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Hahn EE, Munoz-Plaza CE, Jensen CD, Ghai NR, Pak K, Amundsen BI, Contreras R, Cannizzaro N, Chubak J, Green BB, Skinner CS, Halm EA, Schottinger JE, Levin TR. Patterns of Care Following a Positive Fecal Blood Test for Colorectal Cancer: A Mixed Methods Study. J Gen Intern Med 2024:10.1007/s11606-024-08764-0. [PMID: 38771535 DOI: 10.1007/s11606-024-08764-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/13/2023] [Accepted: 04/02/2024] [Indexed: 05/22/2024]
Abstract
BACKGROUND/OBJECTIVE Multilevel barriers to colonoscopy after a positive fecal blood test for colorectal cancer (CRC) are well-documented. A less-explored barrier to appropriate follow-up is repeat fecal testing after a positive test. We investigated this phenomenon using mixed methods. DESIGN This sequential mixed methods study included quantitative data from a large cohort of patients 50-89 years from four healthcare systems with a positive fecal test 2010-2018 and qualitative data from interviews with physicians and patients. MAIN MEASURES Logistic regression was used to evaluate whether repeat testing was associated with failure to complete subsequent colonoscopy and to identify factors associated with repeat testing. Interviews were coded and analyzed to explore reasons for repeat testing. KEY RESULTS A total of 316,443 patients had a positive fecal test. Within 1 year, 76.3% received a colonoscopy without repeat fecal testing, 3% repeated testing and then received a colonoscopy, 4.4% repeated testing without colonoscopy, and 16.3% did nothing. Among repeat testers (7.4% of total cohort, N = 23,312), 59% did not receive a colonoscopy within 1 year. In adjusted models, those with an initial positive test followed by a negative second test were significantly less likely to receive colonoscopy than those with two successive positive tests (OR 0.37, 95% CI 0.35-0.40). Older age (65-75 vs. 50-64 years: OR 1.37, 95% CI 1.33-1.41) and higher comorbidity score (≥ 4 vs. 0: OR 1.75, 95% CI 1.67-1.83) were significantly associated with repeat testing compared to those who received colonoscopy without repeat tests. Qualitative interview data revealed reasons underlying repeat testing, including colonoscopy avoidance, bargaining, and disbelief of positive results. CONCLUSIONS Among patients in this cohort, 7.4% repeated fecal testing after an initial positive test. Of those, over half did not go on to receive a colonoscopy within 1 year. Efforts to improve CRC screening must address repeat fecal testing after a positive test as a barrier to completing colonoscopy.
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Affiliation(s)
- Erin E Hahn
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, CA, USA.
- Department of Health Systems Science, Kaiser Permanente Bernard J. Tyson School of Medicine, Pasadena, CA, USA.
| | - Corrine E Munoz-Plaza
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, CA, USA
| | | | - Nirupa R Ghai
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, CA, USA
| | - Katherine Pak
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, CA, USA
| | - Britta I Amundsen
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, CA, USA
| | - Richard Contreras
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, CA, USA
| | - Nancy Cannizzaro
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, CA, USA
| | - Jessica Chubak
- Kaiser Permanente Washington Health Research Institute, Seattle, WA, USA
| | - Beverly B Green
- Kaiser Permanente Washington Health Research Institute, Seattle, WA, USA
| | - Celette Sugg Skinner
- Peter O'Donnell Jr. School of Public Health, University of Texas Southwestern Medical Center, Dallas, TX, USA
- Harold C. Simmons Comprehensive Cancer Center, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Ethan A Halm
- Department of Medicine, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ, USA
| | - Joanne E Schottinger
- Department of Health Systems Science, Kaiser Permanente Bernard J. Tyson School of Medicine, Pasadena, CA, USA
| | - Theodore R Levin
- Kaiser Permanente Division of Research, Oakland, CA, USA
- Kaiser Permanente Medical Center, Walnut Creek, CA, USA
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Lee JK, Jensen CD, Udaltsova N, Zheng Y, Levin TR, Chubak J, Kamineni A, Halm EA, Skinner CS, Schottinger JE, Ghai NR, Burnett-Hartman A, Issaka R, Corley DA. Predicting Risk of Colorectal Cancer After Adenoma Removal in a Large Community-Based Setting. Am J Gastroenterol 2024:00000434-990000000-01034. [PMID: 38354214 DOI: 10.14309/ajg.0000000000002721] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/20/2023] [Accepted: 01/23/2024] [Indexed: 02/16/2024]
Abstract
INTRODUCTION Colonoscopy surveillance guidelines categorize individuals as high or low risk for future colorectal cancer (CRC) based primarily on their prior polyp characteristics, but this approach is imprecise, and consideration of other risk factors may improve postpolypectomy risk stratification. METHODS Among patients who underwent a baseline colonoscopy with removal of a conventional adenoma in 2004-2016, we compared the performance for postpolypectomy CRC risk prediction (through 2020) of a comprehensive model featuring patient age, diabetes diagnosis, and baseline colonoscopy indication and prior polyp findings (i.e., adenoma with advanced histology, polyp size ≥10 mm, and sessile serrated adenoma or traditional serrated adenoma) with a polyp model featuring only polyp findings. Models were developed using Cox regression. Performance was assessed using area under the receiver operating characteristic curve (AUC) and calibration by the Hosmer-Lemeshow goodness-of-fit test. RESULTS Among 95,001 patients randomly divided 70:30 into model development (n = 66,500) and internal validation cohorts (n = 28,501), 495 CRC were subsequently diagnosed; 354 in the development cohort and 141 in the validation cohort. Models demonstrated adequate calibration, and the comprehensive model demonstrated superior predictive performance to the polyp model in the development cohort (AUC 0.71, 95% confidence interval [CI] 0.68-0.74 vs AUC 0.61, 95% CI 0.58-0.64, respectively) and validation cohort (AUC 0.70, 95% CI 0.65-0.75 vs AUC 0.62, 95% CI 0.57-0.67, respectively). DISCUSSION A comprehensive CRC risk prediction model featuring patient age, diabetes diagnosis, and baseline colonoscopy indication and polyp findings was more accurate at predicting postpolypectomy CRC diagnosis than a model based on polyp findings alone.
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Affiliation(s)
- Jeffrey K Lee
- Division of Research, Kaiser Permanente Northern California, Oakland, California, USA
| | - Christopher D Jensen
- Division of Research, Kaiser Permanente Northern California, Oakland, California, USA
| | - Natalia Udaltsova
- Division of Research, Kaiser Permanente Northern California, Oakland, California, USA
| | - Yingye Zheng
- Fred Hutchinson Cancer Research Center, Seattle, Washington, USA
| | - Theodore R Levin
- Division of Research, Kaiser Permanente Northern California, Oakland, California, USA
| | - Jessica Chubak
- Kaiser Permanente Washington Health Research Institute, Kaiser Permanente Washington, Seattle, Washington, USA
| | - Aruna Kamineni
- Kaiser Permanente Washington Health Research Institute, Kaiser Permanente Washington, Seattle, Washington, USA
| | - Ethan A Halm
- Rutgers Biological Health Sciences, Rutgers University, New Brunswick, New Jersey, USA
| | - Celette S Skinner
- Simmons Comprehensive Cancer Center and Department of Population & Data Sciences, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Joanne E Schottinger
- Kaiser Permanente Bernard J. Tyson School of Medicine, Pasadena, California, USA
| | - Nirupa R Ghai
- Department of Quality and Systems of Care, Kaiser Permanente Southern California, Pasadena, California, USA
| | | | - Rachel Issaka
- Fred Hutchinson Cancer Research Center, Seattle, Washington, USA
| | - Douglas A Corley
- Division of Research, Kaiser Permanente Northern California, Oakland, California, USA
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Podmore C, Selby K, Jensen CD, Zhao WK, Weiss NS, Levin TR, Schottinger J, Doubeni CA, Corley DA. Colorectal Cancer Screening After Sequential Outreach Components in a Demographically Diverse Cohort. JAMA Netw Open 2024; 7:e245295. [PMID: 38625704 PMCID: PMC11022110 DOI: 10.1001/jamanetworkopen.2024.5295] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2023] [Accepted: 01/31/2024] [Indexed: 04/17/2024] Open
Abstract
Importance Organized screening outreach can reduce differences in colorectal cancer (CRC) incidence and mortality between demographic subgroups. Outcomes associated with additional outreach, beyond universal outreach, are not well known. Objective To compare CRC screening completion by race and ethnicity, age, and sex after universal automated outreach and additional personalized outreach. Design, Setting, and Participants This observational cohort study included screening-eligible individuals aged 50 to 75 years assessed during 2019 in a community-based organized CRC screening program within the Kaiser Permanente Northern California (KPNC) integrated health care delivery setting. For KPNC members who are not up to date with screening by colonoscopy, each year the program first uses automated outreach (mailed prescreening notification postcards and fecal immunochemical test [FIT] kits, automated telephone calls, and postcard reminders), followed by personalized components for nonresponders (telephone calls, electronic messaging, and screening offers during office visits). Data analyses were performed between November 2021 and February 2023 and completed on February 5, 2023. Exposures Completed CRC screening via colonoscopy, sigmoidoscopy, or FIT. Main Outcomes and Measures The primary outcome was the proportion of participants completing an FIT or colonoscopy after each component of the screening process. Differences across subgroups were assessed using the χ2 test. Results This study included 1 046 745 KPNC members. Their mean (SD) age was 61.1 (6.9) years, and more than half (53.2%) were women. A total of 0.4% of members were American Indian or Alaska Native, 18.5% were Asian, 7.2% were Black, 16.2% were Hispanic, 0.8% were Native Hawaiian or Other Pacific Islander, and 56.5% were White. Automated outreach significantly increased screening participation by 31.1%, 38.1%, 29.5%, 31.9%, 31.8%, and 34.5% among these groups, respectively; follow-up personalized outreach further significantly increased participation by absolute additional increases of 12.5%, 12.4%, 13.3%, 14.4%, 14.7%, and 11.2%, respectively (all differences P < .05 compared with White members). Overall screening coverage at the end of the yearly program differed significantly among members who were American Indian or Alaska Native (74.1%), Asian (83.5%), Black (77.7%), Hispanic (76.4%), or Native Hawaiian or Other Pacific Islander (74.4%) compared with White members (82.2%) (all differences P < .05 compared with White members). Screening completion was similar by sex; older members were substantially more likely to be up to date with CRC screening both before and at the end of the screening process. Conclusions and Relevance In this cohort study of a CRC screening program, sequential automated and personalized strategies each contributed to substantial increases in screening completion in all demographic groups. These findings suggest that such programs may potentially reduce differences in CRC screening completion across demographic groups.
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Affiliation(s)
- Clara Podmore
- Department of Ambulatory Care and Community Medicine, Lausanne University Hospital, Lausanne, Switzerland
- Institute of Family Medicine, University of Fribourg, Fribourg, Switzerland
| | - Kevin Selby
- Department of Ambulatory Care and Community Medicine, Lausanne University Hospital, Lausanne, Switzerland
| | | | - Wei K. Zhao
- Division of Research, Kaiser Permanente Northern California, Oakland
| | - Noel S. Weiss
- Department of Epidemiology, University of Washington, Shoreline
| | - Theodore R. Levin
- Division of Research, Kaiser Permanente Northern California, Oakland
| | - Joanne Schottinger
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena
| | | | - Douglas A. Corley
- Division of Research, Kaiser Permanente Northern California, Oakland
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4
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Lee JK, Roy A, Jensen CD, Chan JT, Zhao WK, Levin TR, Chubak J, Halm EA, Skinner CS, Schottinger JE, Ghai NR, Burnett-Hartman AN, Kamineni A, Udaltsova N, Corley DA. Surveillance Colonoscopy Findings in Older Adults With a History of Colorectal Adenomas. JAMA Netw Open 2024; 7:e244611. [PMID: 38564216 PMCID: PMC10988351 DOI: 10.1001/jamanetworkopen.2024.4611] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/20/2023] [Accepted: 02/05/2024] [Indexed: 04/04/2024] Open
Abstract
Importance Postpolypectomy surveillance is a common colonoscopy indication in older adults; however, guidelines provide little direction on when to stop surveillance in this population. Objective To estimate surveillance colonoscopy yields in older adults. Design, Setting, and Participants This population-based cross-sectional study included individuals 70 to 85 years of age who received surveillance colonoscopy at a large, community-based US health care system between January 1, 2017, and December 31, 2019; had an adenoma detected 12 or more months previously; and had at least 1 year of health plan enrollment before surveillance. Individuals were excluded due to prior colorectal cancer (CRC), hereditary CRC syndrome, inflammatory bowel disease, or prior colectomy or if the surveillance colonoscopy had an inadequate bowel preparation or was incomplete. Data were analyzed from September 1, 2022, to February 22, 2024. Exposures Age (70-74, 75-79, or 80-85 years) at surveillance colonoscopy and prior adenoma finding (ie, advanced adenoma vs nonadvanced adenoma). Main Outcomes and Measures The main outcomes were yields of CRC, advanced adenoma, and advanced neoplasia overall (all ages) by age group and by both age group and prior adenoma finding. Multivariable logistic regression was used to identify factors associated with advanced neoplasia detection at surveillance. Results Of 9740 surveillance colonoscopies among 9601 patients, 5895 (60.5%) were in men, and 5738 (58.9%), 3225 (33.1%), and 777 (8.0%) were performed in those aged 70-74, 75-79, and 80-85 years, respectively. Overall, CRC yields were found in 28 procedures (0.3%), advanced adenoma in 1141 (11.7%), and advanced neoplasia in 1169 (12.0%); yields did not differ significantly across age groups. Overall, CRC yields were higher for colonoscopies among patients with a prior advanced adenoma vs nonadvanced adenoma (12 of 2305 [0.5%] vs 16 of 7435 [0.2%]; P = .02), and the same was observed for advanced neoplasia (380 of 2305 [16.5%] vs 789 of 7435 [10.6%]; P < .001). Factors associated with advanced neoplasia at surveillance were prior advanced adenoma (adjusted odds ratio [AOR], 1.65; 95% CI, 1.44-1.88), body mass index of 30 or greater vs less than 25 (AOR, 1.21; 95% CI, 1.03-1.44), and having ever smoked tobacco (AOR, 1.14; 95% CI, 1.01-1.30). Asian or Pacific Islander race was inversely associated with advanced neoplasia (AOR, 0.81; 95% CI, 0.67-0.99). Conclusions and Relevance In this cross-sectional study of surveillance colonoscopy yield in older adults, CRC detection was rare regardless of prior adenoma finding, whereas the advanced neoplasia yield was 12.0% overall. Yields were higher among those with a prior advanced adenoma than among those with prior nonadvanced adenoma and did not increase significantly with age. These findings can help inform whether to continue surveillance colonoscopy in older adults.
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Affiliation(s)
- Jeffrey K. Lee
- Division of Research, Kaiser Permanente Northern California, Oakland
| | - Abhik Roy
- Kaiser Permanente San Leandro Medical Center, San Leandro, California
| | | | - Jennifer T. Chan
- Kaiser Permanente San Leandro Medical Center, San Leandro, California
| | - Wei K. Zhao
- Division of Research, Kaiser Permanente Northern California, Oakland
| | - Theodore R. Levin
- Division of Research, Kaiser Permanente Northern California, Oakland
| | - Jessica Chubak
- Kaiser Permanente Washington Health Research Institute, Seattle
- Kaiser Permanente Bernard J. Tyson School of Medicine, Pasadena, California
| | - Ethan A. Halm
- Rutgers Biological Health Sciences, Rutgers University, New Brunswick, New Jersey
| | - Celette S. Skinner
- Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas
- Simmons Comprehensive Cancer Center, University of Texas Southwestern Medical Center, Dallas
- Peter O’Donnell Jr School of Public Health, University of Texas Southwestern Medical Center, Dallas
| | - Joanne E. Schottinger
- Kaiser Permanente Southern California Department of Research and Evaluation, Pasadena
- Department of Quality and Systems of Care, Kaiser Permanente Southern California, Pasadena
| | - Nirupa R. Ghai
- Kaiser Permanente Southern California Department of Research and Evaluation, Pasadena
- Department of Quality and Systems of Care, Kaiser Permanente Southern California, Pasadena
| | | | - Aruna Kamineni
- Kaiser Permanente Washington Health Research Institute, Seattle
| | - Natalia Udaltsova
- Division of Research, Kaiser Permanente Northern California, Oakland
| | - Douglas A. Corley
- Division of Research, Kaiser Permanente Northern California, Oakland
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5
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Karlsson MB, Benedini L, Jensen CD, Kamp A, Henriksen UB, Thomsen TP. Climate footprint assessment of plastic waste pyrolysis and impacts on the Danish waste management system. J Environ Manage 2024; 351:119780. [PMID: 38091733 DOI: 10.1016/j.jenvman.2023.119780] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/24/2023] [Revised: 11/17/2023] [Accepted: 12/03/2023] [Indexed: 01/14/2024]
Abstract
Increased plastic recycling is necessary to reduce environmental impacts related to manufacturing and end-of-life of plastic products, however, mechanical recycling (MR) - currently the most widespread recycling option for plastic waste - is limited by quality requirements for inputs and reduced quality of outputs. In this study, pyrolysis of plastic waste is assessed against MR, municipal solid waste incineration (MSWI) and fuel substitution through climate footprint assessment (CFA) based on primary data from pyrolysis of plastic waste sourced from Danish waste producers. Results of the CFA are scaled to the Danish plastic waste resource in an impact assessment of current Danish plastic waste management, and scenarios are constructed to assess reductions through utilization of pyrolysis. Results of the CFA show highest benefits utilizing pyrolysis for monomer recovery (-1400 and -4800 kg CO2e per ton polystyrene (PS) and polymethyl methacrylate (PMMA), respectively) and MR for single polymer polyolefins (-1000 kg CO2e per ton PE). The two management options perform similarly with mixed plastic waste (200 kg CO2e per ton plastic waste). MSWI has the highest impact (1600-2200 kg CO2e per ton plastic waste) and should be avoided when alternatives are available. Scaling the results of the CFA to the full Danish plastic waste resource reveals an impact of 0.79 Mt CO2e in year 2020 of current plastic waste management. Utilizing pyrolysis to manage MR residues reduces the system impact by 15%. Greater reductions are possible through increased separation of plastic from residual waste. The best performance is achieved through a combination of MR and pyrolysis.
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Affiliation(s)
- M B Karlsson
- Roskilde University, Institute of People and Technology, Universitetsvej 1, 4000, Roskilde, Denmark.
| | - L Benedini
- Technical University of Denmark, Department of Chemical and Biochemical Engineering, CHEC Research Centre, Miljøvej, 2800, Kgs. Lyngby, Denmark
| | - C D Jensen
- Technical University of Denmark, Department of Chemical and Biochemical Engineering, CHEC Research Centre, Miljøvej, 2800, Kgs. Lyngby, Denmark
| | - A Kamp
- Roskilde University, Institute of People and Technology, Universitetsvej 1, 4000, Roskilde, Denmark
| | - U B Henriksen
- Technical University of Denmark, Department of Chemical and Biochemical Engineering, CHEC Research Centre, Miljøvej, 2800, Kgs. Lyngby, Denmark
| | - T P Thomsen
- Roskilde University, Institute of People and Technology, Universitetsvej 1, 4000, Roskilde, Denmark
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Lee JK, Koripella PC, Jensen CD, Merchant SA, Fox JM, Chang SX, Dang CH, Velayos FS, Boparai ES, Evans NS, Leung LJ, Badalov JM, Quesenberry CP, Corley DA, Levin TR. Randomized Trial of Patient Outreach Approaches to De-implement Outdated Colonoscopy Surveillance Intervals. Clin Gastroenterol Hepatol 2024:S1542-3565(24)00008-9. [PMID: 38191014 DOI: 10.1016/j.cgh.2023.12.027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/02/2023] [Revised: 12/18/2023] [Accepted: 12/18/2023] [Indexed: 01/10/2024]
Abstract
BACKGROUND AND AIMS Guidelines now recommend patients with low-risk adenomas receive colonoscopy surveillance in 7-10 years and those with the previously recommended 5-year interval be re-evaluated. We tested 3 outreach approaches for transitioning patients to the 10-year interval recommendation. METHODS This was a 3-arm pragmatic randomized trial comparing telephone, secure messaging, and mailed letter outreach. The setting was Kaiser Permanente Northern California, a large integrated healthcare system. Participants were patients 54-70 years of age with 1-2 small (<10 mm) tubular adenomas at baseline colonoscopy, due for 5-year surveillance in 2022, without high-risk conditions, and with access to all 3 outreach modalities. Patients were randomly assigned to the outreach arm (telephone [n = 200], secure message [n = 203], and mailed letter [n = 201]) stratified by age, sex, and race/ethnicity. Outreach in each arm was performed by trained medical assistants (unblinded) communicating in English with 1 reminder attempt at 2-4 weeks. Participants could change their assigned interval to 10 years or continue their planned 5-year interval. RESULTS Sixty-day response rates were higher for telephone (64.5%) and secure messaging outreach (51.7%) vs mailed letter (31.3%). Also, more patients adopted the 10-year surveillance interval in the telephone (37.0%) and secure messaging arms (32.0%) compared with mailed letter (18.9%) and rate differences were significant for telephone (18.1%; 97.5% confidence interval: 8.3%-27.9%) and secure message outreach (13.1%; 97.5% confidence interval: 3.5%-22.7%) vs mailed letter outreach. CONCLUSIONS Telephone and secure messaging were more effective than mailed letter outreach for de-implementing outdated colonoscopy surveillance recommendations among individuals with a history of low-risk adenomas in an integrated healthcare setting. (ClinicalTrials.gov, Number: NCT05389397).
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Affiliation(s)
- Jeffrey K Lee
- Division of Research, Kaiser Permanente Northern California, Oakland, California; Department of Gastroenterology, Kaiser Permanente San Francisco Medical Center, San Francisco, California.
| | - Pradeep C Koripella
- Department of Gastroenterology, Kaiser Permanente San Francisco Medical Center, San Francisco, California
| | - Christopher D Jensen
- Division of Research, Kaiser Permanente Northern California, Oakland, California
| | - Sophie A Merchant
- Division of Research, Kaiser Permanente Northern California, Oakland, California
| | - Jeffrey M Fox
- Department of Gastroenterology, Kaiser Permanente San Rafael Medical Center, San Rafael, California
| | - Suyi X Chang
- Department of Gastroenterology, Kaiser Permanente Walnut Creek Medical Center, Walnut Creek, California
| | - Christian H Dang
- Department of Gastroenterology, Kaiser Permanente San Leandro Medical Center, San Leandro, California
| | - Fernando S Velayos
- Department of Gastroenterology, Kaiser Permanente San Francisco Medical Center, San Francisco, California
| | - Eshandeep S Boparai
- Department of Gastroenterology, Kaiser Permanente Walnut Creek Medical Center, Walnut Creek, California
| | - Nicole S Evans
- Department of Gastroenterology, Kaiser Permanente San Francisco Medical Center, San Francisco, California
| | - Lawrence J Leung
- Department of Gastroenterology, Kaiser Permanente San Francisco Medical Center, San Francisco, California
| | - Jessica M Badalov
- Division of Research, Kaiser Permanente Northern California, Oakland, California
| | | | - Douglas A Corley
- Division of Research, Kaiser Permanente Northern California, Oakland, California; Department of Gastroenterology, Kaiser Permanente San Francisco Medical Center, San Francisco, California
| | - Theodore R Levin
- Division of Research, Kaiser Permanente Northern California, Oakland, California; Department of Gastroenterology, Kaiser Permanente Walnut Creek Medical Center, Walnut Creek, California
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Lee JK, Kang JHE, Merchant SA, Jensen CD, Burr NE, Corley DA. Overall and Annual Postcolonoscopy Colorectal Cancer Rates in a Large Integrated Healthcare Setting: A Cross-Sectional Study. Clin Gastroenterol Hepatol 2024; 22:188-190.e5. [PMID: 36965651 DOI: 10.1016/j.cgh.2023.03.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/14/2022] [Revised: 03/07/2023] [Accepted: 03/16/2023] [Indexed: 03/27/2023]
Affiliation(s)
- Jeffrey K Lee
- Kaiser Permanente San Francisco Medical Center, Division of Research, Kaiser Permanente Northern California, Oakland, California
| | - James H-E Kang
- School of Public Health, University of California, Berkeley, Berkeley, California; East of England Deanery, Cambridge, United Kingdom
| | - Sophie A Merchant
- Division of Research, Kaiser Permanente Northern California, Oakland, California
| | - Christopher D Jensen
- Division of Research, Kaiser Permanente Northern California, Oakland, California
| | - Nicholas E Burr
- Cancer Epidemiology Group, Institute of Cancer and Pathology and Institute of Data Analytics, University of Leeds, Leeds, United Kingdom; Mid Yorkshire Hospitals NHS Trust, Pinderfields General Hospital, Wakefield, United Kingdom
| | - Douglas A Corley
- Division of Research, Kaiser Permanente Northern California, Oakland, California
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Corley DA, Jensen CD, Lee JK, Levin TR, Zhao WK, Schottinger JE, Ghai NR, Doubeni CA, Halm EA, Sugg Skinner C, Udaltsova N, Contreras R, Fireman BH, Quesenberry CP. Impact of a scalable training program on the quality of colonoscopy performance and risk of postcolonoscopy colorectal cancer. Gastrointest Endosc 2023; 98:609-617. [PMID: 37094690 PMCID: PMC10523929 DOI: 10.1016/j.gie.2023.04.2073] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2023] [Revised: 04/05/2023] [Accepted: 04/14/2023] [Indexed: 04/26/2023]
Abstract
BACKGROUND AND AIMS Endoscopist adenoma detection rates (ADRs) vary widely and are associated with patients' risk of postcolonoscopy colorectal cancers (PCCRCs). However, few scalable physician-directed interventions demonstrably both improve ADR and reduce PCCRC risk. METHODS Among patients undergoing colonoscopy, we evaluated the influence of a scalable online training on individual-level ADRs and PCCRC risk. The intervention was a 30-minute, interactive, online training, developed using behavior change theory, to address factors that potentially impede detection of adenomas. Analyses included interrupted time series analyses for pretraining versus posttraining individual-physician ADR changes (adjusted for temporal trends) and Cox regression for associations between ADR changes and patients' PCCRC risk. RESULTS Across 21 endoscopy centers and all 86 eligible endoscopists, ADRs increased immediately by an absolute 3.13% (95% confidence interval [CI], 1.31-4.94) in the 3-month quarter after training compared with .58% per quarter (95% CI, .40-.77) and 0.33% per quarter (95% CI, .16-.49) in the 3-year pretraining and posttraining periods, respectively. Posttraining ADR increases were higher among endoscopists with pretraining ADRs below the median. Among 146,786 posttraining colonoscopies (all indications), each 1% absolute increase in screening ADR posttraining was associated with a 4% decrease in their patients' PCCRC risk (hazard ratio, .96; 95% CI, .93-.99). An ADR increase of ≥10% versus <1% was associated with a 55% reduced risk of PCCRC (hazard ratio, .45; 95% CI, .24-.82). CONCLUSIONS A scalable, online behavior change training intervention focused on modifiable factors was associated with significant and sustained improvements in ADR, particularly among endoscopists with lower ADRs. These ADR changes were associated with substantial reductions in their patients' risk of PCCRC.
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Affiliation(s)
- Douglas A Corley
- Division of Research, Kaiser Permanente Northern California, Oakland, California, USA.
| | - Christopher D Jensen
- Division of Research, Kaiser Permanente Northern California, Oakland, California, USA
| | - Jeffrey K Lee
- Division of Research, Kaiser Permanente Northern California, Oakland, California, USA
| | - Theodore R Levin
- Division of Research, Kaiser Permanente Northern California, Oakland, California, USA; Kaiser Permanente Medical Center, Walnut Creek, California, USA
| | - Wei K Zhao
- Division of Research, Kaiser Permanente Northern California, Oakland, California, USA
| | - Joanne E Schottinger
- Kaiser Permanente Bernard J. Tyson School of Medicine, Pasadena, California, USA
| | | | - Chyke A Doubeni
- Department of Family and Community Medicine, The Ohio State University College of Medicine, Columbus, Ohio, USA; The Ohio State University Comprehensive Cancer Center/The James Cancer Hospital, Wexner Medical Center, Columbus, Ohio, USA
| | - Ethan A Halm
- Rutgers Biological Health Sciences, Rutgers University, New Brunswick, New Jersey, USA
| | - Celette Sugg Skinner
- Simmons Comprehensive Cancer Center and Department of Population & Data Sciences, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Natalia Udaltsova
- Division of Research, Kaiser Permanente Northern California, Oakland, California, USA
| | - Richard Contreras
- Department of Research & Evaluation, Kaiser Permanente Southern California, Pasadena, California, USA
| | - Bruce H Fireman
- Division of Research, Kaiser Permanente Northern California, Oakland, California, USA
| | - Charles P Quesenberry
- Division of Research, Kaiser Permanente Northern California, Oakland, California, USA
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Corley DA, Jensen CD, Chubak J, Schottinger JE, Halm EA, Udaltsova N. Evaluating Different Approaches for Calculating Adenoma Detection Rate: Is Screening Colonoscopy the Gold Standard? Gastroenterology 2023; 165:784-787.e4. [PMID: 37263304 PMCID: PMC10529997 DOI: 10.1053/j.gastro.2023.05.025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/18/2022] [Revised: 04/26/2023] [Accepted: 05/08/2023] [Indexed: 06/03/2023]
Affiliation(s)
- Douglas A Corley
- Division of Research, Kaiser Permanente Northern California, Oakland, California.
| | - Christopher D Jensen
- Division of Research, Kaiser Permanente Northern California, Oakland, California
| | - Jessica Chubak
- Kaiser Permanente Washington Health Research Institute, Kaiser Permanente Washington, Seattle, Washington
| | | | - Ethan A Halm
- Rutgers Biological Health Sciences, Rutgers University, New Brunswick, New Jersey
| | - Natalia Udaltsova
- Division of Research, Kaiser Permanente Northern California, Oakland, California
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10
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Leung LJ, Lee JK, Merchant SA, Jensen CD, Alam A, Corley DA. Post-Colonoscopy Colorectal Cancer Etiologies in a Large Integrated US Health Care Setting. Gastroenterology 2023; 164:470-472.e3. [PMID: 36462551 PMCID: PMC9975052 DOI: 10.1053/j.gastro.2022.11.031] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/14/2022] [Revised: 10/31/2022] [Accepted: 11/26/2022] [Indexed: 12/29/2022]
Affiliation(s)
| | - Jeffrey K Lee
- Kaiser Permanente San Francisco, San Francisco, California; Division of Research, Kaiser Permanente Northern California, Oakland, California
| | - Sophie A Merchant
- Division of Research, Kaiser Permanente Northern California, Oakland, California
| | - Christopher D Jensen
- Division of Research, Kaiser Permanente Northern California, Oakland, California
| | - Asim Alam
- Kaiser Permanente San Francisco, San Francisco, California
| | - Douglas A Corley
- Kaiser Permanente San Francisco, San Francisco, California; Division of Research, Kaiser Permanente Northern California, Oakland, California
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11
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Lam AY, Lee JK, Merchant S, Jensen CD, Sedki M, Corley DA. Biopsy of Non-tumor Sites After Biopsy of a Colorectal Cancer is not Associated With Metachronous Cancers: A Case-control Study. Clin Gastroenterol Hepatol 2023; 21:487-496.e3. [PMID: 35644341 PMCID: PMC9699896 DOI: 10.1016/j.cgh.2022.05.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2022] [Revised: 05/11/2022] [Accepted: 05/12/2022] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Recent research has demonstrated biologic plausibility for iatrogenic tumor seeding via colonoscopy as a cause of metachronous colorectal cancers (CRC). This study evaluated the association between biopsy of non-tumor sites after CRC biopsy and risk of metachronous CRC in a large community-based health care organization. METHODS This was a retrospective case-control study of adults with an initial CRC diagnosed by colonoscopy between January 2006 and June 2018 who underwent curative resection. Cases developed a second primary (metachronous) CRC diagnosed 6 months to 4 years after the initial CRC, and were matched by age, sex, diagnosis of inflammatory bowel disease, race, and ethnicity with up to 5 controls without a second CRC diagnosis. The exposure was biopsy in the colonic segment of the metachronous CRC (or corresponding segment in controls) after tumor biopsy, ascertained with blinding to case status. Associations were evaluated using conditional logistic regression and adjusted for potential cofounders. RESULTS Among 14,119 patients diagnosed with an initial CRC during colonoscopy, 107 received a second CRC diagnosis. After exclusions for recurrent or synchronous CRC, 45 cases and 212 controls were included. There was no significant association between biopsy of non-tumor sites after initial CRC biopsy and risk of metachronous CRC in the segment of the additional biopsy site (adjusted odds ratio, 2.29; 95% confidence interval, 0.77-6.81). CONCLUSIONS Metachronous cancers are not significantly associated with biopsy of non-tumor sites after biopsy of the primary cancer. Although the sample size does not allow definite exclusion of any association, these findings do not support iatrogenic tumor seeding as a common risk factor for metachronous CRC.
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Affiliation(s)
- Angela Y Lam
- Department of Gastroenterology, Kaiser Permanente San Francisco, San Francisco, California.
| | - Jeffrey K Lee
- Department of Gastroenterology, Kaiser Permanente San Francisco, San Francisco, California; Division of Research, Kaiser Permanente Northern California, Oakland, California
| | - Sophie Merchant
- Division of Research, Kaiser Permanente Northern California, Oakland, California
| | - Christopher D Jensen
- Division of Research, Kaiser Permanente Northern California, Oakland, California
| | - Mai Sedki
- Division of Research, Kaiser Permanente Northern California, Oakland, California
| | - Douglas A Corley
- Department of Gastroenterology, Kaiser Permanente San Francisco, San Francisco, California; Division of Research, Kaiser Permanente Northern California, Oakland, California
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12
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Lee JK, Lam AY, Jensen CD, Marks AR, Badalov J, Layefsky E, Kao K, Ho NJ, Schottinger JE, Ghai NR, Carlson CM, Halm EA, Green B, Li D, Corley DA, Levin TR. Impact of the COVID-19 Pandemic on Fecal Immunochemical Testing, Colonoscopy Services, and Colorectal Neoplasia Detection in a Large United States Community-based Population. Gastroenterology 2022; 163:723-731.e6. [PMID: 35580655 PMCID: PMC9107101 DOI: 10.1053/j.gastro.2022.05.014] [Citation(s) in RCA: 17] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2022] [Revised: 04/21/2022] [Accepted: 05/11/2022] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS The COVID-19 pandemic has affected clinical services globally, including colorectal cancer (CRC) screening and diagnostic testing. We investigated the pandemic's impact on fecal immunochemical test (FIT) screening, colonoscopy utilization, and colorectal neoplasia detection across 21 medical centers in a large integrated health care organization. METHODS We performed a retrospective cohort study in Kaiser Permanente Northern California patients ages 18 to 89 years in 2019 and 2020 and measured changes in the numbers of mailed, completed, and positive FITs; colonoscopies; and cases of colorectal neoplasia detected by colonoscopy in 2020 vs 2019. RESULTS FIT kit mailings ceased in mid-March through April 2020 but then rebounded and there was an 8.7% increase in kits mailed compared with 2019. With the later mailing of FIT kits, there were 9.0% fewer FITs completed and 10.1% fewer positive tests in 2020 vs 2019. Colonoscopy volumes declined 79.4% in April 2020 compared with April 2019 but recovered to near pre-pandemic volumes in September through December, resulting in a 26.9% decline in total colonoscopies performed in 2020. The number of patients diagnosed by colonoscopy with CRC and advanced adenoma declined by 8.7% and 26.9%, respectively, in 2020 vs 2019. CONCLUSIONS The pandemic led to fewer FIT screenings and colonoscopies in 2020 vs 2019; however, after the lifting of shelter-in-place orders, FIT screenings exceeded, and colonoscopy volumes nearly reached numbers from those same months in 2019. Overall, there was an 8.7% reduction in CRC cases diagnosed by colonoscopy in 2020. These data may help inform the development of strategies for CRC screening and diagnostic testing during future national emergencies.
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Affiliation(s)
- Jeffrey K. Lee
- Department of Gastroenterology, Kaiser Permanente San Francisco Medical Center, San Francisco, California,Division of Research, Kaiser Permanente Northern California, Oakland, California,Correspondence Address correspondence to Jeffrey K. Lee, MD, MPH, Division of Research, Kaiser Permanente Northern California, 2000 Broadway, Oakland, California 94612
| | - Angela Y. Lam
- Department of Gastroenterology, Kaiser Permanente San Francisco Medical Center, San Francisco, California
| | | | - Amy R. Marks
- Division of Research, Kaiser Permanente Northern California, Oakland, California
| | - Jessica Badalov
- Division of Research, Kaiser Permanente Northern California, Oakland, California
| | - Evan Layefsky
- Division of Research, Kaiser Permanente Northern California, Oakland, California
| | - Kevin Kao
- Department of Gastroenterology, Kaiser Permanente Downey Medical Center, Downey, California,Research and Evaluation, Kaiser Permanente Southern California, Pasadena, California
| | - Ngoc J. Ho
- Research and Evaluation, Kaiser Permanente Southern California, Pasadena, California
| | | | - Nirupa R. Ghai
- Department of Quality and Systems of Care, Kaiser Permanente Southern California, Pasadena, California
| | - Cheryl M. Carlson
- Research and Evaluation, Kaiser Permanente Southern California, Pasadena, California
| | - Ethan A. Halm
- Department of Population and Data Sciences and the Harold C. Simmons Comprehensive Cancer Center, University of Texas Southwestern Medical Center, Dallas, Texas,Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Beverly Green
- Kaiser Permanente Washington Health Research Institute, Seattle, Washington
| | - Dan Li
- Division of Research, Kaiser Permanente Northern California, Oakland, California,Department of Gastroenterology, Kaiser Permanente Santa Clara Medical Center, Santa Clara, California
| | - Douglas A. Corley
- Department of Gastroenterology, Kaiser Permanente San Francisco Medical Center, San Francisco, California,Division of Research, Kaiser Permanente Northern California, Oakland, California
| | - Theodore R. Levin
- Division of Research, Kaiser Permanente Northern California, Oakland, California,Department of Gastroenterology, Kaiser Permanente Walnut Creek Medical Center, Walnut Creek, California
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13
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Schottinger JE, Jensen CD, Ghai NR, Chubak J, Lee JK, Kamineni A, Halm EA, Sugg-Skinner C, Udaltsova N, Zhao WK, Ziebell RA, Contreras R, Kim EJ, Fireman BH, Quesenberry CP, Corley DA. Association of Physician Adenoma Detection Rates With Postcolonoscopy Colorectal Cancer. JAMA 2022; 327:2114-2122. [PMID: 35670788 PMCID: PMC9175074 DOI: 10.1001/jama.2022.6644] [Citation(s) in RCA: 44] [Impact Index Per Article: 22.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2021] [Accepted: 04/06/2022] [Indexed: 12/14/2022]
Abstract
Importance Although colonoscopy is frequently performed in the United States, there is limited evidence to support threshold values for physician adenoma detection rate as a quality metric. Objective To evaluate the association between physician adenoma detection rate values and risks of postcolonoscopy colorectal cancer and related deaths. Design, Setting, and Participants Retrospective cohort study in 3 large integrated health care systems (Kaiser Permanente Northern California, Kaiser Permanente Southern California, and Kaiser Permanente Washington) with 43 endoscopy centers, 383 eligible physicians, and 735 396 patients aged 50 to 75 years who received a colonoscopy that did not detect cancer (negative colonoscopy) between January 2011 and June 2017, with patient follow-up through December 2017. Exposures The adenoma detection rate of each patient's physician based on screening examinations in the calendar year prior to the patient's negative colonoscopy. Adenoma detection rate was defined as a continuous variable in statistical analyses and was also dichotomized as at or above vs below the median for descriptive analyses. Main Outcomes and Measures The primary outcome (postcolonoscopy colorectal cancer) was tumor registry-verified colorectal adenocarcinoma diagnosed at least 6 months after any negative colonoscopy (all indications). The secondary outcomes included death from postcolonoscopy colorectal cancer. Results Among 735 396 patients who had 852 624 negative colonoscopies, 440 352 (51.6%) were performed on female patients, median patient age was 61.4 years (IQR, 55.5-67.2 years), median follow-up per patient was 3.25 years (IQR, 1.56-5.01 years), and there were 619 postcolonoscopy colorectal cancers and 36 related deaths during more than 2.4 million person-years of follow-up. The patients of physicians with higher adenoma detection rates had significantly lower risks for postcolonoscopy colorectal cancer (hazard ratio [HR], 0.97 per 1% absolute adenoma detection rate increase [95% CI, 0.96-0.98]) and death from postcolonoscopy colorectal cancer (HR, 0.95 per 1% absolute adenoma detection rate increase [95% CI, 0.92-0.99]) across a broad range of adenoma detection rate values, with no interaction by sex (P value for interaction = .18). Compared with adenoma detection rates below the median of 28.3%, detection rates at or above the median were significantly associated with a lower risk of postcolonoscopy colorectal cancer (1.79 vs 3.10 cases per 10 000 person-years; absolute difference in 7-year risk, -12.2 per 10 000 negative colonoscopies [95% CI, -10.3 to -13.4]; HR, 0.61 [95% CI, 0.52-0.73]) and related deaths (0.05 vs 0.22 cases per 10 000 person-years; absolute difference in 7-year risk, -1.2 per 10 000 negative colonoscopies [95%, CI, -0.80 to -1.69]; HR, 0.26 [95% CI, 0.11-0.65]). Conclusions and Relevance Within 3 large community-based settings, colonoscopies by physicians with higher adenoma detection rates were significantly associated with lower risks of postcolonoscopy colorectal cancer across a broad range of adenoma detection rate values. These findings may help inform recommended targets for colonoscopy quality measures.
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Affiliation(s)
| | | | - Nirupa R. Ghai
- Department of Quality and Systems of Care, Kaiser Permanente Southern California, Pasadena
| | - Jessica Chubak
- Kaiser Permanente Washington Health Research Institute, Kaiser Permanente Washington, Seattle
| | - Jeffrey K. Lee
- Division of Research, Kaiser Permanente Northern California, Oakland
| | - Aruna Kamineni
- Kaiser Permanente Washington Health Research Institute, Kaiser Permanente Washington, Seattle
| | - Ethan A. Halm
- Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas
- Simmons Comprehensive Cancer Center and Department of Population & Data Sciences, University of Texas Southwestern Medical Center, Dallas
| | - Celette Sugg-Skinner
- Simmons Comprehensive Cancer Center and Department of Population & Data Sciences, University of Texas Southwestern Medical Center, Dallas
| | - Natalia Udaltsova
- Division of Research, Kaiser Permanente Northern California, Oakland
| | - Wei K. Zhao
- Division of Research, Kaiser Permanente Northern California, Oakland
| | - Rebecca A. Ziebell
- Kaiser Permanente Washington Health Research Institute, Kaiser Permanente Washington, Seattle
| | - Richard Contreras
- Research and Evaluation, Kaiser Permanente Southern California, Pasadena
| | - Eric J. Kim
- Simmons Comprehensive Cancer Center and Department of Population & Data Sciences, University of Texas Southwestern Medical Center, Dallas
| | - Bruce H. Fireman
- Division of Research, Kaiser Permanente Northern California, Oakland
| | | | - Douglas A. Corley
- Division of Research, Kaiser Permanente Northern California, Oakland
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14
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Alam A, Ma C, Jiang SF, Jensen CD, Webb KH, Boparai ES, Jue TL, Munroe CA, Gupta S, Fox J, Hamerski CM, Velayos FS, Corley DA, Lee JK. Declining Colectomy Rates for Nonmalignant Colorectal Polyps in a Large, Ethnically Diverse, Community-Based Population. Clin Transl Gastroenterol 2022; 13:e00477. [PMID: 35347095 PMCID: PMC9132519 DOI: 10.14309/ctg.0000000000000477] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/29/2021] [Accepted: 02/09/2022] [Indexed: 11/17/2022] Open
Abstract
INTRODUCTION Despite studies showing improved safety, efficacy, and cost-effectiveness of endoscopic resection for nonmalignant colorectal polyps, colectomy rates for nonmalignant colorectal polyps have been increasing in the United States and Europe. Given this alarming trend, we aimed to investigate whether colectomy rates for nonmalignant colorectal polyps are increasing or declining in a large, integrated, community-based healthcare system with access to advanced endoscopic resection procedures. METHODS We identified all individuals aged 50-85 years who underwent a colonoscopy between 2008 and 2018 and were diagnosed with a nonmalignant colorectal polyp(s) at the Kaiser Permanente Northern California integrated healthcare system. Among these individuals, we identified those who underwent a colectomy for nonmalignant colorectal polyps within 12 months after the colonoscopy. We calculated annual colectomy rates for nonmalignant colorectal polyps and stratified rates by age, sex, and race and ethnicity. Changes in rates over time were tested by the Cochran-Armitage test for a linear trend. RESULTS Among 229,730 patients who were diagnosed with nonmalignant colorectal polyps between 2008 and 2018, 1,611 patients underwent a colectomy. Colectomy rates for nonmalignant colorectal polyps decreased significantly from 125 per 10,000 patients with nonmalignant polyps in 2008 to 12 per 10,000 patients with nonmalignant polyps in 2018 (P < 0.001 for trend). When stratified by age, sex, and race and ethnicity, colectomy rates for nonmalignant colorectal polyps also significantly declined from 2008 to 2018. DISCUSSION In a large, ethnically diverse, community-based population in the United States, we found that colectomy rates for nonmalignant colorectal polyps declined significantly over the past decade likely because of the establishment of advanced endoscopy centers, improved care coordination, and an organized colorectal cancer screening program.
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Affiliation(s)
- Asim Alam
- Internal Medicine/Preventive Medicine Residency Program, Kaiser Permanente San Francisco Medical Center, San Francisco, California, USA;
| | - Christopher Ma
- Division of Gastroenterology & Hepatology, Department of Medicine, University of Calgary, Calgary, Alberta, Canada, Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Sheng-Fang Jiang
- Division of Research, Kaiser Permanente Northern California, Oakland, California, USA;
| | - Christopher D. Jensen
- Division of Research, Kaiser Permanente Northern California, Oakland, California, USA;
| | - Kenneth H. Webb
- University of California, Berkeley, School of Public Health and Haas School of Business, Berkeley, California, USA;
| | - Eshandeep S. Boparai
- Department of Gastroenterology, Kaiser Permanente San Francisco Medical Center, San Francisco, California, USA;
| | - Terry L. Jue
- Division of Gastroenterology and Hepatology, Mayo Clinic, Scottsdale, Arizona, USA;
| | - Craig A. Munroe
- Division of Gastroenterology, University of California San Francisco, San Francisco, California, USA;
| | - Suraj Gupta
- Department of Gastroenterology, Kaiser Permanente San Francisco Medical Center, San Francisco, California, USA;
| | - Jeffrey Fox
- Department of Gastroenterology, Kaiser Permanente San Rafael Medical Center, San Rafael, California, USA.
| | - Christopher M. Hamerski
- Department of Gastroenterology, Kaiser Permanente San Francisco Medical Center, San Francisco, California, USA;
| | - Fernando S. Velayos
- Department of Gastroenterology, Kaiser Permanente San Francisco Medical Center, San Francisco, California, USA;
| | - Douglas A. Corley
- Division of Research, Kaiser Permanente Northern California, Oakland, California, USA;
- Department of Gastroenterology, Kaiser Permanente San Francisco Medical Center, San Francisco, California, USA;
| | - Jeffrey K. Lee
- Division of Research, Kaiser Permanente Northern California, Oakland, California, USA;
- Department of Gastroenterology, Kaiser Permanente San Francisco Medical Center, San Francisco, California, USA;
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15
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Affiliation(s)
| | | | - Wei Zhao
- Kaiser Permanente Medical Center, Walnut Creek, CA
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16
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Lee JK, Merchant SA, Jensen CD, Murphy CC, Udaltsova N, Corley DA. Rising Early-onset Colorectal Cancer Incidence Is Not an Artifact of Increased Screening Colonoscopy Use in a Large, Diverse Healthcare System. Gastroenterology 2022; 162:325-327.e3. [PMID: 34555382 PMCID: PMC8678196 DOI: 10.1053/j.gastro.2021.09.034] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2021] [Revised: 09/15/2021] [Accepted: 09/17/2021] [Indexed: 01/03/2023]
Affiliation(s)
- Jeffrey K. Lee
- Division of Research, Kaiser Permanente Northern California, Oakland, CA
| | - Sophie A. Merchant
- Division of Research, Kaiser Permanente Northern California, Oakland, CA
| | | | - Caitlin C. Murphy
- School of Public Health, University of Texas Health Science Center at Houston, Houston, TX
| | - Natalia Udaltsova
- Division of Research, Kaiser Permanente Northern California, Oakland, CA
| | - Douglas A. Corley
- Division of Research, Kaiser Permanente Northern California, Oakland, CA
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17
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Levin TR, Jensen CD, Chawla NM, Sakoda LC, Lee JK, Zhao WK, Landau MA, Herm A, Eby E, Quesenberry CP, Corley DA. Early Screening of African Americans (45-50 Years Old) in a Fecal Immunochemical Test-Based Colorectal Cancer Screening Program. Gastroenterology 2020; 159:1695-1704.e1. [PMID: 32702368 PMCID: PMC9007323 DOI: 10.1053/j.gastro.2020.07.011] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2019] [Revised: 07/06/2020] [Accepted: 07/12/2020] [Indexed: 12/15/2022]
Abstract
BACKGROUND & AIMS Some guidelines recommend starting colorectal cancer (CRC) screening before age 50 years for African Americans, but there are few data on screening uptake and yield in this population. METHODS We performed a prospective study of fecal immunochemical test (FIT) screening among African American members of the Kaiser Permanente Northern California health plan. We compared data from African American members screened when they were 45-50 years old (early screening group) in 2018 with data from previously unscreened African American, white, Hispanic, and Asian/Pacific Islander health plan members who were 51-56 years old. Screening outreach was performed with mailed FIT kits. Logistic regression models, adjusted for sex, were used to evaluate differences among groups in screening uptake, colonoscopy follow-up of abnormal test results, and test yield. RESULTS Among 10,232 African Americans in the early screening group who were mailed a FIT, screening was completed by 33.1%. Among the 4% with positive test results, 85.3% completed a follow-up colonoscopy: 57.8% had any adenoma, 33.6% had an advanced adenoma (adenoma with advanced histology or polyp ≥10 mm), and 2.6% were diagnosed with CRC. African Americans in the early screening group were modestly more likely to have completed screening than previously unscreened African Americans, whites, and Hispanics 51-56 years old. The groups did not differ significantly in positive results from the FIT (range, 3.8%-4.6%) and more than 74% received a follow-up colonoscopy after a positive test result. The test yields for any adenoma (range, 56.7%-70.7%), advanced adenoma (range, 20.0%-33.6%), and CRC (range, 0%-7.1%) were similar. CONCLUSIONS Proportions of African Americans who participated in early (aged 45-50 years) FIT screening and test yield were comparable to those of previously unscreened African Americans, whites, Hispanics, and Asian/Pacific Islanders who were 51-56 years old.
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Affiliation(s)
- Theodore R. Levin
- Kaiser Permanente Medical Center, Walnut Creek, CA.,Division of Research, Kaiser Permanente Northern California, Oakland, CA.,Co-first authors
| | - Christopher D. Jensen
- Division of Research, Kaiser Permanente Northern California, Oakland, CA.,Co-first authors
| | - Neetu M. Chawla
- Division of Research, Kaiser Permanente Northern California, Oakland, CA.,Veterans Administration, Los Angeles, CA
| | - Lori C. Sakoda
- Division of Research, Kaiser Permanente Northern California, Oakland, CA
| | - Jeffrey K. Lee
- Division of Research, Kaiser Permanente Northern California, Oakland, CA
| | - Wei K. Zhao
- Division of Research, Kaiser Permanente Northern California, Oakland, CA
| | - Molly A. Landau
- The Permanente Medical Group Consulting Services, Kaiser Permanente Northern California, CA
| | - Ariel Herm
- Regional Health Education, Kaiser Permanente Northern California, CA
| | - Eryn Eby
- The Permanente Medical Group Consulting Services, Kaiser Permanente Northern California, CA
| | | | - Douglas A. Corley
- Division of Research, Kaiser Permanente Northern California, Oakland, CA
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18
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Ghai NR, Jensen CD, Merchant SA, Schottinger JE, Lee JK, Chubak J, Kamineni A, Halm EA, Skinner CS, Haas JS, Green BB, Cannizzaro NT, Schneider JL, Corley DA. Primary Care Provider Beliefs and Recommendations About Colorectal Cancer Screening in Four Healthcare Systems. Cancer Prev Res (Phila) 2020; 13:947-958. [PMID: 32669318 DOI: 10.1158/1940-6207.capr-20-0109] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2020] [Revised: 06/01/2020] [Accepted: 07/08/2020] [Indexed: 12/31/2022]
Abstract
Primary care provider's (PCP) perceptions of colorectal cancer screening test effectiveness and their recommendations for testing intervals influence patient screening uptake. Few large studies have examined providers' perceptions and recommendations, including their alignment with evidence suggesting comparable test effectiveness and guideline recommendations for screening frequency. Providers (n = 1,281) within four healthcare systems completed a survey in 2017-2018 regarding their perceptions of test effectiveness and recommended intervals for colonoscopy and fecal immunochemical testing (FIT) for patients ages 40-49, 50-74, and ≥75 years. For patients 50-74 (screening eligible), 82.9% of providers rated colonoscopy as very effective versus 59.6% for FIT, and 26.3% rated colonoscopy as more effective than FIT. Also, for this age group, 77.9% recommended colonoscopy every 10 years and 92.4% recommended FIT annually. For patients ages 40-49 and ≥75, more than one-third of providers believed the tests were somewhat or very effective, although >80% did not routinely recommend screening by either test for these age groups. Provider screening test interval recommendations generally aligned with colorectal cancer guidelines; however, 25% of providers believed colonoscopy was more effective than FIT for mortality reduction, which differs from some modeling studies that suggest comparable effectiveness. The latter finding may have implications for health systems where FIT is the dominant screening strategy. Only one-third of providers reported believing these screening tests were effective in younger and older patients (i.e., <50 and ≥75 years). Evidence addressing these beliefs may be relevant if cancer screening recommendations are modified to include older and/or younger patients.
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Affiliation(s)
- Nirupa R Ghai
- Department of Patient Care Services, Kaiser Permanente Southern California, Pasadena, CA.
| | | | - Sophie A Merchant
- Division of Research, Kaiser Permanente Northern California, Oakland, CA
| | - Joanne E Schottinger
- Department of Quality and Clinical Analysis, Kaiser Permanente Southern California, Pasadena, CA
| | - Jeffrey K Lee
- Division of Research, Kaiser Permanente Northern California, Oakland, CA
| | - Jessica Chubak
- Kaiser Permanente Washington Health Research Institute, Kaiser Permanente Washington, Seattle, WA
| | - Aruna Kamineni
- Kaiser Permanente Washington Health Research Institute, Kaiser Permanente Washington, Seattle, WA
| | - Ethan A Halm
- Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, TX.,Simmons Comprehensive Cancer Center and Department of Population & Data Sciences, University of Texas Southwestern Medical Center, Dallas, TX
| | - Celette Sugg Skinner
- Simmons Comprehensive Cancer Center and Department of Population & Data Sciences, University of Texas Southwestern Medical Center, Dallas, TX
| | - Jennifer S Haas
- Division of General Internal Medicine, Massachusetts General Hospital, Harvard Medical School, Dana Farber Harvard Cancer Institute, Harvard School of Public Health, Boston, MA
| | - Beverly B Green
- Kaiser Permanente Washington Health Research Institute, Kaiser Permanente Washington, Seattle, WA
| | - Nancy T Cannizzaro
- Department Research & Evaluation, Kaiser Permanente Southern California, Pasadena, CA
| | | | - Douglas A Corley
- Division of Research, Kaiser Permanente Northern California, Oakland, CA
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Doubeni CA, Corley DA, Jensen CD, Schottinger JE, Lee JK, Ghai NR, Levin TR, Zhao WK, Saia CA, Wainwright JV, Mehta SJ, Selby K, Doria-Rose VP, Zauber AG, Fletcher RH, Weiss NS. The effect of using fecal testing after a negative sigmoidoscopy on the risk of death from colorectal cancer. J Med Screen 2020; 28:140-147. [PMID: 32438892 PMCID: PMC7679284 DOI: 10.1177/0969141320921427] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
OBJECTIVE To examine whether receiving a fecal occult blood test after a negative sigmoidoscopy reduced mortality from colorectal cancer. METHODS We used a nested case-control design with incidence-density matching in historical cohorts of 1,877,740 50-90-year-old persons during 2006-2012, in an integrated health-system setting. We selected 1758 average risk patients who died from colorectal cancer and 3503 matched colorectal cancer-free persons. Colorectal cancer-specific death was ascertained from cancer and mortality registries. Screening histories were determined from electronic and chart-audit clinical data in the 5- to 10-year period prior to the reference date. We evaluated receipt of subsequent fecal occult blood test within five years of the reference date among patients with negative sigmoidoscopy two to six years before the reference date. RESULTS Of the 5261 patients, 831 patients (204 colorectal cancer deaths/627 controls) had either negative sigmoidoscopy only (n = 592) or negative sigmoidoscopy with subsequent screening fecal occult blood test (n = 239). Fifty-six (27.5%) of the 204 patients dying of colorectal cancer and 183 (29.2%) of the 627 colorectal cancer-free patients received fecal occult blood test following a negative sigmoidoscopy. Conditional regressions found no significant association between fecal occult blood test receipt and colorectal cancer death risk, overall (adjusted odds ratio = 0.93, confidence interval: 0.65-1.33), or for right (odds ratio = 1.02, confidence interval: 0.65-1.60) or left-colon/rectum (odds ratio = 0.77, confidence interval: 0.39-1.52) cancers. Similar results were obtained in sensitivity analyses with alternative exposure ascertainment windows or timing of fecal occult blood test. CONCLUSIONS Our results suggest that receipt of at least one fecal occult blood test during the several years after a negative sigmoidoscopy did not substantially reduce mortality from colorectal cancer.
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Affiliation(s)
- Chyke A Doubeni
- Center for Health Equity and Community Engagement Research, Mayo Clinic, Rochester, MN, USA.,Department of Family Medicine, Mayo Clinic, Rochester, MN, USA
| | - Douglas A Corley
- Division of Research, Kaiser Permanente Northern California, Oakland, CA, USA
| | | | | | - Jeffery K Lee
- Division of Research, Kaiser Permanente Northern California, Oakland, CA, USA
| | - Nirupa R Ghai
- Kaiser Permanente Southern California, Pasadena, CA, USA
| | - Theodore R Levin
- Division of Research, Kaiser Permanente Northern California, Oakland, CA, USA
| | - Wei K Zhao
- Division of Research, Kaiser Permanente Northern California, Oakland, CA, USA
| | - Chelsea A Saia
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | | | - Shivan J Mehta
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Kevin Selby
- Center for Primary Care and Public Health (Unisanté), Lausanne, Switzerland
| | - V Paul Doria-Rose
- Healthcare Assessment Research Branch in the Healthcare Delivery Research Program, Division of Cancer Control and Population Sciences, National Cancer Institute, Bethesda, MD, USA
| | - Ann G Zauber
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Robert H Fletcher
- Department of Population Medicine, Harvard Medical School, Boston, MA, USA
| | - Noel S Weiss
- Department of Epidemiology, University of Washington, Seattle, WA, USA
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20
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Lee JK, Jensen CD, Levin TR, Doubeni CA, Zauber AG, Chubak J, Kamineni AS, Schottinger JE, Ghai NR, Udaltsova N, Zhao WK, Fireman BH, Quesenberry CP, Orav EJ, Skinner CS, Halm EA, Corley DA. Long-term Risk of Colorectal Cancer and Related Death After Adenoma Removal in a Large, Community-based Population. Gastroenterology 2020; 158:884-894.e5. [PMID: 31589872 PMCID: PMC7083250 DOI: 10.1053/j.gastro.2019.09.039] [Citation(s) in RCA: 74] [Impact Index Per Article: 18.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/22/2019] [Revised: 07/12/2019] [Accepted: 09/24/2019] [Indexed: 12/14/2022]
Abstract
BACKGROUND & AIMS The long-term risks of colorectal cancer (CRC) and CRC-related death following adenoma removal are uncertain. Data are needed to inform evidence-based surveillance guidelines, which vary in follow-up recommendations for some polyp types. Using data from a large, community-based integrated health care setting, we examined the risks of CRC and related death by baseline colonoscopy adenoma findings. METHODS Participants at 21 medical centers underwent baseline colonoscopies from 2004 through 2010; findings were categorized as no-adenoma, low-risk adenoma, or high-risk adenoma. Participants were followed until the earliest of CRC diagnosis, death, health plan disenrollment, or December 31, 2017. Risks of CRC and related deaths among the high- and low-risk adenoma groups were compared with the no-adenoma group using Cox regression adjusting for confounders. RESULTS Among 186,046 patients, 64,422 met eligibility criteria (54.3% female; mean age, 61.6 ± 7.1 years; median follow-up time, 8.1 years from the baseline colonoscopy). Compared with the no-adenoma group (45,881 patients), the high-risk adenoma group (7563 patients) had a higher risk of CRC (hazard ratio [HR] 2.61; 95% confidence interval [CI] 1.87-3.63) and related death (HR 3.94; 95% CI 1.90-6.56), whereas the low-risk adenoma group (10,978 patients) did not have a significant increase in risk of CRC (HR 1.29; 95% CI 0.89-1.88) or related death (HR 0.65; 95% CI 0.19-2.18). CONCLUSIONS With up to 14 years of follow-up, high-risk adenomas were associated with an increased risk of CRC and related death, supporting early colonoscopy surveillance. Low-risk adenomas were not associated with a significantly increased risk of CRC or related deaths. These results can inform current surveillance guidelines for high- and low-risk adenomas.
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Affiliation(s)
- Jeffrey K. Lee
- Department of Gastroenterology, Kaiser Permanente San Francisco, San Francisco, CA,Division of Research, Kaiser Permanente Northern California, Oakland, CA
| | | | - Theodore R. Levin
- Division of Research, Kaiser Permanente Northern California, Oakland, CA.,Department of Gastroenterology, Kaiser Permanente Walnut Creek, Walnut Creek, CA
| | - Chyke A. Doubeni
- Department of Family Medicine, and the Center for Health Equity and Community Engagement Research, Mayo Clinic, Rochester, MN
| | - Ann G. Zauber
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Jessica Chubak
- Kaiser Permanente Washington Health Research Institute, Seattle, Washington,Department of Epidemiology, School of Public Health, University of Washington, Seattle, Washington
| | - Aruna S. Kamineni
- Kaiser Permanente Washington Health Research Institute, Seattle, Washington
| | - Joanne E. Schottinger
- Department of Quality and Clinical Analysis, Kaiser Permanente Southern California, Pasadena, CA
| | - Nirupa R. Ghai
- Department of Regional Clinical Effectiveness, Kaiser Permanente Southern California, Pasadena, CA
| | - Natalia Udaltsova
- Division of Research, Kaiser Permanente Northern California, Oakland, CA
| | - Wei K. Zhao
- Division of Research, Kaiser Permanente Northern California, Oakland, CA
| | - Bruce H. Fireman
- Division of Research, Kaiser Permanente Northern California, Oakland, CA
| | | | - E. John Orav
- Department of Biostatistics, Harvard University T.H. Chan School of Public Health, Boston, MA
| | - Celette Sugg Skinner
- Department of Population and Data Sciences and the Harold C. Simmons Comprehensive Cancer Center, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Ethan A. Halm
- Department of Population and Data Sciences and the Harold C. Simmons Comprehensive Cancer Center, University of Texas Southwestern Medical Center, Dallas, Texas.,Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Douglas A. Corley
- Department of Gastroenterology, Kaiser Permanente San Francisco, San Francisco, CA,Division of Research, Kaiser Permanente Northern California, Oakland, CA
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21
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Selby K, Jensen CD, Zhao WK, Lee JK, Slam A, Schottinger JE, Bacchetti P, Levin TR, Corley DA. Strategies to Improve Follow-up After Positive Fecal Immunochemical Tests in a Community-Based Setting: A Mixed-Methods Study. Clin Transl Gastroenterol 2019; 10:e00010. [PMID: 30829917 PMCID: PMC6407828 DOI: 10.14309/ctg.0000000000000010] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/15/2018] [Accepted: 01/07/2019] [Indexed: 01/07/2023] Open
Abstract
OBJECTIVES The effectiveness of fecal immunochemical test (FIT) screening for colorectal cancer depends on timely colonoscopy follow-up of positive tests, although limited data exist regarding effective system-level strategies for improving follow-up rates. METHODS Using a mixed-methods design (qualitative and quantitative), we first identified system-level strategies that were implemented for improving timely follow-up after a positive FIT test in a large community-based setting between 2006 and 2016. We then evaluated changes in time to colonoscopy among FIT-positive patients across 3 periods during the study interval, controlling for screening participant age, sex, race/ethnicity, comorbidity, FIT date, and previous screening history. RESULTS Implemented strategies over the study period included setting a goal of colonoscopy follow-up within 30 days of a positive FIT, tracking FIT-positive patients, early telephone contact to directly schedule follow-up colonoscopies, assigning the responsibility for follow-up tracking and scheduling to gastroenterology departments (vs primary care), and increasing colonoscopy capacity. Among 160,051 patients who had a positive FIT between 2006 and 2016, 126,420 (79%) had a follow-up colonoscopy within 180 days, including 67% in 2006-2008, 79% in 2009-2012, and 83% in 2013-2016 (P < 0.001). Follow-up within 180 days in 2016 varied moderately across service areas, between 72% (95% CI 70-75) and 88% (95% CI 86-91), but there were no obvious differences in the pattern of strategies implemented in higher- vs lower-performing service areas. CONCLUSIONS The implementation of system-level strategies coincided with substantial improvements in timely colonoscopy follow-up after a positive FIT. Intervention studies are needed to identify the most effective strategies for promoting timely follow-up.
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Affiliation(s)
- Kevin Selby
- Kaiser Permanente Division of Research, Oakland, California, USA
- Department of Ambulatory Care and Community Medicine, University of Lausanne, Lausanne, Switzerland
| | | | - Wei K. Zhao
- Kaiser Permanente Division of Research, Oakland, California, USA
| | - Jeffrey K. Lee
- Kaiser Permanente Division of Research, Oakland, California, USA
| | | | - Joanne E. Schottinger
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, California, USA
| | - Peter Bacchetti
- Department of Epidemiology and Biostatistics, University of California, San Francisco, San Francisco, California, USA
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22
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Lee JK, Jensen CD, Levin TR, Zauber AG, Schottinger JE, Quinn VP, Udaltsova N, Zhao WK, Fireman BH, Quesenberry CP, Doubeni CA, Corley DA. Long-term Risk of Colorectal Cancer and Related Deaths After a Colonoscopy With Normal Findings. JAMA Intern Med 2019; 179:153-160. [PMID: 30556824 PMCID: PMC6439662 DOI: 10.1001/jamainternmed.2018.5565] [Citation(s) in RCA: 42] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2018] [Accepted: 08/22/2018] [Indexed: 12/23/2022]
Abstract
Importance Guidelines recommend a 10-year rescreening interval after a colonoscopy with normal findings (negative colonoscopy results), but evidence supporting this recommendation is limited. Objective To examine the long-term risks of colorectal cancer and colorectal cancer deaths after a negative colonoscopy result, in comparison with individuals unscreened, in a large, community-based setting. Design, Setting, and Participants A retrospective cohort study was conducted in an integrated health care delivery organization serving more than 4 million members across Northern California. A total of 1 251 318 average-risk screening-eligible patients (age 50-75 years) between January 1, 1998, and December 31, 2015, were included. The study was concluded on December 31, 2016. Exposures Screening was examined as a time-varying exposure; all participants contributed person-time unscreened until they were either screened or censored. If the screening received was a negative colonoscopy result, the participants contributed person-time in the negative colonoscopy results group until they were censored. Main Outcomes and Measures Using Cox proportional hazards regression models, the hazard ratios (HRs) for colorectal cancer and related deaths were calculated according to time since negative colonoscopy result (or since cohort entry for those unscreened). Hazard ratios were adjusted for age, sex, race/ethnicity, Charlson comorbidity score, and body mass index. Results Of the 1 251 318 patients, 613 692 were men (49.0%); mean age was 55.6 (7.0) years. Compared with the unscreened participants, those with a negative colonoscopy result had a reduced risk of colorectal cancer and related deaths throughout the more than 12-year follow-up period, and although reductions in risk were attenuated with increasing years of follow-up, there was a 46% lower risk of colorectal cancer (hazard ratio, 0.54; 95% CI, 0.31-0.94) and 88% lower risk of related deaths (hazard ratio, 0.12; 95% CI, 0.02-0.82) at the current guideline-recommended 10-year rescreening interval. Conclusions and Relevance A negative colonoscopy result in average-risk patients was associated with a lower risk of colorectal cancer and related deaths for more than 12 years after examination, compared with unscreened patients. Our study findings may be able to inform guidelines for rescreening after a negative colonoscopy result and future studies to evaluate the costs and benefits of earlier vs later rescreening intervals.
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Affiliation(s)
- Jeffrey K. Lee
- Department of Gastroenterology, Kaiser Permanente San Francisco, San Francisco, California
- Division of Research, Kaiser Permanente Northern California, Oakland, California
| | | | - Theodore R. Levin
- Division of Research, Kaiser Permanente Northern California, Oakland, California
| | - Ann G. Zauber
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Joanne E. Schottinger
- Department of Research & Evaluation, Kaiser Permanente Southern California, Pasadena, California
| | - Virginia P. Quinn
- Department of Research & Evaluation, Kaiser Permanente Southern California, Pasadena, California
| | - Natalia Udaltsova
- Division of Research, Kaiser Permanente Northern California, Oakland, California
| | - Wei K. Zhao
- Division of Research, Kaiser Permanente Northern California, Oakland, California
| | - Bruce H. Fireman
- Division of Research, Kaiser Permanente Northern California, Oakland, California
| | | | - Chyke A. Doubeni
- Department of Family Medicine and Community Health, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Douglas A. Corley
- Department of Gastroenterology, Kaiser Permanente San Francisco, San Francisco, California
- Division of Research, Kaiser Permanente Northern California, Oakland, California
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23
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Doubeni CA, Fedewa SA, Levin TR, Jensen CD, Saia C, Zebrowski AM, Quinn VP, Rendle KA, Zauber AG, Becerra-Culqui TA, Mehta SJ, Fletcher RH, Schottinger J, Corley DA. Modifiable Failures in the Colorectal Cancer Screening Process and Their Association With Risk of Death. Gastroenterology 2019; 156:63-74.e6. [PMID: 30268788 PMCID: PMC6309478 DOI: 10.1053/j.gastro.2018.09.040] [Citation(s) in RCA: 58] [Impact Index Per Article: 11.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/14/2018] [Revised: 09/14/2018] [Accepted: 09/18/2018] [Indexed: 12/12/2022]
Abstract
BACKGROUND & AIMS Colorectal cancer (CRC) deaths occur when patients do not receive screening or have inadequate follow-up of abnormal results or when the screening test fails. We have few data on the contribution of each to CRC-associated deaths or factors associated with these events. METHODS We performed a retrospective cohort study of patients in the Kaiser Permanente Northern and Southern California systems (55-90 years old) who died of CRC from 2006 through 2012 and had ≥5 years of enrollment before diagnosis. We compared data from patients with those from a matched cohort of cancer-free patients in the same system. Receipt, results, indications, and follow-up of CRC tests in the 10-year period before diagnosis were obtained from electronic databases and chart audits. RESULTS Of 1750 CRC deaths, 75.9% (n = 1328) occurred in patients who were not up to date in screening and 24.1% (n = 422) occurred in patients who were up to date. Failure to screen was associated with fewer visits to primary care physicians. Of 3486 cancer-free patients, 44.6% were up to date in their screening. Patients who were up to date in their screening had a lower risk of CRC death (odds ratio, 0.38; 95% confidence interval, 0.33-0.44). Failure to screen, or failure to screen at appropriate intervals, occurred in a 67.8% of patients who died of CRC vs 53.2% of cancer-free patients; failure to follow-up on abnormal results occurred in 8.1% of patients who died of CRC vs 2.2% of cancer-free patients. CRC death was associated with higher odds of failure to screen or failure to screen at appropriate intervals (odds ratio, 2.40; 95% confidence interval, 2.07-2.77) and failure to follow-up on abnormal results (odds ratio, 7.26; 95% confidence interval, 5.26-10.03). CONCLUSIONS Being up to date on screening substantially decreases the risk of CRC death. In 2 health care systems with high rates of screening, most people who died of CRC had failures in the screening process that could be rectified, such as failure to follow-up on abnormal findings; these significantly increased the risk for CRC death.
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Affiliation(s)
- Chyke A. Doubeni
- Department of Family Medicine and Community Health, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA,Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Stacey A. Fedewa
- Surveillance and Health Services Research, American Cancer Society, Atlanta, GA
| | - Theodore R. Levin
- Division of Research, Kaiser Permanente Northern California, Oakland, CA
| | | | - Chelsea Saia
- Department of Family Medicine and Community Health, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Alexis M. Zebrowski
- Department of Family Medicine and Community Health, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA,Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Virginia P. Quinn
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, CA
| | - Katharine A. Rendle
- Department of Family Medicine and Community Health, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Ann G. Zauber
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY
| | | | - Shivan J. Mehta
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | | | - Joanne Schottinger
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, CA
| | - Douglas A. Corley
- Division of Research, Kaiser Permanente Northern California, Oakland, CA
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24
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Levin TR, Corley DA, Jensen CD, Schottinger JE, Quinn VP, Zauber AG, Lee JK, Zhao WK, Udaltsova N, Ghai NR, Lee AT, Quesenberry CP, Fireman BH, Doubeni CA. Effects of Organized Colorectal Cancer Screening on Cancer Incidence and Mortality in a Large Community-Based Population. Gastroenterology 2018; 155:1383-1391.e5. [PMID: 30031768 PMCID: PMC6240353 DOI: 10.1053/j.gastro.2018.07.017] [Citation(s) in RCA: 299] [Impact Index Per Article: 49.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2018] [Revised: 07/02/2018] [Accepted: 07/16/2018] [Indexed: 12/15/2022]
Abstract
BACKGROUND & AIMS Little information is available on the effectiveness of organized colorectal cancer (CRC) screening on screening uptake, incidence, and mortality in community-based populations. METHODS We contrasted screening rates, age-adjusted annual CRC incidence, and incidence-based mortality rates before (baseline year 2000) and after (through 2015) implementation of organized screening outreach, from 2007 through 2008 (primarily annual fecal immunochemical testing and colonoscopy), in a large community-based population. Among screening-eligible individuals 51-75 years old, we calculated annual up-to-date status for cancer screening (by fecal test, sigmoidoscopy, or colonoscopy), CRC incidence, cancer stage distributions, and incidence-based mortality. RESULTS Initiation of organized CRC screening significantly increased the up-to-date status of screening, from 38.9% in 2000 to 82.7% in 2015 (P < .01). Higher rates of screening were associated with a 25.5% reduction in annual CRC incidence between 2000 and 2015, from 95.8 to 71.4 cases/100,000 (P < .01), and a 52.4% reduction in cancer mortality, from 30.9 to 14.7 deaths/100,000 (P < .01). Increased screening was initially associated with increased CRC incidence, due largely to greater detection of early-stage cancers, followed by decreases in cancer incidence. Advanced-stage CRC incidence rates decreased 36.2%, from 45.9 to 29.3 cases/100,000 (P < .01), and early-stage CRC incidence rates decreased 14.5%, from 48.2 to 41.2 cases/100,000 (P < .04). CONCLUSIONS Implementing an organized CRC screening program in a large community-based population rapidly increased screening participation to the ≥80% target set by national organizations. Screening rates were sustainable and associated with substantial decreases in CRC incidence and mortality within short time intervals, consistent with early detection and cancer prevention.
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Affiliation(s)
- Theodore R. Levin
- Kaiser Permanente Medical Center, Walnut Creek, CA.,Division of Research, Kaiser Permanente Northern California, Oakland, CA
| | - Douglas A. Corley
- Division of Research, Kaiser Permanente Northern California, Oakland, CA
| | | | - Joanne E. Schottinger
- Department of Research & Evaluation, Kaiser Permanente Southern California, Pasadena, CA
| | - Virginia P. Quinn
- Department of Research & Evaluation, Kaiser Permanente Southern California, Pasadena, CA
| | - Ann G. Zauber
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Jeffrey K. Lee
- Division of Research, Kaiser Permanente Northern California, Oakland, CA
| | - Wei K. Zhao
- Division of Research, Kaiser Permanente Northern California, Oakland, CA
| | - Natalia Udaltsova
- Division of Research, Kaiser Permanente Northern California, Oakland, CA
| | - Nirupa R. Ghai
- Department of Research & Evaluation, Kaiser Permanente Southern California, Pasadena, CA
| | - Alexander T. Lee
- Department of Research & Evaluation, Kaiser Permanente Southern California, Pasadena, CA
| | | | - Bruce H. Fireman
- Division of Research, Kaiser Permanente Northern California, Oakland, CA
| | - Chyke A. Doubeni
- Department of Family Medicine and Community Health, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
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Selby K, Jensen CD, Lee JK, Doubeni CA, Schottinger JE, Zhao WK, Chubak J, Halm E, Ghai NR, Contreras R, Skinner C, Kamineni A, Levin TR, Corley DA. Influence of Varying Quantitative Fecal Immunochemical Test Positivity Thresholds on Colorectal Cancer Detection: A Community-Based Cohort Study. Ann Intern Med 2018; 169:439-447. [PMID: 30242328 PMCID: PMC6433467 DOI: 10.7326/m18-0244] [Citation(s) in RCA: 32] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Background The fecal immunochemical test (FIT) is commonly used for colorectal cancer (CRC) screening. Despite demographic variations in stool hemoglobin concentrations, few data exist regarding optimal positivity thresholds by age and sex. Objective To identify programmatic (multitest) FIT performance characteristics and optimal FIT quantitative hemoglobin positivity thresholds in a large, population-based, screening program. Design Retrospective cohort study. Setting Kaiser Permanente Northern and Southern California. Participants Adults aged 50 to 75 years who were eligible for screening and had baseline quantitative FIT results (2013 to 2014) and 2 years of follow-up. Nearly two thirds (411 241) had FIT screening in the previous 2 years. Measurements FIT programmatic sensitivity for CRC and number of positive test results per cancer case detected, overall and by age and sex. Results Of 640 859 persons who completed a baseline FIT and were followed for 2 years, 481 817 (75%) had at least 1 additional FIT and 1245 (0.19%) received a CRC diagnosis. Cancer detection (programmatic sensitivity) increased at lower positivity thresholds, from 822 in 1245 (66.0%) at 30 µg/g to 925 (74.3%) at 20 µg/g and 987 (79.3%) at 10 µg/g; the number of positive test results per cancer case detected increased from 43 at 30 µg/g to 52 at 20 µg/g and 85 at 10 µg/g. Reducing the positivity threshold from 20 to 15 µg/g would detect 3% more cancer cases and require 23% more colonoscopies. At the conventional FIT threshold of 20 µg/g, programmatic sensitivity decreased with increasing age (79.0%, 73.4%, and 68.9% for ages 50 to 59, 60 to 69, and 70 to 75 years, respectively; P = 0.009) and was higher in men than women (77.0% vs. 70.6%; P = 0.011). Limitation Information on advanced adenoma was lacking. Conclusion Increased cancer detection at lower positivity thresholds is counterbalanced by substantial increases in positive tests. Tailored thresholds may provide screening benefits that are more equal among different demographic groups, depending on local resources. Primary Funding Source National Cancer Institute.
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Affiliation(s)
- Kevin Selby
- Division of Research, Kaiser Permanente Northern California, Oakland, California
- Department of Ambulatory Care and Community Medicine, University of Lausanne, Switzerland
| | | | - Jeffrey K. Lee
- Division of Research, Kaiser Permanente Northern California, Oakland, California
| | - Chyke A. Doubeni
- Department of Family Medicine and Community Health, University of Pennsylvania, Philadelphia, PA
| | - Joanne E. Schottinger
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, CA
| | - Wei K. Zhao
- Division of Research, Kaiser Permanente Northern California, Oakland, California
| | - Jessica Chubak
- Kaiser Permanente Center for Health Research, Seattle, Washington
| | - Ethan Halm
- University of Texas Southwestern Medical Center, Dallas TX
| | - Nirupa R. Ghai
- Department of Regional Clinical Effectiveness, Kaiser Permanente Southern California, Pasadena, CA
| | - Richard Contreras
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, CA
| | | | - Aruna Kamineni
- Kaiser Permanente Center for Health Research, Seattle, Washington
| | | | - Douglas A. Corley
- Division of Research, Kaiser Permanente Northern California, Oakland, California
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26
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Ghai NR, Jensen CD, Corley DA, Doubeni CA, Schottinger JE, Zauber AG, Lee AT, Contreras R, Levin TR, Lee JK, Quinn VP. Colorectal Cancer Screening Participation Among Asian Americans Overall and Subgroups in an Integrated Health Care Setting with Organized Screening. Clin Transl Gastroenterol 2018; 9:186. [PMID: 30242160 PMCID: PMC6155113 DOI: 10.1038/s41424-018-0051-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/08/2018] [Revised: 08/01/2018] [Accepted: 08/13/2018] [Indexed: 01/01/2023] Open
Abstract
Background Screening reduces colorectal cancer deaths, but <50% of Asian Americans are screening up-to-date according to surveys, with variability across Asian subgroups. We examined colorectal cancer screening participation among Asian Americans overall and Asian subgroups in a large integrated health care system with organized screening. Methods Data were electronically accessed to characterize screening in 2016 for Asians overall and subgroups relative to the National Colorectal Cancer Roundtable target of ≥80% screening and compared with non-Hispanic whites. Screening up-to-date was defined as a colonoscopy with 10 years, a sigmoidoscopy within 5 years, or a fecal immunochemical test (FIT) completed in 2016. Results Among 436,398 patients, 69,826 (16.0%) were Asian, of whom 79.8% were screening up-to-date vs. 77.6% of non-Hispanic whites (p < 0.001). Almost all subgroups met the 80% target: Chinese (83.3%), Vietnamese (82.4%), Korean (82.1%), other Asian (80.3%), Filipino (78.7%), Asian Indian (79.6%), and Japanese (79.0%). Among Asians overall and non-Hispanic whites, 50.6% and 48.4% of members were up-to-date with screening by colonoscopy, and 28.0% and 28.2% were up-to-date by FIT, respectively. Across Asian subgroups, colonoscopy most frequently accounting for being screening up-to-date (range: 47.4–59.7%), followed by FIT (range: 21.6–31.5%). Conclusions In an organized screening setting, there were minimal differences in screening participation among Asian subgroups and almost all met the 80% screening target, despite differences in language preference. Screening test type differences across subgroups suggest possible preferences in screening modality, which can inform future research into tailored education or outreach.
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Affiliation(s)
- Nirupa R Ghai
- Kaiser Foundation Health Plan, Department of Regional Clinical Effectiveness, 393 East Walnut Street, Pasadena, CA, 91188, USA.
| | - Christopher D Jensen
- Kaiser Permanente Northern California, Division of Research, 2000 Broadway, Oakland, CA, 94612, USA
| | - Douglas A Corley
- Kaiser Permanente Northern California, Division of Research, 2000 Broadway, Oakland, CA, 94612, USA
| | - Chyke A Doubeni
- Department of Family Medicine and Community Health, The Perelman School of Medicine at the University of Pennsylvania, 51N 39th Street, Andrew Mutch Building, 7th Floor, Philadelphia, PA, 19104, USA
| | - Joanne E Schottinger
- Kaiser Permanente Southern California Regional Offices, 393 East Walnut Street, Pasadena, CA, 91188, USA
| | - Ann G Zauber
- Department of Epidemiology & Biostatistics, Memorial Sloan Kettering Cancer Center, 485 Lexington Avenue, 2063A, New York, NY, 10017, USA
| | - Alexander T Lee
- Southern California Permanente Medical Group, Kaiser Permanente Woodland Hills, 5601 De Soto Ave, Woodland Hills, CA, 91365, USA
| | - Richard Contreras
- Kaiser Foundation Health Plan, Department of Regional Clinical Effectiveness, 393 East Walnut Street, Pasadena, CA, 91188, USA
| | - Theodore R Levin
- Kaiser Permanente Medical Center, 1425 South Main Street, Walnut Creek, CA, 94596, USA
| | - Jeffrey K Lee
- Kaiser Permanente Northern California, Division of Research, 2000 Broadway, Oakland, CA, 94612, USA
| | - Virginia P Quinn
- Kaiser Foundation Health Plan, Department of Regional Clinical Effectiveness, 393 East Walnut Street, Pasadena, CA, 91188, USA
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Singal AG, Corley DA, Kamineni A, Garcia M, Zheng Y, Doria-Rose PV, Quinn VP, Jensen CD, Chubak J, Tiro J, Doubeni CA, Ghai NR, Skinner CS, Wernli K, Halm EA. Patterns and predictors of repeat fecal immunochemical and occult blood test screening in four large health care systems in the United States. Am J Gastroenterol 2018; 113:746-754. [PMID: 29487413 PMCID: PMC6476786 DOI: 10.1038/s41395-018-0023-x] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2017] [Accepted: 01/23/2018] [Indexed: 12/11/2022]
Abstract
OBJECTIVES Effectiveness of fecal occult blood test (FOBT) for colorectal cancer (CRC) screening depends on annual testing, but little is known about patterns of repeat stool-based screening within different settings. Our study's objective was to characterize screening patterns and identify factors associated with repeat screening among patients who completed an index guaiac FOBT (gFOBT) or fecal immunochemical test (FIT). METHODS We performed a multi-center retrospective cohort study among people who completed a FOBT between January 2010 and December 2011 to characterize repeat screening patterns over the subsequent 3 years. We studied at 4 large health care delivery systems in the United States. Logistic regression analyses were used to identify factors associated with repeat screening patterns. We included individuals aged 50-71 years who completed an index FOBT and had at least 3 years of follow-up. We excluded people with a history of CRC, colonoscopy within 10 years or flexible sigmoidoscopy within 5 years before the index test, or positive index stool test. Consistent screening was defined as repeat FOBT within every 15 months and inconsistent screening as repeat testing at least once during follow-up but less than consistent screening. RESULTS Among 959,857 eligible patients who completed an index FIT or gFOBT, 344,103 had three years of follow-up and met inclusion criteria. Of these, 46.6% had consistent screening, 43.4% inconsistent screening, and 10% had no repeat screening during follow-up. Screening patterns varied substantially across healthcare systems, with consistent screening proportions ranging from 1 to 54.3% and no repeat screening proportions ranging from 6.9 to 42.8%. Higher consistent screening proportions were observed in health systems with screening outreach and in-reach programs, whereas the safety-net health system, which uses opportunistic clinic-based screening, had the lowest consistent screening. Consistent screening increased with older age but was less common among racial/ethnic minorities and patients with more comorbidities. CONCLUSIONS Adherence with annual FOBT screening is highly variable across healthcare delivery systems. Settings with more organized screening programs performed better than those with opportunistic screening, but evidence-based interventions are needed to improve CRC screening adherence in all settings.
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Affiliation(s)
- Amit G. Singal
- University of Texas Southwestern Medical Center, Dallas TX
| | | | | | | | - Yingye Zheng
- Fred Hutchinson Cancer Research Center, Seattle WA
| | | | | | | | | | - Jasmin Tiro
- University of Texas Southwestern Medical Center, Dallas TX
| | | | | | | | | | - Ethan A. Halm
- University of Texas Southwestern Medical Center, Dallas TX
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28
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Doubeni CA, Corley DA, Quinn VP, Jensen CD, Zauber AG, Goodman M, Johnson JR, Mehta SJ, Becerra TA, Zhao WK, Schottinger J, Doria-Rose VP, Levin TR, Weiss NS, Fletcher RH. Effectiveness of screening colonoscopy in reducing the risk of death from right and left colon cancer: a large community-based study. Gut 2018; 67:291-298. [PMID: 27733426 PMCID: PMC5868294 DOI: 10.1136/gutjnl-2016-312712] [Citation(s) in RCA: 231] [Impact Index Per Article: 38.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/24/2016] [Revised: 09/20/2016] [Accepted: 09/25/2016] [Indexed: 12/14/2022]
Abstract
OBJECTIVE Screening colonoscopy's effectiveness in reducing colorectal cancer mortality risk in community populations is unclear, particularly for right-colon cancers, leading to recommendations against its use for screening in some countries. This study aimed to determine whether, among average-risk people, receipt of screening colonoscopy reduces the risk of dying from both right-colon and left-colon/rectal cancers. DESIGN We conducted a nested case-control study with incidence-density matching in screening-eligible Kaiser Permanente members. Patients who were 55-90 years old on their colorectal cancer death date during 2006-2012 were matched on diagnosis (reference) date to controls on age, sex, health plan enrolment duration and geographical region. We excluded patients at increased colorectal cancer risk, or with prior colorectal cancer diagnosis or colectomy. The association between screening colonoscopy receipt in the 10-year period before the reference date and colorectal cancer death risk was evaluated while accounting for other screening exposures. RESULTS We analysed 1747 patients who died from colorectal cancer and 3460 colorectal cancer-free controls. Compared with no endoscopic screening, receipt of a screening colonoscopy was associated with a 67% reduction in the risk of death from any colorectal cancer (adjusted OR (aOR)=0.33, 95% CI 0.21 to 0.52). By cancer location, screening colonoscopy was associated with a 65% reduction in risk of death for right-colon cancers (aOR=0.35, CI 0.18 to 0.65) and a 75% reduction for left-colon/rectal cancers (aOR=0.25, CI 0.12 to 0.53). CONCLUSIONS Screening colonoscopy was associated with a substantial and comparably decreased mortality risk for both right-sided and left-sided cancers within a large community-based population.
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Affiliation(s)
- Chyke A Doubeni
- Department of Family Medicine and Community Health, The Abramson Cancer Center, Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Douglas A Corley
- Division of Research, Kaiser Permanente Northern California, Oakland, California, USA
| | - Virginia P Quinn
- Department of Research & Evaluation, Kaiser Permanente Southern California, Pasadena, California, USA
| | - Christopher D Jensen
- Division of Research, Kaiser Permanente Northern California, Oakland, California, USA
| | - Ann G Zauber
- Department of Epidemiology & Biostatistics, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Michael Goodman
- Department of Epidemiology, Emory University, Atlanta, Georgia, USA
| | - Jill R Johnson
- Department of Family Medicine and Community Health, The Abramson Cancer Center, Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Shivan J Mehta
- Division of Gastroenterology, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Tracy A Becerra
- Department of Research & Evaluation, Kaiser Permanente Southern California, Pasadena, California, USA
| | - Wei K Zhao
- Division of Research, Kaiser Permanente Northern California, Oakland, California, USA
| | - Joanne Schottinger
- Department of Research & Evaluation, Kaiser Permanente Southern California, Pasadena, California, USA
| | - V Paul Doria-Rose
- Division of Cancer Control and Population Sciences, National Cancer Institute, National Institutes of Health, Bethesda, Maryland, USA
| | - Theodore R Levin
- Division of Research, Kaiser Permanente Northern California, Oakland, California, USA
| | - Noel S Weiss
- Department of Epidemiology, University of Washington, Seattle, Washington, USA
| | - Robert H Fletcher
- Department of Population Medicine, Harvard Medical School, Boston, Massachusetts, USA
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29
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Selby K, Baumgartner C, Levin TR, Doubeni CA, Zauber AG, Schottinger J, Jensen CD, Lee JK, Corley DA. Interventions to Improve Follow-up of Positive Results on Fecal Blood Tests: A Systematic Review. Ann Intern Med 2017; 167:565-575. [PMID: 29049756 PMCID: PMC6178946 DOI: 10.7326/m17-1361] [Citation(s) in RCA: 70] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Fecal immunochemical testing is the most commonly used method for colorectal cancer screening worldwide. However, its effectiveness is frequently undermined by failure to obtain follow-up colonoscopy after positive test results. PURPOSE To evaluate interventions to improve rates of follow-up colonoscopy for adults after a positive result on a fecal test (guaiac or immunochemical). DATA SOURCES English-language studies from the Cochrane Central Register of Controlled Trials, PubMed, and Embase from database inception through June 2017. STUDY SELECTION Randomized and nonrandomized studies reporting an intervention for colonoscopy follow-up of asymptomatic adults with positive fecal test results. DATA EXTRACTION Two reviewers independently extracted data and ranked study quality; 2 rated overall strength of evidence for each category of study type. DATA SYNTHESIS Twenty-three studies were eligible for analysis, including 7 randomized and 16 nonrandomized studies. Three were at low risk of bias. Eleven studies described patient-level interventions (changes to invitation, provision of results or follow-up appointments, and patient navigators), 5 provider-level interventions (reminders or performance data), and 7 system-level interventions (automated referral, precolonoscopy telephone calls, patient registries, and quality improvement efforts). Moderate evidence supported patient navigators and provider reminders or performance data. Evidence for system-level interventions was low. Seventeen studies reported the proportion of test-positive patients who completed colonoscopy compared with a control population, with absolute differences of -7.4 percentage points (95% CI, -19 to 4.3 percentage points) to 25 percentage points (CI, 14 to 35 percentage points). LIMITATION More than half of studies were at high or very high risk of bias; heterogeneous study designs and characteristics precluded meta-analysis. CONCLUSION Patient navigators and giving providers reminders or performance data may help improve colonoscopy rates of asymptomatic adults with positive fecal blood test results. Current evidence about useful system-level interventions is scant and insufficient. PRIMARY FUNDING SOURCE National Cancer Institute. (PROSPERO: CRD42016048286).
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Affiliation(s)
- Kevin Selby
- From Kaiser Permanente Division of Research, Oakland, California; University of Lausanne, Lausanne, Switzerland; University of California at San Francisco, San Francisco, California; Bern University Hospital, Bern, Switzerland; Kaiser Permanente Medical Center, Walnut Creek, California; University of Pennsylvania, Philadelphia, Pennsylvania; Memorial Sloan Kettering Cancer Center, New York, New York; and Kaiser Permanente, Pasadena, California
| | - Christine Baumgartner
- From Kaiser Permanente Division of Research, Oakland, California; University of Lausanne, Lausanne, Switzerland; University of California at San Francisco, San Francisco, California; Bern University Hospital, Bern, Switzerland; Kaiser Permanente Medical Center, Walnut Creek, California; University of Pennsylvania, Philadelphia, Pennsylvania; Memorial Sloan Kettering Cancer Center, New York, New York; and Kaiser Permanente, Pasadena, California
| | - Theodore R Levin
- From Kaiser Permanente Division of Research, Oakland, California; University of Lausanne, Lausanne, Switzerland; University of California at San Francisco, San Francisco, California; Bern University Hospital, Bern, Switzerland; Kaiser Permanente Medical Center, Walnut Creek, California; University of Pennsylvania, Philadelphia, Pennsylvania; Memorial Sloan Kettering Cancer Center, New York, New York; and Kaiser Permanente, Pasadena, California
| | - Chyke A Doubeni
- From Kaiser Permanente Division of Research, Oakland, California; University of Lausanne, Lausanne, Switzerland; University of California at San Francisco, San Francisco, California; Bern University Hospital, Bern, Switzerland; Kaiser Permanente Medical Center, Walnut Creek, California; University of Pennsylvania, Philadelphia, Pennsylvania; Memorial Sloan Kettering Cancer Center, New York, New York; and Kaiser Permanente, Pasadena, California
| | - Ann G Zauber
- From Kaiser Permanente Division of Research, Oakland, California; University of Lausanne, Lausanne, Switzerland; University of California at San Francisco, San Francisco, California; Bern University Hospital, Bern, Switzerland; Kaiser Permanente Medical Center, Walnut Creek, California; University of Pennsylvania, Philadelphia, Pennsylvania; Memorial Sloan Kettering Cancer Center, New York, New York; and Kaiser Permanente, Pasadena, California
| | - Joanne Schottinger
- From Kaiser Permanente Division of Research, Oakland, California; University of Lausanne, Lausanne, Switzerland; University of California at San Francisco, San Francisco, California; Bern University Hospital, Bern, Switzerland; Kaiser Permanente Medical Center, Walnut Creek, California; University of Pennsylvania, Philadelphia, Pennsylvania; Memorial Sloan Kettering Cancer Center, New York, New York; and Kaiser Permanente, Pasadena, California
| | - Christopher D Jensen
- From Kaiser Permanente Division of Research, Oakland, California; University of Lausanne, Lausanne, Switzerland; University of California at San Francisco, San Francisco, California; Bern University Hospital, Bern, Switzerland; Kaiser Permanente Medical Center, Walnut Creek, California; University of Pennsylvania, Philadelphia, Pennsylvania; Memorial Sloan Kettering Cancer Center, New York, New York; and Kaiser Permanente, Pasadena, California
| | - Jeffrey K Lee
- From Kaiser Permanente Division of Research, Oakland, California; University of Lausanne, Lausanne, Switzerland; University of California at San Francisco, San Francisco, California; Bern University Hospital, Bern, Switzerland; Kaiser Permanente Medical Center, Walnut Creek, California; University of Pennsylvania, Philadelphia, Pennsylvania; Memorial Sloan Kettering Cancer Center, New York, New York; and Kaiser Permanente, Pasadena, California
| | - Douglas A Corley
- From Kaiser Permanente Division of Research, Oakland, California; University of Lausanne, Lausanne, Switzerland; University of California at San Francisco, San Francisco, California; Bern University Hospital, Bern, Switzerland; Kaiser Permanente Medical Center, Walnut Creek, California; University of Pennsylvania, Philadelphia, Pennsylvania; Memorial Sloan Kettering Cancer Center, New York, New York; and Kaiser Permanente, Pasadena, California
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Hillyer GC, Jensen CD, Zhao WK, Neugut AI, Lebwohl B, Tiro JA, Kushi LH, Corley DA. Primary care visit use after positive fecal immunochemical test for colorectal cancer screening. Cancer 2017. [PMID: 28621809 DOI: 10.1002/cncr.30809] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND For some patients, positive cancer screening test results can be a stressful experience that can affect future screening compliance and increase the use of health care services unrelated to medically indicated follow-up. METHODS Among 483,216 individuals aged 50 to 75 years who completed a fecal immunochemical test to screen for colorectal cancer at a large integrated health care setting between 2007 and 2011, the authors evaluated whether a positive test was associated with a net change in outpatient primary care visit use within the year after screening. Multivariable regression models were used to evaluate the relationship between test result group and net changes in primary care visits after fecal immunochemical testing. RESULTS In the year after the fecal immunochemical test, use increased by 0.60 clinic visits for patients with true-positive results. The absolute change in visits was largest (3.00) among individuals with positive test results who were diagnosed with colorectal cancer, but significant small increases also were found for patients treated with polypectomy and who had no neoplasia (0.36) and those with a normal examination and no polypectomy performed (0.17). Groups of patients who demonstrated an increase in net visit use compared with the true-negative group included patients with true-positive results (odds ratio [OR], 1.60; 95% confidence interval [95% CI], 1.54-1.66), and positive groups with a colorectal cancer diagnosis (OR, 7.19; 95% CI, 6.12-8.44), polypectomy/no neoplasia (OR, 1.37; 95% CI, 1.27-1.48), and normal examination/no polypectomy (OR, 1.24; 95% CI, 1.18-1.30). CONCLUSIONS Given the large size of outreach programs, these small changes can cumulatively generate thousands of excess visits and have a substantial impact on total health care use. Therefore, these changes should be included in colorectal cancer screening cost models and their causes investigated further. Cancer 2017;123:3744-3753. © 2017 American Cancer Society.
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Affiliation(s)
- Grace Clarke Hillyer
- Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, New York.,Herbert Irving Comprehensive Cancer Center, College of Physicians and Surgeons of Columbia University, New York, New York
| | | | - Wei K Zhao
- Division of Research, Kaiser Permanente, Oakland, California
| | - Alfred I Neugut
- Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, New York.,Herbert Irving Comprehensive Cancer Center, College of Physicians and Surgeons of Columbia University, New York, New York.,Department of Medicine, College of Physicians and Surgeons of Columbia University, New York, New York
| | - Benjamin Lebwohl
- Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, New York.,Herbert Irving Comprehensive Cancer Center, College of Physicians and Surgeons of Columbia University, New York, New York.,Department of Medicine, College of Physicians and Surgeons of Columbia University, New York, New York
| | - Jasmin A Tiro
- Division of Behavioral and Communication Sciences, Department of Clinical Sciences, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Lawrence H Kushi
- Division of Research, Kaiser Permanente, Oakland, California.,Cancer Research Network, National Cancer Institute, Bethesda, Maryland
| | - Douglas A Corley
- Division of Research, Kaiser Permanente, Oakland, California.,Cancer Research Network, National Cancer Institute, Bethesda, Maryland
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31
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Fedewa SA, Corley DA, Jensen CD, Zhao W, Goodman M, Jemal A, Ward KC, Levin TR, Doubeni CA. Colorectal Cancer Screening Initiation After Age 50 Years in an Organized Program. Am J Prev Med 2017; 53:335-344. [PMID: 28427954 PMCID: PMC5562515 DOI: 10.1016/j.amepre.2017.02.018] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/22/2016] [Revised: 01/25/2017] [Accepted: 02/24/2017] [Indexed: 12/19/2022]
Abstract
INTRODUCTION Recent studies report racial disparities among individuals in organized colorectal cancer (CRC) programs; however, there is a paucity of information on CRC screening utilization by race/ethnicity among newly age-eligible adults in such programs. METHODS This was a retrospective cohort study among Kaiser Permanente Northern California enrollees who turned age 50 years between 2007 and 2012 (N=138,799) and were served by a systemwide outreach and facilitated in-reach screening program based primarily on mailed fecal immunochemical tests to screening-eligible people. Kaplan-Meier and Cox model analyses were used to estimate differences in receipt of CRC screening in 2015-2016. RESULTS Cumulative probabilities of CRC screening within 1 and 2 years of subjects' 50th birthday were 51% and 73%, respectively. Relative to non-Hispanic whites, the likelihood of completing any CRC screening was similar in blacks (hazard ratio, 0.98; 95% CI=0.96, 1.00); 5% lower in Hispanics (hazard ratio, 0.95; 95% CI=0.93, 0.96); and 13% higher in Asians (hazard ratio, 1.13; 95% CI=1.11, 1.15) in adjusted analyses. Fecal immunochemical testing was the most common screening modality, representing 86% of all screening initiations. Blacks and Hispanics had lower receipt of fecal immunochemical testing in adjusted analyses. CONCLUSIONS CRC screening uptake was high among newly screening-eligible adults in an organized CRC screening program, but Hispanics were less likely to initiate screening near age 50 years than non-Hispanic whites, suggesting that cultural and other individual-level barriers not addressed within the program likely contribute. Future studies examining the influences of culturally appropriate and targeted efforts for screening initiation are needed.
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Affiliation(s)
- Stacey A Fedewa
- Department of Epidemiology, Emory University, Atlanta, Georgia; Surveillance and Health Services Research, American Cancer Society, Atlanta, Georgia.
| | | | | | - Wei Zhao
- Kaiser Permanente Division of Research, Oakland, California
| | - Michael Goodman
- Department of Epidemiology, Emory University, Atlanta, Georgia
| | - Ahmedin Jemal
- Surveillance and Health Services Research, American Cancer Society, Atlanta, Georgia
| | - Kevin C Ward
- Department of Epidemiology, Emory University, Atlanta, Georgia
| | | | - Chyke A Doubeni
- Department of Family Medicine and Community Health, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
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Corley DA, Jensen CD, Quinn VP, Doubeni CA, Zauber AG, Lee JK, Schottinger JE, Marks AR, Zhao WK, Ghai NR, Lee AT, Contreras R, Quesenberry CP, Fireman BH, Levin TR. Association Between Time to Colonoscopy After a Positive Fecal Test Result and Risk of Colorectal Cancer and Cancer Stage at Diagnosis. JAMA 2017; 317:1631-1641. [PMID: 28444278 PMCID: PMC6343838 DOI: 10.1001/jama.2017.3634] [Citation(s) in RCA: 186] [Impact Index Per Article: 26.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
IMPORTANCE The fecal immunochemical test (FIT) is commonly used for colorectal cancer screening and positive test results require follow-up colonoscopy. However, follow-up intervals vary, which may result in neoplastic progression. OBJECTIVE To evaluate time to colonoscopy after a positive FIT result and its association with risk of colorectal cancer and advanced-stage disease at diagnosis. DESIGN, SETTING, AND PARTICIPANTS Retrospective cohort study (January 1, 2010-December 31, 2014) within Kaiser Permanente Northern and Southern California. Participants were 70 124 patients aged 50 through 70 years eligible for colorectal cancer screening with a positive FIT result who had a follow-up colonoscopy. EXPOSURES Time (days) to colonoscopy after a positive FIT result. MAIN OUTCOMES AND MEASURES Risk of any colorectal cancer and advanced-stage disease (defined as stage III and IV cancer). Odds ratios (ORs) and 95% CIs were adjusted for patient demographics and baseline risk factors. RESULTS Of the 70 124 patients with positive FIT results (median age, 61 years [IQR, 55-67 years]; men, 52.7%), there were 2191 cases of any colorectal cancer and 601 cases of advanced-stage disease diagnosed. Compared with colonoscopy follow-up within 8 to 30 days (n = 27 176), there were no significant differences between follow-up at 2 months (n = 24 644), 3 months (n = 8666), 4 to 6 months (n = 5251), or 7 to 9 months (n = 1335) for risk of any colorectal cancer (cases per 1000 patients: 8-30 days, 30; 2 months, 28; 3 months, 31; 4-6 months, 31; and 7-9 months, 43) or advanced-stage disease (cases per 1000 patients: 8-30 days, 8; 2 months, 7; 3 months, 7; 4-6 months, 9; and 7-9 months, 13). Risks were significantly higher for examinations at 10 to 12 months (n = 748) for any colorectal cancer (OR, 1.48 [95% CI, 1.05-2.08]; 49 cases per 1000 patients) and advanced-stage disease (OR, 1.97 [95% CI, 1.14-3.42]; 19 cases per 1000 patients) and more than 12 months (n = 747) for any colorectal cancer (OR, 2.25 [95% CI, 1.89-2.68]; 76 cases per 1000 patients) and advanced-stage disease (OR, 3.22 [95% CI, 2.44-4.25]; 31 cases per 1000 patients). CONCLUSIONS AND RELEVANCE Among patients with a positive fecal immunochemical test result, compared with follow-up colonoscopy at 8 to 30 days, follow-up after 10 months was associated with a higher risk of colorectal cancer and more advanced-stage disease at the time of diagnosis. Further research is needed to assess whether this relationship is causal.
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Affiliation(s)
- Douglas A. Corley
- Division of Research, Kaiser Permanente Northern California, Oakland, CA
| | | | - Virginia P. Quinn
- Department of Research & Evaluation, Kaiser Permanente Southern California, Pasadena, CA
| | - Chyke A. Doubeni
- Department of Family Medicine and Community Health, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Ann G. Zauber
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Jeffrey K. Lee
- Division of Research, Kaiser Permanente Northern California, Oakland, CA
| | - Joanne E. Schottinger
- Department of Research & Evaluation, Kaiser Permanente Southern California, Pasadena, CA
| | - Amy R. Marks
- Division of Research, Kaiser Permanente Northern California, Oakland, CA
| | - Wei K. Zhao
- Division of Research, Kaiser Permanente Northern California, Oakland, CA
| | - Nirupa R. Ghai
- Department of Research & Evaluation, Kaiser Permanente Southern California, Pasadena, CA
| | - Alexander T. Lee
- Department of Research & Evaluation, Kaiser Permanente Southern California, Pasadena, CA
| | - Richard Contreras
- Department of Research & Evaluation, Kaiser Permanente Southern California, Pasadena, CA
| | | | - Bruce H. Fireman
- Division of Research, Kaiser Permanente Northern California, Oakland, CA
| | - Theodore R. Levin
- Division of Research, Kaiser Permanente Northern California, Oakland, CA
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Levin TR, Corley DA, Jensen CD, Marks AR, Zhao WK, Zebrowski AM, Quinn VP, Browne LW, Taylor WR, Ahlquist DA, Lidgard GP, Berger BM. Genetic Biomarker Prevalence Is Similar in Fecal Immunochemical Test Positive and Negative Colorectal Cancer Tissue. Dig Dis Sci 2017; 62:678-688. [PMID: 28044229 PMCID: PMC6178951 DOI: 10.1007/s10620-016-4433-6] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/22/2016] [Accepted: 12/21/2016] [Indexed: 12/14/2022]
Abstract
BACKGROUND Fecal immunochemical test (FIT) screening detects most asymptomatic colorectal cancers. Combining FIT screening with stool-based genetic biomarkers increases sensitivity for cancer, but whether DNA biomarkers (biomarkers) differ for cancers detected versus missed by FIT screening has not been evaluated in a community-based population. AIMS To evaluate tissue biomarkers among Kaiser Permanente Northern California patients diagnosed with colorectal cancer within 2 years after FIT screening. METHODS FIT-negative and FIT-positive colorectal cancer patients 50-77 years of age were matched on age, sex, and cancer stage. Adequate DNA was isolated from paraffin-embedded specimens in 210 FIT-negative and 211 FIT-positive patients. Quantitative allele-specific real-time target and signal amplification assays were performed for 7 K-ras mutations and 10 aberrantly methylated DNA biomarkers (NDRG4, BMP3, SFMBT2_895, SFMBT2_896, SFMBT2_897, CHST2_7890, PDGFD, VAV3, DTX1, CHST2_7889). RESULTS One or more biomarkers were found in 414 of 421 CRCs (98.3%). Biomarker expression was not associated with FIT status, with the exception of higher SFMBT2_897 expression in FIT-negative (194 of 210; 92.4%) than in FIT-positive cancers (180 of 211; 85.3%; p = 0.02). There were no consistent differences in biomarker expression by FIT status within age, sex, stage, and cancer location subgroups. CONCLUSIONS The biomarkers of a currently in-use multi-target stool DNA test (K-ras, NDRG4, and BMP3) and eight newly characterized methylated biomarkers were commonly expressed in tumor tissue specimens, independent of FIT result. Additional study using stool-based testing with these new biomarkers will allow assessment of sensitivity, specificity, and clinical utility.
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Affiliation(s)
- Theodore R. Levin
- Division of Research, Kaiser Permanente Northern California and Kaiser Permanente Walnut Creek Medical Center; ; 1425 South Main Street, Walnut Creek, CA 94596
| | - Douglas A. Corley
- Division of Research, Kaiser Permanente Northern California; ; 2000 Broadway, Oakland, CA 94612
| | - Christopher D. Jensen
- Division of Research, Kaiser Permanente Northern California; ; 2000 Broadway, Oakland, CA 94612
| | - Amy R. Marks
- Division of Research, Kaiser Permanente Northern California; ; 2000 Broadway, Oakland, CA 94612
| | - Wei K. Zhao
- Division of Research, Kaiser Permanente Northern California; ; 2000 Broadway, Oakland, CA 94612
| | - Alexis M. Zebrowski
- Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania; ; Blockley Hall, 1st Floor, 423 Guardian Drive, University of Pennsylvania, Philadelphia, PA 19104
| | - Virginia P. Quinn
- Department of Research & Evaluation, Kaiser Permanente Southern California; ; Pasadena, CA, United States
| | - Lawrence W. Browne
- Division of Research, Kaiser Permanente Northern California; ; 2000 Broadway, Oakland, CA 94612
| | - William R. Taylor
- Gastroenterology Mayo Clinic; ; Mayo Building, 200 First St. NW, 19th Floor, Rochester, MN 55905
| | - David A. Ahlquist
- Gastroenterology Mayo Clinic; ; Mayo Building, 200 First St. NW, 19th Floor, Rochester, MN 55905
| | - Graham P. Lidgard
- Research and Development, Exact Sciences Corporation; ; 441 Charmany Dr. Madison WI 53719
| | - Barry M. Berger
- Medical Affairs, Exact Sciences Corporation; ; 441 Charmany Dr. Madison WI 53719
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Lee A, Jensen CD, Marks AR, Zhao WK, Doubeni CA, Zauber AG, Quinn VP, Levin TR, Corley DA. Endoscopist fatigue estimates and colonoscopic adenoma detection in a large community-based setting. Gastrointest Endosc 2017; 85:601-610.e2. [PMID: 27702568 PMCID: PMC5318254 DOI: 10.1016/j.gie.2016.09.033] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/05/2016] [Accepted: 09/19/2016] [Indexed: 12/11/2022]
Abstract
BACKGROUND AND AIMS Endoscopist fatigue may impact colonoscopy quality, but prior studies conflict, and minimal data exist from community-based practices where most colonoscopies are performed. METHODS Within a large, community-based integrated healthcare system, we evaluated the associations among 4 measures of endoscopist fatigue and colonoscopic adenoma detection from 2010 to 2013. Fatigue measures included afternoon versus morning colonoscopy and the number of GI procedures performed before a given colonoscopy, including consideration of prior procedure complexity. Analyses were adjusted for potential confounders using multivariate logistic regression. RESULTS We identified 126 gastroenterologists who performed 259,064 total GI procedures (median, 6 per day; range, 1-24), including 76,445 screening and surveillance colonoscopies. Compared with morning examinations, colonoscopies in the afternoon were not associated with lower adenoma detection for screening examinations, surveillance examinations, or their combination (OR for combination, .99; 95% CI, .96-1.03). The number of procedures performed before a given colonoscopy, with or without consideration of prior procedure complexity, was also not inversely associated with adenoma detection (OR for adenoma detection for colonoscopies in the fourth quartile of fatigue based on the number of prior procedures performed vs colonoscopies performed as the first procedure of the day, .99; 95% CI, .94-1.04). CONCLUSIONS In a large community-based setting, adenoma detection for screening and surveillance colonoscopies were not associated with either time of day or the number of prior procedures performed by the endoscopist, within the range of procedure volumes evaluated. The lack of association persisted after accounting for prior procedure complexity.
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Affiliation(s)
- Alexander Lee
- Division of Research, Kaiser Permanente Northern California, Oakland, CA
| | | | - Amy R. Marks
- Division of Research, Kaiser Permanente Northern California, Oakland, CA
| | - Wei K. Zhao
- Division of Research, Kaiser Permanente Northern California, Oakland, CA
| | - Chyke A. Doubeni
- Department of Family Medicine and Community Health, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Ann G. Zauber
- Memorial Sloan Kettering Cancer Center, New York, NY
| | - Virginia P. Quinn
- Department of Research & Evaluation, Kaiser Permanente Southern California, Pasadena, CA
| | - Theodore R. Levin
- Division of Research, Kaiser Permanente Northern California, Oakland, CA
| | - Douglas A. Corley
- Division of Research, Kaiser Permanente Northern California, Oakland, CA
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Mehta SJ, Jensen CD, Quinn VP, Schottinger JE, Zauber AG, Meester R, Laiyemo AO, Fedewa S, Goodman M, Fletcher RH, Levin TR, Corley DA, Doubeni CA. Race/Ethnicity and Adoption of a Population Health Management Approach to Colorectal Cancer Screening in a Community-Based Healthcare System. J Gen Intern Med 2016; 31:1323-1330. [PMID: 27412426 PMCID: PMC5071288 DOI: 10.1007/s11606-016-3792-1] [Citation(s) in RCA: 47] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/06/2016] [Revised: 05/16/2016] [Accepted: 06/17/2016] [Indexed: 12/23/2022]
Abstract
BACKGROUND Screening outreach programs using population health management principles offer services uniformly to all eligible persons, but racial/ethnic colorectal cancer (CRC) screening patterns in such programs are not well known. OBJECTIVE To examine the association between race/ethnicity and the receipt of CRC screening and timely follow-up of positive results before and after implementation of a screening program. DESIGN Retrospective cohort study of screen-eligible individuals at the Kaiser Permanente Northern California community-based integrated healthcare delivery system (2004-2013). SUBJECTS A total of 868,934 screen-eligible individuals 51-74 years of age at cohort entry, which included 662,872 persons in the period before program implementation (2004-2006), 654,633 during the first 3 years after implementation (2007-2009), and 665,268 in the period from 4 to 7 years (2010-2013) after program implementation. INTERVENTION A comprehensive system-wide long-term effort to increase CRC that included leadership alignment, goal-setting, and quality assurance through a PHM approach, using mailed fecal immunochemical testing (FIT) along with offering screening at office visits. MAIN MEASURES Differences over time and by race/ethnicity in up-to-date CRC screening (overall and by test type) and timely follow-up of a positive screen. Race/ethnicity categories included non-Hispanic white, non-Hispanic black, Hispanic/Latino, Asian/Pacific Islander, Native American, and multiple races. KEY RESULTS From 2004 to 2013, age/sex-adjusted CRC screening rates increased in all groups, including 35.2 to 81.1 % among whites and 35.6 to 78.0 % among blacks. Screening rates among Hispanics (33.1 to 78.3 %) and Native Americans (29.4 to 74.5 %) remained lower than those for whites both before and after program implementation. Blacks, who had slightly higher rates before program implementation (adjusted rate ratio [RR] = 1.04, 99 % CI: 1.02-1.05), had lower rates after program implementation (RR for period from 4 to 7 years = 0.97, 99 % CI: 0.96-0.97). There were also substantial improvements in timely follow-up of positive screening results. CONCLUSIONS In this screening program using core PHM principles, CRC screening increased markedly in all racial/ethnic groups, but disparities persisted for some groups and developed in others, which correlated with levels of adoption of mailed FIT.
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Affiliation(s)
- Shivan J Mehta
- Division of Gastroenterology, Department of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | | | | | | | - Ann G Zauber
- Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Reinier Meester
- Erasmus University Medical Center (Erasmus MC), Rotterdam, Netherlands
| | - Adeyinka O Laiyemo
- Division of Gastroenterology, Howard University College of Medicine, Washington, DC, USA
| | - Stacey Fedewa
- Surveillance and Health Services Research, American Cancer Society, Atlanta, GA, USA.,Emory University, Atlanta, GA, USA
| | | | | | | | | | - Chyke A Doubeni
- Department of Family Medicine and Community Health, University of Pennsylvania Perelman School of Medicine, 3400 Spruce Street, Gates 2 Pavilion, Philadelphia, PA, 19104, USA.
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Meester RG, Zauber AG, Doubeni CA, Jensen CD, Quinn VP, Helfand M, Dominitz JA, Levin TR, Corley DA, Lansdorp-Vogelaar I. Consequences of Increasing Time to Colonoscopy Examination After Positive Result From Fecal Colorectal Cancer Screening Test. Clin Gastroenterol Hepatol 2016; 14:1445-1451.e8. [PMID: 27211498 PMCID: PMC5028249 DOI: 10.1016/j.cgh.2016.05.017] [Citation(s) in RCA: 66] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2016] [Revised: 04/15/2016] [Accepted: 05/02/2016] [Indexed: 02/06/2023]
Abstract
BACKGROUND & AIMS Delays in diagnostic testing after a positive result from a screening test can undermine the benefits of colorectal cancer (CRC) screening, but there are few empirical data on the effects of such delays. We used microsimulation modeling to estimate the consequences of time to colonoscopy after a positive result from a fecal immunochemical test (FIT). METHODS We used an established microsimulation model to simulate an average-risk United States population cohort that underwent annual FIT screening (from ages 50 to 75 years), with follow-up colonoscopy examinations for individuals with positive results (cutoff, 20 μg/g) at different time points in the following 12 months. Main evaluated outcomes were CRC incidence and mortality; additional outcomes were total life-years lost and net costs of screening. RESULTS For individuals who underwent diagnostic colonoscopy within 2 weeks of a positive result from an FIT, the estimated lifetime risk of CRC incidence was 35.5/1000 persons, and mortality was 7.8/1000 persons. Every month added until colonoscopy was associated with a 0.1/1000 person increase in cancer incidence risk (an increase of 0.3%/month, compared with individuals who received colonoscopies within 2 weeks) and mortality risk (increase of 1.4%/month). Among individuals who received colonoscopy examinations 12 months after a positive result from an FIT, the incidence of CRC was 37.0/1000 persons (increase of 4%, compared with 2 weeks), and mortality was 9.1/1000 persons (increase of 16%). Total years of life gained for the entire screening cohort decreased from an estimated 93.7/1000 persons with an almost immediate follow-up colonoscopy (cost savings of $208 per patient, compared with no colonoscopy) to 84.8/1000 persons with follow-up colonoscopies at 12 months (decrease of 9%; cost savings of $100/patient, compared with no colonoscopy). CONCLUSIONS By using a microsimulation model of an average-risk United States screening cohort, we estimated that delays of up to 12 months after a positive result from an FIT can produce proportional losses of up to nearly 10% in overall screening benefits. These findings indicate the importance of timely follow-up colonoscopy examinations of patients with positive results from FITs.
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Affiliation(s)
- Reinier G.S. Meester
- Department of Public Health, Erasmus MC University Medical Center, Rotterdam, Netherlands
| | - Ann G. Zauber
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY, United States
| | - Chyke A. Doubeni
- Department of Family Medicine and Community Health in the Perelman School of Medicine, Department of Epidemiology in the Perelman School of Medicine, and the Leonard Davis Institute of Health Economics and Center for Public Health Initiatives, University of Pennsylvania, Philadelphia, PA, United States
| | | | - Virginia P. Quinn
- Kaiser Permanente Southern California, Research & Evaluation, Pasadena, CA, United States
| | - Mark Helfand
- Veterans Affairs Portland Healthcare System, Portland, OR, United States
| | - Jason A. Dominitz
- Veterans Affairs Puget Sound Healthcare System, Seattle, WA, United States,Division of Gastroenterology, University of Washington School of Medicine, Seattle, Washington, USA
| | | | | | - Iris Lansdorp-Vogelaar
- Department of Public Health, Erasmus MC University Medical Center, Rotterdam, Netherlands
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Jensen CD, Corley DA, Quinn VP, Doubeni CA, Zauber AG, Lee JK, Zhao WK, Marks AR, Schottinger JE, Ghai NR, Lee AT, Contreras R, Klabunde CN, Quesenberry CP, Levin TR, Mysliwiec PA. Fecal Immunochemical Test Program Performance Over 4 Rounds of Annual Screening: A Retrospective Cohort Study. Ann Intern Med 2016; 164:456-63. [PMID: 26811150 PMCID: PMC4973858 DOI: 10.7326/m15-0983] [Citation(s) in RCA: 161] [Impact Index Per Article: 20.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND The fecal immunochemical test (FIT) is a common method for colorectal cancer (CRC) screening, yet its acceptability and performance over several rounds of annual testing are largely unknown. OBJECTIVE To assess FIT performance characteristics over 4 rounds of annual screening. DESIGN Retrospective cohort study. SETTING Kaiser Permanente Northern and Southern California. PATIENTS 323 349 health plan members aged 50 to 70 years on their FIT mailing date in 2007 or 2008 who completed the first round of FIT and were followed for up to 4 screening rounds. MEASUREMENTS Screening participation, FIT positivity (≥20 µg of hemoglobin/g), positive predictive values for adenoma and CRC, and FIT sensitivity for detecting CRC obtained from Kaiser Permanente electronic databases and cancer registries. RESULTS Of the patients invited for screening, 48.2% participated in round 1. Of those who remained eligible, 75.3% to 86.1% participated in subsequent rounds. Median follow-up was 4.0 years, and 32% of round 1 participants crossed over to endoscopy over 4 screening rounds-7.0% due to a positive FIT result. The FIT positivity rate (5.0%) and positive predictive values (adenoma, 51.5%; CRC, 3.4%) were highest in round 1. Overall, programmatic FIT screening detected 80.4% of patients with CRC diagnosed within 1 year of testing, including 84.5% in round 1 and 73.4% to 78.0% in subsequent rounds. LIMITATION Screening detection, rather than long-term cancer prevention, was evaluated. CONCLUSION Annual FIT screening was associated with high sensitivity for CRC, with high adherence to annual follow-up screening among initial participants. The findings indicate that annual programmatic FIT screening is feasible and effective for population-level CRC screening. PRIMARY FUNDING SOURCE National Institutes of Health.
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Atkins L, Hunkeler EM, Jensen CD, Michie S, Lee JK, Doubeni CA, Zauber AG, Levin TR, Quinn VP, Corley DA. Factors influencing variation in physician adenoma detection rates: a theory-based approach for performance improvement. Gastrointest Endosc 2016; 83:617-26.e2. [PMID: 26366787 PMCID: PMC4762744 DOI: 10.1016/j.gie.2015.08.075] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/14/2015] [Accepted: 08/07/2015] [Indexed: 02/07/2023]
Abstract
BACKGROUND AND AIMS Interventions to improve physician adenoma detection rates for colonoscopy have generally not been successful, and there are little data on the factors contributing to variation that may be appropriate targets for intervention. We sought to identify factors that may influence variation in detection rates by using theory-based tools for understanding behavior. METHODS We separately studied gastroenterologists and endoscopy nurses at 3 Kaiser Permanente Northern California medical centers to identify potentially modifiable factors relevant to physician adenoma detection rate variability by using structured group interviews (focus groups) and theory-based tools for understanding behavior and eliciting behavior change: the Capability, Opportunity, and Motivation behavior model; the Theoretical Domains Framework; and the Behavior Change Wheel. RESULTS Nine factors potentially associated with adenoma detection rate variability were identified, including 6 related to capability (uncertainty about which types of polyps to remove, style of endoscopy team leadership, compromised ability to focus during an examination due to distractions, examination technique during withdrawal, difficulty detecting certain types of adenomas, and examiner fatigue and pain), 2 related to opportunity (perceived pressure due to the number of examinations expected per shift and social pressure to finish examinations before scheduled breaks or the end of a shift), and 1 related to motivation (valuing a meticulous examination as the top priority). Examples of potential intervention strategies are provided. CONCLUSIONS By using theory-based tools, this study identified several novel and potentially modifiable factors relating to capability, opportunity, and motivation that may contribute to adenoma detection rate variability and be appropriate targets for future intervention trials.
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Affiliation(s)
- Louise Atkins
- Centre for Behaviour Change, University College London, London, England
| | | | | | - Susan Michie
- Centre for Behaviour Change, University College London, London, England
| | | | - Chyke A. Doubeni
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Ann G. Zauber
- Department of Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY
| | | | - Virginia P. Quinn
- Kaiser Permanente Southern California, Research and Evaluation, Pasadena, CA
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Marks AR, Pietrofesa RA, Jensen CD, Zebrowski A, Corley DA, Doubeni CA. Metformin use and risk of colorectal adenoma after polypectomy in patients with type 2 diabetes mellitus. Cancer Epidemiol Biomarkers Prev 2015; 24:1692-8. [PMID: 26377195 DOI: 10.1158/1055-9965.epi-15-0559] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2015] [Accepted: 08/24/2015] [Indexed: 12/28/2022] Open
Abstract
BACKGROUND Existing literature suggests that metformin, the most commonly used biguanide, may lower colorectal cancer risk. Because most colorectal cancers originate in precancerous adenomas, we examined whether metformin use lowered colorectal adenoma risk after polypectomy in patients with type-2 diabetes. METHODS Retrospective cohort study of 40- to 89-year-old Kaiser Permanente Northern California patients who had type 2 diabetes, and ≥1 adenoma detected at baseline colonoscopy during 2000 to 2009 and a repeat colonoscopy 1 to 10 years from baseline adenoma diagnosis through 2012. Cox models evaluated the association between metformin use during follow-up and subsequent adenoma diagnoses, controlling for age, race/ethnicity, sex, body mass index, and repeat examination indication. RESULTS Study included 2,412 patients followed for a median of 4.5 years; cumulatively, 1,117 (46%) patients had ≥1 adenoma at repeat colonoscopy. Compared with patients not receiving diabetes medications (n = 1,578), metformin-only use (n = 457) was associated with lower adenoma recurrence risk [adjusted HR, 0.76; 95% confidence interval (CI), 0.65-0.89], and the association was stronger with increasing total metformin dose [quartile (Q) 1: HR, 0.90; 95% CI, 0.72-1.12; Q2: HR, 0.89; 95% CI, 0.70-1.12; Q3: HR, 0.80; 95% CI, 0.63-1.01; Q4: HR, 0.50; 95% CI, 0.42-0.60, Ptrend < 0.001]. Findings were unchanged in sensitivity analyses, including evaluating only outcomes during the 3- to 10-year period from baseline. CONCLUSION Our study suggests a potential benefit of metformin use in lowering the risk of subsequent adenomas after polypectomy in patients with type 2 diabetes. IMPACT Metformin may lower colorectal cancer risk by reducing the formation of precancerous lesions, reinforcing the potential additional benefits of its use.
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Affiliation(s)
- Amy R Marks
- Division of Research, Kaiser Permanente Northern California, Oakland, California
| | - Ralph A Pietrofesa
- Department of Family Medicine and Community Health, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania. Center for Public Health Initiatives, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Christopher D Jensen
- Division of Research, Kaiser Permanente Northern California, Oakland, California
| | - Alexis Zebrowski
- Department of Family Medicine and Community Health, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
| | - Douglas A Corley
- Division of Research, Kaiser Permanente Northern California, Oakland, California
| | - Chyke A Doubeni
- Department of Family Medicine and Community Health, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania.
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Goodman M, Fletcher RH, Doria-Rose VP, Jensen CD, Zebrowski AM, Becerra TA, Quinn VP, Zauber AG, Corley DA, Doubeni CA. Observational methods to assess the effectiveness of screening colonoscopy in reducing right colon cancer mortality risk: SCOLAR. J Comp Eff Res 2015. [PMID: 26201973 DOI: 10.2217/cer.15.39] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
AIMS Screening colonoscopy's effectiveness in reducing risk of death from right colon cancers remains unclear. Methodological challenges of existing observational studies addressing this issue motivated the design of 'Effectiveness of Screening for Colorectal Cancer in Average-Risk Adults (SCOLAR)'. METHODS SCOLAR is a nested case-control study based on two large integrated health systems. This affords access to a large, well-defined historical cohort linked to integrated data on cancer outcomes, patient eligibility, test indications and important confounders. RESULTS We found electronic data adequate for excluding ineligible patients (except family history), but not the detailed information needed for test indication assignment. CONCLUSION The lessons of SCOLAR's design and implementation may be useful for future studies seeking to evaluate the effectiveness of screening tests in community settings.
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Affiliation(s)
- Michael Goodman
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA 30322, USA
| | - Robert H Fletcher
- Department of Population Health, Harvard Medical School, Boston, MA 02115, USA
| | - V Paul Doria-Rose
- Division of Cancer Control & Population Sciences, National Cancer Institute, Bethesda, MD 20892, USA
| | | | - Alexis M Zebrowski
- Department of Family Medicine & Community Health, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA
| | - Tracy A Becerra
- Department of Research & Evaluation, Kaiser Permanente, Pasadena, CA 91107, USA
| | - Virginia P Quinn
- Department of Research & Evaluation, Kaiser Permanente, Pasadena, CA 91107, USA
| | - Ann G Zauber
- Department of Epidemiology & Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY 10065, USA
| | | | - Chyke A Doubeni
- Department of Family Medicine & Community Health, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA
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Meester RGS, Doubeni CA, Lansdorp-Vogelaar I, Jensen CD, van der Meulen MP, Levin TR, Quinn VP, Schottinger JE, Zauber AG, Corley DA, van Ballegooijen M. Variation in Adenoma Detection Rate and the Lifetime Benefits and Cost of Colorectal Cancer Screening: A Microsimulation Model. JAMA 2015; 313:2349-58. [PMID: 26080339 PMCID: PMC4631392 DOI: 10.1001/jama.2015.6251] [Citation(s) in RCA: 62] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
IMPORTANCE Colonoscopy is the most commonly used colorectal cancer screening test in the United States. Its quality, as measured by adenoma detection rates (ADRs), varies widely among physicians, with unknown consequences for the cost and benefits of screening programs. OBJECTIVE To estimate the lifetime benefits, complications, and costs of an initial colonoscopy screening program at different levels of adenoma detection. DESIGN, SETTING, AND PARTICIPANTS Microsimulation modeling with data from a community-based health care system on ADR variation and cancer risk among 57,588 patients examined by 136 physicians from 1998 through 2010. EXPOSURES Using modeling, no screening was compared with screening initiation with colonoscopy according to ADR quintiles (averages 15.3%, quintile 1; 21.3%, quintile 2; 25.6%, quintile 3; 30.9%, quintile 4; and 38.7%, quintile 5) at ages 50, 60, and 70 years with appropriate surveillance of patients with adenoma. MAIN OUTCOMES AND MEASURES Estimated lifetime colorectal cancer incidence and mortality, number of colonoscopies, complications, and costs per 1000 patients, all discounted at 3% per year and including 95% confidence intervals from multiway probabilistic sensitivity analysis. RESULTS In simulation modeling, among unscreened patients the lifetime risk of colorectal cancer incidence was 34.2 per 1000 (95% CI, 25.9-43.6) and risk of mortality was 13.4 per 1000 (95% CI, 10.0-17.6). Among screened patients, simulated lifetime incidence decreased with lower to higher ADRs (26.6; 95% CI, 20.0-34.3 for quintile 1 vs 12.5; 95% CI, 9.3-16.5 for quintile 5) as did mortality (5.7; 95% CI, 4.2-7.7 for quintile 1 vs 2.3; 95% CI, 1.7-3.1 for quintile 5). Compared with quintile 1, simulated lifetime incidence was on average 11.4% (95% CI, 10.3%-11.9%) lower for every 5 percentage-point increase of ADRs and for mortality, 12.8% (95% CI, 11.1%-13.7%) lower. Complications increased from 6.0 (95% CI, 4.0-8.5) of 2777 colonoscopies (95% CI, 2626-2943) in quintile 1 to 8.9 (95% CI, 6.1-12.0) complications of 3376 (95% CI, 3081-3681) colonoscopies in quintile 5. Estimated net screening costs were lower from quintile 1 (US $2.1 million, 95% CI, $1.8-$2.4 million) to quintile 5 (US $1.8 million, 95% CI, $1.3-$2.3 million) due to averted cancer treatment costs. Results were stable across sensitivity analyses. CONCLUSIONS AND RELEVANCE In this microsimulation modeling study, higher adenoma detection rates in screening colonoscopy were associated with lower lifetime risks of colorectal cancer and colorectal cancer mortality without being associated with higher overall costs. Future research is needed to assess whether increasing adenoma detection would be associated with improved patient outcomes.
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Affiliation(s)
- Reinier G S Meester
- the Netherlands Institute of Health Sciences, Erasmus MC University Medical Center, Rotterdam2Department of Public Health, Erasmus MC University Medical Center, Rotterdam, the Netherlands
| | - Chyke A Doubeni
- Department of Family Medicine and Community Health, Perelman School of Medicine, University of Pennsylvania, Philadelphia4Department of Epidemiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia5The Leonard Davis Center for Health
| | - Iris Lansdorp-Vogelaar
- Department of Public Health, Erasmus MC University Medical Center, Rotterdam, the Netherlands
| | | | - Miriam P van der Meulen
- Department of Public Health, Erasmus MC University Medical Center, Rotterdam, the Netherlands
| | | | - Virginia P Quinn
- Research and Evaluation, Kaiser Permanente Southern California, Pasadena
| | | | - Ann G Zauber
- Department of Epidemiology and Biostatistics, Memorial Sloan-Kettering Cancer Center, New York, New York
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Ghai NR, Corley DA, Doubeni CA, Jensen CD, Schottinger JE, Zauber AG, Levin TR, Quinn VP. Disparities in Colorectal Cancer Screening Rates Among Asian Subgroups in a Large Managed Care Organization. J Patient Cent Res Rev 2015. [DOI: 10.17294/2330-0698.1062] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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Becerra TA, Quinn VP, Corley DA, Goodman M, Zauber AG, Jensen CD, Zebrowski A, Doubeni CA. Implementing a Multisite, Transdisciplinary Case-Control Study to Assess Effectiveness of Screening Colonoscopy for Preventing Death From Colorectal Cancer (SCOLAR). J Patient Cent Res Rev 2015. [DOI: 10.17294/2330-0698.1067] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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Hillyer GC, Jensen CD, Zhao WK, Neugut AI, Lebwohl B, Corley DA. Adverse Effects of Fecal-Based Colorectal Cancer Screening. J Patient Cent Res Rev 2015. [DOI: 10.17294/2330-0698.1166] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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Lee JK, Jensen CD, Lee A, Doubeni CA, Zauber AG, Levin TR, Zhao WK, Corley DA. Development and validation of an algorithm for classifying colonoscopy indication. Gastrointest Endosc 2015; 81:575-582.e4. [PMID: 25577596 PMCID: PMC4340717 DOI: 10.1016/j.gie.2014.07.031] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/12/2014] [Accepted: 07/10/2014] [Indexed: 01/01/2023]
Abstract
BACKGROUND Accurate determination of colonoscopy indication is required for managing clinical programs and performing research; however, existing algorithms that use available electronic databases (eg, diagnostic and procedure codes) have yielded limited accuracy. OBJECTIVE To develop and validate an algorithm for classifying colonoscopy indication that uses comprehensive electronic medical data sources. DESIGN We developed an algorithm for classifying colonoscopy indication by using commonly available electronic diagnostic, pathology, cancer, and laboratory test databases and validated its performance characteristics in comparison with a comprehensive review of patient medical records. We also evaluated the influence of each data source on the algorithm's performance characteristics. SETTING Kaiser Permanente Northern California healthcare system. PATIENTS A total of 300 patients who underwent colonoscopy between 2007 and 2010. INTERVENTIONS Colonoscopy. MAIN OUTCOME MEASUREMENTS Algorithm's sensitivity, specificity, and positive predictive value (PPV) for classifying screening, surveillance, and diagnostic colonoscopies. The reference standard was the indication assigned after comprehensive medical record review. RESULTS For screening indications, the algorithm's sensitivity was 88.5% (95% confidence interval [CI], 80.4%-91.7%), specificity was 91.7% (95% CI, 87.0%-95.1%), and PPV was 83.3% (95% CI, 74.7%-90.0%). For surveillance indications, the algorithm's sensitivity was 93.4% (95% CI, 86.2%-97.5%), specificity was 92.8% (95% CI, 88.4%-95.9%), and PPV was 85.0% (95% CI, 76.5%-91.4%). The algorithm's sensitivity, specificity, and PPV for diagnostic indications were 81.4% (95% CI, 73.0%-88.1%), 96.8% (95% CI, 93.2%-98.8%), and 93.9% (95% CI, 87.2%-97.7%), respectively. LIMITATIONS Validation was confined to a single healthcare system. CONCLUSION An algorithm that uses commonly available modern electronic medical data sources yielded a high sensitivity, specificity, and PPV for classifying screening, surveillance, and diagnostic colonoscopy indications. This algorithm had greater accuracy than the indication listed on the colonoscopy report.
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Affiliation(s)
- Jeffrey K Lee
- Department of Medicine, Division of Gastroenterology, University of California San Francisco, San Francisco, California, USA
| | - Christopher D Jensen
- Division of Research, Kaiser Permanente Northern California, Oakland, California, USA
| | - Alexander Lee
- Department of Medicine, Division of Gastroenterology, University of California San Francisco, San Francisco, California, USA
| | - Chyke A Doubeni
- Department of Family Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Ann G Zauber
- Department of Epidemiology and Biostatistics, Memorial Sloan-Kettering Cancer Center, New York, New York, USA
| | - Theodore R Levin
- Division of Research, Kaiser Permanente Northern California, Oakland, California, USA
| | - Wei K Zhao
- Division of Research, Kaiser Permanente Northern California, Oakland, California, USA
| | - Douglas A Corley
- Division of Research, Kaiser Permanente Northern California, Oakland, California, USA
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Corley DA, Jensen CD, Marks AR, Zhao WK, Lee JK, Doubeni CA, Zauber AG, de Boer J, Fireman BH, Schottinger JE, Quinn VP, Ghai NR, Levin TR, Quesenberry CP. Adenoma detection rate and risk of colorectal cancer and death. N Engl J Med 2014. [PMID: 24693890 DOI: 10.1056/nejmoa1309086)] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND The proportion of screening colonoscopic examinations performed by a physician that detect one or more adenomas (the adenoma detection rate) is a recommended quality measure. However, little is known about the association between this rate and patients' risks of a subsequent colorectal cancer (interval cancer) and death. METHODS Using data from an integrated health care delivery organization, we evaluated the associations between the adenoma detection rate and the risks of colorectal cancer diagnosed 6 months to 10 years after colonoscopy and of cancer-related death. With the use of Cox regression, our estimates of attributable risk were adjusted for the demographic characteristics of the patients, indications for colonoscopy, and coexisting conditions. RESULTS We evaluated 314,872 colonoscopies performed by 136 gastroenterologists; the adenoma detection rates ranged from 7.4 to 52.5%. During the follow-up period, we identified 712 interval colorectal adenocarcinomas, including 255 advanced-stage cancers, and 147 deaths from interval colorectal cancer. The unadjusted risks of interval cancer according to quintiles of adenoma detection rates, from lowest to highest, were 9.8, 8.6, 8.0, 7.0, and 4.8 cases per 10,000 person-years of follow-up, respectively. Among patients of physicians with adenoma detection rates in the highest quintile, as compared with patients of physicians with detection rates in the lowest quintile, the adjusted hazard ratio for any interval cancer was 0.52 (95% confidence interval [CI], 0.39 to 0.69), for advanced-stage interval cancer, 0.43 (95% CI, 0.29 to 0.64), and for fatal interval cancer, 0.38 (95% CI, 0.22 to 0.65). Each 1.0% increase in the adenoma detection rate was associated with a 3.0% decrease in the risk of cancer (hazard ratio, 0.97; 95% CI, 0.96 to 0.98). CONCLUSIONS The adenoma detection rate was inversely associated with the risks of interval colorectal cancer, advanced-stage interval cancer, and fatal interval cancer. (Funded by the Kaiser Permanente Community Benefit program and the National Cancer Institute.).
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Affiliation(s)
- Douglas A Corley
- From the Division of Research, Kaiser Permanente, Oakland (D.A.C., C.D.J., A.R.M., W.K.Z., J.K.L., J.B., B.H.F., T.R.L., C.P.Q.), and Research and Evaluation, Kaiser Permanente Southern California, Pasadena (J.E.S., V.P.Q., N.R.G.) - both in California; the Department of Family Medicine and Community Health, Perelman School of Medicine, University of Pennsylvania, Philadelphia (C.A.D.); and the Department of Public Health, Memorial Sloan-Kettering Cancer Center, New York (A.G.Z.)
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Corley DA, Jensen CD, Marks AR, Zhao WK, Lee JK, Doubeni CA, Zauber AG, de Boer J, Fireman BH, Schottinger JE, Quinn VP, Ghai NR, Levin TR, Quesenberry CP. Adenoma detection rate and risk of colorectal cancer and death. N Engl J Med 2014; 370:1298-306. [PMID: 24693890 PMCID: PMC4036494 DOI: 10.1056/nejmoa1309086] [Citation(s) in RCA: 1378] [Impact Index Per Article: 137.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND The proportion of screening colonoscopic examinations performed by a physician that detect one or more adenomas (the adenoma detection rate) is a recommended quality measure. However, little is known about the association between this rate and patients' risks of a subsequent colorectal cancer (interval cancer) and death. METHODS Using data from an integrated health care delivery organization, we evaluated the associations between the adenoma detection rate and the risks of colorectal cancer diagnosed 6 months to 10 years after colonoscopy and of cancer-related death. With the use of Cox regression, our estimates of attributable risk were adjusted for the demographic characteristics of the patients, indications for colonoscopy, and coexisting conditions. RESULTS We evaluated 314,872 colonoscopies performed by 136 gastroenterologists; the adenoma detection rates ranged from 7.4 to 52.5%. During the follow-up period, we identified 712 interval colorectal adenocarcinomas, including 255 advanced-stage cancers, and 147 deaths from interval colorectal cancer. The unadjusted risks of interval cancer according to quintiles of adenoma detection rates, from lowest to highest, were 9.8, 8.6, 8.0, 7.0, and 4.8 cases per 10,000 person-years of follow-up, respectively. Among patients of physicians with adenoma detection rates in the highest quintile, as compared with patients of physicians with detection rates in the lowest quintile, the adjusted hazard ratio for any interval cancer was 0.52 (95% confidence interval [CI], 0.39 to 0.69), for advanced-stage interval cancer, 0.43 (95% CI, 0.29 to 0.64), and for fatal interval cancer, 0.38 (95% CI, 0.22 to 0.65). Each 1.0% increase in the adenoma detection rate was associated with a 3.0% decrease in the risk of cancer (hazard ratio, 0.97; 95% CI, 0.96 to 0.98). CONCLUSIONS The adenoma detection rate was inversely associated with the risks of interval colorectal cancer, advanced-stage interval cancer, and fatal interval cancer. (Funded by the Kaiser Permanente Community Benefit program and the National Cancer Institute.).
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Affiliation(s)
- Douglas A Corley
- From the Division of Research, Kaiser Permanente, Oakland (D.A.C., C.D.J., A.R.M., W.K.Z., J.K.L., J.B., B.H.F., T.R.L., C.P.Q.), and Research and Evaluation, Kaiser Permanente Southern California, Pasadena (J.E.S., V.P.Q., N.R.G.) - both in California; the Department of Family Medicine and Community Health, Perelman School of Medicine, University of Pennsylvania, Philadelphia (C.A.D.); and the Department of Public Health, Memorial Sloan-Kettering Cancer Center, New York (A.G.Z.)
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Block G, Shaikh N, Jensen CD, Volberg V, Holland N. Serum vitamin C and other biomarkers differ by genotype of phase 2 enzyme genes GSTM1 and GSTT1. Am J Clin Nutr 2011; 94:929-37. [PMID: 21813807 PMCID: PMC3155929 DOI: 10.3945/ajcn.111.011460] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Glutathione S-transferases (GSTs) detoxify environmental chemicals and are involved in oxidative stress pathways. Deletion polymorphisms affect enzyme activities and have been associated with risk of disease. OBJECTIVE The objective was to clarify whether biomarkers of oxidation, antioxidation, inflammation, and nutritional factors differ by GST genotype in healthy adults. DESIGN Subjects (n = 383) consisted of nonsmokers and nonusers of antiinflammatory drugs and antioxidant vitamin supplements. Deletion polymorphisms of GSTM1 and GSTT1 were genotyped. F(2)-isoprostanes, malondialdehyde, C-reactive protein, serum vitamin C, carotenoids, tocopherols, and other nutritional factors were assessed. RESULTS The concentration of serum vitamin C was higher in persons with the inactive GSTM1-0 genotype (P = 0.006). This relation was unchanged after adjustment for age, sex, BMI, or dietary vitamin C. F(2)-isoprostanes and malondialdehyde were lower in the GSTM1-0 and GSTT1-0 groups, respectively, but significance was lost after control for serum vitamin C. The dual deletion, GSTM1-0/GSTT1-0 (n = 37), was associated with higher serum iron and total and LDL-cholesterol concentrations (all P < 0.01) and lower malondialdehyde concentrations, which persisted after adjustment for age, sex, BMI, and serum vitamin C. Carotenoids and α- and γ-tocopherols were not associated with either genotype. CONCLUSIONS Oxidative stress and inflammation biomarkers differ by GST genotype, but serum vitamin C appears to be the most consistent factor. Examination of other relevant genes may be needed to understand the concentration and function of ascorbic acid in the GST enzyme system. This trial is registered at clinicaltrials.gov as NCT00079963.
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Affiliation(s)
- Gladys Block
- School of Public Health, University of California at Berkeley, 94720-7360, USA.
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Jensen CD, Steval A, Partington PF, Reed MR, Muller SD. Return to theatre following total hip and knee replacement, before and after the introduction of rivaroxaban: a retrospective cohort study. ACTA ACUST UNITED AC 2011; 93:91-5. [PMID: 21196550 DOI: 10.1302/0301-620x.93b1.24987] [Citation(s) in RCA: 77] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Rivaroxaban has been recommended for routine use as a thromboprophylactic agent in patients undergoing lower-limb arthroplasty. However, trials supporting its use have not fully evaluated the risks of wound complications. This study of 1048 total hip/knee replacements records the rates of return to theatre and infection before and after the change from a low molecular weight heparin (tinzaparin) to rivaroxaban as the agent of chemical thromboprophylaxis in patients undergoing lower-limb arthroplasty. During a period of 13 months, 489 consecutive patients undergoing lower-limb arthroplasty received tinzaparin and the next 559 consecutive patients received rivaroxaban as thromboprophylaxis. Nine patients in the control (tinzaparin) group (1.8%, 95% confidence interval 0.9 to 3.5) returned to theatre with wound complications within 30 days, compared with 22 patients in the rivaroxaban group (3.94%, 95% confidence interval 2.6 to 5.9). This increase was statistically significant (p = 0.046). The proportion of patients who returned to theatre and became infected remained similar (p = 0.10). Our study demonstrates the need for further randomised controlled clinical trials to be conducted to assess the safety and efficacy of rivaroxaban in clinical practice, focusing on the surgical complications as well as the potential prevention of venous thromboembolism.
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Affiliation(s)
- C D Jensen
- Wansbeck General Hospital, Woodhorn Lane, Ashington, Northumberland NE63 9JJ, UK.
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Maki KC, Rubin MR, Wong LG, McManus JF, Jensen CD, Lawless A. Effects of vitamin D supplementation on 25-hydroxyvitamin D, high-density lipoprotein cholesterol, and other cardiovascular disease risk markers in subjects with elevated waist circumference. Int J Food Sci Nutr 2011; 62:318-27. [PMID: 21250901 DOI: 10.3109/09637486.2010.536146] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
The objective of the present trial was to assess the effects of vitamin D supplementation on serum 25-hydroxyvitamin D [25(OH)D] and high-density lipoprotein cholesterol (HDL-C) in subjects with high waist circumference. Subjects were randomly assigned a daily multivitamin and mineral (MVM) supplement or a MVM supplement plus vitamin D 1,200 IU/day (MVM+D) for 8 weeks. There was a significant difference in mean change for 25(OH)D between the MVM and MVM+D treatment groups ( - 1.2 ± 2.5 nmol/l vs. 11.7 ± 3.0 nmol/l, respectively; P = 0.003). Vitamin D 1,200 IU/day did not increase 25(OH)D to a desirable level ( ≥ 75 nmol/l) in 61% of participants. There were no significant changes in cardiovascular disease risk markers. Thus, vitamin D supplementation with 1,200 IU/day was insufficient to achieve desirable serum 25(OH)D in most participants and did not affect cardiovascular disease risk markers.
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Affiliation(s)
- Kevin C Maki
- Provident Clinical Research, Glen Ellyn, Illinois 60137, USA.
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