Reducing inequities in colorectal cancer screening in North America

The projected health and economic impact of increased colorectal cancer screening participation among Canadians by income quintile

OBJECTIVES

Disparities in colorectal cancer (CRC) screening uptake by socioeconomic status have been observed in Canada. We used the OncoSim-Colorectal model to evaluate the health and economic outcomes associated with increasing the participation rates of CRC screening programs to 60% among Canadians in different income quintiles.

METHODS

Baseline CRC screening participation rates were obtained from the 2017 Canadian Community Health Survey. The survey participants were categorized into income quintiles using their reported household income and 2016 Canadian Census income quintile thresholds. Within each quintile, the participation rate was the proportion of respondents aged 50-74 who reported having had a fecal test in the past two years. Using the OncoSim-Colorectal model, we simulated an increase in CRC screening uptake to 60% across income quintiles to assess the effects on CRC incidence, mortality, and associated economic costs from 2024 to 2073.

RESULTS

Increasing CRC screening participation rates to 60% across all income quintiles would prevent 69,100 CRC cases and 36,600 CRC deaths over 50 years. The improvement of clinical outcomes would also translate to increased person-years and health-adjusted person-years. The largest impact was observed in the lowest income group, with 22,200 cases and 11,700 deaths prevented over 50 years. Increased participation could lead to higher screening costs ($121 million CAD more per year) and lower treatments costs ($95 million CAD less per year), averaged over the period 2024-2073.

CONCLUSION

Increased screening participation will improve clinical outcomes across all income groups while alleviating associated treatment costs. The benefits of increased participation will be strongest among the lowest income quintile.

Colorectal cancer mortality trend in Mato Grosso, Brazil, 2000 to 2019

OBJECTIVE

To analyze the time series of colorectal cancer (CRC) mortality, according to sex and age group, in Mato Grosso, Brazil, from 2000 to 2019.

METHODS

Ecological time series study, with standardized mortality rates from CRC (C18 to C21) among residents of Mato Grosso. Information on deaths was provided by the Mato Grosso State Health Department, comprising the Mortality Information System and demographic information obtained from the Brazilian Institute of Geography and Statistics. The joinpoint regression analysis was used in the analysis of temporal trend.

RESULTS

A total of 2,406 deaths from CRC were identified in Mato Grosso between 2000 and 2019. The highest rates were found among the age group from 60 to 79 years. There was an increasing trend in mortality rates among men due to CRC for almost all age groups, with the exception of those aged 40 to 49 years and 80 years and older. For women, there was a significant increase in the age groups from 50 to 59 years and 80 years and older.

CONCLUSION

The results showed an increase in mortality rates from CRC in the state of Mato Grosso, from 2000 to 2019, in certain age groups for both sexes, but especially for men. Knowledge about the evolution of mortality can provide data on the epidemiological situation of cancer at the local level and, thus, contribute to the development of actions to control and prevent this disease.

Tendência da mortalidade por câncer colorretal em Mato Grosso, Brasil, de 2000 a 2019

RESUMO: Objetivo: Analisar a tendência temporal da mortalidade por câncer colorretal (CCR) segundo sexo e faixa etária, em Mato Grosso, Brasil, de 2000 a 2019. Métodos: Estudo ecológico de série temporal das taxas ajustadas de mortalidade pelo CCR (C18 a C21) de residentes de Mato Grosso. As informações sobre os óbitos foram fornecidas pela Secretaria de Estado de Saúde de Mato Grosso e compõem o Sistema de Informações sobre Mortalidade, e as informações demográficas foram obtidas do Instituto Brasileiro de Geografia e Estatística. Para a tendência temporal, foi empregada a análise de regressão por joinpoint. Resultados: Foram identificados 2.406 óbitos por CCR em Mato Grosso no período de 2000 a 2019. As maiores taxas foram encontradas entre as faixas etárias de 60 e 79 anos. Para os homens, evidenciou-se tendência crescente das taxas de mortalidade por CCR para quase todas as faixas etárias, com exceção das de 40 a 49 anos e de 80 anos ou mais. Para as mulheres, houve aumento significativo nas faixas etárias de 50 a 59 anos e de 80 anos ou mais. Conclusão: Os resultados do estudo mostraram aumento das taxas de mortalidade por CCR no estado do Mato Grosso, no período de 2000 a 2019, em determinadas faixas etárias de ambos os sexos, mas sobretudo para os homens. O conhecimento sobre a evolução da mortalidade pode oferecer dados da situação epidemiológica do câncer em nível local e, assim, contribuir para a elaboração de ações de controle e prevenção desse agravo.

Afrocentric screening program for breast, colorectal, and cervical cancer among immigrant patients in Ontario

PROBLEM ADDRESSED

Black and immigrant populations across Canada have lower screening rates than Canadian-born white populations, predisposing them to increased cancer morbidity and mortality. Effective interventions are required to increase cancer screening rates among these populations.

OBJECTIVE OF PROGRAM

To improve breast, colorectal, and cervical cancer screening rates at TAIBU Community Health Centre, which has a mandate to provide primary health care services to the Black and immigrant community in the greater Toronto area.

PROGRAM DESCRIPTION

An Afrocentric quality improvement program was developed and implemented, consisting of provider audits, cancer screening education programs, a patient call-back program, and a mammography promotion day.

CONCLUSION

TAIBU Community Health Centre's continuous quality improvement approach was successful in engaging health care providers and patients to increase cancer screening participation sustainably in a racially and socioeconomically diverse setting. Rates of breast, colorectal, and cervical cancer screening offered to eligible patients increased from 17% to 72%, 18% to 67%, and 59% to 70%, respectively, between 2011 and 2018.

Multilevel Pathways of Colorectal Cancer Screening Among Low-Income Vietnamese Americans: A Structural Equation Modeling Analysis

Background:

Colorectal cancer (CRC) disproportionately affects Vietnamese Americans, especially those with low income and were born outside of the United States. CRC screening tests are crucial for prevention and early detection. Despite the availability of noninvasive, simple-to-conduct tests, CRC screening rates in Asian Americans, particularly Vietnamese Americans, remain suboptimal. The purpose of this study was to evaluate the interplay of multilevel factors – individual, interpersonal, and community – on CRC screening behaviors among low-income Vietnamese Americans with limited English proficiency.

Methods:

This study is based on the Sociocultural Health Behavior Model, a research-based model that incorporates 6 factors associated with decision-making and health-seeking behaviors that result in health care utilization. Using a community-based participatory research approach, we recruited 801 Vietnamese Americans from community-based organizations. We administered a survey to collect information on sociodemographic characteristics, health-related factors, and CRC screening-related factors. We used structural equation modeling (SEM) to identify direct and indirect predictors of lifetime CRC screening.

Results:

Bivariate analysis revealed that a greater number of respondents who never screened for CRC reported limited English proficiency, fewer years of US residency, and lower self-efficacy related to CRC screening. The SEM model identified self-efficacy (coefficient = 0.092, P < .01) as the only direct predictor of lifetime CRC screening. Educational attainment (coefficient = 0.13, P < .01) and health beliefs (coefficient = 0.040, P < .001) had a modest significant positive relationship with self-efficacy. Health beliefs (coefficient = 0.13, P < .001) and educational attainment (coefficient = 0.16, P < .01) had significant positive relationships with CRC knowledge.

Conclusions:

To increase CRC screening uptake in medically underserved Vietnamese American populations, public health interventions should aim to increase community members’ confidence in their abilities to screen for CRC and to navigate associated processes, including screening preparation, discussions with doctors, and emotional complications.

An examination of colorectal cancer burden by socioeconomic status: evidence from GLOBOCAN 2018

AIM AND BACKGROUND

Colon and rectum (colorectal) cancer cause substantial mortality and morbidity worldwide. The management and control of a complex disease such as cancer cannot rely on the old strategy of "one disease one medicine" and must make a transition into new-age practices involving predictive, preventive, and personalized medicine (PPPM) at its core. Adoption of PPPM approach to cancer management at the policy level requires quantification of cancer burden at the country level. For this purpose, we examine the burden of colorectal cancer in 185 countries in 2018. Based on results, we discuss the opportunities presented by PPPM and challenges to be encountered while adopting PPPM for the treatment and prevention of colorectal cancer.

DATA AND METHODS

Age- and sex-wise estimates of colorectal cancer were procured from the GLOBOCAN 2018. The country- and region-wise burden of colorectal cancer in 185 countries was examined using all-age and age-standardized incidence and mortality estimates. Human development index (HDI) was employed as the indicator of socioeconomic status of a country. Mortality-to-incidence ratio (MIR) was employed as the proxy of 5-year survival rate.

RESULTS

Globally, colorectal cancer claimed an estimated 880,792 lives (males 484,224; females 396,568) with 1.85 million new cases (males 1.03 million; females 823,303) were estimated to be diagnosed in 2018. Globally, the age-standardized incidence rate (ASIR) was 19.7/100,000, whereas age-standardized mortality rate (ASMR) recorded to be 16.3/100,000 in 2018. Age-standardized rates were the highest in developed countries led by Hungary with ASIR of 51.2/100,000 followed by South Korea with ASIR of 44.5/100,000. ASMR followed the patterns of ASIR with the highest ASMR recorded by Hungary (21.5 per 100,000) and Slovakia (20.4 per 100,000). Globally, MIR stood at 0.48, and among the countries recording more than 1000 cases, Nepal registered the highest MIR of 0.83 and the lowest was recorded by South Korea (0.27). The age-standardized rates exhibited nonlinear association with HDI, whereas MIR was negatively associated with HDI.

CONCLUSION

Colorectal cancer causes a substantial burden worldwide and exhibit a positive association with the socioeconomic status. With the aid of improving screening modalities, preventable nature of the disease (due to dietary and lifestyle risk factors) and improving treatment procedures, the burden of CRC can largely be curtailed. The high burden of CRC in developing countries, therefore, calls for effective prevention strategies, cost-effective screening, and early-stage detection, cost-effective predictive, and personalized treatment regime.

Associations between area-level deprivation, rural residence, physician density, screening policy and late-stage colorectal cancer in Canada

BACKGROUND

Important social disparities in colorectal screening exist in Canada. Few studies have assessed disparities further along the cancer control continuum. Here we assess the associations between social and material deprivation, physician density, rural residence, and the absence of provincial mail-based screening programs and colorectal cancer (CRC) stage at diagnosis.

METHODS

Colorectal cancer cases and stage data ("local or regional" if stage 0, I, or II, "late" if stage III or IV) were obtained through the Canadian Cancer Registry (2011-2015, N = 54,745). Cases were linked to 2006 Canadian Census Dissemination Area-level data on rural/urban status, exposure to a provincial mail-based screening program, and social and material deprivation (Pampalon Index quintile groups); and to Scott's Medical Database 2011 physician density data (<7 vs. ≥ 7/10,000). Age, sex, and predictor-adjusted Generalized estimating equation (GEE) Poisson models were used to determine independent associations between predictors and late-stage at diagnosis.

RESULTS

Half of CRC cases are diagnosed at stage III or IV (51 %), with younger age groups experiencing higher late-stage prevalence (57 % among those aged 18-49). The covariate-adjusted late-stage prevalence was 2-percentage points higher in most materially- and socially-deprived areas (95 % CI: 1 %, 4 %, in both, respectively) and in provinces with no mail-based screening programs (95 % CI: 1 %, 2 %). No significant differences were observed according to rural residence or physician density.

CONCLUSIONS

Social disparities in late-stage CRC diagnosis are modest. Continued surveillance of these disparities may be warranted as provinces continue to promote early cancer detection through screening, and stage distributions may change overtime.

Disparities in Thyroid Screening and Medication Use in Quebec, Canada

Background: No studies have examined the frequency of thyroid screening in the Canadian population, and whether thyroid screening and medication use vary by sex, race, income, and preexisting health conditions.

Methods: Using data from the 2011, 2012 cycles of the Canadian Community Health Survey, we report rates of thyroid screening among Quebec residents ≥35 (n=7024) and rates of thyroid medication use among Quebec residents ≥35 (n=16,081). We examine variations in medication use and screening by sex, age, race, immigration status, access to a regular doctor, and health conditions that have been linked to thyroid disease.

Results: Of the Quebec residents ≥35, 10.3% reported taking thyroid medication and 0.4% reported that the last blood test a physician ordered was to check for a new thyroid condition. Canadian-born residents and those who identified as White reported higher medication use and screening rates, compared to immigrants and those who identified as visible minorities. Racial disparities were especially pronounced, with White Quebec residents reporting three times greater odds of thyroid screening than visible minorities. The strongest predictors of both thyroid medication use and screening were access to a regular doctor. Despite women being eight times more likely to suffer from thyroid disease, women were not significantly more likely to be screened, compared to men (odds ratio=1.38, 95% confidence interval: 0.74–2.60).

Discussion: Strategies are needed to decrease disparities in thyroid screening and medication use. Interventions that target health systems (e.g., increasing physician supply), providers (continuing professional education modules about thyroid disease for family physicians), and recipients of care (multilanguage public awareness campaigns and posters at walk-in clinics that describe common symptoms of different thyroid disorders) should be implemented and tested.

Colorectal cancer screening: Understanding the health literacy needs of hispanic rural residents

Purpose

Hispanics residing in rural areas are among those who are least likely to be screened for colorectal cancer (CRC) and more likely to present with late stage CRC than other racial or ethnic groups. We conducted a pilot study utilizing a mixed-method approach to explore perceptions of CRC and CRC screening among Hispanic adults residing in South Texas rural communities and to identify health literacy needs associated with CRC screening uptake.

Methods

A convenience sample of 58 participants, aged 35–65, were recruited to complete questionnaires and participate in focus groups, ranging in size from 4 to 13 participants. Six focus groups were conducted across 3 adjacent rural counties. A semi-structured moderator's guide was designed to elicit discussion about participants' experiences, knowledge, and perceptions of CRC and CRC screening.

Findings

Lack of knowledge of CRC and CRC screening as cancer prevention was a common theme across focus groups. A majority, 59%, reported never been screened. Thirty-nine percent reported they had been screened for colon cancer and 5% reported they did not know if they had been screened. Participants with lower educational levels perceived themselves at high risk for developing CRC polyps, would not want to know if they had CRC, and if they did have CRC, would not want to know until the very end. Limited information about CRC and CRC screening, a lack of specialized providers, limited transportation assistance, and compromised personal privacy in small-town medical facilities were perceived to be barriers to CRC screening.

Conclusions

Low screening rates persist among rural Hispanics. Improving CRC screening literacy and addressing factors unique to rural Hispanics may be a beneficial strategy for reducing screening disparities in this at-risk population.

Area-level income disparities in colorectal screening in Canada: evidence to inform future surveillance

Background

Participation in colorectal screening remains low even in countries with universal health coverage. Area-level determinants of low screening participation in Canada remain poorly understood.

Methods

We assessed the association between area-level income and two indicators of colorectal screening (having never been screened, having not been screened recently) by linking census-derived local area-level income data with self-reported screening data from urban-dwelling respondents to the Canadian Community Health Survey (50-75 years of age, cycles 2005 and 2007, n = 18,362) who reported no known risk factors for colorectal cancer. Generalized estimating equation Poisson models estimated the prevalence ratios and differences for having never been screened and having not been screened recently, adjusting for individual-level income, education, marital status, having a regular physician, age, and sex.

Results

About 53% of the study population had never been screened. Among individuals who had ever been screened, 35% had been screened recently. Adjusting for covariates, lower area-level income was associated with having never been screened [covariate-adjusted prevalence ratios: 1.24 for quartile 1; 95% confidence limits (cl): 1.16, 1.34; 1.25 for quartile 2; 95% cl: 1.15, 1.33; 1.15 for quartile 3; 95% cl: 1.08, 1.23]. Among individuals who had been screened in their lifetime, area-level income was not associated with having not been screened recently.

Conclusions

Lower area-level income is associated with having never been screened for colorectal cancer even after adjusting for individual socioeconomic factors. Those findings highlight the potential importance of socioeconomic contexts for colorectal screening initiation and merit attention in both future research and surveillance efforts.

The Role of Access to a Regular Primary Care Physician in Mediating Immigration-Based Disparities in Colorectal Screening: Application of Multiple Mediation Methods

BACKGROUND

Colorectal cancer screening participation is lower among recent immigrants than among Canadian-born individuals. We assessed whether this screening disparity is mediated by access to regular primary care physicians (PCP).

METHODS

Pooling years 2003 to 2014 of the Canadian Community Health Survey, lifetime screening in respondents aged 50 to 75 years of age who immigrated in the previous 10 years (n = 1,067) was compared with Canadian-born respondents (N = 102,366). Regression- and inverse probability weighting-based methods were used to estimate the total effect (TE) and controlled direct effect (CDE) of recent immigration on never having received either a stool- or endoscopic-based screening test. The proportion of the TE that would be eliminated if all had a PCP was computed using these estimates [proportion eliminated (PE) = (TE - CDE)/(TE - 1)]. Analyses were stratified by visible minority status and adjusted for income, rurality, age, sex, marital status, education, and exposure to a provincially organized colorectal screening program.

RESULTS

The prevalence of never having been screened was 71% and 57% in visible minority and white recent immigrants, respectively, and 46% in white Canadian-born respondents. If all had regular PCPs, there would be no reduction in the screening inequality between white recent immigrants and Canadian-born (null PE), and the inequality between visible minority immigrants and white Canadian-born may increase by 6% to 13%.

CONCLUSIONS

Ensuring all have regular PCPs may lead to greater screening gains among Canadian-born than recent immigrants.

IMPACT

Improving access to PCPs may increase colorectal screening overall, but not reduce immigration-based disparities screening. Alternative interventions to reduce this disparity should be explored.

Eliciting vulnerable patients' preferences regarding colorectal cancer screening: a systematic review

BACKGROUND

Patient preferences are important to consider in the decision-making process for colorectal cancer (CRC) screening. Vulnerable populations, such as racial/ethnic minorities and low-income, veteran, and rural populations, exhibit lower screening uptake. This systematic review summarizes the existing literature on vulnerable patient populations' preferences regarding CRC screening.

METHODS

We searched the CINAHL, PsycINFO, PubMed, Scopus, and Web of Science databases for articles published between January 1, 1996 and December 31, 2017. We screened studies for eligibility and systematically abstracted and compared study designs and outcomes.

RESULTS

A total of 43 articles met the inclusion criteria, out of 2,106 articles found in our search. These 43 articles were organized by the primary sub-population(s) whose preferences were reported: 27 report on preferences among racial/ethnic minorities, eight among low-income groups, six among veterans, and two among rural populations. The majority of studies (n=34) focused on preferences related to test modality. No single test modality was overwhelmingly supported by all sub-populations, although veterans seemed to prefer colonoscopy. Test attributes such as accuracy, sensitivity, cost, and convenience were also noted as important features. Furthermore, a preference for shared decision-making between vulnerable patients and providers was found.

CONCLUSION

The heterogeneity in study design, populations, and outcomes of the selected studies revealed a wide spectrum of CRC screening preferences within vulnerable populations. More decision aids and discrete choice experiments that focus on vulnerable populations are needed to gain a more nuanced understanding of how vulnerable populations weigh particular features of screening methods. Improved CRC screening rates may be achieved through the alignment of vulnerable populations' preferences with screening program design and provider practices. Collaborative decision-making between providers and vulnerable patients in preventive care decisions may also be important.

Socioeconomic and ethnic inequities within organised colorectal cancer screening programmes worldwide

OBJECTIVE

Colorectal cancer (CRC) screening programmes can reduce CRC mortality. However, the implementation of a screening programme may create or exacerbate socioeconomic and ethnic health inequities if participation varies by subgroup. We determined which organised programmes characterise participation inequities by socioeconomic and ethnic subgroups, and assessed the variation in subgroup participation among programmes collecting group-specific data.

DESIGN

Employing a literature review and survey among leaders of national or regional screening programmes, this study identified published and unpublished data on participation by socioeconomic status and ethnicity. We assessed programmes offering faecal occult blood tests (FOBT) for screening. Primary outcome was screening participation rate.

RESULTS

Across 24 organised FOBT-screening programmes meeting the inclusion criteria, participation rates ranged from 21% to 73%. Most programmes (13/24, 54%) did not collect data on participation by socioeconomic status and ethnicity. Among the 11 programmes with data on participation by socioeconomic status, 90% (28/31 publications) reported lower participation among lower socioeconomic groups. Differences across socioeconomic gradients were moderate (66% vs 71%) to severe (35% vs 61%). Only six programmes reported participation results by ethnicity. Ethnic differences were moderate, though only limited data were available for evaluation.

CONCLUSIONS

Across organised CRC screening programmes worldwide, variation in participation by socioeconomic status and ethnicity is often not assessed. However, when measured, marked disparities in participation by socioeconomic status have been observed. Limited data were available to assess inequities by ethnicity. To avoid exacerbating health inequities, screening programmes should systematically monitor participation by socioeconomic status and ethnicity, and investigate and address determinants of low participation.

Heterogeneous expression of A33 in colorectal cancer: possible explanation for A33 antibody treatment failure

The A33 protein, expressed in colorectal tumors, is a target for improving treatment of patients with colorectal cancer. Over the last decade, studies have tested anti-A33 antibody as a therapeutic agent for these patients. Preclinical results were promising, but clinical trials did not confirm positive results. Here, immunohistochemistry in colorectal cancer tissue showed that samples from well-differentiated tumors presented a strong A33 membrane staining, whereas poorly differentiated tumors and mucinous adenocarcinomas showed weak cytoplasmic and nuclear staining. Moderately differentiated tumors presented variable staining. We suggest that in future clinical trials, patients should be selected on the basis of membrane expression of A33.

Risk of colorectal cancer among immigrants to Ontario, Canada

Background

The risk of colorectal cancer (CRC) varies around the world and between females and males. We aimed to compare the risk of CRC among immigrants to Ontario, Canada, to its general population.

Methods

We used an exposure-control matched design. We identified persons in the Immigration, Refugees and Citizenship Canada Permanent Resident Database with first eligibility for the Ontario Health Insurance Plan between July 1, 1991 and June 30, 2008 at age 40 years or older, and matched five controls by year of birth and sex on the immigrant’s first eligibility date. We identified CRC from the Ontario Cancer Registry between the index date and December 31, 2014. All analyses were stratified by sex. We calculated crude and relative rates of CRC. We estimated risk of CRC over time by the Kaplan-Meier method and compared immigrants to controls in age and sex stratified strata using log-rank tests. We modeled the hazard of CRC using Cox proportional hazards regression, accounting for within-cluster correlation by a robust sandwich variance estimation approach, and assessed an interaction with time since eligibility.

Results

Among females, 1877 cases of CRC were observed among 209,843 immigrants, and 16,517 cases among 1,049,215 controls; the crude relative rate among female immigrants was 0.623. Among males, 1956 cases of CRC were observed among 191,792 immigrants and 18,329 cases among 958,960 controls; the crude relative rate among male immigrants was 0.582.. Comparing immigrants to controls in all age and sex stratified strata, the log rank test p < 0.0001 except for females aged > = 75 years at index, where p = 0.01. The age-adjusted hazard ratio (HR) for CRC among female immigrants was 0.63 (95% CI 0.59, 0.67) during the first 10 years, and 0.66 (95% CI 0.59, 0.74) thereafter. Among male immigrants the age-adjusted HR = 0.55 (95% CI 0.52, 0.59) during the first 10 years and increased to 0.63 (95% CI 0.57, 0.71) thereafter. The adjusted HR > = 1 only among immigrants born in Europe and Central Asia.

Conclusions

The risk of CRC among immigrants to Ontario relative to controls varies by origin and over time since immigration.

Classifications of Multispectral Colorectal Cancer Tissues Using Convolution Neural Network

BACKGROUND

Colorectal cancer (CRC) is the third most common cancer among men and women. Its diagnosis in early stages, typically done through the analysis of colon biopsy images, can greatly improve the chances of a successful treatment. This paper proposes to use convolution neural networks (CNNs) to predict three tissue types related to the progression of CRC: benign hyperplasia (BH), intraepithelial neoplasia (IN), and carcinoma (Ca).

METHODS

Multispectral biopsy images of thirty CRC patients were retrospectively analyzed. Images of tissue samples were divided into three groups, based on their type (10 BH, 10 IN, and 10 Ca). An active contour model was used to segment image regions containing pathological tissues. Tissue samples were classified using a CNN containing convolution, max-pooling, and fully-connected layers. Available tissue samples were split into a training set, for learning the CNN parameters, and test set, for evaluating its performance.

RESULTS

An accuracy of 99.17% was obtained from segmented image regions, outperforming existing approaches based on traditional feature extraction, and classification techniques.

CONCLUSIONS

Experimental results demonstrate the effectiveness of CNN for the classification of CRC tissue types, in particular when using presegmented regions of interest.

Toward the Elimination of Colorectal Cancer Disparities Among African Americans

BACKGROUND

In the USA, race and socioeconomic status are well-known factors associated with colorectal cancer incidence and mortality rates. These are higher among blacks than whites and other racial/ethnic groups.

METHODS

In this article, we review opportunities to address disparities in colorectal cancer incidence, mortality, and survivorship among African Americans.

RESULTS

First, we summarize the primary prevention of colorectal cancer and recent advances in the early detection of the disease and disparities in screening. Then, we consider black-white disparities in colorectal cancer treatment and survival including factors that may contribute to such disparities and the important roles played by cultural competency, patient trust in one's physician, and health literacy in addressing colorectal cancer disparities, including the need for studies involving the use of colorectal cancer patient navigators who are culturally competent.

CONCLUSION

To reduce these disparities, intervention efforts should focus on providing high-quality screening and treatment for colorectal cancer and on educating African Americans about the value of diet, weight control, screening, and treatment. Organized approaches for delivering colorectal cancer screening should be accompanied by programs and policies that provide access to diagnostic follow-up and treatment for underserved populations.

Impact of non-clinical community-based promotional campaigns on bowel cancer screening engagement: An integrative literature review

OBJECTIVE

This paper reviewed the relationship between non-clinical, client-oriented promotional campaigns to raise bowel cancer awareness and screening engagement.

METHOD

An integrative literature review using predefined search terms was conducted to summarise the accumulated knowledge. Data was analysed by coding and categorising, then synthesized through development of themes.

RESULTS

Eighteen of 116 studies met inclusion criteria. Promotional campaigns had varying impact on screening uptake for bowel cancer. Mass media was found to moderately increase screening, predominately amongst "worried well". Small media used in conjunction with other promotional activities, thus its effect on screening behaviours was unclear. One-on-one education was less effective and less feasible than group education in increasing intention to screen. Financial support was ineffective in increasing screening rates when compared to other promotional activities. Screening engagement increased because of special events and celebrity endorsement.

CONCLUSION

Non-clinical promotional campaigns did impact uptake of bowel cancer screening engagement. However, little is evident on the effect of single types of promotion and most research is based on clinician-directed campaigns.

PRACTICE IMPLICATIONS

Cancer awareness and screening promotions should be implemented at community and clinical level to maximize effectiveness. Such an approach will ensure promotional activities are targeting consumers, thus strengthening screening engagement.

Effectiveness of three interventions to improve participation in colorectal cancer screening

BACKGROUND AND OBJECTIVE

Participation in colorectal cancer (CRC) screening varies widely among different countries and different socio-demographic groups. Our objective was to assess the effectiveness of three primary-care interventions to increase CRC screening participation among persons over the age of 50 years and to identify the health and socio-demographic-related factors that determine greater participation.

METHODS

We conducted a randomized experimental study with only one post-test control group. A total of 1,690 subjects were randomly distributed into four groups: written briefing; telephone briefing; an invitation to attend a group meeting; and no briefing. Subjects were evaluated 2 years post-intervention, with the outcome variable being participation in CRC screening.

RESULTS

A total of 1,129 subjects were interviewed. Within the groups, homogeneity was tested in terms of socio-demographic characteristics and health-related variables. The proportion of subjects who participated in screening was: 15.4% in the written information group (95% confidence interval [CI]: 11.2-19.7); 28.8% in the telephone information group (95% CI: 23.6-33.9); 8.1% in the face-to-face information group (95% CI: 4.5-11.7); and 5.9% in the control group (95% CI: 2.9-9.0), with this difference proving statistically significant (p < 0.001). Logistic regression showed that only interventions based on written or telephone briefing were effective. Apart from type of intervention, number of reported health problems and place of residence remained in the regression model.

CONCLUSIONS

Both written and telephone information can serve to improve participation in CRC screening. This preventive activity could be optimized by means of simple interventions coming within the scope of primary health-care professionals.

Reducing income-related inequities in colorectal cancer screening: lessons learned from a retrospective analysis of organised programme and non-programme screening delivery in Winnipeg, Manitoba

OBJECTIVE

We examined organised colorectal cancer (CRC) screening programme and non-programme faecal occult blood test (FOBT) use from 2008 to 2012 for individuals living in Winnipeg, Manitoba, by area-level income.

SETTING

Winnipeg, Manitoba, a region with universal healthcare and an organised CRC screening programme.

PARTICIPANTS

Individuals who had a non-programme FOBT were identified from the Provincial Medical Claims database. Individuals who had a programme FOBT were identified from the provincial screening registry. Census data were used to determine average household income based on area of residence.

STATISTICAL ANALYSIS

Trends in age-standardised FOBT rates were examined using Joinpoint Regression. Logistic regression was performed to explore the association between programme and non-programme FOBT use and income quintile.

RESULTS

FOBT use (non-programme and programme) increased from 32.2% in 2008 to 41.6% in 2012. Individuals living in the highest income areas (Q5) were more likely to have a non-programme FOBT compared with those living in other areas. Individuals living in areas with the lowest average income level (Q1) were less likely to have had programme FOBT than those living in areas with the highest average income level (OR 0.80, 95% CI 0.77 to 0.82). There was no difference in programme FOBT use for individuals living in areas with the second lowest income level (Q2) compared with those living in areas with the highest. Individuals living in areas with a moderate-income level (Q3 and Q4) were more likely to have had a programme FOBT compared with those living in an area with the highest income level (OR 1.12, 95% CI 1.09 to 1.15 for Q3 and OR 1.10, 95% CI 1.07 to 1.13 for Q4).

CONCLUSIONS

Inequities by income observed for non-programme FOBTs were largely eliminated when programme FOBTs were examined. Targeted interventions within organised screening programmes in very low-income areas are needed.

Usefulness of oil lubrication during colonoscopy: A comparative study with the conventional technique

BACKGROUND

The different forms of lubrication are among the most simple, accessible, and economic techniques that have been implemented for improving the diagnostic performance of colonoscopy.

AIM

To determine whether the use of oil improved the number of complete colonoscopies, facilitated the procedure, reduced pain, or improved the study's diagnostic performance, compared with the conventional lubrication technique.

PATIENTS AND METHODS

One hundred and seventy-five patients referred for colonoscopy were alternately allocated to receive treatment with the standard lubrication method with chlorhexidine gel (group 1) or lubrication with corn oil administered through the working channel (group II). The number of complete colonoscopies, the length of time needed to reach the cecum, the degree of difficulty estimated by the endoscopist and the assistant, the level of pain at the end of the study estimated by the patient, and the endoscopic findings were all determined.

RESULTS

Eighty-eight patients made up group I and 87 made up group II. No statistically significant differences were found between the two groups in relation to general characteristics, the number of complete colonoscopies (93 vs. 97%, respectively), the time needed to reach the cecum (8:00 vs. 8:41min, respectively), the level of pain at the end of the study, or the detection of polyps. The degree of difficulty was slightly lower in group II, but with no statistical significance.

CONCLUSIONS

Lubrication with oil during colonoscopy did not improve the number of complete colonoscopies, did not facilitate the study, nor did it reduce pain or increase the diagnostic performance of the study, when compared with the conventional technique.

Longitudinal Rates of Colon Cancer Screening Use in Winnipeg, Canada: The Experience of a Universal Health-Care System with an Organized Colon Screening Program

OBJECTIVES

We examined trends in colorectal cancer (CRC) screening (fecal occult blood test (FOBT), colonoscopy, and flexible sigmoidoscopy (FS)) and differences in CRC screening by income in a population with an organized CRC screening program and universal health-care coverage.

METHODS

Individuals who had an FOBT, colonoscopy, or FS were identified from the provincial Physician Claims database and the population-based colon cancer screening registry. Trends in age-standardized rates were determined. Logistic regression was performed to explore the association between CRC screening and income quintiles by year.

RESULTS

Up-to-date CRC screening (FOBT, colonoscopy, or FS) increased over time for men and women, all age groups, and all income quintiles. Up-to-date CRC screening was very high among 65- to 69- and 70- to 74-year-olds (70% and 73%, respectively). There was a shift toward the use of an FOBT for CRC screening for individuals in the lower income quintiles. The disparity in colonoscopy/FS coverage by income quintile was greater in 2012 than in 1995. Overall, there was no reduction in disparities by income in up-to-date CRC screening nor did the rate of increase in up-to-date CRC screening or FOBT use change after the introduction of the organized provincial CRC screening program.

CONCLUSIONS

CRC screening is increasing over time for both men and women and all age groups. However, a disparity in up-to-date CRC screening by income persisted even with an organized CRC screening program in a universal health-care setting.

Promoting colorectal cancer screening among Haitian Americans

BACKGROUND

Few studies have examined colorectal cancer screening among Haitian Americans, although striking disparities in colorectal cancer screening and mortality are well-documented among U.S. Blacks. Race, socioeconomic status, and place of birth are factors associated with colorectal cancer incidence and mortality patterns.

METHODS

In this article, we summarize published studies on colorectal cancer screening among Haitian Americans, identified through bibliographic searches in PubMed and CINAHL through August 2015, and offer recommendations for further research.

RESULTS

Only one qualitative study and three quantitative surveys have examined colorectal cancer screening among Haitian Americans. A qualitative study found important differences in perceptions of the curability of colorectal cancer, preventive practices, and preferred sources of information among Haitian Americans and other ethnic subgroups of U.S. Blacks. Awareness of colorectal cancer screening tests, risk perception, healthcare provider recommendation, and self-reported use of screening are suboptimal among Haitian Americans and other subgroups. In preliminary quantitative studies, Haitian immigrants have been found to have lower colorectal cancer screening rates than other groups such as African Americans.

CONCLUSIONS

Culturally appropriate educational interventions are needed to encourage Haitian American adults aged ≥ 50 years to undergo screening for colorectal cancer and to ensure that they are well informed about the value of healthy eating and physical activity.