Implementing an Organized Colorectal Cancer Screening Program: Lessons Learned From an Academic-Community Practice

Introduction

The effectiveness of mailed fecal immunochemical test outreach might be enhanced through an organized colorectal cancer screening program, yet published real-world experiences are limited. We synthesized the process of implementing a colorectal cancer screening program that used mailed fecal immunochemical test outreach in a large integrated academic-community practice.

Methods

Data from a pilot mailed fecal immunochemical test program were shared with healthcare system leadership, which inspired the creation of a cross-institutional organized colorectal cancer screening program. In partnership with a centralized population health team and primary care, we defined (1) the institutional approach to colorectal cancer screening, (2) the target population and method for screening, (3) the team responsible for implementation, (4) the healthcare team responsible for decisions and care, (5) a quality assurance structure, and (6) a method for identifying cancer occurrence.

Results

The Fred Hutch/UW Medicine Population Health Colorectal Cancer Screening Program began in September 2021. The workflow for mailed fecal immunochemical test outreach included a mailed postcard, a MyChart message from the patient's primary care provider, a fecal immunochemical test kit with a letter signed by the primary care provider and program director, and up to 3 biweekly reminders. Patients without a colonoscopy 3 months after an abnormal fecal immunochemical test result received navigation through the program. In the first program year, we identified 9,719 patients eligible for outreach, and in an intention-to-treat analysis, 32% of patients completed colorectal cancer screening by fecal immunochemical test or colonoscopy.

Conclusions

Real-world experiences detailing how to implement organized colorectal cancer screening programs might increase adoption. In our experience, broadly disseminating pilot data, early institutional support, robust data management, and strong cross-departmental relationships were critical to successfully implementing a colorectal cancer screening program that benefits all patients.

A Cell-free DNA Blood-Based Test for Colorectal Cancer Screening

BACKGROUND

Colorectal cancer is the third most diagnosed cancer in adults in the United States. Early detection could prevent more than 90% of colorectal cancer-related deaths, yet more than one third of the screening-eligible population is not up to date with screening despite multiple available tests. A blood-based test has the potential to improve screening adherence, detect colorectal cancer earlier, and reduce colorectal cancer-related mortality.

METHODS

We assessed the performance characteristics of a cell-free DNA (cfDNA) blood-based test in a population eligible for colorectal cancer screening. The coprimary outcomes were sensitivity for colorectal cancer and specificity for advanced neoplasia (colorectal cancer or advanced precancerous lesions) relative to screening colonoscopy. The secondary outcome was sensitivity to detect advanced precancerous lesions.

RESULTS

The clinical validation cohort included 10,258 persons, 7861 of whom met eligibility criteria and were evaluable. A total of 83.1% of the participants with colorectal cancer detected by colonoscopy had a positive cfDNA test and 16.9% had a negative test, which indicates a sensitivity of the cfDNA test for detection of colorectal cancer of 83.1% (95% confidence interval [CI], 72.2 to 90.3). Sensitivity for stage I, II, or III colorectal cancer was 87.5% (95% CI, 75.3 to 94.1), and sensitivity for advanced precancerous lesions was 13.2% (95% CI, 11.3 to 15.3). A total of 89.6% of the participants without any advanced colorectal neoplasia (colorectal cancer or advanced precancerous lesions) identified on colonoscopy had a negative cfDNA blood-based test, whereas 10.4% had a positive cfDNA blood-based test, which indicates a specificity for any advanced neoplasia of 89.6% (95% CI, 88.8 to 90.3). Specificity for negative colonoscopy (no colorectal cancer, advanced precancerous lesions, or nonadvanced precancerous lesions) was 89.9% (95% CI, 89.0 to 90.7).

CONCLUSIONS

In an average-risk screening population, this cfDNA blood-based test had 83% sensitivity for colorectal cancer, 90% specificity for advanced neoplasia, and 13% sensitivity for advanced precancerous lesions. (Funded by Guardant Health; ECLIPSE ClinicalTrials.gov number, NCT04136002.).

Patient perspectives on a proposed pharmacy-based colorectal cancer screening program

Colorectal cancer (CRC) is a common and preventable cancer. CRC screening is underutilized, particularly within medically underserved communities. Most interventions aimed at increasing CRC screening are delivered through primary care clinics. Pharmacies are more accessible than traditional primary care settings and may be ideally suited for delivering CRC screening and increasing access. Fecal immunochemical test is an at-home, stool-based CRC screening test that could be distributed through pharmacies. The purpose of our study was to assess patient perspectives on receiving fecal immunochemical test-based CRC screening through pharmacies. We conducted semi-structured interviews with participants residing in North Carolina and Washington. Interviews explored acceptability and intervention design preferences for a pharmacy-based CRC screening program. The interview guide was informed by Andersen's Healthcare Utilization Model and the Theoretical Domains Framework. Interviews were conducted at the University of North Carolina at Chapel Hill and Fred Hutchinson Cancer Research Center, audio-recorded, and transcribed. Patients perceived a pharmacy-based CRC screening program to be highly acceptable, citing factors such as ease of pharmacy access and avoiding co-pays for an office visit. Some concerns about privacy and coordination with patients' primary care provider tempered acceptability. Trust and positive relationships with providers and pharmacists as well as seamless care across the CRC screening continuum also were viewed as important. Patients viewed pharmacy-based CRC screening as an acceptable option for CRC screening. To improve programmatic success, it will be important to ensure privacy, determine how communication between the pharmacy and the patient's provider will take place, and establish closed-loop care, particularly for patients with abnormal results.

AGA Clinical Practice Update on Risk Stratification for Colorectal Cancer Screening and Post-Polypectomy Surveillance: Expert Review

DESCRIPTION

Since the early 2000s, there has been a rapid decline in colorectal cancer (CRC) mortality, due in large part to screening and removal of precancerous polyps. Despite these improvements, CRC remains the second leading cause of cancer deaths in the United States, with approximately 53,000 deaths projected in 2023. The aim of this American Gastroenterological Association (AGA) Clinical Practice Update Expert Review was to describe how individuals should be risk-stratified for CRC screening and post-polypectomy surveillance and to highlight opportunities for future research to fill gaps in the existing literature.

METHODS

This Expert Review was commissioned and approved by the American Gastroenterological Association (AGA) Institute Clinical Practice Updates Committee (CPUC) and the AGA Governing Board to provide timely guidance on a topic of high clinical importance to the AGA membership, and underwent internal peer review by the CPUC and external peer review through standard procedures of Gastroenterology. These Best Practice Advice statements were drawn from a review of the published literature and from expert opinion. Because systematic reviews were not performed, these Best Practice Advice statements do not carry formal ratings regarding the quality of evidence or strength of the presented considerations. Best Practice Advice Statements BEST PRACTICE ADVICE 1: All individuals with a first-degree relative (defined as a parent, sibling, or child) who was diagnosed with CRC, particularly before the age of 50 years, should be considered at increased risk for CRC. BEST PRACTICE ADVICE 2: All individuals without a personal history of CRC, inflammatory bowel disease, hereditary CRC syndromes, other CRC predisposing conditions, or a family history of CRC should be considered at average risk for CRC. BEST PRACTICE ADVICE 3: Individuals at average risk for CRC should initiate screening at age 45 years and individuals at increased risk for CRC due to having a first-degree relative with CRC should initiate screening 10 years before the age at diagnosis of the youngest affected relative or age 40 years, whichever is earlier. BEST PRACTICE ADVICE 4: Risk stratification for initiation of CRC screening should be based on an individual's age, a known or suspected predisposing hereditary CRC syndrome, and/or a family history of CRC. BEST PRACTICE ADVICE 5: The decision to continue CRC screening in individuals older than 75 years should be individualized, based on an assessment of risks, benefits, screening history, and comorbidities. BEST PRACTICE ADVICE 6: Screening options for individuals at average risk for CRC should include colonoscopy, fecal immunochemical test, flexible sigmoidoscopy plus fecal immunochemical test, multitarget stool DNA fecal immunochemical test, and computed tomography colonography, based on availability and individual preference. BEST PRACTICE ADVICE 7: Colonoscopy should be the screening strategy used for individuals at increased CRC risk. BEST PRACTICE ADVICE 8: The decision to continue post-polypectomy surveillance for individuals older than 75 years should be individualized, based on an assessment of risks, benefits, and comorbidities. BEST PRACTICE ADVICE 9: Risk-stratification tools for CRC screening and post-polypectomy surveillance that emerge from research should be examined for real-world effectiveness and cost-effectiveness in diverse populations (eg, by race, ethnicity, sex, and other sociodemographic factors associated with disparities in CRC outcomes) before widespread implementation.

Health System-Provided Rideshare Is Safe and Addresses Barriers to Colonoscopy Completion

In 2019, nearly 14 million colonoscopies were performed in the United States.1 In these settings, the accepted practice is that a responsible person drives and chaperones patients home after receiving procedural sedation, including colonoscopy.2 Lack of access to transportation and/or a chaperone is a persistent barrier to care in safety-net health systems and federally qualified health centers as a result of lower incomes, underinsurance, and higher social needs.3 Given racial, ethnic, and socioeconomic disparities in many digestive diseases that require colonoscopy for diagnosis and management, innovative solutions are needed to overcome logistical barriers to colonoscopy completion, especially in these settings.

Tools to Measure the Impact of Structural Racism and Discrimination on Gastrointestinal and Hepatology Disease Outcomes: A Scoping Review

BACKGROUND & AIMS

Structural racism and discrimination (SRD) are important upstream determinants of health perpetuated by discriminatory laws and policies. Therefore, measuring SRD and its impact on health is critical to developing interventions that address resultant health disparities. We aimed to identify gastrointestinal (GI) or liver studies that report measures of SRD or interventions to achieve health equity in these domains by addressing upstream determinants of health.

METHODS

We conducted a scoping review according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses scoping reviews guidelines. Studies that used an SRD measure or examined an upstream intervention in GI or liver disease were included. Studies that described health disparities in GI or liver conditions without mentioning SRD were excluded. Study characteristics, findings, and limitations were extracted.

RESULTS

Forty-six articles (19 studies using SRD measures and 27 studies of upstream interventions) were identified. Measures of residential racial segregation were reported most frequently. SRD was associated with poorer health outcomes for racial and ethnic minority populations. Although upstream intervention studies focused primarily on policies related to colon cancer screening and organ graft allocation, racial and ethnic disparities often persisted post-intervention.

CONCLUSIONS

To achieve health equity in GI and liver conditions, there is an urgent need for research that goes beyond describing health disparities to incorporating measures of SRD and implementing interventions that address this understudied determinant of health.

Performance of OC-Auto Micro 80 Fecal Immunochemical Test in an Integrated Academic-Community Health System

GOALS

We aimed to determine the performance of the OC-Auto Micro 80 fecal immunochemical test (FIT) in an average-risk population receiving care in an integrated, academic-community health system.

BACKGROUND

The FIT is the most used colorectal cancer (CRC) screening test worldwide. However, many Food and Drug Administration-cleared FIT products have not been evaluated in clinical settings.

STUDY

We performed a retrospective cohort study of patients (50 to 75 y old) in the University of Washington Medicine health care system who were screened for CRC by OC-Auto Micro 80 FIT between March 2016 and September 2021. We used electronic health records to extract patient-level and clinic-level factors, FIT use, colonoscopy, and pathology findings. The primary outcomes were the FIT positivity rate and neoplasms detected at colonoscopy. Secondary outcomes were FIT positivity by sex and safety-net versus non-safety-net clinical settings.

RESULTS

We identified 39,984 FITs completed by 26,384 patients; 2411 (6.0%) had a positive FIT result (>100 ng/mL of hemoglobin in buffer), and 1246 (51.7%) completed a follow-up colonoscopy. The FIT positive rate was 7.0% in men and 5.2% in women (P <0.01). Among those who completed a colonoscopy after an abnormal FIT result, the positive predictive value for CRC, advanced adenoma, and advanced neoplasia was 3.0%, 20.9%, and 23.9%, respectively.

CONCLUSIONS

In a retrospective analysis of a large heterogeneous population, the OC-Auto Micro 80 FIT for CRC screening demonstrated a positivity rate of 6.0% and a positive predictive value for CRC of 3.0%.

Primary care provider perspectives on the role of community pharmacy in colorectal cancer screening: a qualitative study

BACKGROUND

The United States Preventive Services Task Force (USPSTF) lists 32 grade A or B recommended preventive services for non-pregnant United States (US) adults, including colorectal cancer screening (CRC). Little guidance is given on how to implement these services with consistency and fidelity in primary care. Given limited patient visit time and competing demands, primary care providers (PCPs) tend to prioritize a small subset of these recommendations. Completion rates of some of these services, including CRC screening, are suboptimal. Expanding delivery of preventive services to other healthcare providers, where possible, can improve access and uptake, particularly in medically underserved areas or populations. Fecal immunochemical testing (FIT) (at-home, stool-based testing) for CRC screening can be distributed and resulted without PCP involvement. Pharmacists have long delivered preventive services (e.g., influenza vaccination) and may be a good option for expanding CRC screening delivery using FIT, but it is not clear how PCPs would perceive this expansion.

METHODS

We used semi-structured interviews with PCPs in North Carolina and Washington state to assess perceptions and recommendations for a potential pharmacy-based FIT distribution program (PharmFIT™). Transcripts were coded and analyzed using a hybrid inductive-deductive content analysis guided by the Consolidated Framework for Implementation Research (CFIR) to elucidate potential multi-level facilitators of and barriers to implementation of PharmFIT™.

RESULTS

We completed 30 interviews with PCPs in North Carolina (N = 12) and Washington state (N = 18). PCPs in both states were largely accepting of PharmFIT™, with several important considerations. First, PCPs felt that pharmacists should receive appropriate training for identifying patients eligible and due for FIT screening. Second, a clear understanding of responsibility for tracking tests, communication, and, particularly, follow-up of positive test results should be established and followed. Finally, clear electronic workflows should be established for relay of test result information between the pharmacy and the primary care clinic.

CONCLUSION

If the conditions are met regarding pharmacist training, follow-up for positive FITs, and transfer of documentation, PCPs are likely to support PharmFIT™ as a way for their patients to obtain and complete CRC screening using FIT.

Addressing racial and ethnic disparities in US liver cancer care

HCC, the most common form of primary liver cancer, is the fastest rising cause of cancer-related death in the United States. HCC disproportionately affects racial and ethnic minorities in the United States. A practical framework is needed to organize the complex patient, provider, health system, and societal factors that drive these racial and ethnic disparities. In this narrative review, we adapted and applied the National Institute on Minority Health and Health Disparities (NIMHD) Research Framework to the HCC care continuum, as a step toward better understanding and addressing existing HCC-related disparities. We first summarize the literature on HCC-related disparities by race and ethnicity organized by the framework's 5 domains (biological, behavioral, physical/built environment, sociocultural environment, and health care system) and 4 levels (individual, interpersonal, community, and societal) of influence. We then offer strategies to guide future research initiatives toward promotion of health equity in HCC care. Clinicians and researchers may help mitigate further inequities and better address racial and ethnic disparities in HCC care by prioritizing the following in HCC research: (1) increasing racial and ethnic minority representation, (2) collecting and reporting HCC-related data by racial and ethnic subgroups, (3) assessing the patient experience of HCC care by race and ethnicity, and (4) evaluating HCC-specific social determinants of health by race and ethnicity. These 4 priorities will help inform the development of future programs and interventions that are tailored to the unique experiences of each racial and ethnic group.

Association between patient, clinic, and geographical-level factors and 1-year surveillance colonoscopy adherence

INTRODUCTION

Surveillance colonoscopy 1-year after surgical resection for patients with stages I-III colorectal cancer (CRC) is suboptimal and data on factors associated with lack of adherence are limited. Using surveillance colonoscopy data from Washington state, we aimed to determine the patient, clinic, and geographical factors associated with adherence.

METHODS

Using administrative insurance claims linked to Washington (WA) cancer registry data we conducted a retrospective cohort study of adult patients diagnosed with stage I-III CRC between 2011 and 2018 with continuous insurance for at least 18 months after diagnosis. We determined the adherence rate to 1-year surveillance colonoscopy and conducted logistic regression analysis to identify factors associated with completion.

RESULTS

Of 4,481 stage I-III CRC patients identified, 55.8% completed a 1-year surveillance colonoscopy. The median time to colonoscopy completion was 370 days. On multivariate analysis, older age, higher stage CRC, Medicare insurance or multiple insurance carriers, higher Charlson Comorbidity Index score and living without a partner were significantly associated with decreased adherence to 1-year surveillance colonoscopy. Among 29 eligible clinics, 51% (n=15) reported lower than expected surveillance colonoscopy rates based on patient mix.

CONCLUSION

Surveillance colonoscopy 1-year after surgical resection is sub-optimal in WA state. Patient and clinic factors, but not geographic factors (Area Deprivation Index), were significantly associated with surveillance colonoscopy completion. This data will inform the development of patient and clinic level interventions to address an important quality of care issue across Washington.

Diversity, equity, and inclusion in gastroenterology and hepatology: A survey of where we stand

BACKGROUND AND AIMS

In the setting of increasing attention to representation in medicine, we aimed to assess current perspectives of racial and ethnic workforce diversity and health care disparities among gastroenterology (GI) and hepatology professionals in the United States.

APPROACH AND RESULTS

We developed and administered a 33-item electronic cross-sectional survey to members of five national GI and hepatology societies. Survey items were organized into thematic modules and solicited perspectives on racial and ethnic workforce diversity, health care disparities in GI and hepatology, and potential interventions to enhance workforce diversity and improve health equity. Of the 1219 survey participants, 62.3% were male, 48.7% were non-Hispanic White, and 19.9% were from backgrounds underrepresented in medicine. The most frequently reported barriers to increasing racial and ethnic diversity in GI and hepatology were insufficient representation of underrepresented racial and ethnic minority groups in the education and training pipeline (n = 431 [35.4%]), in professional leadership (n = 340 [27.9%]), and among practicing GI and hepatology professionals (n = 324 [26.6%]). Suggested interventions were to increase career mentorship opportunities (n = 545 [44.7%]), medical student opportunities (n = 520 [42.7%]), and program and professional society leadership roles for underrepresented racial and ethnic minority groups (n = 473 [38.8%]).

CONCLUSIONS

Our survey explored imperative and timely perspectives on racial and ethnic representation and health equity among professionals in GI and hepatology. The findings should inform future interventions to address workforce diversity and establish priorities toward improving health equity, ultimately serving as a springboard for professional societies, academic institutions, and other organizations that aim to increase diversity, equity, and inclusion in our field.

Diversity, Equity, and Inclusion in Gastroenterology and Hepatology: A Survey of Where We Stand

BACKGROUND & AIMS

In the setting of increasing attention to representation in medicine, we aimed to assess current perspectives of racial and ethnic workforce diversity and health care disparities among gastroenterology (GI) and hepatology professionals in the United States.

METHODS

We developed and administered a 33-item electronic cross-sectional survey to members of 5 national GI and hepatology societies. Survey items were organized into thematic modules and solicited perspectives on racial and ethnic workforce diversity, health care disparities in GI and hepatology, and potential interventions to enhance workforce diversity and improve health equity.

RESULTS

Of the 1219 survey participants, 62.3% were male, 48.7% were non-Hispanic White, and 19.9% were from backgrounds underrepresented in medicine. The most frequently reported barriers to increasing racial and ethnic diversity in GI and hepatology were insufficient representation of underrepresented racial and ethnic minority groups in the education and training pipeline (n = 431 [35.4%]), in professional leadership (n = 340 [27.9%]), and among practicing GI and hepatology professionals (n = 324 [26.6%]). Suggested interventions were to increase career mentorship opportunities (n = 545 [44.7%]), medical student opportunities (n = 520 [42.7%]), and program and professional society leadership roles for underrepresented racial and ethnic minority groups (n = 473 [38.8%]).

CONCLUSIONS

Our survey explored imperative and timely perspectives on racial and ethnic representation and health equity among professionals in GI and hepatology. The findings should inform future interventions to address workforce diversity and establish priorities toward improving health equity, ultimately serving as a springboard for professional societies, academic institutions, and other organizations that aim to increase diversity, equity, and inclusion in our field.

Barriers Associated with Inadequate Follow-up of Abnormal Fecal Immunochemical Test Results in a Safety-Net System: A Mixed-Methods Analysis

•

Less than 50% of patients with an abnormal FIT result had a documented reason.

•

Patient-level (e.g., declined colonoscopy) reasons were most frequently documented.

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Interviews revealed discordance in documented and patient-reported reasons.

•

Mixed-methods analyses are needed to improve colonoscopy after abnormal FIT results.

In safety-net healthcare systems, colonoscopy completion within 1-year of an abnormal fecal immunochemical test (FIT) result rarely exceeds 50%. Understanding how electronic health records (EHR) documented reasons for missed colonoscopy match or differ from patient-reported reasons, is critical to optimize effective interventions to address this challenge. We conducted a convergent mixed-methods study which included a retrospective analysis of EHR data and semi-structured interviews of adults 50–75 years old, with abnormal FIT results between 2014 and 2020 in a large safety-net healthcare system. Of the 299 patients identified, 59.2% (n = 177) did not complete a colonoscopy within one year of their abnormal result. EHR abstraction revealed a documented reason for lack of follow-up colonoscopy in 49.2% (n = 87/177); patient-level (e.g., declined colonoscopy; 51.5%) and multi-factorial reasons (e.g., lost to follow-up; 37.9%) were most common. In 18 patient interviews, patient (e.g., fear of colonoscopy), provider (e.g., lack of result awareness), and system-level reasons (e.g., scheduling challenges) were most common. Only three reasons for lack of colonoscopy overlapped between EHR data and patient interviews (competing health issues, lack of transportation, and abnormal FIT result attributed to another cause). In a cohort of safety-net patients with abnormal FIT results, the most common reasons for lack of follow-up were patient-related. Our analysis revealed a discordance between EHR documented and patient-reported reasons for lack of colonoscopy after an abnormal FIT result. Mixed-methods analyses, as in the present study, may give us the greatest insight into modifiable determinants to develop effective interventions beyond quantitative and qualitative data analysis alone.

Analysis of Speaker Introduction Formality by Gender at the American College of Gastroenterology 2020 Annual Scientific Meeting

BACKGROUND

Gender-based differences in the use of professional titles during speaker introductions have been described in other medical specialties.

AIMS

Our primary aim was to assess gender-based differences in the formality of speaker introductions at the American College of Gastroenterology 2020 Virtual Annual Scientific Meeting. Our secondary aim was to assess gender-based differences in the formality of speaker self-introductions.

METHODS

Reviewed presentations from the American College of Gastroenterology Annual Meeting for gender-based differences in professional title use during speaker introductions and self-introductions.

RESULTS

Speakers included 29 women (37.2%) and 49 men (62.8%). We found no significant gender differences in the use of professional titles by introducers (t(67) = -  0.775, p = 0.441) or in self-introductions (36.4% of women vs. 41.9% of men, t(63) = 0.422, p = 0.674).

CONCLUSION

The lack of gender differences in professional title use may represent a novel advantage of virtual meeting formats or suggest increased attention to gender bias in introductions.

Operationalizing a Rideshare Intervention for Colonoscopy Completion: Barriers, Facilitators, and Process Recommendations

INTRODUCTION

Transportation is a common barrier to colonoscopy completion for colorectal cancer (CRC) screening. The study aims to identify the barriers, facilitators, and process recommendations to implement a rideshare non-emergency medical transportation (NEMT) intervention following colonoscopy completion within a safety-net healthcare setting.

METHODS

We used informal stakeholder engagement, story boards - a novel user-centered design technique, listening sessions and the nominal group technique to identify the barriers, facilitators, and process to implementing a rideshare NEMT program following colonoscopy completion in a large safety-net healthcare system.

RESULTS

Barriers to implementing a rideshare NEMT intervention for colonoscopy completion included: inability to expand an existing NEMT program beyond Medicaid patients and lack of patient chaperones with rideshare NEMT programs. Facilitators included: commercially available rideshare NEMT platforms that were lower cost and had shorter wait times than the alternative of taxis. Operationalizing and implementing a rideshare NEMT intervention in our healthcare system required the following steps: 1) identifying key stakeholders, 2) engaging stakeholder groups in discussion to identify barriers and solutions, 3) obtaining institutional sign-off, 4) developing a process for reviewing and selecting a rideshare NEMT program, 5) executing contracts, 6) developing a standard operating procedure and 7) training clinic staff to use the rideshare platform.

DISCUSSION

Rideshare NEMT after procedural sedation is administered may improve colonoscopy completion rates and provide one solution to inadequate CRC screening. If successful, our rideshare model could be broadly applicable to other safety-net health systems, populations with high social needs, and settings where procedural sedation is administered.

Perceptions on Barriers and Facilitators to Colonoscopy Completion After Abnormal Fecal Immunochemical Test Results in a Safety Net System

IMPORTANCE

The effectiveness of stool-based colorectal cancer (CRC) screening, including fecal immunochemical tests (FITs), relies on colonoscopy completion among patients with abnormal results, but in safety net systems and federally qualified health centers, in which FIT is frequently used, colonoscopy completion within 1 year of an abnormal result rarely exceeds 50%. Clinician-identified factors in follow-up of abnormal FIT results are understudied and could lead to more effective interventions to address this issue.

OBJECTIVE

To describe clinician-identified barriers and facilitators to colonoscopy completion among patients with abnormal FIT results in a safety net health care system.

DESIGN, SETTING, AND PARTICIPANTS

This qualitative study was conducted using semistructured key informant interviews with primary care physicians (PCPs) and staff members in a large safety net health care system in Washington state. Eligible clinicians were recruited through all-staff meetings and clinic medical directors. Interviews were conducted from February to December 2020 through face-to-face interactions or digital meeting platforms. Interview transcripts were analyzed deductively and inductively using a content analysis approach. Data were analyzed from September through December 2020.

MAIN OUTCOMES AND MEASURES

Barriers and facilitators to colonoscopy completion after an abnormal FIT result were identified by PCPs and staff members.

RESULTS

Among 21 participants, there were 10 PCPs and 11 staff members; 20 participants provided demographic information. The median (interquartile range) age was 38.5 (33.0-51.5) years, 17 (85.0%) were women, and 9 participants (45.0%) spent more than 75% of their working time engaging in patient care. All participants identified social determinants of health, organizational factors, and patient cognitive factors as barriers to colonoscopy completion. Participants suggested that existing resources that addressed these factors facilitated colonoscopy completion but were insufficient to meet national follow-up colonoscopy goals.

CONCLUSIONS AND RELEVANCE

In this qualitative study, responses of interviewed PCPs and staff members suggested that the barriers to colonoscopy completion in a safety net health system may be modifiable. These findings suggest that interventions to improve follow-up of abnormal FIT results should be informed by clinician-identified factors to address multilevel challenges to colonoscopy completion.

Real-World Data on the Impact of COVID-19 on Endoscopic Procedural Delays

INTRODUCTION

The initial surge of the coronavirus disease 2019 (COVID-19) pandemic prompted national recommendations to delay nonurgent endoscopic procedures. The objective of this study was to provide real-world data on the impact of COVID-19 on endoscopic procedures in a safety-net healthcare system and cancer center affiliated with a tertiary academic center.

METHODS

This retrospective cohort study used a combination of electronic health record data and a prospective data tool created to track endoscopy procedures throughout COVID-19 to describe patient and procedural characteristics of endoscopic procedures delayed during the initial COVID-19 surge.

RESULTS

Of the 480 patients identified, the median age was 57 years (interquartile range 46-66), 55% (n = 262) were male, and 59% self-identified as white. Colonoscopy was the most common type of delayed procedure (49%), followed by combined esophagogastroduodenoscopy (EGD) and colonoscopy (22%), and EGD alone (20%). Colorectal cancer screening was the most common indication for delayed colonoscopy (35%), and evaluation of suspected bleeding (30%) was the most common indication for delayed combined EGD and colonoscopy. To date, 46% (223/480) of delayed cases have been completed with 12 colorectal, pancreatic, and stomach cancers diagnosed. Sociodemographic factors, procedure type, and sedation type were not significantly associated with endoscopy completion. The median time to endoscopy after delayed procedure was 88 days (interquartile range 63-119) with no differences by procedure type.

DISCUSSION

To minimize potential losses to follow-up, delayed, or missed diagnoses and to reduce progression of gastrointestinal diseases, all efforts should be used to ensure follow-up in those whose endoscopic procedures were delayed because of COVID-19.

What Multilevel Interventions Do We Need to Increase the Colorectal Cancer Screening Rate to 80%?

Screening reduces colorectal cancer mortality; however, this remains the second leading cause of cancer deaths in the United States and adherence to colorectal cancer screening falls far short of the National Colorectal Cancer Roundtable goal of 80%. Numerous studies have examined the effectiveness of interventions to increase colorectal cancer screening uptake. Outreach is the active dissemination of screening outside of the primary care setting, such as mailing fecal blood tests to individuals' homes. Navigation uses trained personnel to assist individuals through the screening process. Patient education may take the form of brochures, videos, or websites. Provider education can include feedback about screening rates of patient panels. Reminders to healthcare providers can be provided by dashboards of patients due for screening. Financial incentives provide monetary compensation to individuals when they complete screening tests, either as fixed payments or via a lottery. Individual preference for specific screening strategies has also been examined in several trials, with a choice of screening strategies yielding higher adherence than recommendation of a single strategy.

Model-Based Estimation of Colorectal Cancer Screening and Outcomes During the COVID-19 Pandemic

Importance

COVID-19 has decreased colorectal cancer screenings.

Objective

To estimate the degree to which expanding fecal immunochemical test-based colorectal cancer screening participation during the COVID-19 pandemic is associated with clinical outcomes.

Design, Setting, and Participants

A previously developed simulation model was adopted to estimate how much COVID-19 may have contributed to colorectal cancer outcomes. The model included the US population estimated to have completed colorectal cancer screening pre-COVID-19 according the American Cancer Society. The model was designed to estimate colorectal cancer outcomes between 2020 and 2023. This analysis was completed between July and December 2020.

Exposures

Adults screened for colorectal cancer and colorectal cancer cases detected by stage.

Main Outcomes and Measures

Estimates of colorectal cancer outcomes across 4 scenarios: (1) 9 months of 50% colorectal cancer screenings followed by 21 months of 75% colorectal cancer screenings; (2) 18 months of 50% screening followed by 12 months of 75% screening; (3) scenario 1 with increased use of fecal immunochemical tests; and (4) scenario 2 with increased use of fecal immunochemical tests.

Results

In our simulation model, COVID-19-related reductions in care utilization resulted in an estimated 1 176 942 to 2 014 164 fewer colorectal cancer screenings, 8346 to 12 894 fewer colorectal cancer diagnoses, and 6113 to 9301 fewer early-stage colorectal cancer diagnoses between 2020 and 2023. With an abbreviated period of reduced colorectal cancer screenings, increasing fecal immunochemical test use was associated with an estimated additional 588 844 colorectal cancer screenings and 2836 colorectal cancer diagnoses, of which 1953 (68.9%) were early stage. In the event of a prolonged period of reduced colorectal cancer screenings, increasing fecal immunochemical test use was associated with an estimated additional 655 825 colorectal cancer screenings and 2715 colorectal cancer diagnoses, of which 1944 (71.6%) were early stage.

Conclusions and Relevance

These results suggest that the increased use of fecal immunochemical tests during the COVID-19 pandemic was associated with increased colorectal cancer screening participation and more colorectal cancer diagnoses at earlier stages. If our estimates are borne out in real-world clinical practice, increasing fecal immunochemical test-based colorectal cancer screening participation during the COVID-19 pandemic could mitigate the consequences of reduced screening rates during the pandemic for colorectal cancer outcomes.

Selection of patients for large mailed fecal immunochemical test colorectal cancer screening outreach programs: A systematic review

OBJECTIVE

Digital health care offers an opportunity to scale and personalize cancer screening programs, such as mailed outreach for colorectal cancer (CRC) screening. However, studies that describe the patient selection strategy and process for CRC screening are limited. Our objective was to evaluate implementation strategies for selecting patients for CRC screening programs in large health care systems.

METHODS

We conducted a systematic review of 30 studies along with key informant surveys and interviews to describe programmatic implementation strategies for selecting patients for CRC screening. PubMed and Embase were searched since inception through December 2018, and hand searches were performed of the retrieved reference lists but none were incorporated (n = 0). No language exclusions were applied.

RESULTS

Common criteria for outreach exclusion included: being up-to-date with routine CRC screening (n = 22), comorbidities (n = 20), and personal history (n = 22) or family history of cancer (n = 9). Key informant surveys and interviews were performed (n = 28) to understand data sources and practices for patient outreach selection, and found that 13 studies leveraged electronic medical care records, 10 studies leveraged a population registry (national, municipal, community, health), 4 studies required patient opt-in, and 1 study required primary care provider referral. Broad ranges in fecal immunochemical test completion were observed in community clinic (n = 8, 31.0-59.6%), integrated health system (n = 5, 21.2-82.7%), and national regional CRC screening programs (n = 17, 23.0-64.7%). Six studies used technical codes, and four studies required patient self-reporting from a questionnaire to participate.

CONCLUSION

This systematic review provides health systems with the diverse outreach practices and technical tools to support efforts to automate patient selection for CRC screening outreach.

Impact of COVID-19 on colorectal cancer disparities and the way forward

In response to the coronavirus disease 2019 (COVID-19) pandemic, the U.S. Surgeon General advised all hospitals and ambulatory care centers to delay nonurgent medical procedures and surgeries. This recommendation, echoed by a multigastroenterology society guideline, led to the suspension of colonoscopies for colorectal cancer (CRC) screening and surveillance. Although this temporary suspension was necessary to contain COVID-19 infections, we as gastroenterologists, patient advocates, and CRC researchers have witnessed the downstream impact of COVID-19 and this recommendation on CRC screening, research, and advocacy. These effects are particularly noticeable in medically underserved communities where CRC morbidity and mortality are highest. COVID-19-related pauses in medical care, as well as shifts in resource allocation and workforce deployment, threaten decades worth of work to improve CRC disparities in medically underserved populations. In this perspective, we present the unique challenges COVID-19 poses to health equity in CRC prevention and provide potential solutions as we navigate these uncharted waters.

Effectiveness and Cost of Organized Outreach for Colorectal Cancer Screening: A Randomized, Controlled Trial

BACKGROUND

Colorectal cancer (CRC) screening remains underused, especially in safety-net systems. The objective of this study was to determine the effectiveness, costs, and cost-effectiveness of organized outreach using fecal immunochemical tests (FITs) compared with usual care.

METHODS

Patients age 50-75 years eligible for CRC screening from eight participating primary care safety-net clinics were randomly assigned to outreach intervention with usual care vs usual care alone. The intervention included a mailed postcard and call, followed by a mailed FIT kit, and a reminder phone call if the FIT kit was not returned. The primary outcome was screening participation at 1 year and a microcosting analysis of the outreach activities with embedded long-term cost-effectiveness of outreach. All statistical tests were two-sided.

RESULTS

A total of 5386 patients were randomly assigned to the intervention group and 5434 to usual care. FIT screening was statistically significantly higher in the intervention group than in the control group (57.9% vs 37.4%, P < .001; difference = 20.5%, 95% confidence interval = 18.6% to 22.4%). In the intervention group, FIT completion rate was higher in patients who had previously completed a FIT vs those who had not (71.9% vs 35.7%, P < .001). There was evidence of effect modification of the intervention by language, and clinic. Outreach cost approximately $23 per patient and $112 per additional patient screened. Projecting long-term outcomes, outreach was estimated to cost $9200 per quality-adjusted life-year gained vs usual care.

CONCLUSION

Population-based management with organized FIT outreach statistically significantly increased CRC screening and was cost-effective in a safety-net system. The sustainability of the program and any impact of economies of scale remain to be determined.

Effectiveness of a mailed fecal immunochemical test outreach: a Medicare Advantage pilot study

BACKGROUND

Mailed fecal immunochemical test (FIT) outreach effectively increases colorectal cancer (CRC) screening but is underutilized. This pilot aimed to determine the use of FIT for CRC screening among Medicare Advantage enrollees when offered via mailed outreach and the factors associated with FIT return.

METHODS

Our pilot study included Medicare Advantage enrollees who were 50-75-years old, not up to date with CRC screening, and had a billable primary care encounter in the prior 3 years. Eligible patients received a letter containing information about CRC screening and a FIT kit, screening status by FIT was then assessed using the electronic health record.

RESULTS

Of the 1142 patients identified, 945 were eligible for outreach. On 12-month follow up, 29% of patients (n = 276) completed CRC screening via FIT, with a median return time of 140 days [interquartile range (IQR) 52-257]; 6% (n = 17) of the completed tests were positive, and 53% (n = 9) of patients have completed a diagnostic colonoscopy. Patients with primary encounter <12 months prior to mailed outreach were most likely to complete a FIT. Over the 12-month study period, CRC screening rates increased by 5% (63-68%).

CONCLUSIONS

Mailed FIT outreach in a Medicare Advantage population was feasible and led to a 5% increase in CRC screening completion. Our pilot revealed rare incorrect patient addresses and high lab discard rate; both important factors that were addressed prior to larger-scale implementation of a mailed FIT program. Further research is needed to understand the potential impact of multilevel interventions on CRC screening in this healthcare system.

Text Message Preferences for Surveillance Colonoscopy Reminders Among Colorectal Cancer Survivors

Background. Surveillance colonoscopy 1-year after colorectal cancer (CRC) surgery effectively reduces CRC mortality, yet less than half of survivors undergo this procedure. Text message reminders can improve CRC screening and other health behaviors, but use of this strategy to address barriers to CRC surveillance has not been reported. Objectives. The goal of this qualitative study was to assess CRC survivor perspectives on barriers to colonoscopy to inform the design of a theory-based, short message service (SMS) intervention to increase surveillance colonoscopy utilization. Method. CRC survivors in Western Washington participated in one of two focus groups to explore perceived barriers to completing surveillance colonoscopy and preferences for SMS communication. Content analysis using codes representative of the health belief model and prospect theory constructs were applied to qualitative data. Results. Thirteen CRC survivors reported individual-, interpersonal-, and system-level barriers to surveillance colonoscopy completion. Participants were receptive to receiving SMS reminders to mitigate these barriers. They suggested that reminders offer supportive, loss-framed messaging; include educational content; and be personalized to communication preferences. Finally, they recommended that reminders begin no earlier than 9 months following CRC surgery and not include response prompts. Conclusions. Our study demonstrates that CRC survivors perceive SMS reminders as an acceptable, valuable tool for CRC surveillance. Furthermore, there may be value in integrating theoretical frameworks to design, implement, and evaluate SMS interventions to address barriers to CRC surveillance. As physicians play a key role in CRC surveillance, provider- and system-level interventions that could additively improve the impact of SMS interventions are also worth exploring.

Mailed fecal immunochemical test outreach for colorectal cancer screening: Summary of a Centers for Disease Control and Prevention-sponsored Summit

Uptake of colorectal cancer screening remains suboptimal. Mailed fecal immunochemical testing (FIT) offers promise for increasing screening rates, but optimal strategies for implementation have not been well synthesized. In June 2019, the Centers for Disease Control and Prevention convened a meeting of subject matter experts and stakeholders to answer key questions regarding mailed FIT implementation in the United States. Points of agreement included: 1) primers, such as texts, telephone calls, and printed mailings before mailed FIT, appear to contribute to effectiveness; 2) invitation letters should be brief and easy to read, and the signatory should be tailored based on setting; 3) instructions for FIT completion should be simple and address challenges that may lead to failed laboratory processing, such as notation of collection date; 4) reminders delivered to initial noncompleters should be used to increase the FIT return rate; 5) data infrastructure should identify eligible patients and track each step in the outreach process, from primer delivery through abnormal FIT follow-up; 6) protocols and procedures such as navigation should be in place to promote colonoscopy after abnormal FIT; 7) a high-quality, 1-sample FIT should be used; 8) sustainability requires a program champion and organizational support for the work, including sufficient funding and external policies (such as quality reporting requirements) to drive commitment to program investment; and 9) the cost effectiveness of mailed FIT has been established. Participants concluded that mailed FIT is an effective and efficient strategy with great potential for increasing colorectal cancer screening in diverse health care settings if more widely implemented.

Inequities in multi-gene hereditary cancer testing: lower diagnostic yield and higher VUS rate in individuals who identify as Hispanic, African or Asian and Pacific Islander as compared to European

The identification of germline pathogenic/likely pathogenic (P/LP) variants in cancer predisposition genes can guide treatment and management decisions for the individual being tested and potentially at-risk relatives. Prior studies have raised concerns of racial/ethnic disparities in the detection rates of P/LP variants and variants of uncertain significance (VUSs). In 2018, Color Genomics™, a commercial laboratory, made de-identified, aggregate genetic and clinical information from 50,000 individuals who completed testing for 30 cancer predisposition genes publicly available. It is the largest publicly available database of its kind from a single laboratory. An analysis of individuals from this database with a negative personal history of cancer that identify as European (n = 31,920), Hispanic (n = 1700), African (n = 462) or Asian and Pacific Islander (n = 2602), demonstrated that the VUS rate in the hereditary breast and ovarian cancer syndrome and Lynch syndrome genes was higher for all non-European groups as compared to the European group; Hispanic (7.1% vs. 5.8%; p = 0.029), African (12.3% vs. 5.8%; p < 0.001), Asian and Pacific Islander (13.1% vs. 5.8%; p < 0.001). In the other cancer genes (OCGs), the P/LP rate was lower; Hispanic (5.1% vs. 7.6%; p < 0.001), African (2.4% vs. 7.6%; p < 0.001), and Asian and Pacific Islander (4.3% vs. 7.6%; p < 0.001). The VUS rate was also higher in the OCGs; Hispanic (16.2% vs. 12.2%; p < 0.001), African (21.6% vs. 12.2%; p < 0.001), Asian and Pacific Islander (24.4% vs. 12.2%; p < 0.001). Our study emphasizes the reality of disparities in the results of cancer genetic testing and highlights factors that propagate these inequities.

Racial Disparities in Colorectal Cancer Mortality: the Role of Endoscopy Wait-Time and Stage at Diagnosis

INTRODUCTION

In Western Washington (WA), colorectal cancer (CRC) mortality between 2012 and 2016 was highest in American Indian/Alaska Natives (AI/AN) and African-Americans (AA) at 20.7 and 18.7, respectively, compared with non-Hispanic Whites at 14.1/100,000 people. We hypothesized that time from billed encounters for CRC-associated symptoms to endoscopy completion or CRC stage at diagnosis contributed to observed differences.

METHODS

Using administrative insurance claims linked to WA cancer registry data, we performed a retrospective cohort study of patients diagnosed with CRC between 2011 and 2017, with continuous insurance for 15 months prior to diagnosis and a billed encounter for CRC-associated symptoms. We determined the wait-time (days) and stage at diagnosis and conducted logistic regression analysis to identify the factors associated with endoscopy completion.

RESULTS

Of the 3461 CRC patients identified, 57% had stage 2 or 3 disease with no differences in stage by race, and 84% completed an endoscopy after a billed encounter for CRC-associated symptoms. The median wait-time to endoscopy was 52 days (IQR 14-218) without differences by race. Compared with patients diagnosed with stage 1 CRC, patients with stage 4 CRC were more likely to complete an endoscopy within the first quartile of time (22.2% vs. 17.4%, p < 0.01). Living arrangement, insurance type, and comorbidity, but not race, were significant factors associated with endoscopy completion.

CONCLUSIONS

We found no statistically significant differences in time from billed CRC-associated symptoms to endoscopy completion or in CRC stage among AA and AI/AN compared to Whites. This suggests that other factors are more likely to contribute to observed mortality disparities.

Disseminated adenovirus infection after autologous stem cell transplant

Adenovirus is an infrequent but challenging viral complication of transplantation that is rarely reported after autologous stem cell transplant. We present a case of disseminated adenovirus infection in a woman who received an autologous stem cell transplant for treatment of multiple sclerosis. After presenting with post-transplant episodic diarrhea and viremia, endoscopic biopsies and immunohistochemical staining confirmed the diagnosis of disseminated adenovirus infection. Her symptoms and viremia resolved after treatment with cidofovir. This case demonstrates that a high index of suspicion, a systematic clinical approach, and immunohistochemical tissue staining are necessary to diagnose disseminated adenovirus infection in an unexpected host.

COVID-19 and the other pandemic: populations made vulnerable by systemic inequity

Greater than the coronavirus disease 2019 (COVID-19) crisis, systemic inequity in social determinants of health is the pandemic that has long fostered vulnerability to disease and poor health outcomes in the USA. Our response has major implications for the health of our nations.

Population health interventions to improve colorectal cancer screening by fecal immunochemical tests: A systematic review

Despite clear evidence that colorectal cancer (CRC) screening reduces mortality, screening, including fecal immunochemical tests (FIT), is underutilized. We conducted a systematic review to determine the evidence of efficacy of interventions to improve FIT completion that could be scaled and utilized in population health management. We systematically searched publication databases for studies evaluating provider- or system-level interventions to improve CRC screening by FIT between 1 January 1996 and 13 December 2017 without language restrictions. Twenty articles describing 25 studies were included, 23 were randomized controlled trials with 1 quasi-experimental and 1 observational study. Ten studies discussed mailed FIT outreach, 4 pre-FIT patient reminders, 3 tailored patient messages, 2 post-FIT reminders, 2 paired FIT with influenza vaccinations, 2 provider alerts and 1 study each described the use of high-quality small media and patient financial incentives. Mailed FIT outreach was consistently effective with median improvement in CRC screening of 21.5% (interquartile range (IQR) 13.6%-29.0%). FIT paired with vaccinations led to a median 15.9% (IQR 15.6%-16.3%) improvement, while pre-FIT and post-FIT reminders demonstrated modest efficacy with median 4.1% (IQR 3.6%-6.7%) and 3.1% (IQR 2.9%-3.3%) improvement in CRC screening, respectively. More than half the studies were at high or unclear risk of bias; heterogeneous study designs and characteristics precluded meta-analysis. FIT-based CRC screening programs utilizing multilevel interventions (e.g. mailed FIT outreach, FIT paired with other preventative services, and provider alerts) have the potential to significantly increase screening participation. However, such programs must also follow-up patients with abnormal FIT results.

Inadequate Utilization of Diagnostic Colonoscopy Following Abnormal FIT Results in an Integrated Safety-Net System

OBJECTIVES

The effectiveness of stool-based colorectal cancer (CRC) screening is contingent on colonoscopy completion in patients with an abnormal fecal immunochemical test (FIT). Understanding system and patient factors affecting follow-up of abnormal screening tests is essential to optimize care for high-risk cohorts.

METHODS

This retrospective cohort study was conducted in an integrated safety-net system comprised of 11 primary-care clinics and one Gastroenterology referral unit and included patients 50-75 years, with a positive FIT between April 2012 and February 2015.

RESULTS

Of the 2,238 patients identified, 1,245 (55.6%) completed their colonoscopy within 1-year of the positive FIT. The median time from positive FIT to colonoscopy was 184 days (interquartile range 140-232). Of the 13% of FIT positive patients not referred to gastroenterology, 49% lacked documentation addressing their abnormal result or counseling on the increased risk of CRC. Of the patients referred but who missed their appointments, 62% lacked documentation following up on the abnormal result in the absence of a completed colonoscopy. FIT positive patients never referred to gastroenterology or who missed their appointment after referrals were more likely to have comorbid conditions and documented illicit substance use compared with patients who completed a colonoscopy.

CONCLUSIONS

Despite access to colonoscopy and a shared electronic health record system, colonoscopy completion after an abnormal FIT is inadequate within this safety-net system. Inadequate follow-up is in part explained by inappropriate screening, but there is an absence of clear documentation and systematic workflow within both primary care and GI specialty care addressing abnormal FIT results.

Palliative venting percutaneous endoscopic gastrostomy tube is safe and effective in patients with malignant obstruction

BACKGROUND AND STUDY AIMS

Obstructive symptoms are common in advanced malignancies. Venting percutaneous endoscopic gastrostomy (VPEG) tubes can be placed for palliation. The aim of this study was to determine the outcomes of VPEG placement in patients with advanced malignancy.

METHODS

We retrospectively reviewed patients in whom a VPEG tube was attempted for a malignant indication from 1998 to 2010 at a tertiary care center. Clinical information, procedure details, and adverse events (AEs) were recorded.

RESULTS

Ninety-six patients meeting the inclusion criteria were identified. Colorectal (27 %), pancreas (18.8 %), and gynecologic (17.7 %) malignancies were most common. Overall, 46.9 % of patients had ascites, with 35.6 % undergoing drainage prior to VPEG placement. VPEG placement was successful in 89 patients (92.7 %), and relief of obstructive symptoms was observed in 91.0 % of patients. Seven patients had refractory symptoms despite functioning VPEG tube. Ten post-procedural AEs were noted in nine patients, with one death. Infectious complications were more common in patients with ascites (12.2 %) versus those without (0 %; p = 0.02). There was a trend towards decreased infectious AEs when ascites was drained prior to VPEG (14.8 vs. 7.1 %; p = 0.64) in our patient cohort. We observed a decreased survival when AEs occurred (73 ± 47.8 days) compared with when they did not occur (141 ± 367.8 days; p = 0.61).

CONCLUSIONS

VPEG tubes can be safely placed in patients with obstructive symptoms due to inoperable malignancy, with complete relief in the majority of patients. Ascites was a risk factor for post-procedural infectious AEs. Drainage of ascites prior to VPEG tube placement may decrease this risk, although this requires further study.

Efficacy and safety of venting percutaneous endoscopic gastrostomy (VPEG) tube placement in patients with malignant obstruction

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Background: Refractory nausea and vomiting are common in patients with advanced malignancy. A venting percutaneous endoscopic gastrostomy (VPEG) tube can be placed to eliminate the need for a nasogastric tube and palliate obstructive symptoms. The aim of this study was to determine the outcomes of VPEG placement in patients with advanced malignancy. Methods: We retrospectively reviewed all patients in whom a VPEG tube was attempted for a malignant indication over a 13-year period (1998-2010). Demographic and clinical information, procedure details, and immediate & delayed complications were recorded. Results: Endoscopic VPEG placement was attempted in 96 patients (95% inpatient) with a median age of 57y. Colorectal (27%), pancreas (18.8%), and gynecologic (17.7%) malignancies were most common. Ascites was present in 46.9% of patients with drainage performed in a minority of patients (35.6%). VPEG was successfully placed by endoscopy in 89 patients (92.7%). Relief of obstructive symptoms was observed in 91.7% of patients. Eight patients had refractory obstructive symptoms despite functioning VPEG tube. Ten post-procedural complications were noted in 9 patients, with 1 death. Patients with ascites were more likely to have infectious complications (12.2%) than those without ascites (0%, p=0.02) with a trend towards decreased infectious complication when ascites was drained prior to VPEG placement (14.8% vs. 7.1%, p=NS). We observed decreased survival when complications occurred (73 days) compared to when they did not (141 days, p = NS). Conclusions: VPEG tubes can be safely placed in patients with inoperable malignancy and obstructive symptoms with complete relief of symptoms in the majority of patients. The presence of ascites was a risk factor for post-procedural infectious complications. Drainage of ascites prior to VPEG tube placement may minimize this risk, though this warrants further study.

Vascular endothelial growth factors C and D induces proliferation of lymphangioleiomyomatosis cells through autocrine crosstalk with endothelium

Lymphangioleiomyomatosis (LAM) is a potentially fatal lung disease characterized by nodules of proliferative smooth muscle-like cells. The exact nature of these LAM cells and their proliferative stimuli are poorly characterized. Herein we report the novel findings that the lymphangiogenic vascular endothelial growth factors (VEGF) C and D induce LAM cell proliferation through activation of their cognate receptor VEGF-R3 and activation of the signaling intermediates Akt/mTOR/S6. Furthermore, we identify expression of the proteoglycan NG2, a marker of immature smooth muscle cells, as a characteristic of LAM cells both in vitro and in human lung tissue. VEGF-C-induced LAM cell proliferation was in part a result of autocrine stimulation that resulted from cross talk with lymphatic endothelial cells. Ultimately, these findings identify the lymphangiogenic VEGF proteins as pathogenic growth factors in LAM disease and at the same time provide a novel pharmacotherapeutic target for a lung disease that to date has no known effective treatment.

Integrin alpha9beta1 directly binds to vascular endothelial growth factor (VEGF)-A and contributes to VEGF-A-induced angiogenesis

Vascular endothelial growth factor A (VEGF-A) is a potent inducer of angiogenesis. We now show that VEGF-A-induced adhesion and migration of human endothelial cells are dependent on the integrin alpha9beta1 and that VEGF-A is a direct ligand for this integrin. Adhesion and migration of these cells on the 165 and 121 isoforms of VEGF-A depend on cooperative input from alpha9beta1 and the cognate receptor for VEGF-A, VEGF receptor 2 (VEGF-R2). Unlike alpha3beta1or alphavbeta3 integrins, alpha9beta1 was also found to bind the 121 isoform of VEGF-A. This interaction appears to be biologically significant, because alpha9beta1-blocking antibody dramatically and specifically inhibited angiogenesis induced by VEGF-A165 or -121. Together with our previous findings that alpha9beta1 directly binds to VEGF-C and -D and contributes to lymphangiogenesis, these results identify the integrin alpha9beta1 as a potential pharmacotherapeutic target for inhibition of pathogenic angiogenesis and lymphangiogenesis.