Low Rates of Lung and Colorectal Cancer Screening Uptake Among a Safety-net Emergency Department Population

Increasing Uptake of Lung Cancer Screening Among Emergency Department Patients: A Pilot Study

BACKGROUND

Lung cancer is the leading cause of cancer death in the United States. Lung cancer screening (LCS) decreases lung cancer mortality. Emergency department (ED) patients are at disproportionately high risk for lung cancer. The ED, therefore, is an optimal environment for interventions to promote LCS.

OBJECTIVES

Demonstrate the operational feasibility of identifying ED patients in need of LCS, referring them to LCS services, deploying a text message intervention to promote LCS, and conducting follow-up to determine LCS uptake.

METHODS

We conducted a randomized clinical trial to determine the feasibility and provide estimates of the preliminary efficacies of 1) basic referral for LCS and 2) basic referral plus a text messaging intervention, grounded in behavioral change theory, to promote uptake of LCS among ED patients. Participants aged 50 to 80, identified as eligible for LCS, were randomized to study arms and followed up at 150 days to assess interval LCS uptake (primary outcome), barriers to screening, and perceptions of the study interventions.

RESULTS

A total of 303 patients were surveyed, with 198 identified as eligible for LCS and subsequently randomized. Results indicated that 24% of participants with follow-up data received LCS (11% of the total randomized sample). Rates of screening at follow-up were similar across study arms. The intervention significantly improved normative perceptions of LCS (p = 0.015; Cohen's d = 0.45).

CONCLUSION

This pilot study demonstrates the feasibility of ED-based interventions to increase uptake of LCS among ED patients. A scalable ED-based intervention that increases LCS uptake could reduce lung cancer mortality.

Effectiveness of colonoscopy, immune fecal occult blood testing, and risk-graded screening strategies in colorectal cancer screening

BACKGROUND

Colorectal cancer (CRC) is one of the most common malignant tumors, and early screening is crucial to improving the survival rate of patients. The combination of colonoscopy and immune fecal occult blood detection has garnered significant attention as a novel method for CRC screening. Colonoscopy and fecal occult blood tests, when combined, can improve screening accuracy and early detection rates, thereby facilitating early intervention and treatment. However, certain risks and costs accompany it, making the establishment of a risk classification model crucial for accurate classification and management of screened subjects.

AIM

To evaluate the feasibility and effectiveness of colonoscopy, immune fecal occult blood test (FIT), and risk-graded screening strategies in CRC screening.

METHODS

Based on the randomized controlled trial of CRC screening in the population conducted by our hospital May 2020 to May 2023, participants who met the requirements were randomly assigned to a colonoscopy group, an FIT group, or a graded screening group at a ratio of 1:2:2 (after risk assessment, the high-risk group received colonoscopy, the low-risk group received an FIT test, and the FIT-positive group received colonoscopy). The three groups received CRC screening with different protocols, among which the colonoscopy group only received baseline screening, and the FIT group and the graded screening group received annual follow-up screening based on baseline screening. The primary outcome was the detection rate of advanced tumors, including CRC and advanced adenoma. The population participation rate, advanced tumor detection rate, and colonoscopy load of the three screening programs were compared.

RESULTS

A total of 19373 subjects who met the inclusion and exclusion criteria were enrolled, including 8082 males (41.7%) and 11291 females (58.3%). The mean age was 60.05 ± 6.5 years. Among them, 3883 patients were enrolled in the colonoscopy group, 7793 in the FIT group, and 7697 in the graded screening group. Two rounds of follow-up screening were completed in the FIT group and the graded screening group. The graded screening group (89.2%) and the colonoscopy group (42.3%) had the lowest overall screening participation rates, while the FIT group had the highest (99.3%). The results of the intentional analysis showed that the detection rate of advanced tumors in the colonoscopy group was greater than that of the FIT group [2.76% vs 2.17%, odds ratio (OR) = 1.30, 95% confidence interval (CI): 1.01-1.65, P = 0.037]. There was no significant difference in the detection rate of advanced tumors between the colonoscopy group and the graded screening group (2.76% vs 2.35%, OR = 1.9, 95%CI: 0.93-1.51, P = 0.156), as well as between the graded screening group and the FIT group (2.35% vs 2.17%, OR = 1.09%, 95%CI: 0.88-1.34, P = 0.440). The number of colonoscopy examinations required for each patient with advanced tumors was used as an index to evaluate the colonoscopy load during population screening. The graded screening group had the highest colonoscopy load (15.4 times), followed by the colonoscopy group (10.2 times), and the FIT group had the lowest (7.8 times).

CONCLUSION

A hierarchical screening strategy based on CRC risk assessment is feasible for screening for CRC in the population. It can be used as an effective supplement to traditional colonoscopy and FIT screening programs.

Prediction and analysis of albumin-bilirubin score combined with liver function index and carcinoembryonic antigen on liver metastasis of colorectal cancer

BACKGROUND

Colorectal cancer (CRC) is a common malignant tumor, and liver metastasis is one of the main recurrence and metastasis modes that seriously affect patients' survival rate and quality of life. Indicators such as albumin bilirubin (ALBI) score, liver function index, and carcinoembryonic antigen (CEA) have shown some potential in the prediction of liver metastasis but have not been fully explored.

AIM

To evaluate its predictive value for liver metastasis of CRC by conducting the combined analysis of ALBI, liver function index, and CEA, and to provide a more accurate liver metastasis risk assessment tool for clinical treatment guidance.

METHODS

This study retrospectively analyzed the clinical data of patients with CRC who received surgical treatment in our hospital from January 2018 to July 2023 and were followed up for 24 months. According to the follow-up results, the enrolled patients were divided into a liver metastasis group and a nonliver metastasis group and randomly divided into a modeling group and a verification group at a ratio of 2:1. The risk factors for liver metastasis in patients with CRC were analyzed, a prediction model was constructed by least absolute shrinkage and selection operator (LASSO) logistic regression, internal validation was performed by the bootstrap method, the reliability of the prediction model was evaluated by subject-work characteristic curves, calibration curves, and clinical decision curves, and a column graph was drawn to show the prediction results.

RESULTS

Of 130 patients were enrolled in the modeling group and 65 patients were enrolled in the verification group out of the 195 patients with CRC who fulfilled the inclusion and exclusion criteria. Through LASSO regression variable screening and logistic regression analysis. The ALBI score, alanine aminotransferase (ALT), and CEA were found to be independent predictors of liver metastases in CRC patients [odds ratio (OR) = 8.062, 95% confidence interval (CI): 2.545-25.540], (OR = 1.037, 95%CI: 1.004-1.071) and (OR = 1.025, 95%CI: 1.008-1.043). The area under the receiver operating characteristic curve (AUC) for the combined prediction of CRLM in the modeling group was 0.921, with a sensitivity of 78.0% and a specificity of 95.0%. The H-index was 0.921, and the H-L fit curve had χ2 = 0.851, a P value of 0.654, and a slope of the calibration curve approaching 1. This indicates that the model is extremely accurate, and the clinical decision curve demonstrates that it can be applied effectively in the real world. We conducted internal verification of one thousand resamplings of the modeling group data using the bootstrap method. The AUC was 0.913, while the accuracy was 0.869 and the kappa consistency was 0.709. The combination prediction of liver metastasis in patients with CRC in the verification group had an AUC of 0.918, sensitivity of 85.0%, specificity of 95.6%, C-index of 0.918, and an H-L fitting curve with χ 2 = 0.586, P = 0.746.

CONCLUSION

The ALBI score, ALT level, and CEA level have a certain value in predicting liver metastasis in patients with CRC. These three criteria exhibit a high level of efficacy in forecasting liver metastases in patients diagnosed with CRC. The risk prediction model developed in this work shows great potential for practical application.

Intervention to increase colorectal cancer screening among emergency department patients: results from a randomised pilot study

BACKGROUND

Colorectal cancer (CRC) is the second leading cause of cancer-related deaths worldwide. Emergency departments (ED) represent a promising setting to address preventive health measures like CRC screening.

OBJECTIVES

The current study adapted an existing cervical cancer screening intervention for use in catalysing CRC screening. We evaluated feasibility of identification, provided preliminary effect size estimates and documented participant acceptability.

METHODS

This study was funded by the University of Rochester (ClinicalTrials.gov # NCT05004376). We enrolled ED patients, 45-75 years old, in the Greater Rochester, NY region into a randomised controlled pilot from January to May 2022. Patients were excluded if non-English speaking, lacking a cell phone or had a history of CRC, colorectal resection, inflammatory bowel disease or abdominal radiation. Participants were surveyed to determine adherence with recommended CRC screening guidelines. Patients found non-adherent were randomised to receive (1) recommendation for CRC screening only or (2) recommendation and a text-based intervention aimed at generating intention and motivation to get screened. Patients were blind to allocation at enrolment. The primary outcome was patient CRC screening or scheduling.

RESULTS

1438 patients were approached, with 609 found ineligible, 576 declining participation and 253 enrolled. A randomised sample of 114 non-adherent patients were split evenly between the control and intervention arms. Among participants with follow-up data (n control=38, n intervention=36), intervention participants had a 2%-3% higher rate of scheduling or receiving screening (7%-27% relative improvement). When using the complete sample (n=114) and conservatively assuming no screening for those lost to follow-up, differences in screening across arms were mildly decreased (0%-2% absolute difference). Acceptability of CRC intervention was high, and participants offered formative feedback.

CONCLUSION

The piloted text message intervention through the ED shows potential promise for catalysing CRC screening. Subsequent replication in a fully powered trial is needed.

Characteristics and Barriers of Emergency Department Patients Overdue for Cancer Screening

Introduction

People without reliable access to healthcare are more likely to be diagnosed with late-stage cancer that could have been treated more effectively if diagnosed earlier. Emergency departments (ED) may be a novel place for cancer screening education for underserved patients. In this study we sought to determine patient characteristics and barriers to cancer screening for those patients who presented to a large, academic safety-net ED and were overdue for breast, cervical, and colorectal cancer screening since the coronavirus 2019 (COVID-19) pandemic.

Methods

Adult ED patients eligible for at least one cancer screening based on US Preventive Serivces Task Force guidelines completed a web-based survey. We examined the association of demographic characteristics and having a personal physician with being overdue on screening using chi-square or the Fisher exact test for categorical variables and t-tests for continuous variables.

Results

Of 221 participants, 144 were eligible for colorectal, 96 for cervical, and 55 for breast cancer screening. Of eligible patients, 46% (25/55) were overdue for breast cancer screening, 43% (62/144) for colorectal, and 40% (38/96) for cervical cancer screening. There were no significant characteristics associated with breast cancer screening. Being overdue for cervical cancer screening was significantly more likely for patients who were of Asian race (P = 0.02), had less than a high school diploma (P = 0.01), and were without a routine checkup within the prior five years (P = 0.01). Overdue for colorectal cancer screening was associated with patients not having insurance (P = 0.04), being in their 40s (P = 0.03), being Hispanic (P = 0.01), and not having a primary care physician (P=0.01). Of 97 patients overdue for at least one screening, the most common barriers were cost (37%), lack of time (37%), and lack of knowledge of screening recommendations (34%). Only 8.3% reported that the COVID-19 pandemic delayed their screening.

Conclusion

The ED may be a novel setting to target patients for cancer screening education. Future work that refers patients to free screening programs and primary care physicians may help improve disparities in cancer screening and cancer mortality rates for underserved populations.

Cancer Screening Abstinence Rates and Rationales Among Regular Outpatients at a Rural Hospital in Japan: A Cross-Sectional Study

Purpose

This study aimed to investigate cancer screening rates and the reasons for not undergoing screening among patients who regularly visited the Sanmu Medical Center.

Patients and Methods

This prospective observational study recruited patients aged ≥40 years with regular clinic visits to Sanmu Medical Center during October 2019. We conducted a self-administered survey to determine the patient's sex and whether they underwent cancer screening in 2019, and if not, the reason for the same. The primary outcome measure was the percentage of people who did not undergo cancer screening.

Results

A total of 198 responses (108 male respondents) were obtained. Among them, 189 were valid responses (valid response rate 94.5%). One hundred and twenty-nine patients (68.2%, 76 male) had not undergone screening. The most common reasons provided were "I have regular regular clinic visits and do not think they are necessary" (N = 65, 50.3%), "I underwent a gastroscopy within 2 years, a colorectal camera examination within a few years, and a chest radiography within a year" (42.5%), and "I have a separate complete medical checkup" (N = 15, 11.6%). Of the 65 patients who responded that their cancer screenings were unnecessary, 42 patients (64.6%) had not undergone a gastroscopy within 2 years, a colorectal camera examination within a few years, or a chest radiography or examination within a year.

Conclusion

Roughly half of the respondents who did not undergo cancer screening elected to abstain because they believed that regular hospital visits were sufficient. Encouraging patients who regularly visit medical institutions to receive cancer screening is therefore necessary.

Lung cancer in the emergency department

Background

Though decreasing in incidence and mortality in the USA, lung cancer remains the deadliest of all cancers. For a significant number of patients, the emergency department (ED) provides the first pivotal step in lung cancer prevention, diagnosis, and management. As screening recommendations and treatments advance, ED providers must stay up-to-date with the latest lung cancer recommendations. The purpose of this review is to identify the many ways that emergency providers may intersect with the disease spectrum of lung cancer and provide an updated array of knowledge regarding detection, management, complications, and interdisciplinary care.

Findings

Lung cancer, encompassing 10-12% of cancer-related emergency department visits and a 66% admission rate, is the most fatal malignancy in both men and women. Most patients presenting to the ED have not seen a primary care provider or undergone screening. Ultimately, half of those with a new lung cancer diagnosis in the ED die within 1 year. Incidental findings on computed tomography are mostly benign, but emergency staff must be aware of the factors that make them high risk. Radiologic presentations range from asymptomatic nodules to diffuse metastatic lesions with predominately pulmonary symptoms, and some may present with extra-thoracic manifestations including neurologic. The short-term prognosis for ED lung cancer patients is worse than that of other malignancies. Screening offers new hope through earlier diagnosis but is underutilized which may be due to racial and socioeconomic disparities. New treatments provide optimism but lead to new complications, some long-term. Multidisciplinary care is essential, and emergency medicine is responsible for the disposition of patients to the appropriate specialists at inpatient and outpatient centers.

Conclusion

ED providers are intimately involved in all aspects of lung cancer care. Risk factor modification and referral for lung cancer screening are opportunities to further enhance patient care. In addition, with the advent of newer cancer therapies, ED providers must stay vigilant and up-to-date with all aspects of lung cancer including disparities, staging, symptoms of disease, prognosis, treatment, and therapy-related complications.