risk areas.

Offering patients a choice for colorectal cancer screening: a quality improvement pilot study in a quality circle of primary care physicians

Background

Guidelines recommend primary care physicians (PCPs) offer patients a choice between colonoscopy and faecal immunochemical test (FIT) for colorectal cancer (CRC) screening. Patients choose almost evenly between both tests but in Switzerland, most are tested with colonoscopy while screening rates are low. A quality circle (QC) of PCPs is an ideal site to train physicians in shared decision-making (SDM) that will help more patients decide if they want to be tested and choose the test they prefer.

Objective

Systematically assess CRC screening status of eligible 50–75 y.o. patients and through SDM increase the proportion of patients who have the opportunity to choose CRC screening and the test (FIT or colonoscopy).

Methods

Working through four Plan-Do-Study-Act (PDSA) cycles in their QC, PCPs adapted tools for SDM and surmounted organisational barriers by involving practice assistants. Each PCP included 20, then 40 consecutive 50–75 y.o. patients, repeatedly reported CRC status as well as the proportion of eligible patients with whom CRC screening could be discussed and patients’ decisions.

Results

9 PCPs initially included 176, then 320 patients. CRC screening status was routinely noted in the electronic medical record and CRC screening was implemented in daily routine, increasing eligible patients’ chance to be offered screening. Over a year, screening rates trended upwards, from 37% to 40% (p=0.46) and FIT use increased (2%–7%, p=0.008). Initially, 7/9 PCPs had no patient ever tested with FIT; after the intervention, only 2/8 recorded no FIT tests.

Conclusions

Through data-driven PDSA cycles and significant organisational changes, PCPs of a QC systematically collected data on CRC screening status and implemented SDM tools in their daily routine. This increased patients’ chance to discuss CRC screening. The more balanced use of FIT and colonoscopy suggests that patients’ values and preferences were better respected.

Trends in colonoscopy and fecal occult blood test use after the introduction of dual screening offers in Germany: Results from a large population-based study, 2003-2016

An increasing number of countries have recently introduced colorectal cancer (CRC) screening programs. Typically, one specific screening exam, such as fecal occult blood test (FOBT) or flexible sigmoidoscopy, is offered as a primary screening test. We aimed to assess trends in FOBT and colonoscopy use in Germany following the introduction of the offer of screening colonoscopy as an alternative to FOBT in 2002. We used data from 4052 control participants aged 50-79 years recruited during 2003-2016 for a population-based case-control study in Germany. Prevalence of FOBT and colonoscopy lifetime and recent use was analyzed and trends over time were examined. The percentage of all respondents who had ever undergone a colonoscopy (for either screening or diagnostic purpose) increased markedly over time from 44.6% in 2003-2005 to 57.5% in 2013-2016 (p < 0.0001). Large increases were also observed for colonoscopy use within 10 years (from 38.0% to 52.8%, p < 0.0001), whereas FOBT uptake within one to two years declined from 54.0% to 33.3%. By 2013-2016, 67.2% of respondents either had an FOBT within one to two years or a colonoscopy within 10 years, and this percentage had remained relatively stable over time. This study demonstrates a large increase in colonoscopy utilization since colonoscopy was included as an alternative primary screening test, which was accompanied by a substantial decline in FOBT use. Although the overall adherence to CRC screening recommendations remained stable, the substantial shift of share from FOBT to colonoscopy is expected to yield more protection against CRC incidence and mortality.

A provider feedback intervention to increase uptake of colorectal cancer screening in a Swiss academic general practice

Colorectal cancer (CRC) cancer screening uptake is low in our diverse, outpatient teaching clinic. A state-level public screening programme was recently launched that provides faecal immunochemical tests or screening colonoscopy to all citizens aged 50-69 years via mailed invitations, with the possibility of earlier, opportunistic inclusion. Mailed outreach is expected to be rolled out over the next 5 years. In the interim, we aimed to increase CRC screening by accelerating the inclusion of patients into the programme by implementing a provider feedback programme with residents. We used billing reports to define the eligible target population and monthly lists of included patients to track progress. All residents received a standard intervention that provided basic training and communication tools facilitating shared decision making in CRC screening decisions. We then developed and implemented the intervention over 3 Plan-Do-Study-Act cycles in 2 of 4 groups of residents, each with 7 residents and approximately 250 eligible patients. The intervention consisted of individualised reports on the proportion of each resident's patients that had been included in the screening programme and the names of patients who had not yet been included. The first group that received the intervention had included 58 of 232 eligible patients (25%) at 8 months after the feedback intervention and the second group 51 of 249 eligible patients (20%) at 4 months. In comparison, the 2 groups with only the standard intervention had included 32 of 252 (13%) and 27 of 260 (10%) of their patients, respectively, at 11 months after the baseline intervention. These results suggest that provider feedback to medical residents can promote resident self-awareness and increase the proportion of patients included in a public programme when provided in addition to educational interventions.

Time to fecal immunochemical test completion for colorectal cancer screening

OBJECTIVES

Fecal immunochemical tests (FITs) can efficiently screen for colorectal cancer (CRC), but little is known on the timing to their completion. We investigate the time to return of a FIT following an order and describe patient characteristics associated with FIT return.

STUDY DESIGN

Retrospective cohort study.

METHODS

We identified 63,478 members of Kaiser Permanente Washington, aged 50 to 74 years, who received a FIT order from 2011 through 2012. Patient characteristics were ascertained through administrative and electronic health record data sources. We compared time from FIT order to return by patient characteristics using Kaplan-Meier and Cox regression methods.

RESULTS

About half (53.7%) of members completed a FIT. Median time from order to return was 13 days (mean, 44.5 days; interquartile range, 6-42 days). There was higher completion of FITs among Asian patients (hazard ratio [HR], 1.43; 95% CI, 1.38-1.48), black patients (HR, 1.13; 95% CI, 1.08-1.19), and Hispanic patients (HR, 1.10; 95% CI, 1.04-1.16) compared with white patients; among patients with recent CRC testing (vs no testing in past 2 years; HR, 1.90; 95% CI, 1.86-1.95); and among patients with Medicare insurance (vs commercial; HR, 1.30; 95% CI, 1.24-1.37). Factors associated with decreased FIT completion included younger age (50-54 years vs 70-74 years; HR, 0.87; 95% CI, 0.82-0.92), obesity (vs normal body mass index; HR, 0.88; 95% CI, 0.86-0.91), and higher Charlson Comorbidity Index score (≥3 vs 0; HR, 0.82; 95% CI, 0.79-0.87).

CONCLUSIONS

Time to return of FIT varies by patient characteristics. We observed greater FIT completion among people of color, suggesting that racial disparities in CRC may not be due to patient completion of the test after an order is received.

Organised population-based programmes and change in socioeconomic inequalities in mammography screening: A 1992-2012 nationwide quasi-experimental study

Organised mammography screening programmes may reduce socioeconomic inequalities in breast cancer screening, but evidence is contradictory. Switzerland has no national organised mammography screening programme, but regional programmes were progressively introduced since 1999, giving the opportunity to conduct a nationwide quasi-experimental study. We examined the evolution of socioeconomic inequalities in mammography screening in Switzerland and if exposure to regional organised programmes reduced socioeconomic inequalities. Data of 10,927 women aged 50 to 70 years old were collected from the Swiss Health Interview Survey, a nationally representative cross-sectional survey repeated 5 times (1992-2012). Socioeconomic characteristics were assessed using education, income, employment status, and occupational class. Adjusted prevalence ratios of up-to-date mammography screening were estimated with Poisson regressions and weighted for sampling strategy and non-participation bias. In the absence of organised screening programmes (1992-1997), prevalence of mammography screening increased by 23% and was associated with tertiary education and working part time. During the period of progressive introduction of regionally organised programmes (2002-2012), prevalence of mammography screening increased by 19% every 5 years and was associated with exposure to regional programmes and with independent/artisan occupations. Tertiary education and working part time were no longer associated. Exposure to organised programmes did not modify socioeconomic inequalities except for employment status: not employed women benefitted more from organised programmes compared to women working full time. In conclusion, socioeconomic inequalities in mammography screening decreased over time but organised programmes did not greatly modify them, except women not employed whose prevalence passed employed women.

Socioeconomic and demographic inequalities in stage at diagnosis and survival among colorectal cancer patients: evidence from a Swiss population-based study

Socioeconomic inequalities in cancer stage at diagnosis and survival are important public health issues. This study investigates the association between socioeconomic position (SEP) and colorectal cancer (CRC) stage at diagnosis and survival in Switzerland, a European country with highest level of medical facilities and life expectancy. We used population-based CRC data from seven Swiss cantonal cancer registries 2001-2008 (N = 10,088) linked to the Swiss National Cohort (SNC). Follow-up information was available until the end of 2013. SEP was estimated based on education. The association between cancer stage and SEP was assessed using logistic regression models including cancer localization (colon/rectum), sex, age, civil status, urbanity of residence, language region, and nationality (Swiss/non-Swiss). Survival was analyzed using competing risk regressions reporting subhazard ratios (SHRs) for the risk of dying due to CRC. We observed a social gradient for later stage CRC with adjusted odds ratios (ORs) of 1.11 (95% CI: 0.97-1.19) and 1.28 (95% CI: 1.08-1.50) for middle and low SEP compared to high SEP. Further, single compared to married people had elevated odds of being diagnosed at later stages. Survival was lower in patients with CRC with low SEP in the unadjusted model (SHR: 1.18, 95% CI: 1.07-1.30). After adjustment for stage at diagnosis and further sociodemographic characteristics, significant survival inequalities by SEP disappeared but remained for non-Swiss compared to Swiss citizens and for patients living in nonurban areas compared to their urban counterparts. Swiss public health strategies should facilitate equal access to CRC screening and optimal CRC care for all social groups and in all regions of Switzerland.

Disparities in cancer screening by occupational characteristics

Cancer screening patterns according to occupation characteristics in the United States are not well known, but could be used to help inform cancer control efforts. We examined cervical (CC), breast (BC) and colorectal cancer (CRC) screening prevalence and prevalence ratios (PR) by occupational characteristics in 2010, 2013 and 2015 National Health Interview Surveys (NHIS) among eligible US workers (CC women 21-65years; n=20,997), (BC women ≥40years; n=14,258) and (CRC men and women ≥50years; n=17,333). Cervical, breast and colorectal cancer screening prevalence among US workers was 84.0%, 68.9%, and 56.8%, respectively. Unadjusted prevalence ratios for cervical (PR=0.92, 95%CI 0.90, 0.94), breast (PR=0.86, 95%CI 0.83, 0.90) and colorectal cancer screening (PR=0.83, 95%CI 0.80, 0.87) were lower among workers in small (<25 employees) compared to large organizations (≥500 employees). People in food service, construction, production, and sales occupations were 13-26%, 17-28% and 9-30% less likely to be up to date with cervical, breast, and colorectal cancer screening, respectively, compared to healthcare professionals. Adjustment for socioeconomic factors and insurance status eliminated most associations. Disparities in cancer screening by occupational characteristics were mostly attributed to lower socioeconomic status and lack of insurance. These findings underscore the need for innovative public health strategies to improve cancer screening in vulnerable populations.

How do general practitioners put preventive care recommendations into practice? A cross-sectional study in Switzerland and France

OBJECTIVES

We previously identified that general practitioners (GPs) in French-speaking regions of Europe had a variable uptake of common preventive recommendations. In this study, we describe GPs' reports of how they put different preventive recommendations into practice.

DESIGN, SETTING AND PARTICIPANTS

Cross-sectional study conducted in 2015 in Switzerland and France. 3400 randomly selected GPs were asked to complete a postal (n=1100) or online (n=2300) questionnaire. GPs who exclusively practiced complementary and alternative medicine were not eligible for the study. 764 GPs (response rate: postal 47%, online 11%) returned the questionnaire (428 in Switzerland and 336 in France).

MAIN OUTCOME MEASURES

We investigated how the GPs performed five preventive practices (screening for dyslipidaemia, colorectal and prostate cancer, identification of hazardous alcohol consumption and brief intervention), examining which age group they selected, the screening frequency, the test they used, whether they favoured shared decision for prostate cancer screening and their definition of hazardous alcohol use.

RESULTS

A large variability was observed in the way in which GPs provide these practices. 41% reported screening yearly for cholesterol, starting and stopping at variable ages. 82% did not use any test to identify hazardous drinking. The most common responses for defining hazardous drinking were, for men, ≥21 drinks/week (24%) and ≥4 drinks/occasion for binge drinking (20%), and for women, ≥14 drinks/week (28%) and ≥3 drinks/occasion (21%). Screening for colorectal cancer, mainly with colonoscopy in Switzerland (86%) and stool-based tests in France (93%), was provided every 10 years in Switzerland (65%) and 2 years in France (91%) to patients between 50 years (87%) and 75 years (67%). Prostate cancer screening, usually with shared decision (82%), was provided yearly (62%) to patients between 50 years (74%) and 75-80 years (32%-34%).

CONCLUSIONS

The large diversity in the way these practices are provided needs to be addressed, as it could be related to some misunderstandingof the current guidelines, to barriers for guideline uptake or, more likely, to the absence of agreement between the various recommendations.

Introduction of an organised programme and social inequalities in mammography screening: A 22-year population-based study in Geneva, Switzerland

In developed countries, breast cancer mortality has decreased during the last decades due to, at least partially, the advent of mammography screening. Organised programmes aim, among other objectives, to increase participation and decrease social inequalities in screening access. We aimed to characterise the evolution of socioeconomic disparities in mammography screening before and after the implementation of an organised programme in Geneva, Switzerland. We included 5345 women, aged 50-74years, without past history of breast cancer who participated in the cross-sectional Bus Santé study, between 1992 and 2014. Outcome measures were: 1) never had a mammography (1992-2014) and 2) never had a mammography or not screened in the two years before being surveyed (subgroup analysis, 2007-2014). Educational attainment was divided in three groups (primary, secondary and tertiary) and period in two (before/after introduction of a screening programme in 1999). We calculated measures of relative and absolute change, including the relative (RII) and slope (SII) indices of social inequality adjusted for age and nationality. We compared the prevalence of screening before and after screening programme implementation using Poisson models. The proportion of unscreened women decreased during the study period from 30.5% to 3.6%. Lower educated women were more frequently unscreened (RII=2.39, p<0.001; SII=0.10, p<0.001). Organised screening decreased the proportion of unscreened women independently of education (prevalence ratio_{before vs. after}=4.41, p<0.001), but absolute and relative inequalities persisted (RII=2.11, p=0.01; SII=0.04, p=0.01). Introduction of an organised programme increased women's adherence to mammography screening but did not eliminate social disparities in screening participation.

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

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

Cervical cancer screening in Switzerland: cross-sectional trends (1992-2012) in social inequalities

Background: Incidence and mortality of cervical cancer declined thanks to Pap smear screening. However cervical cancer screening (CCS) inequalities are documented, including in high income countries. This population-based study aims to assess the importance and 20-year trends of CCS inequalities in Switzerland, where healthcare costs and medical coverage are among the highest in the world. Methods: We analyzed data from five waves of the population-based Swiss Health Interview Survey (SHIS) covering the period 1992–2012. Multivariable Poisson regression were used to estimate weighted prevalence ratios (PR) of CCS and 95% Confidence Intervals (CI) adjusting for socio-economic, socio-demographic characteristics, family status, health status, and use of healthcare. Results: The study included 32’651 women aged between 20 and 70 years old. Between 1992 and 2012, rates of CCS over the past 3 years fluctuated between 71.7 and 79.6% (adjusted P < 0.001). Lower CCS was observed among women with low education, low income, those having limited emotional support, who were non-Swiss, single, older, living in non-metropolitan area or in the French-speaking region, overweight. Over the analyzed period, differences in CCS across age groups diminished while rates among women who visited a GP over the previous year, versus those who did not, increased. Conclusions : While important changes occurred in screening recommendations and in social circumstances of the targeted population, CCS rates remained fairly stable in Switzerland between 1992 and 2012. At the same time, inequalities in CCS persisted over that period.

Blood glucose screening among elderly Malaysians: Who to target?

BACKGROUND

Early detection of raised blood glucose can reduce the risk of developing diabetes. Despite being a high-risk group, a significant proportion of the elderly population does not undergo blood glucose screening. The aim of the present study was to examine the factors affecting blood glucose screening among the elderly.

METHODS

Data from a sample of 2463 respondents in the National Health and Morbidity Survey 2011 were used. Pearson Chi-squared tests were conducted to find factors associated with screening behavior. A logit model was used to analyze the likelihood of screening.

RESULTS

Income, age, education, ethnicity, employment status, availability of medical coverage, and smoking behavior were significantly associated with blood glucose screening. The likelihood of blood glucose screening was positively correlated with available monthly income and was higher in those aged 60-69 years, those attaining higher education, Malays, and elderly who are medically covered.

CONCLUSIONS

The findings of the present study provide insights for health policy formulation for the elderly. As part of their efforts to reduce national health costs, governments should pay particular attention to the elderly, who are likely to be unscreened for blood glucose levels, because they face even larger risk exposure.

Colorectal cancer screening in countries of European Council outside of the EU-28

AIM

To provide an update on colorectal cancer (CRC) screening programmes in non-European Union (EU)-28 Council of Europe member states as of December 2015.

METHODS

The mission of the Council of Europe is to protect and promote human rights in its 47 member countries. Its 19 non-EU member states are Albania, Andorra, Armenia, Azerbaijan, Bosnia and Herzegovina, Republika Srpska, Georgia, Iceland, Liechtenstein, Republic of Moldova, Monaco, Montenegro, Norway, Russian Federation, San Marino, Serbia, Switzerland, FYR of Macedonia, Turkey, and Ukraine (EU-19). The main data source were GLOBOCAN, IARC, WHO, EUCAN, NORDCAN, ENCR, volume X of the CI5, the ministerial and Public Health Agency websites of the individual countries, PubMed, EMBASE, registries of some websites and the www.cochranelibrary.com, Scopus, www.clinicaltrials.gov, www.clinicaltrialsregister.eu, Research gate, Google and data extracted from screening programme results.

RESULTS

Our results show that epidemiological data quality varies broadly between EU-28 and EU-19 countries. In terms of incidence, only 30% of EU-19 countries rank high in data quality as opposed to 86% of EU-28 states. The same applies to mortality data, since 52% of EU-19 countries as against all EU-28 countries are found in the high ranks. Assessment of the method of collection of incidence data showed that only 32% of EU-19 countries are found in the top three quality classes as against 89% of EU-28 countries. For the mortality data, 63% of EU-19 countries are found in the highest ranks as opposed to all EU-28 member states. Interestingly, comparison of neighbouring countries offering regional screening shows, for instance, that incidence and mortality rates are respectively 38.9 and 13.0 in Norway and 29.2 and 10.9 in Sweden, whereas in Finland, where a national organised programme is available, they are respectively 23.5 and 9.3.

CONCLUSION

Cancer screening should be viewed as a key health care tool, also because investing in screening protects the weakest in the population, decreases the social burden of cancer, and reduces all types of health care costs, including those for radical surgery, long-term hospitalisation, and chemotherapy.

Training primary care physicians to offer their patients faecal occult blood testing and colonoscopy for colorectal cancer screening on an equal basis: a pilot intervention with before-after and parallel group surveys

OBJECTIVES

Primary care physicians (PCPs) should prescribe faecal immunochemical testing (FIT) or colonoscopy for colorectal cancer screening based on their patient's values and preferences. However, there are wide variations between PCPs in the screening method prescribed. The objective was to assess the impact of an educational intervention on PCPs' intent to offer FIT or colonoscopy on an equal basis.

DESIGN

Survey before and after training seminars, with a parallel comparison through a mailed survey to PCPs not attending the training seminars.

SETTING

All PCPs in the canton of Vaud, Switzerland.

PARTICIPANTS

Of 592 eligible PCPs, 133 (22%) attended a seminar and 106 (80%) filled both surveys. 109 (24%) PCPs who did not attend the seminars returned the mailed survey.

INTERVENTION

A 2 h-long interactive seminar targeting PCP knowledge, skills and attitudes regarding offering a choice of colorectal cancer (CRC) screening options.

OUTCOME MEASURES

The primary outcome was PCP intention of having their patients screened with FIT and colonoscopy in equal proportions (between 40% and 60% each). Secondary outcomes were the perceived role of PCPs in screening decisions (from paternalistic to informed decision-making) and correct answer to a clinical vignette.

RESULTS

Before the seminars, 8% of PCPs reported that they had equal proportions of their patients screened for CRC by FIT and colonoscopy; after the seminar, 33% foresaw having their patients screened in equal proportions (p<0.001). Among those not attending, there was no change (13% vs 14%, p=0.8). Of those attending, there was no change in their perceived role in screening decisions, while the proportion responding correctly to a clinical vignette increased (88-99%, p<0.001).

CONCLUSIONS

An interactive training seminar increased the proportion of physicians with the intention to prescribe FIT and colonoscopy in equal proportions.

Prostate cancer screening in Switzerland: 20-year trends and socioeconomic disparities

BACKGROUND

Despite important controversy in its efficacy, prostate cancer (PCa) screening has become widespread. Important socioeconomic screening disparities have been reported. However, trends in PCa screening and social disparities have not been investigated in Switzerland, a high risk country for PCa. We used data from five waves (from 1992-2012) of the population-based Swiss Health Interview Survey to evaluate trends in PCa screening and its association with socioeconomic indicators.

METHODS

We used multivariable Poisson regression to estimate prevalence ratios (PR) and 95% Confidence Intervals (CI) adjusting for demographics, health status, and use of healthcare.

RESULTS

The study included 12,034 men aged ≥50 years (mean age: 63.9). Between 1992 and 2012, ever use of PCa screening increased from 55.3% to 70.0% and its use within the last two years from 32.6% to 42.4% (p-value <0.05). Income, education, and occupational class were independently associated with PCa screening. PCa screening within the last two years was greater in men with the highest (>$6,000/month) vs. lowest income (≤$2,000) (46.5% vs. 38.7% in 2012, PR for overall period =1.29, 95%CI: 1.13-1.48). These socioeconomic disparities did not significantly change over time.

CONCLUSIONS

This study shows that about half of Swiss men had performed at least one PCa screening. Men belonging to high socioeconomic status are clearly more frequently screened than those less favored. Given the uncertainty of the usefulness of PCa screening, men, including those with high socioeconomic status, should be clearly informed about benefits and harms of PCa screening, in particular, the adverse effect of over-diagnosis and of associated over-treatment.