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Wee HL, Canfell K, Chiu HM, Choi KS, Cox B, Bhoo-Pathy N, Simms KT, Hamashima C, Shen Q, Chua B, Siwaporn N, Toes-Zoutendijk E. Cancer screening programs in South-east Asia and Western Pacific. BMC Health Serv Res 2024; 24:102. [PMID: 38238704 PMCID: PMC10797973 DOI: 10.1186/s12913-023-10327-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2023] [Accepted: 11/14/2023] [Indexed: 01/22/2024] Open
Abstract
BACKGROUND The burden of cancer can be altered by screening. The field of cancer screening is constantly evolving; from the initiation of program for new cancer types as well as exploring innovative screening strategies (e.g. new screening tests). The aim of this study was to perform a landscape analysis of existing cancer screening programs in South-East Asia and the Western Pacific. METHODS We conducted an overview of cancer screening in the region with the goal of summarizing current designs of cancer screening programs. First, a selective narrative literature review was used as an exploration to identify countries with organized screening programs. Second, representatives of each country with an organized program were approached and asked to provide relevant information on the organizations of their national or regional cancer screening program. RESULTS There was wide variation in the screening strategies offered in the considered region with only eight programs identified as having an organized design. The majority of these programs did not meet all the essential criteria for being organized screening. The greatest variation was observed in the starting and stopping ages. CONCLUSIONS Essential criteria of organized screening are missed. Improving organization is crucial to ensure that the beneficial effects of screening are achieved in the long-term. It is strongly recommended to consider a regional cancer screening network.
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Affiliation(s)
- Hwee-Lin Wee
- Saw Swee Hock School of Public Health, National University of Singapore, Singapore, Singapore
| | - Karen Canfell
- The Daffodil Centre, A Joint Venture with Cancer Council NSW and the University of Sydney, Sydney, NSW, Australia
| | - Han-Mo Chiu
- Department of Internal Medicine, College of Medicine, National Taiwan University, Taipei, Taiwan
| | - Kui Son Choi
- Graduate School of Cancer Science and Policy, National Cancer Center, Ilsandonggu, Goyang, Republic of Korea
| | - Brian Cox
- Dunedin School of Medicine, University of Otago, Dunedin, New Zealand
| | - Nirmala Bhoo-Pathy
- Centre for Epidemiology and Evidence-Based Practice, Faculty of Medicine, Universiti Malaya, Kuala Lumpur, Malaysia
| | - Kate T Simms
- The Daffodil Centre, A Joint Venture with Cancer Council NSW and the University of Sydney, Sydney, NSW, Australia
| | - Chisato Hamashima
- Division of Cancer Screening Assessment and Management, Institute of Cancer Control, National Cancer Center, Tokyo, Japan
- Teikyo University, Tokyo, Japan
| | - Qianyu Shen
- Saw Swee Hock School of Public Health, National University of Singapore, Singapore, Singapore
| | - Brandon Chua
- Saw Swee Hock School of Public Health, National University of Singapore, Singapore, Singapore
| | - Niyomsri Siwaporn
- Department of Medical Services, Ministry of Public Health, National Cancer Institute of Thailand, Bangkok, Thailand
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Esther Toes-Zoutendijk
- Saw Swee Hock School of Public Health, National University of Singapore, Singapore, Singapore.
- Department of Public Health, Erasmus MC University Medical Center, P.O. Box 2014, Rotterdam, CA, 3000, the Netherlands.
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Cheng YW, Li YC. Examining the Factors That Affect the Diagnosis of Patients with Positive Fecal Occult Blood Test Results. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:ijerph19137569. [PMID: 35805251 PMCID: PMC9265584 DOI: 10.3390/ijerph19137569] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/21/2022] [Revised: 06/02/2022] [Accepted: 06/20/2022] [Indexed: 11/17/2022]
Abstract
Due to the threat of colorectal cancer (CRC) to health, Taiwan included the fecal occult blood test (FOBT) under preventive health services in 2010. We examined the factors that affect the diagnosis of people with positive FOBT results. Data were retrospectively collected from the CRC screening database. In the model predicting factors that affect the diagnosis of 89,046 people with positive FOBT results, the risks of disease in the CRC group were lower in medical institutions that conducted follow-up examinations in regions such as Northern Taiwan compared to that in Eastern Taiwan (p = 0.013); they were lower in the age group of 50 to 65 years than those in the age group of 71 to 75 years (p < 0.001, p = 0.016), and lower in the outpatient medical units that conducted follow-up examinations than those in the inpatient medical units by 0.565 times (p < 0.001, 95% CI: 0.493−0.647). Factors affecting the diagnosis of patients with positive FOBT results were gender, the region of the medical institution, medical unit for follow-up examinations, age, screening site, family history, type of follow-up examinations, and follow-up time. Therefore, the identification of characteristics of patients with positive FOBT results and the promotion of follow-up examination are important prevention strategies for CRC.
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Affiliation(s)
- Yin-Wen Cheng
- Department of Business Management, College of Management, National Sun Yat-Sen University, No. 70, Lien-Hai Rd., Gushan Dist., Kaohsiung 80424, Taiwan;
| | - Ying-Chun Li
- Institute of Health Care Management, National Sun Yat-Sen University, No. 70, Lien-Hai Rd., Gushan Dist., Kaohsiung 80424, Taiwan
- Correspondence: ; Tel.: +886-7-5252000 (ext. 4875)
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Schliemann D, Ramanathan K, Matovu N, O'Neill C, Kee F, Su TT, Donnelly M. The implementation of colorectal cancer screening interventions in low-and middle-income countries: a scoping review. BMC Cancer 2021; 21:1125. [PMID: 34666704 PMCID: PMC8524916 DOI: 10.1186/s12885-021-08809-1] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2021] [Accepted: 09/23/2021] [Indexed: 12/22/2022] Open
Abstract
BACKGROUND Low- and middle-income countries (LMICs) experienced increasing rates of colorectal cancer (CRC) incidence in the last decade and lower 5-year survival rates compared to high-income countries (HICs) where the implementation of screening and treatment services have advanced. This review scoped and mapped the literature regarding the content, implementation and uptake of CRC screening interventions as well as opportunities and challenges for the implementation of CRC screening interventions in LMICs. METHODS We systematically followed a five-step scoping review framework to identify and review relevant literature about CRC screening in LMICs, written in the English language before February 2020. We searched Medline, Embase, Web of Science and Google Scholar for studies targeting the general, asymptomatic, at-risk adult population. The TIDieR tool and an implementation checklist were used to extract data from empirical studies; and we extracted data-informed insights from policy reviews and commentaries. RESULTS CRC screening interventions (n = 24 studies) were implemented in nine middle-income countries. Population-based screening programmes (n = 11) as well as small-scale screening interventions (n = 13) utilised various recruitment strategies. Interventions that recruited participants face-to-face (alone or in combination with other recruitment strategies) (10/15), opportunistic clinic-based screening interventions (5/6) and educational interventions combined with screening (3/4), seemed to be the strategies that consistently achieved an uptake of > 65% in LMICs. FOBT/FIT and colonoscopy uptake ranged between 14 and 100%. The most commonly reported implementation indicator was 'uptake/reach'. There was an absence of detail regarding implementation indicators and there is a need to improve reporting practice in order to disseminate learning about how to implement programmes. CONCLUSION Opportunities and challenges for the implementation of CRC screening programmes were related to the reporting of CRC cases and screening, cost-effective screening methods, knowledge about CRC and screening, staff resources and training, infrastructure of the health care system, financial resources, public health campaigns, policy commitment from governments, patient navigation, planning of screening programmes and quality assurance.
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Affiliation(s)
- Désirée Schliemann
- Centre for Public Health and UKCRC Centre of Excellence for Public Health, Queen's University Belfast, Belfast, UK.
| | - Kogila Ramanathan
- Global Public Health, Jeffrey Cheah School of Medicine and Health Sciences, Monash University Malaysia, Subang Jaya, Selangor, Malaysia
- South East Asia Community Observatory (SEACO), Jeffrey Cheah School of Medicine and Health Sciences, Monash University Malaysia, Subang Jaya, Selangor, Malaysia
| | - Nicholas Matovu
- Centre for Public Health and UKCRC Centre of Excellence for Public Health, Queen's University Belfast, Belfast, UK
| | - Ciaran O'Neill
- Centre for Public Health and UKCRC Centre of Excellence for Public Health, Queen's University Belfast, Belfast, UK
| | - Frank Kee
- Centre for Public Health and UKCRC Centre of Excellence for Public Health, Queen's University Belfast, Belfast, UK
| | - Tin Tin Su
- Global Public Health, Jeffrey Cheah School of Medicine and Health Sciences, Monash University Malaysia, Subang Jaya, Selangor, Malaysia
- South East Asia Community Observatory (SEACO), Jeffrey Cheah School of Medicine and Health Sciences, Monash University Malaysia, Subang Jaya, Selangor, Malaysia
| | - Michael Donnelly
- Centre for Public Health and UKCRC Centre of Excellence for Public Health, Queen's University Belfast, Belfast, UK
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Sazali MF, Syed Abdul Rahim SS, Avoi R, Hassan MR, Hayati F, Azhar ZI, Jeffree MS, Lukman KA, Tha NO, Sajali H, Atil A, Abd Rahim MA. Factors of Never Screened with Faecal Occult Blood Test in Public Primary Care Facilities. Asian Pac J Cancer Prev 2021; 22:163-169. [PMID: 33507695 PMCID: PMC8184202 DOI: 10.31557/apjcp.2021.22.1.163] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2020] [Accepted: 01/23/2021] [Indexed: 01/22/2023] Open
Abstract
BACKGROUND Colorectal cancer (CRC) is still a major public health threat. In the effort to reduce CRC incidence and mortality, faecal occult blood test (FOBT) is currently the screening tools used for early detection of CRC. However, the uptake of FOBT screening is less than promising. This study aims to identify the prevalence and predictors of Never Screened with FOBT (NS-FOBT). METHODS A cross sectional study was conducted in five health clinics under Kota Kinabalu district, Sabah, Malaysia Borneo involving 162 attendees with age of 50 years old and above. A validated self-administered questionnaire was used to collect the data. Multiple logistic regression analysis was used to determine the predictors of NS-FOBT. RESULTS The prevalence of NS-FOBT was 85.8% (n=139). Important predictors of NS-FOBT were age (aOR: 0.922; 95% CI: 0.855, 0.995; p=0.035), Bumiputera ethnicity (vs Non Bumiputera; aOR: 4.285; 95% CI: 1.384, 13.263; p=0.012), knowledge score (aOR: 0.921; 95% CI: 0.856, 0.99; p=0.027), and attitude score (aOR: 0.801; 95% CI: 0.702, 0.913; p=0.001). CONCLUSION There is high prevalence of NS-FOBT. Age, ethnicity, knowledge, and attitude were important predictors of NS-FOBT. Strategies are needed to improve FOBT screening rate among the public. Socio-culturally tailored health promotion strategies as well as strengthening the communication, collaboration, and education to enhance the role of family physician is vital in improving the CRC prevention and care.
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Affiliation(s)
- Mohd Fazeli Sazali
- Department of Community Health and Family Medicine, Faculty Medicine and Health Sciences, Universiti Malaysia Sabah, Malaysia.
| | - Syed Sharizman Syed Abdul Rahim
- Department of Community Health and Family Medicine, Faculty Medicine and Health Sciences, Universiti Malaysia Sabah, Malaysia.
| | - Richard Avoi
- Department of Community Health and Family Medicine, Faculty Medicine and Health Sciences, Universiti Malaysia Sabah, Malaysia.
| | - Mohd Rohaizat Hassan
- Department of Community Health, Faculty of Medicine, Universiti Kebangsaan Malaysia, Malaysia.
| | - Firdaus Hayati
- Department of Surgery, Faculty of Medicine and Health Sciences, Universiti Malaysia Sabah, Kota Kinabalu, Malaysia.
| | - Zahir Izuan Azhar
- Department of Public Health Medicine, Faculty of Medicine, Universiti Teknologi MARA, Malaysia.
| | - Mohammad Saffree Jeffree
- Department of Community Health and Family Medicine, Faculty Medicine and Health Sciences, Universiti Malaysia Sabah, Malaysia.
| | - Khamisah Awang Lukman
- Department of Community Health and Family Medicine, Faculty Medicine and Health Sciences, Universiti Malaysia Sabah, Malaysia.
| | - Naing Oo Tha
- Department of Community Health and Family Medicine, Faculty Medicine and Health Sciences, Universiti Malaysia Sabah, Malaysia.
| | - Helmy Sajali
- Department of Community Health and Family Medicine, Faculty Medicine and Health Sciences, Universiti Malaysia Sabah, Malaysia.
| | - Azman Atil
- Department of Community Health and Family Medicine, Faculty Medicine and Health Sciences, Universiti Malaysia Sabah, Malaysia.
| | - Muhammad Aklil Abd Rahim
- Department of Community Health and Family Medicine, Faculty Medicine and Health Sciences, Universiti Malaysia Sabah, Malaysia.
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A 5-year evaluation of using stool-based test for opportunistic colorectal cancer screening in primary health institutions across Malaysia. Cancer Epidemiol 2020; 69:101829. [PMID: 32998070 DOI: 10.1016/j.canep.2020.101829] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2020] [Revised: 09/11/2020] [Accepted: 09/13/2020] [Indexed: 12/31/2022]
Abstract
INTRODUCTION The immunochemical fecal occult blood test (iFOBT) has been widely used for opportunistic colorectal cancer (CRC) screening in average-risk individuals seeking care from public health clinics in Malaysia. This study provides a 5-year outcome evaluation of such a practice. METHODS The findings for a few outcome indicators, ranging from the iFOBT uptake to the CRC and polyp detection rates, were generated from the data contributed by 583 public health clinics between 2014 and 2018. The trends in their changes were also evaluated. RESULTS The iFOBT uptake constantly increased over the years (p < 0.001), totaling 2.29 % (n = 127,957) as at 2018. Nearly 10 % (n = 11,872) of the individuals screened had a positive test result. Of those who underwent colonoscopy (n = 6,491), 4.04 % (n = 262) and 13.93 % (n = 904) were found to have CRC and polyps, respectively. CONCLUSION An uptrend in the CRC screening uptake was witnessed following the introduction of the iFOBT in public health clinics.
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Mohd Suan MA, Tan WL, Ismail I, Abu Hassan MR. Perceived Deterrence Towards Colonoscopy for Colorectal Cancer Screening among Northern Malaysia Population: A Qualitative Study. Asian Pac J Cancer Prev 2020; 21:1253-1258. [PMID: 32458630 PMCID: PMC7541869 DOI: 10.31557/apjcp.2020.21.5.1253] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2019] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND Patients with positive immunochemical faecal occult blood test results were found to have poor compliance for a subsequent colonoscopy procedure. This study was conducted to explore patients' perceived deterrence for colonoscopy following a positive stool test. METHODS Using qualitative study method, a phone interview was conducted with 16 patients to elicit their views on the reasons for failure to attend the colonoscopy procedure following a positive stool test. The interviews were audio recorded, transcribed verbatim and translated before proceeded with the data analysis. Content analysis was made on the translated interview, followed by systematic classification of data by major themes. RESULTS Reasons for nonattendance were categorized under five main themes; unnecessary test, fear of the procedure, logistic obstacles (subthemes; time constraint, transportation problem), social influences, and having other health priority. Lacking in information about the procedure during the referral process was identified to cause misperception and unnecessary worry towards colonoscopy. Fear of the procedure was commonly cited by female respondents while logistic issues pertaining to time constraint were raised by working respondents. CONCLUSIONS More effective communication between patients and health care providers are warranted to avoid misconception regarding colonoscopy procedure. Support from primary care doctors, customer-friendly appointment system, use of educational aids and better involvement from family members were among the strategies to increase colonoscopy compliance.
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Affiliation(s)
- Mohd Azri Mohd Suan
- Clinical Research Center, Hospital Sultanah Bahiyah, Alor Setar, Kedah, Malaysia
| | - Wei Leong Tan
- Kedah State Health Department, Alor etar, Kedah, Malaysia
| | - Ibtisam Ismail
- Clinical Research Center, Hospital Sultanah Bahiyah, Alor Setar, Kedah, Malaysia
| | - Muhammad Radzi Abu Hassan
- Clinical Research Center, Hospital Sultanah Bahiyah, Alor Setar, Kedah, Malaysia.,3Medical Department, Hospital Sultanah Bahiyah, Alor Setar, Kedah, Malaysia
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Abdullah N, Abd Jalal N, Ismail N, Kamaruddin MA, Abd Mutalib NS, Alias MR, Mazlan L, Sagap I, Jamal R. Colorectal screening using the immunochemical faecal occult blood test kit among the Malaysian cohort participants. Cancer Epidemiol 2020; 65:101656. [PMID: 31923638 DOI: 10.1016/j.canep.2019.101656] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2019] [Revised: 11/19/2019] [Accepted: 12/04/2019] [Indexed: 01/01/2023]
Abstract
BACKGROUND There has been a rapid increase in colorectal cancer (CRC) cases in Asian countries, including Malaysia. CRC is usually diagnosed at a late stage, and early detection of CRC is vital in improving survival. This study was conducted to determine the uptake rate of the immunochemical faecal occult blood test (iFOBT), the response rate to colonoscopy, and the CRC detection rate. We also wanted to identify the association between colorectal neoplasia and the Asia Pacific Colorectal Cancer Screening (APCS) scoring system. METHODS We recruited 2264 individuals from The Malaysian Cohort participants aged 35-65 years who consented to colorectal screening using the iFOBT kit from July 2017 until January 2019. RESULTS The response rate and positive iFOBT test rate of this study were 79.6% and 13.1% respectively. Among those with positive results, 125 individuals (52.7%) underwent colonoscopy; CRC was detected in six of them while 45 others (36.0%) had polyps. The overall CRC detection rate was 0.3% while the colorectal neoplasia detection rate (both colorectal cancer and colorectal polyps) was 2.3%. The APCS scoring indicated a significant association with colorectal neoplasia risk, with increasing trend by severity from moderate to high risk (3.46-11.14) compared to low risk. Most of the participants who were positive for iFOBT were those at high risk. CONCLUSIONS The awareness of CRC risk and iFOBT screening are important strategies for early detection of CRC. We showed a CRC detection rate of 0.3 % among those who volunteered to have the iFOBT screening.
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Affiliation(s)
- Noraidatulakma Abdullah
- UKM Medical Molecular Biology Institute (UMBI), Universiti Kebangsaan Malaysia, Kuala Lumpur, Malaysia
| | - Nazihah Abd Jalal
- UKM Medical Molecular Biology Institute (UMBI), Universiti Kebangsaan Malaysia, Kuala Lumpur, Malaysia
| | - Norliza Ismail
- UKM Medical Molecular Biology Institute (UMBI), Universiti Kebangsaan Malaysia, Kuala Lumpur, Malaysia
| | - Mohd Arman Kamaruddin
- UKM Medical Molecular Biology Institute (UMBI), Universiti Kebangsaan Malaysia, Kuala Lumpur, Malaysia
| | - Nurul Syakima Abd Mutalib
- UKM Medical Molecular Biology Institute (UMBI), Universiti Kebangsaan Malaysia, Kuala Lumpur, Malaysia
| | - Mohd Raziff Alias
- UKM Medical Molecular Biology Institute (UMBI), Universiti Kebangsaan Malaysia, Kuala Lumpur, Malaysia
| | - Luqman Mazlan
- Department of Surgery, Faculty of Medicine, Universiti Kebangsaan Malaysia, Kuala Lumpur, Malaysia
| | - Ismail Sagap
- Department of Surgery, Faculty of Medicine, Universiti Kebangsaan Malaysia, Kuala Lumpur, Malaysia
| | - Rahman Jamal
- UKM Medical Molecular Biology Institute (UMBI), Universiti Kebangsaan Malaysia, Kuala Lumpur, Malaysia.
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Gingold-Belfer R, Leibovitzh H, Boltin D, Issa N, Tsadok Perets T, Dickman R, Niv Y. The compliance rate for the second diagnostic evaluation after a positive fecal occult blood test: A systematic review and meta-analysis. United European Gastroenterol J 2019; 7:424-448. [PMID: 31019712 DOI: 10.1177/2050640619828185] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/11/2018] [Accepted: 01/02/2019] [Indexed: 12/12/2022] Open
Abstract
Introduction Only a minority of patients with a positive fecal occult blood test (FOBT) undergo a follow-up second diagnostic procedure, thus minimizing its contribution for colorectal cancer (CRC) prevention. We aimed to obtain a precise estimation of this problem and also assess the diagnostic yield of CRC and adenomas by colonoscopy in these patients. Methods Literature searches were conducted for "compliance" OR "adherence" AND "fecal occult blood test" OR "fecal immunohistochemical test" AND "colonoscopy." Comprehensive meta-analysis software was used. Results The search resulted in 42 studies (512,496 patients with positive FOBT), published through December 31, 2017. A funnel plot demonstrates a moderate publication bias. Compliance with any second procedure, colonoscopy, or combination of double-contrast barium enema with or without sigmoidoscopy in patients with a positive FOBT was 0.725 with 95% confidence interval (CI) 0.649-0.790 (p = 0.000), 0.804 with 95% CI 0.740-0.856 (p = 0.000) and 0.197 with 95% CI 0.096-0.361 (p = 0.000), respectively. The diagnostic yield for CRC, advanced adenoma and simple adenoma was 0.058 with 95% CI 0.050-0.068 (p = 0.000), 0.242 with 95% CI 0.188-0.306 (p = 0.000) and 0.147 with 95% CI 0.116-0.184 (p < 0.001), respectively. Discussion Compliance with diagnostic evaluation after a positive FOBT is still suboptimal. Therefore, measures to increase compliance need to be taken given the increased risk of CRC in these patients.
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Affiliation(s)
- Rachel Gingold-Belfer
- Division of Gastroenterology, Rabin Medical Center, Beilinson Hospital, Petach Tikva, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Haim Leibovitzh
- Division of Gastroenterology, Rabin Medical Center, Beilinson Hospital, Petach Tikva, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Doron Boltin
- Division of Gastroenterology, Rabin Medical Center, Beilinson Hospital, Petach Tikva, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Nidal Issa
- Department of Surgery B, Rabin Medical Center, Hasharon Hospital, Petach Tikva, Israel
| | - Tsachi Tsadok Perets
- Division of Gastroenterology, Rabin Medical Center, Beilinson Hospital, Petach Tikva, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Ram Dickman
- Division of Gastroenterology, Rabin Medical Center, Beilinson Hospital, Petach Tikva, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Yaron Niv
- Division of Gastroenterology, Rabin Medical Center, Beilinson Hospital, Petach Tikva, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
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