Canadian Colorectal Cancer Screening Guidelines: Do They Need an Update Given Changing Incidence and Global Practice Patterns?

Symptom Burden and Time from Symptom Onset to Cancer Diagnosis in Patients with Early-Onset Colorectal Cancer: A Multicenter Retrospective Analysis

Background: The incidence of colorectal cancer (CRC) is decreasing in individuals >50 years due to organised screening but has increased for younger individuals. We characterized symptoms and their timing before diagnosis in young individuals. Methods: We identified all patients diagnosed with CRC between 1990-2017 in British Columbia, Canada. Individuals <50 years (n = 2544, EoCRC) and a matched cohort >50 (n = 2570, LoCRC) underwent chart review to identify CRC related symptoms at diagnosis and determine time from symptom onset to diagnosis. Results: Across all stages of CRC, EoCRC presented with significantly more symptoms than LoCRC (Stage 1 mean ± SD: 1.3 ± 0.9 vs. 0.7 ± 0.9, p = 0.0008; Stage 4: 3.3 ± 1.5 vs. 2.3 ± 1.7, p < 0.0001). Greater symptom burden at diagnosis was associated with worse survival in both EoCRC (p < 0.0001) and LoCRC (p < 0.0001). When controlling for cancer stage, both age (HR 0.87, 95% CI 0.8-1.0, p = 0.008) and increasing symptom number were independently associated with worse survival in multivariate models. Conclusions: Patients with EoCRC present with a greater number of symptoms of longer duration than LoCRC; however, time from patient reported symptom onset was not associated with worse outcomes.

An Exploratory Analysis of the Cost-Effectiveness of a Multi-cancer Early Detection Blood Test Compared with Standard of Care Screening in Ontario, Canada

BACKGROUND

Determining whether multi-cancer early detection (MCED) tests are cost effective is important in deciding whether they should be included in the clinical path of cancer care, especially for cancers where screening tools do not exist.

RESEARCH OBJECTIVE

The main objective of this study is to determine the cost effectiveness of including a MCED screening regimen together with existing provincial screening protocols for selected cancers that are prevalent in Ontario, Canada, among average risk persons aged 50-75 years. The selected cancers include breast, colorectal, lung, esophageal, liver, pancreatic, stomach, and ovarian.

METHODS

Cost effectiveness was estimated from a provincial Ministry of Health perspective. A state-transition Markov model representing the decision path of both the proposed and existing screening strategies along the natural history of the selected types of cancers was implemented. The incremental cost-effectiveness ratio (ICER) was calculated using data from available literature and the guidelines published by the Canadian Agency for Drugs and Technologies in Health (CADTH) for conducting a cost-effectiveness analysis, which included a discount rate of 1.5% applied to all costs and outcomes. Costs were also converted to 2022 Canadian dollars. To test the robustness of the model, both univariate and probabilistic sensitivity analyses were conducted.

RESULTS

MCED screening resulted in more diagnosed cases of each type of cancer, even at an earlier stage of disease. This was also associated with fewer related deaths compared with standard of care. Notwithstanding, the analysis revealed that the MCED intervention was not cost effective [ICER: CAD$143,369 per quality-adjusted life year (QALY)], given a willingness to pay (WTP) threshold of $100,000 per QALY. The probabilistic sensitivity analyses revealed that the MCED intervention strategy was preferred to standard of care no more than 2% of the time at this WTP for both males and females. The model was most sensitive to the cost of MCED screening, and the levels of specificity of the MCED and colorectal cancer screening tests.

CONCLUSION

The main contribution of the study is to present and execute a methodological approach that can be adopted to test the cost effectiveness of an MCED tool in the Canadian setting. The model is also sufficiently generic that it could be adapted to other jurisdictions, and with consideration for increasing the WTP threshold beyond the common $100,000 per QALY limit, given the life-threatening nature of cancer, to ensure that MCED interventions are cost-effective.

Association of Reducing the Recommended Colorectal Cancer Screening Age With Cancer Incidence, Mortality, and Costs in Canada Using OncoSim

Importance

Recent US guideline updates have advocated for colorectal cancer (CRC) screening to begin at age 45 years in average-risk adults, whereas Canadian screening programs continue to begin screening at age 50 years. Similarities in early-onset CRC rates in Canada and the US warrant discussion of earlier screening in Canada, but there is a lack of Canadian-specific modeling data to inform this.

Objective

To estimate the association of a lowered initiation age for CRC screening by biennial fecal immunochemical test (FIT) with CRC incidence, mortality, and health care system costs in Canada.

Design, Setting, and Participants/Exposures

This economic evaluation computational study used microsimulation modeling via the OncoSim platform.

Main Outcomes and Measures

Modeled rates of CRC incidence, mortality, and health care costs in Canadian dollars.

Results

This analysis included 4 birth cohorts (1973-1977, 1978-1982, 1983-1987, and 1988-1992) representative of the Canadian population accounting for previously documented effects of increasing CRC incidence in younger birth cohorts. Screening initiation at age 45 years resulted in a net 12 188 fewer CRC cases, 5261 fewer CRC deaths, and an added 92 112 quality-adjusted life-years (QALYs) to the cohort population over a 40-year period relative to screening from age 50 years. Screening initiation at age 40 years yielded 18 135 fewer CRC cases, 7988 fewer CRC deaths, and 150 373 QALYs. The cost per QALY decreased with younger birth cohorts to a cost of $762 per QALY when Canadians born in 1988 to 1992 began screening at age 45 years or $2622 per QALY with screening initiation at age 40 years. Although costs associated with screening and resulting therapeutic interventions increased with earlier screening, the overall health care system cost of managing CRC decreased.

Conclusions and Relevance

This economic evaluation study using microsimulation modeling found that earlier screening may reduce CRC disease burden and add life-years to the Canadian population at a modest cost. Guideline changes suggesting earlier CRC screening in Canada may be justified, but evaluation of the resulting effects on colonoscopy capacity is necessary.

Provincial variation in colorectal cancer screening adherence in Canada; evidence from the Canadian Partnership for Tomorrow's Health

Introduction

Although colorectal cancer (CRC) screening program is proven to reduce CRC incidence and mortality, understanding patterns and predictors of suboptimal adherence in screening program requires further investigation in Canada.

Methods

We used self-reported data from five regional cohorts of the Canadian Partnership for Tomorrow's Health (CanPath), namely the BC Generations Project (BCGP), Alberta's Tomorrow Project (ATP), the Ontario Health Study (OHS), Quebec's CARTaGENE, and the Atlantic Partnership for Tomorrow's Health Study (Atlantic PATH). We stratified participants into the following four risk categories: 1) age 50-74 years, 2) family history in a first-degree relative, 3) personal history of chronic inflammatory bowel disease and/or polyps, and 4) co-existence of personal risk and family history. Multivariable logistic regression was used to identify predictors of adherence to the screening guidelines.

Results

Adherence to CRC screening varied considerably between regions, ranging from 16.6% in CARTaGENE to 47.7% in OHS. Compared to the largest cohort OHS, the likelihood of non-adherence to CRC screening was significantly higher in BCGP (OR 1.15, 95% CI 1.11-1.19), the Atlantic PATH (OR 1.90, 95% CI 1.82-1.99) and CARTaGENE (OR 5.10, 95% CI 4.85-5.36). Low physical activity, current smoking, presence of personal risk, family history of CRC significantly reduced the likelihood of adherence to screening recommendations.

Discussion/conclusion

Compared to the national target of ≥ 60% for participation in CRC screening, adherence to regular CRC screening was suboptimal in this cohort of Canadians and varied by region. Further efforts are needed to identify the specific barriers to screening adherence in different provinces and across risk categories.

Young-onset colorectal cancer

In the past decades the incidence of colorectal cancer (CRC) in people under the age of 50 years has increased, which is referred to as early-onset CRC or young-onset CRC (YO-CRC). YO-CRC is expected to account for 11% of colon cancers and 23% of rectal cancers by 2030. This trend is observed in different parts of the world and in both men and women. In 20% of patients with YO-CRC, a hereditary cancer syndrome is found as the underlying cause; however, in the majority of patients no genetic predisposition is present. Beginning in the 1950s, major changes in lifestyle such as antibiotic use, low physical activity and obesity have affected the gut microbiome and may be an important factor in YO-CRC development. Owing to a lack of screening, patients with YO-CRC are often diagnosed with advanced-stage disease. Long-term treatment-related complications should be taken into account in these younger patients, making the more traditional sequential approaches of drug therapy not always the most appropriate option. To better understand the underlying mechanism and define relationships between environmental factors and YO-CRC development, long-term prospective studies are needed with lifestyle data collected from childhood.

A Real-Time Endoscope Motion Tracker

OBJECTIVE

In colonoscopy, it is desirable to accurately localize the position of the endoscope's distal tip. Current tip localization techniques are not sufficient for recording the position and movement of the tip, nor is its rotation measured. We hypothesize that integration of multiple tracking modalities can effectively record the endoscope's motion in real time and continuously corrects cumulative errors.

METHODS

A dual modality tracking method is developed to measure the motion of the endoscope's insertion tube in real time, including insertion length, rotation angle, and their velocities. Optical trackballs were used to measure the endoscope insertion tube's motion and cameras were used to correct cumulative errors.

RESULTS

The accuracy of insertion length and rotational angle were measured. For speeds ≤ 10 mm/s, the median and 90th percentile insertion position errors were 0.88 mm and 2.2 mm, respectively. The insertion position error increases with the speed, reaching a maximum of 10 mm for speeds < 40 mm/s. 11° and 21° were the median and 90th percentile rotation angle errors for angular speeds < 40°/s. Cumulative errors are sufficiently reduced by the imaging modality.

CONCLUSION

The prototype device can precisely measure an unmodified endoscope's position, rotation, and motion in real time without significant accumulative error. The prototype device is small and compatible with existing commercial endoscopes as an add-on accessory, which could be used for reporting, localizing the lesions in follow up procedures, operational guidance, quality assurance, and training. Clinical and Translational Impact Statement-This preclinical research develops an endoscope tracker that can be integrated into colonoscopy training, automatically record endoscope motion, and be further developed to improve polyp and tumor localization during colonoscopy.

Patterns of Healthcare Utilization Leading to Diagnosis of Young-Onset Colorectal Cancer (yCRC): Population-Based Case-Control Study

Background: The increasing risk of young-onset colorectal cancer (yCRC) in adults < 50 years has called for better understanding of patients’ pathways to diagnosis. This study evaluated patterns of healthcare utilization before diagnosis of yCRC. Methods: Using linked administrative health databases in British Columbia, Canada, we identified yCRC cases and cancer-free controls matched (1:10) on age, sex, and healthcare utilization. The index date was the date of diagnosis for yCRC cases and matched date for controls. Outpatient visits, emergency department visits, and hospitalizations over a 5-year prediagnosis period (e.g., year-1 to year-5) were compared using descriptive statistics and Poisson regression models. Results: The study included 2567 yCRC cases (49.6% females, 43.0 ± 5.8 years) and 25,455 controls (48.6% females, 43.0 ± 5.8 years). We observed an increasing number of outpatient visits from prediagnosis year-5 (median = 3) to year-1 (median = 8) for yCRC cases. Among controls, outpatient visits were stable and did not have a pattern of increase. Poisson regression models indicated higher adjusted count ratios for outpatient visits for yCRC cases compared to controls in the year before diagnosis (1.11; 95% CI, 1.07 to 1.15). In the year before diagnosis, 35.1% of yCRC cases had potentially related visits to CRC (e.g., nausea, vomiting) and 16.9% had potentially red flag visits (e.g., gastrointestinal hemorrhage or iron deficiency anemia). Conclusions: Using population-based data, we found that individuals with yCRC did not have higher healthcare utilization than individuals without in the prediagnosis period except for the year before diagnosis.

Direct medical costs of young-onset colorectal cancer: a worldwide systematic review

Background

Given the rising incidence of young-onset colorectal cancer (yCRC) among individuals younger than 50 years old, understanding the economic burden of yCRC is required to inform the delivery of healthcare services. Therefore, we conducted a systematic review of studies assessing the direct medical costs of yCRC, and where relevant average-age onset CRC (aCRC).

Methods

We searched MEDLINE, EMBASE, and Web of Science from inception to May 2022 for original, peer-reviewed studies, that reported direct medical costs (e.g., chemotherapy, radiotherapy, outpatient visits, inpatient care, prescription medications) for yCRC and aCRC. We used a modified version of the Consolidated Health Economic Evaluation Reporting Standards checklist to appraise the studies. Costs were inflation-adjusted to 2020 US dollars.

Results

We included 14 studies from 10 countries, including the USA, England, France, Korea, Vietnam, China, Italy, Australia, Canada and Japan. Five studies focused on prevalent disease and reported annualized per-capita cost of prevalent yCRC, ranging from $2,263 to $16,801 and $1,412 to $14,997 among yCRC and aCRC cases, respectively. Nine studies estimated the cost of incident disease. Synthesis of per-capita costs incurred 12 months following colorectal cancer diagnosis ranged from $23,368 to $89,945 for yCRC and $19,929 to $67,195 for aCRC. Five studies used multivariable approaches to compare costs associated with yCRC and aCRC, four showed no differences and one suggested greater costs with yCRC.

Conclusion

Our synthesis of direct medical costs of yCRC across multiple jurisdictions provide relevant information for healthcare decisions, including on-going considerations for expanding CRC screening strategies to younger adults.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-022-08481-6.

Disparities in Recommendations for Colorectal Cancer Screening Among Average-Risk Individuals: An Ecobiosocial Approach

Regardless of the high global burden of colorectal cancer (CRC), the uptake of CRC screening varies across countries. This systematic review aimed to provide a picture of the disparities in recommendations for CRC screening in average-risk individuals using an ecobiosocial approach. It was reported according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. The literature search was conducted through Scopus, Web of Science, PubMed, and EBSCOHost. Full-text guidelines which were published between 2011 and 2021, along with guidelines which provided recommendations on CRC screening in average-risk individuals, were included in the review. However, guidelines focusing only on a single screening modality were excluded. Fourteen guidelines fulfilling the eligibility criteria were retained for the final review and analysis. Quality assessment of each guideline was performed using the AGREE II instrument. Disparities in guidelines identified in this review were classified into ecological (screening modalities and strategies), biological (recommended age, gender and ethnicities), and social (smoking history, socioeconomic status, and behavior) factors. In general, unstandardized practices in CRC screening for average-risk individuals are likely attributable to the inconsistent and non-specific recommendations in the literature. This review calls on stakeholders and policymakers to review the existing colorectal cancer screening practices and pursue standardization.