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Screening for Colorectal (Bowel) Cancer

Prevention and early detection of colorectal cancer is important, many patients do not show symptoms until the disease has reached an advanced stage; screening may help detect changes before they become cancerous, or catch the cancer at an early stage. Screening may by targeted at populations thought to have a higher risk of developing colorectal cancer (for example those over age 50, particularly those with a 1st degree relative dignosed with colorectal cancer, or familial predispostion to adenomatous polyposis).

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Colorectal (Bowel) Cancer

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Latest Research Publications

This list of publications is regularly updated (Source: PubMed).

Lieberman D, Ladabaum U, Cruz-Correa M, et al.
Screening for Colorectal Cancer and Evolving Issues for Physicians and Patients: A Review.
JAMA. 2016; 316(20):2135-2145 [PubMed] Related Publications
Importance: Colorectal cancer (CRC) is the second-leading cause of cancer death in the United States. Screening can reduce CRC mortality and incidence, and numerous screening options, although available, complicate informed decision making. This review provides evidence-based tools for primary care physicians to identify patients with higher-than-average-risk and engage patients in informed decision making about CRC screening options.
Observations: Recently, the US Preventive Services Task Force recommended any of 8 CRC screening approaches for average-risk individuals, beginning at age 50 years. Only 2 methods have been shown in randomized clinical trials to reduce mortality: fecal occult blood testing and flexible sigmoidoscopy. Of the 8 programs, screenings using the fecal immunochemical test annually and colonoscopy every 10 years are now the most commonly used tests in the United States and among the most effective in reducing CRC mortality as determined by decision models. With the exception of primary screening using colonoscopy, all of the other screening approaches have multiple steps. Adherence to each phase of a multistep program is critical to achieving maximal effectiveness of the screening program. It is likely that each of the recommended programs can reduce CRC mortality, but other key outcomes may differ such as lifetime burden of colonoscopy, complications, patient acceptance, and cost. Decisions about the timing of screening cessation should be individualized.
Conclusions and Relevance: CRC screening is effective if patients adhere to the steps in each screening program. There is no evidence that one program is superior to another. Informed decision-making tools are provided to assist patients and clinicians with the goal of improving adherence to effective screening.

Albrecht H, Gallitz J, Hable R, et al.
The Offer of Advanced Imaging Techniques Leads to Higher Acceptance Rates for Screening Colonoscopy - a Prospective Study.
Asian Pac J Cancer Prev. 2016; 17(8):3871-5 [PubMed] Related Publications
BACKGROUND: Colonoscopy plays a fundamental role in early diagnosis and management of colorectal cancer and requires public and professional acceptance to ensure the ongoing success of screening programs. The aim of the study was to prospectively assess whether patient acceptance rates to undergo screening colonoscopy could be improved by the offer of advanced imaging techniques.
MATERIALS AND METHODS: Overall, 372 randomly selected patients were prospectively included. A standardized questionnaire was developed that inquired of the patients their knowledge regarding advanced imaging techniques. Second, several media campaigns and information events were organized reporting about advanced imaging techniques, followed by repeated evaluation. After one year the evaluation ended.
RESULTS: At baseline, 64% of the patients declared that they had no knowledge about new endoscopic methods. After twelve months the overall grade of information increased significantly from 14% at baseline to 34%. The percentage of patients who decided to undergo colonoscopy because of the offer of new imaging methods also increased significantly from 12% at baseline to 42% after 12 months.
CONCLUSIONS: Patients were highly interested in the offer of advanced imaging techniques. Knowledge about these techniques could relatively easy be provided using local media campaigns. The offer of advanced imaging techniques leads to higher acceptance rates for screening colonoscopies.

Buchman S, Rozmovits L, Glazier RH
Equity and practice issues in colorectal cancer screening: Mixed-methods study.
Can Fam Physician. 2016; 62(4):e186-93 [PubMed] Free Access to Full Article Related Publications
OBJECTIVE: To investigate overall colorectal cancer (CRC) screening rates, patterns in the use of types of CRC screening, and sociodemographic characteristics associated with CRC screening; and to gain insight into physicians' perceptions about and use of fecal occult blood testing [FOBT] and colonoscopy for patients at average risk of CRC.
DESIGN: Mixed-methods study using cross-sectional administrative data on patient sociodemographic characteristics and semistructured telephone interviews with physicians.
SETTING: Toronto, Ont.
PARTICIPANTS: Patients aged 50 to 74 years and physicians in family health teams in the Toronto Central Local Health Integration Network.
MAIN OUTCOME MEASURES: Rates of CRC screening by type; sociodemographic characteristics associated with CRC screening; thematic analysis using constant comparative method for semistructured interviews.
MAIN FINDINGS: Ontario administrative data on CRC screening showed lower overall screening rates among those who were younger, male patients, those who had lower income, and recent immigrants. Colonoscopy rates were especially low among those with lower income and those who were recent immigrants. Semistructured interviews revealed that physician opinions about CRC screening for average-risk patients were divided: one group of physicians accepted the evidence and recommendations for FOBT and the other group of physicians strongly supported colonoscopy for these patients, believing that the FOBT was an inferior screening method. Physicians identified specialist recommendations and patient expectations as factors that influenced their decisions regarding CRC screening type.
CONCLUSION: There was considerable variation in CRC screening by sociodemographic characteristics. A key theme that emerged from the interviews was that physicians were divided in their preference for FOBT or colonoscopy; factors that influenced physician preference included the health care system, recommendations by other specialists, and patient characteristics. Providing an informed choice of screening method to patients might result in higher screening rates and fewer disparities. Changes in policy and physician attitudes might be needed in order for this to occur.

Chen CH, Wen CP, Tsai MK
Fecal immunochemical test for colorectal cancer from a prospective cohort with 513,283 individuals: Providing detailed number needed to scope (NNS) before colonoscopy.
Medicine (Baltimore). 2016; 95(36):e4414 [PubMed] Free Access to Full Article Related Publications
The fecal immunochemical test (FIT) is underutilized, in part, because its benefits have not been fully understood. We assessed the relationship of FIT values with cancer incidence and mortality, and explored how repeated administrations of FIT could aid clinicians. A cohort with 513,283 adults in Taiwan participated in a screening program between 1994 and the end of 2007. Colorectal cancer was identified from National Cancer Registry and not from colonoscopy. Positive FIT was FIT ≥ 100 ng/mL. Number needed to scope (NNS) to identify 1 cancer by different FIT values was calculated for the study time. Only 4% of subjects had FIT ≥ 100 ng/mL but contributed 40% of cancer cases, leading to a NNS of 25 for finding 1 in this group. However, within the same FIT ≥ 100 ng/mL, NNS was different by age: 10 for age 60 to 69 years, 42 for age 40 to 49 years, and 156 for age 20 to 39 years. Furthermore, within the same age, NNS was different by FIT values, for instance, 66 for FIT 100 to 199 ng/mL and 12 for FIT 600 to 799 ng/mL, a difference of 5-fold for age 50 to 59 years. The dose-response relationship of FIT can facilitate consultation regarding the need for colonoscopy by providing a quantitative NNS for cancer risk, an index easily understood by patients. Our conclusion made use of (a) age-dependent and (b) quantitative interpretation of FIT values. This single cutpoint practice obliterates a large amount of valuable cancer risk information available to patients.

Siripongpreeda B, Mahidol C, Dusitanond N, et al.
High prevalence of advanced colorectal neoplasia in the Thai population: a prospective screening colonoscopy of 1,404 cases.
BMC Gastroenterol. 2016; 16:101 [PubMed] Free Access to Full Article Related Publications
BACKGROUND: Increasing morbidity and mortality from colorectal cancer is evident in recent years in the developing Asian nations. Particularly in Thailand and most neighbouring low-income countries, screening colonoscopy is not yet recommended nor implemented at the national policy level.
METHODS: Screening colonoscopy was offered to 1,500 healthy volunteers aged 50-65 years old who were registered into the program between July 2009 and June 2010. Biopsy and surgery was performed depending on the identified lesions. Fecal immunochemical tests (FIT) were additionally performed for comparison with colonoscopy.
RESULTS: There were 1,404 participants who underwent colonoscopy. The mean age of the cohort was 56.9 ± 4.2 years and 69.4 % were females. About 30 % (411 cases) of all colonoscopies had abnormal colonoscopic findings, and of these, 256 cases had adenomatous polyps. High risk adenomas (villous or tubulovillous or high grade dysplasia or size > 1 cm or > 3 adenomatous polyps) were found in 98 cases (7 %), low risk adenoma in 158 cases (11.3 %), and hyperplastic polyps in 119 cases (8.5 %). Eighteen cases (1.3 %) had colorectal cancer and 90 % of them (16 cases) were non-metastatic including five stage 0 cases, seven stage I cases, and four stage IIA cases. Only two cases had metastasis: one to regional lymph nodes (stage IIIB) and another to other organs (stage IVA). The most common cancer site was the distal intestine including rectum (7 cases, 38.9 %) and sigmoid colon (7 cases, 38.9 %). Ten colorectal cancer cases had positive FIT whereas 8 colorectal cancer cases were FIT-negative. The sensitivity and specificity of FIT was 55.6 % and 96.2 %, respectively, while the positive predictive value was 16.4 % and negative predictive value was 99.4 %. The overall survival of colorectal cancer cases at 5-year was 83.3 %.
CONCLUSION: High prevalence of colorectal cancer and high-risk adenoma was found in the Thai population aged 50-65 years old by screening colonoscopy. FIT was not sensitive enough to detect colorectal cancer in this asymptomatic cohort. Integration of screening colonoscopy into the national cancer screening program should be implemented to detect early cases of advanced colorectal neoplasia and improve survival of colorectal cancer patients in Thailand.

Simon K
Colorectal cancer development and advances in screening.
Clin Interv Aging. 2016; 11:967-76 [PubMed] Free Access to Full Article Related Publications
Most colon tumors develop via a multistep process involving a series of histological, morphological, and genetic changes that accumulate over time. This has allowed for screening and detection of early-stage precancerous polyps before they become cancerous in individuals at average risk for colorectal cancer (CRC), which may lead to substantial decreases in the incidence of CRC. Despite the known benefits of early screening, CRC remains the second leading cause of cancer-related deaths in the United States. Hence, it is important for health care providers to have an understanding of the risk factors for CRC and various stages of disease development in order to recommend appropriate screening strategies. This article provides an overview of the histological/molecular changes that characterize the development of CRC. It describes the available CRC screening methods and their advantages and limitations and highlights the stages of CRC development in which each screening method is most effective.

Mengual-Ballester M, Pellicer-Franco E, Valero-Navarro G, et al.
Increased survival and decreased recurrence in colorectal cancer patients diagnosed in a screening programme.
Cancer Epidemiol. 2016; 43:70-5 [PubMed] Related Publications
INTRODUCTION: Population-based screening programmes for colorectal cancer (CRC) allow an early diagnosis, even before the onset of symptoms, but there are few studies and none in Spain on the influence they have on patient survival. The aim of the present study is to show that patients receiving surgery for CRC following diagnosis via a screening programme have a higher survival and disease-free survival rate than those diagnosed in the symptomatic stage.
MATERIAL AND METHODS: Prospective study of all the patients undergoing programmed surgery for CRC at the JM Morales Meseguer Hospital in Murcia (Spain) between 2004 and 2010. The patients were divided into two groups: (a) those diagnosed through screening (125 cases); and (b) those diagnosed in the symptomatic stage (565 cases). Survival and disease-free survival were analysed and compared for both groups using the Mantel method.
RESULTS: The screen-detected CRC patients show a higher rate of survival (86.3% versus 72.1% at 5 years, p<0.05) and a lower rate of tumour recurrence (73.4% versus 88.3% at 5 years, p<0.05).
CONCLUSIONS: Population-based screening for CRC is an effective strategic measure for reducing mortality specific to this neoplasia.

Plumb AA, Ghanouni A, Rees CJ, et al.
Patient experience of CT colonography and colonoscopy after fecal occult blood test in a national screening programme.
Eur Radiol. 2017; 27(3):1052-1063 [PubMed] Free Access to Full Article Related Publications
OBJECTIVE: To investigate patient experience of CT colonography (CTC) and colonoscopy in a national screening programme.
METHODS: Retrospective analysis of patient experience postal questionnaires. We included screenees from a fecal occult blood test (FOBt) based screening programme, where CTC was performed when colonoscopy was incomplete or deemed unsuitable. We analyzed questionnaire responses concerning communication of test risks, test-related discomfort and post-test pain, as well as complications. CTC and colonoscopy responses were compared using multilevel logistic regression.
RESULTS: Of 67,114 subjects identified, 52,805 (79 %) responded. Understanding of test risks was lower for CTC (1712/1970 = 86.9 %) than colonoscopy (48783/50975 = 95.7 %, p < 0.0001). Overall, a slightly greater proportion of screenees found CTC unexpectedly uncomfortable (506/1970 = 25.7 %) than colonoscopy (10,705/50,975 = 21.0 %, p < 0.0001). CTC was tolerated well as a completion procedure for failed colonoscopy (unexpected discomfort; CTC = 26.3 %: colonoscopy = 57.0 %, p < 0.001). Post-procedural pain was equally common (CTC: 288/1970,14.6 %, colonoscopy: 7544/50,975,14.8 %; p = 0.55). Adverse event rates were similar in both groups (CTC: 20/2947 = 1.2 %; colonoscopy: 683/64,312 = 1.1 %), but generally less serious with CTC.
CONCLUSIONS: Even though CTC was reserved for individuals either unsuitable for or unable to complete colonoscopy, we found only small differences in test-related discomfort. CTC was well tolerated as a completion procedure and was extremely safe. CTC can be delivered across a national screening programme with high patient satisfaction.
KEY POINTS: • High patient satisfaction at CTC is deliverable across a national screening programme. • Patients who cannot tolerate screening colonoscopy are likely to find CTC acceptable. • CTC is extremely safe; complications are rare and almost never serious. • Patients may require more detailed information regarding the expected discomfort of CTC.

Ghobadi Dashdebi K, Noroozi A, Tahmasebi R
Factors Predicting Fecal Occult Blood Testing among Residents of Bushehr, Iran, Based on the Health Belief Model.
Asian Pac J Cancer Prev. 2016; 17 Spec No.:17-22 [PubMed] Related Publications
Colorectal cancer is a major cause of mortality worldwide. Fecal occult blood testing has proven a very effective screening tool for early detection and mortality reduction. The aim of this study was to determine predictors factors related to fecal occult blood testing using the Health Belief Model method among residents of Bushehr, Iran. A cross sectional study was performed on a sample of 600 men and women more than 50 years of age. The sample was selected by a convenience method from patients referred to public and private laboratories throughout the city. Each subject filled out a questionnaire which was designed and developed based on Health Belief Model constructs. Statistical analysis was conducted using ANOVA, T-test, chi-square test, and logistic regression. Fecal occult blood tests were performed on 179 (29.8%) out of 600 subjects, of which 95 patients (58.1%) did a periodic examination test and 84 patients (46.9%) had a doctor's advice for testing. According to the logistic regression model, the perceived barriers (P=0.0, Exp(B)= 0.3), perceived benefits (P <0.01, Exp(B)= 1.9) and self-efficacy (P<0.01, Exp(B)= 1.6) were predictive factors related to occult blood testing among subjects.The results showed that reducing people's perception of barriers to testing, increasing perceived benefits of screening, and reinforcing self efficacy can have major effect in increasing the rate of fecal occult blood screening for colorectal cancer prevention.

Harvin G
Colon Cancer Screening in North Carolina.
N C Med J. 2016 May-Jun; 77(3):183-7 [PubMed] Related Publications
Colorectal cancer (CRC) is the 2nd leading cause of cancer death both in North Carolina and in the United States. The goal of CRC screening is early detection and prevention. This commentary reviews the evidence for screening, discusses current screening options, and explores which options are best suited for use in North Carolina.

Artama M, Heinävaara S, Sarkeala T, et al.
Determinants of non-participation in a mass screening program for colorectal cancer in Finland.
Acta Oncol. 2016; 55(7):870-4 [PubMed] Related Publications
BACKGROUND: For an effective colorectal cancer (CRC) screening program, high participation rate is essential. However, non-participation in CRC screening program has increased in Finland.
MATERIAL AND METHODS: The study was based on a population-based nationwide cohort of persons invited for CRC screening in 2004-2011. Information on the first round of the CRC screening participation and related background factors was obtained from the Finnish Cancer Registry, and information about health behavior factors from the Health Behavior Survey (HBS) in 1978-1999. Non-participation in CRC screening was analyzed with Poisson regression as incidence rate ratios (IRR) with 95% confidence intervals (95% CI).
RESULTS: Of all persons invited for CRC screening (79 871 men and 80 891 women) 35% of men and 21% of women refused. Of those invited for screening, 2456 men (3.1%) and 2507 women (3.1%) were also invited to the HBS. Persons, who declined HBS, were also more likely to refuse CRC screening (men IRR 1.40, 95% CI 1.26-1.56, women 1.75, 1.52-2.02) compared to HBS participants. Never married persons had about a 75% higher risk for refusing than married ones. The youngest age group (60 years) was more likely to refuse screening than the older age groups (62 or >64 years). Smoking was associated with non-participation in screening (current smokers, men: IRR 1.32, 95% CI 1.05-1.67, women: 2.10, 1.61-2.73).
CONCLUSIONS: Participation in CRC screening was affected by gender, age, and marital status. Persons, who refused the HBS, were also more likely to refuse CRC screening. Smoking was a risk factor for non-participation in CRC screening.

Cai SR, Zhu HH, Huang YQ, et al.
Cost-Effectiveness between Double and Single Fecal Immunochemical Test(s) in a Mass Colorectal Cancer Screening.
Biomed Res Int. 2016; 2016:6830713 [PubMed] Free Access to Full Article Related Publications
This study investigated the cost-effectiveness between double and single Fecal Immunochemical Test(s) (FIT) in a mass CRC screening. A two-stage sequential screening was conducted. FIT was used as a primary screening test and recommended twice by an interval of one week at the first screening stage. We defined the first-time FIT as FIT1 and the second-time FIT as FIT2. If either FIT1 or FIT2 was positive (+), then a colonoscopy was recommended at the second stage. Costs were recorded and analyzed. A total of 24,419 participants completed either FIT1 or FIT2. The detection rate of advanced neoplasm was 19.2% among both FIT1+ and FIT2+, especially high among men with age ≥55 (27.4%). About 15.4% CRC, 18.9% advanced neoplasm, and 29.9% adenoma missed by FIT1 were detected by FIT2 alone. Average cost was $2,935 for double FITs and $2,121 for FIT1 to detect each CRC and $901 for double FITs and $680 for FIT1 to detect each advanced neoplasm. Double FITs are overall more cost-effective, having significantly higher positive and detection rates with an acceptable higher cost, than single FIT. Double FITs should be encouraged for the first screening in a mass CRC screening, especially in economically and medically underserved populations/areas/countries.

Arnold CL, Rademaker A, Wolf MS, et al.
Third Annual Fecal Occult Blood Testing in Community Health Clinics.
Am J Health Behav. 2016; 40(3):302-9 [PubMed] Article available free on PMC after 01/05/2017 Related Publications
OBJECTIVES: Our objective was to determine the effectiveness of 3 approaches to encourage completion of fecal occult blood testing (FOBT) in the third year of the intervention.
METHODS: Between 2008 and 2011, a quasi-experimental intervention was conducted in 8 predominantly rural Federally Qualified Health Centers. Clinics were randomly assigned to enhanced care (screening recommendation and FOBT kit mailed annually), education (patients additionally received a health literacy appropriate pamphlet and simplified FOBT instructions), or nurse support (same as education but with nurse follow-up). Participants included 206 patients with negative FOBTs in years 1 and 2; ages 50-85, 80% female, 70% African American, and 52% had limited health literacy. The main outcome measure was completion of a third annual FOBT.
RESULTS: Third-year FOBT rates were 48% overall, 34.2% enhanced care, 59.6% education, and 47.4% nurse support (p = .21), even after adjustment for sex, marital status, and health literacy.
CONCLUSION: All mailed interventions were similarly effective in sustaining rates of FOBT screening. Post hoc analyses of the results analyzed by health literacy skills found that patients with both limited and adequate health literacy skills were more likely to complete FOBTs when mailed simplified instructions.

V Schönfeld J, Müller-Steden B
Screening colonoscopy and colorectal cancer: a single center long term study.
Z Gastroenterol. 2016; 54(4):312-5 [PubMed] Related Publications
In Germany, colonoscopy has been introduced as a screening instrument more than 10 years ago. Immediate outcome (complications and adenoma detection) is well documented in a nation wide register, but there is only limited information on the decisive end points: long term incidence and mortality of colorectal carcinoma.We therefore tried to contact all those 495 subjects (296 women and 199 men, mean age 63.9 years) that had been screened between 2003 and 2005  at our institution. We were able to trace 472 persons (96 %), 5.1 to 7.8 years after colonoscopy; a total of 2730 person years were analysed. Data were collected by direct telephone calls and follow up colonoscopy reports were retrieved.Four malignant lesions were identified at screening. Another two colorectal carcinomas were diagnosed three and seven years after adenoma-negative colonoscopies: an advanced rectum carcinoma (index endoscopy described inadequate bowel preparation) and a coecum tumor. The patient with the rectum tumor subsequently died from the disease. The other five patients with colorectal carcinoma are disease-free. - Compliance with surveillance was limited, only 38 of 60 patients with advanced benign lesions and 49 out of 82 patients with a small tubular adenoma had a repeat colonoscopy, and this was performed a mean of 1.1 years later than advised. About half of the screened subjects were completely unaware of a recommended control interval or grossly wrong about it.We conclude that colorectal carcinomas can occur despite screening colonoscopy, but this seems to be a rare event. Subjects screened are insufficiently informed as to recommendations on post-polypectomy surveillance. This is particularly worrying in the high risk group with benign, but advanced adenomas.

Koskan AM, LeBlanc N, Rosa-Cunha I
Exploring the Perceptions of Anal Cancer Screening and Behaviors Among Gay and Bisexual Men Infected With HIV.
Cancer Control. 2016; 23(1):52-8 [PubMed] Article available free on PMC after 01/05/2017 Related Publications
BACKGROUND: The incidence of anal cancer is on the rise among HIV-infected men who have sex with men (MSM). Given the increasing availability of screening, this study explored anal cancer screening awareness and behaviors among MSM infected with HIV.
METHODS: In-depth interviews were conducted with 58 MSM infected with HIV.
RESULTS: Other than 2 participants treated for anal cancer and 3 treated for precancerous anal lesions, the majority of participants had never heard of anal cancer. Men reported lack of awareness and recommendations from their health care professionals as the greatest barriers to screening. Upon learning about their risk for anal cancer and the availability of screening, the men were eager to discuss screening with their physicians. Participants provided numerous recommendations for future interventions, including training health care professionals to promote screening, disseminating information pertaining to anal cancer through social networks, and creating media campaigns to raise awareness about the need to screen for this type of cancer.
CONCLUSIONS: Future intervention work should focus on ensuring that health care professionals, particularly among HIV/primary care specialists, promote screening for anal dysplasia. It is critical that intervention methods use a community-based approach to raise awareness about the need to screen for anal cancer, especially among MSM infected with HIV.

Pisera M, Kaminski MF, Kraszewska E, et al.
Reinvitation to screening colonoscopy: a randomized-controlled trial of reminding letter and invitation to educational meeting on attendance in nonresponders to initial invitation to screening colonoscopy (REINVITE).
Eur J Gastroenterol Hepatol. 2016; 28(5):538-42 [PubMed] Related Publications
OBJECTIVES: The response rate to initial invitation to population-based primary screening colonoscopy within the NordICC trial (NCT 00883792) in Poland is around 50%. The aim of this study was to compare the effect of a reinvitation letter and invitation to an educational intervention on participation in screening colonoscopy in nonresponders to initial invitation.
METHODS: Within the NordICC trial framework, individuals living in the region of Warsaw, who were drawn from Population Registries and assigned randomly to the screening group, received an invitation letter and a reminder with a prespecified screening colonoscopy appointment date. One thousand individuals, aged 55 to 64 years, who did not respond to both the invitation and the reminding letter were assigned randomly in a 1:1 ratio to the reinvitation group (REI) and the educational meeting group (MEET). The REI group was sent a reinvitation letter and reminder 6 and 3 weeks before the new colonoscopy appointment date, respectively. The MEET group was sent an invitation 6 weeks before an educational meeting date. Outcome measures were participation in screening colonoscopy within 6 months and response rate within 3 months from the date of reinvitation or invitation to an educational meeting.
RESULTS: The response rate and the participation rate in colonoscopy were statistically significantly higher in the REI group compared with the MEET group (16.5 vs. 4.3%; P<0.001 and 5.2 vs. 2.1%; P=0.008, respectively).
CONCLUSION: A simple reinvitation letter results in a higher response rate and participation rate to screening colonoscopy than invitation to tailored educational meeting in nonresponders to previous invitations. (NCT01183156).

Scully A, Cheung I
Colorectal Cancer Screening: Fecal Occult Blood Test Literature Review for Occupational Health Nurses.
Workplace Health Saf. 2016; 64(3):114-22; quiz 123 [PubMed] Related Publications
Colorectal cancer (CRC) is the third most commonly diagnosed cancer worldwide. It is a potentially preventable disease and ideally suited to a screening program. CRC screening is an early detection strategy for occupational health nurses to offer in the workplace. Education and outreach are key components of this intervention. Many test options are available for CRC screening. This article is an integrative literature review that summarizes evidence to support colorectal screening in the workplace, offers screening recommendations from authoritative agencies, and provides guidance for occupational health nurses who plan to implement a screening program. Current screening limitations using fecal occult blood tests are addressed and an inventory of CRC screening activities in select countries is included.

Bailey JR, Aggarwal A, Imperiale TF
Colorectal Cancer Screening: Stool DNA and Other Noninvasive Modalities.
Gut Liver. 2016; 10(2):204-11 [PubMed] Article available free on PMC after 01/05/2017 Related Publications
Colorectal cancer screening dates to the discovery of precancerous adenomatous tissue. Screening modalities and guidelines directed at prevention and early detection have evolved and resulted in a significant decrease in the prevalence and mortality of colorectal cancer via direct visualization or using specific markers. Despite continued efforts and an overall reduction in deaths attributed to colorectal cancer over the last 25 years, colorectal cancer remains one of the most common causes of malignancy-associated deaths. In attempt to further reduce the prevalence of colorectal cancer and associated deaths, continued improvement in screening quality and adherence remains key. Noninvasive screening modalities are actively being explored. Identification of specific genetic alterations in the adenoma-cancer sequence allow for the study and development of noninvasive screening modalities beyond guaiac-based fecal occult blood testing which target specific alterations or a panel of alterations. The stool DNA test is the first noninvasive screening tool that targets both human hemoglobin and specific genetic alterations. In this review we discuss stool DNA and other commercially available noninvasive colorectal cancer screening modalities in addition to other targets which previously have been or are currently under study.

Arsenault PR, John LS, OʼBrien LM
The Use of the Whole Primary-Care Team, Including Community Health Workers, to Achieve Success in Increasing Colon Cancer Screening Rate.
J Healthc Qual. 2016 Mar-Apr; 38(2):76-83 [PubMed] Related Publications
The National Colorectal Cancer Roundtable, an organization cofounded by the American Cancer Society and the Centers for Disease Control and Prevention, has set an aggressive goal to achieve an 80% colon cancer screening rate by the year 2018 to reduce the burden of colon cancer in the United States. This goal is in alignment with the primary care movement to focus on prevention and population health. However, colon cancer screening has been proven as an especially challenging preventive measure to get traction on with patients. Oakland Family Medicine, a medium primary care practice in Maine, has engaged in a quality improvement project to increase the colon cancer screening rates from 28%, when the project started, to 80.3%. To achieve these results, it required a redesign of the primary care team, including the use of team extenders like community health workers. In addition, it requires understanding the data and its flaws, knowing the workflow and working to simplify it, and finally, to be clear what problem you are trying to solve. The Oakland Family Medicine project shows that closing the gaps in care for colon cancer screening is not only possible but that the new national goal is attainable also.

Decker KM, Demers AA, Nugent Z, et al.
Reducing income-related inequities in colorectal cancer screening: lessons learned from a retrospective analysis of organised programme and non-programme screening delivery in Winnipeg, Manitoba.
BMJ Open. 2016; 6(2):e009470 [PubMed] Article available free on PMC after 01/05/2017 Related Publications
OBJECTIVE: We examined organised colorectal cancer (CRC) screening programme and non-programme faecal occult blood test (FOBT) use from 2008 to 2012 for individuals living in Winnipeg, Manitoba, by area-level income.
SETTING: Winnipeg, Manitoba, a region with universal healthcare and an organised CRC screening programme.
PARTICIPANTS: Individuals who had a non-programme FOBT were identified from the Provincial Medical Claims database. Individuals who had a programme FOBT were identified from the provincial screening registry. Census data were used to determine average household income based on area of residence.
STATISTICAL ANALYSIS: Trends in age-standardised FOBT rates were examined using Joinpoint Regression. Logistic regression was performed to explore the association between programme and non-programme FOBT use and income quintile.
RESULTS: FOBT use (non-programme and programme) increased from 32.2% in 2008 to 41.6% in 2012. Individuals living in the highest income areas (Q5) were more likely to have a non-programme FOBT compared with those living in other areas. Individuals living in areas with the lowest average income level (Q1) were less likely to have had programme FOBT than those living in areas with the highest average income level (OR 0.80, 95% CI 0.77 to 0.82). There was no difference in programme FOBT use for individuals living in areas with the second lowest income level (Q2) compared with those living in areas with the highest. Individuals living in areas with a moderate-income level (Q3 and Q4) were more likely to have had a programme FOBT compared with those living in an area with the highest income level (OR 1.12, 95% CI 1.09 to 1.15 for Q3 and OR 1.10, 95% CI 1.07 to 1.13 for Q4).
CONCLUSIONS: Inequities by income observed for non-programme FOBTs were largely eliminated when programme FOBTs were examined. Targeted interventions within organised screening programmes in very low-income areas are needed.

Colorectal cancer.
Nurs Stand. 2016; 30(25):17 [PubMed] Related Publications
Essential facts Colorectal cancer is the fourth most common cancer in the UK, after breast, lung and prostate cancer, with around 41,600 people in the UK diagnosed each year. It is the second most common cause of cancer death in the UK. According to the charity Bowel Cancer UK, 98% of people diagnosed at the earliest stage will survive, while less than 10% of those diagnosed at the latest stage will survive more than five years.

Dawson G, Crane M, Lyons C, et al.
A qualitative investigation of factors influencing participation in bowel screening in New South Wales.
Health Promot J Austr. 2016; 27(1):48-53 [PubMed] Related Publications
Issue addressed Bowel cancer is Australia's second biggest cancer killer. Yet, despite the existence of a free national bowel-screening program, participation in this program remains low. The aim of the present study was to understand the current factors contributing to this trend to help inform future strategies to increase participation. Methods Eight focus groups (n=61 in total) were conducted with participants aged 45 years and over from metropolitan and regional New South Wales (NSW). Discussions canvassed awareness, knowledge, attitudes and beliefs regarding bowel cancer and screening, and explored how these factors influenced decisions to screen. Results The low public profile of bowel cancer compared with other cancers, together with poor knowledge of its prevalence and treatability, has contributed to a low perception of risk in the community. Minimal understanding of the often-asymptomatic presentation of bowel cancer and the role of screening in prevention has appeared to compromise the perceived value of screening. In addition, confusion regarding when, and how often, individuals should screen was apparent. Knowledge of bowel cancer and screening, and its role in motivating intention to screen, emerged as a dominant theme in the data. Conclusions The present study highlights specific knowledge gaps and confusion with regard to bowel cancer and screening. Addressing these gaps through the provision of clear, coordinated information may shift attitudes to screening and increase participation. So what? Given the Australian Government's recent commitment to expand the National Bowel Cancer Screening Program, insight into what is driving current perceptions, attitudes and subsequent participation in bowel cancer screening is crucial to the development and targeting of new approaches and initiatives.

Zhai RL, Xu F, Zhang P, et al.
The Diagnostic Performance of Stool DNA Testing for Colorectal Cancer: A Systematic Review and Meta-Analysis.
Medicine (Baltimore). 2016; 95(5):e2129 [PubMed] Article available free on PMC after 01/05/2017 Related Publications
This meta-analysis was designed to evaluate the diagnostic performance of stool DNA testing for colorectal cancer (CRC) and compare the performance between single-gene and multiple-gene tests.MEDLINE, Cochrane, EMBASE databases were searched using keywords colorectal cancers, stool/fecal, sensitivity, specificity, DNA, and screening. Sensitivity analysis, quality assessments, and performance bias were performed for the included studies.Fifty-three studies were included in the analysis with a total sample size of 7524 patients. The studies were heterogeneous with regard to the genes being analyzed for fecal genetic biomarkers of CRC, as well as the laboratory methods being used for each assay. The sensitivity of the different assays ranged from 2% to 100% and the specificity ranged from 81% to 100%. The meta-analysis found that the pooled sensitivities for single- and multigene assays were 48.0% and 77.8%, respectively, while the pooled specificities were 97.0% and 92.7%. Receiver operator curves and diagnostic odds ratios showed no significant difference between both tests with regard to sensitivity or specificity.This meta-analysis revealed that using assays that evaluated multiple genes compared with single-gene assays did not increase the sensitivity or specificity of stool DNA testing in detecting CRC.

Wong MC, Ching JY, Ng S, et al.
The discriminatory capability of existing scores to predict advanced colorectal neoplasia: a prospective colonoscopy study of 5,899 screening participants.
Sci Rep. 2016; 6:20080 [PubMed] Article available free on PMC after 01/05/2017 Related Publications
We evaluated the performance of seven existing risk scoring systems in predicting advanced colorectal neoplasia in an asymptomatic Chinese cohort. We prospectively recruited 5,899 Chinese subjects aged 50-70 years in a colonoscopy screening programme(2008-2014). Scoring systems under evaluation included two scoring tools from the US; one each from Spain, Germany, and Poland; the Korean Colorectal Screening(KCS) scores; and the modified Asia Pacific Colorectal Screening(APCS) scores. The c-statistics, sensitivity, specificity, positive predictive values(PPVs), and negative predictive values(NPVs) of these systems were evaluated. The resources required were estimated based on the Number Needed to Screen(NNS) and the Number Needed to Refer for colonoscopy(NNR). Advanced neoplasia was detected in 364 (6.2%) subjects. The German system referred the least proportion of subjects (11.2%) for colonoscopy, whilst the KCS scoring system referred the highest (27.4%). The c-statistics of all systems ranged from 0.56-0.65, with sensitivities ranging from 0.04-0.44 and specificities from 0.74-0.99. The modified APCS scoring system had the highest c-statistics (0.65, 95% C.I. 0.58-0.72). The NNS (12-19) and NNR (5-10) were similar among the scoring systems. The existing scoring systems have variable capability to predict advanced neoplasia among asymptomatic Chinese subjects, and further external validation should be performed.

Young GP, Senore C, Mandel JS, et al.
Recommendations for a step-wise comparative approach to the evaluation of new screening tests for colorectal cancer.
Cancer. 2016; 122(6):826-39 [PubMed] Article available free on PMC after 01/05/2017 Related Publications
BACKGROUND: New screening tests for colorectal cancer continue to emerge, but the evidence needed to justify their adoption in screening programs remains uncertain.
METHODS: A review of the literature and a consensus approach by experts was undertaken to provide practical guidance on how to compare new screening tests with proven screening tests.
RESULTS: Findings and recommendations from the review included the following: Adoption of a new screening test requires evidence of effectiveness relative to a proven comparator test. Clinical accuracy supported by programmatic population evaluation in the screening context on an intention-to-screen basis, including acceptability, is essential. Cancer-specific mortality is not essential as an endpoint provided that the mortality benefit of the comparator has been demonstrated and that the biologic basis of detection is similar. Effectiveness of the guaiac-based fecal occult blood test provides the minimum standard to be achieved by a new test. A 4-phase evaluation is recommended. An initial retrospective evaluation in cancer cases and controls (Phase 1) is followed by a prospective evaluation of performance across the continuum of neoplastic lesions (Phase 2). Phase 3 follows the demonstration of adequate accuracy in these 2 prescreening phases and addresses programmatic outcomes at 1 screening round on an intention-to-screen basis. Phase 4 involves more comprehensive evaluation of ongoing screening over multiple rounds. Key information is provided from the following parameters: the test positivity rate in a screening population, the true-positive and false-positive rates, and the number needed to colonoscope to detect a target lesion.
CONCLUSIONS: New screening tests can be evaluated efficiently by this stepwise comparative approach.

Yang PF, Wong SW
Adenoma Detection Rate in Colonoscopy: Is Indication a Predictor?
Surg Laparosc Endosc Percutan Tech. 2016; 26(2):156-61 [PubMed] Related Publications
PURPOSE: To describe factors that may influence adenoma detection rate (ADR), with an emphasis on the indication for colonoscopy.
METHODS: Consecutive colonoscopies performed by a single endoscopist between January 2008 and December 2014 were reviewed. Indications for colonoscopy were tested for association with ADR after adjusting for age and sex.
RESULTS: A total of 2648 colonoscopies were analyzed. Adenomas were detected in 630 patients (23.8%). Overall ADR was 22.9% in patients undergoing screening colonoscopy. ADR was higher in fecal occult blood test-triggered screening colonoscopies (32%) than colonoscopies performed for patients with a family history of colorectal cancer (21.7%) or asymptomatic average-risk individuals (20.4%) (P=0.05). ADR was 36.1% in patients undergoing surveillance colonoscopy and ranged from 12% to 30% in patients with gastrointestinal symptoms undergoing diagnostic colonoscopy.
CONCLUSIONS: ADR differs depending on whether the indication is screening, surveillance, or diagnosis. Within screening colonoscopies, ADR seems to be higher in patients with a positive fecal occult blood test.

Wiegering A, Ackermann S, Riegel J, et al.
Improved survival of patients with colon cancer detected by screening colonoscopy.
Int J Colorectal Dis. 2016; 31(5):1039-45 [PubMed] Related Publications
BACKGROUND: Screening for colon cancer (CC) may not only reduce its occurrence but has also the potential to reduce the overall mortality. So far, there has been little evidence that detection of colon cancer by screening colonoscopy results in different survival rates compared to symptomatic patients.
PATIENTS AND METHODS: Clinical, histological, diagnostic, and survival data of 1016 consecutive patients with CC from a prospectively expanded single-institutional database were analyzed for diagnostic, treatment, and prognostic factors. Findings were then stratified according to detection by screening colonoscopy vs. patients who became symptomatic prior to further diagnostic work-up.
RESULTS: 7.1 % of all patients were identified by screening colonoscopy for colon cancer. Screened patients were younger (68.2 vs. 64.8 years), had smaller T stage (p = 0.032), lower tumor stage (p = 0.009), and a tendency to less lymph node metastasis. Overall survival was superior in screened patients, and stage-specific survival showed a tendency to improved survival, which was not statistically significant. Furthermore, a higher percentage of screened patients underwent adjuvant chemotherapy (84.6 vs. 55.0 %, p = 0.032).
CONCLUSION: Survival outcome and enrollment in a multimodal treatment was higher in screening-detected patients compared to patients diagnosed after the onset of clinical symptoms. Besides a potential occurrence of lead time bias, these findings strongly support the need for continued improvement of screening programs and the recruitment of more patients for colorectal cancer screening.

Pan J, Xin L, Ma YF, et al.
Colonoscopy Reduces Colorectal Cancer Incidence and Mortality in Patients With Non-Malignant Findings: A Meta-Analysis.
Am J Gastroenterol. 2016; 111(3):355-65 [PubMed] Article available free on PMC after 01/05/2017 Related Publications
OBJECTIVES: Observational studies have shown that colonoscopy reduces colorectal cancer (CRC) incidence and mortality in the general population. We aimed to conduct a meta-analysis quantifying the magnitude of protection by colonoscopy, with screening and diagnostic indications, against CRC in patients with non-malignant findings and demonstrating the potentially more marked effect of screening over diagnostic colonoscopy.
METHODS: PubMed, EMBASE, and conference abstracts were searched through 30 April 2015. The primary outcomes were overall CRC incidence and mortality. Pooled relative risks (RRs) and 95% confidence intervals (CIs) were calculated using random-effect models.
RESULTS: Eleven observational studies with a total of 1,499,521 individuals were included. Pooled analysis showed that colonoscopy was associated with a 61% RR reduction in CRC incidence (RR: 0.39; 95% CI: 0.26-0.60; I(2)=93.6%) and a 61% reduction in CRC mortality (RR: 0.39; 95% CI: 0.35-0.43; I(2)=12.0%) in patients with non-malignant findings, although there was high heterogeneity for the outcome of CRC incidence. After excluding one outlier study, there was low heterogeneity for the outcome of incidence (I(2)=44.7%). Subgroup analysis showed that the effect of screening colonoscopy was more prominent, corresponding to an 89% reduction in CRC incidence (RR: 0.11; 95% CI: 0.08-0.15), in comparison with settings involving diagnostic colonoscopy (RR: 0.51; 95% CI: 0.43-0.59; P<0.001).
CONCLUSIONS: On the basis of this meta-analysis of observational studies, CRC incidence and mortality in patients with non-malignant findings are significantly reduced after colonoscopy. The effect of screening colonoscopy on CRC incidence is more marked than diagnostic colonoscopy.

Malik P
A novel multitarget stool DNA test for colorectal cancer screening.
Postgrad Med. 2016; 128(2):268-72 [PubMed] Related Publications
Review of: Imperiale TF, Ransohoff DF, Itzkowitz SH, Levin TR, Lavin P, Lidgard GP, Ahlquist DA, Berger BM. Multitarget stool DNA testing for colorectal-cancer screening. N Engl J Med 2014;370(14):1287-97. This Practice Pearl reviews the results of a prospective, multicenter, cross-sectional clinical study that evaluated the performance of a new multitarget stool DNA (or mt-sDNA) screening test for colorectal cancer (CRC) and compared it with a fecal immunochemical test (FIT) in individuals at average risk for CRC. The potential impact of this test on the future of CRC screening is also discussed in a brief commentary. mt-sDNA testing is a noninvasive screening test designed to detect DNA biomarkers associated with colorectal neoplasia and occult hemoglobin in the stool. The sensitivity of mt-sDNA testing for detection of CRC was 92.3%, compared with 73.8% for FIT (p = 0.002). Sensitivity for detecting advanced precancerous lesions was 42.4% for mt-sDNA testing and 23.8% for FIT (p < 0.001). The specificities of mt-sDNA testing and FIT were 86.6% and 94.9%, respectively (p < 0.001). mt-sDNA testing thus may be a first-line screening option for asymptomatic individuals at average risk for CRC who do not want to have a colonoscopy.

Sali L, Mascalchi M, Falchini M, et al.
Reduced and Full-Preparation CT Colonography, Fecal Immunochemical Test, and Colonoscopy for Population Screening of Colorectal Cancer: A Randomized Trial.
J Natl Cancer Inst. 2016; 108(2) [PubMed] Related Publications
BACKGROUND: Population screening for colorectal cancer (CRC) is widely adopted, but the preferred strategy is still under debate. We aimed to compare reduced (r-CTC) and full cathartic preparation CT colonography (f-CTC), fecal immunochemical test (FIT), and optical colonoscopy (OC) as primary screening tests for CRC.
METHODS: Citizens of a district of Florence, Italy, age 54 to 65 years, were allocated (8:2.5:2.5:1) with simple randomization to be invited by mail to one of four screening interventions: 1) biennial FIT for three rounds, 2) r-CTC, 3) f-CTC, 4) OC. Patients tested positive to FIT or CTC (at least one polyp ≥6mm) were referred to OC work-up. The primary outcomes were participation rate and detection rate (DR) for cancer or advanced adenoma (advanced neoplasia). All statistical tests were two-sided.
RESULTS: Sixteen thousand eighty-seven randomly assigned subjects were invited to the assigned screening test. Participation rates were 50.4% (4677/9288) for first-round FIT, 28.1% (674/2395) for r-CTC, 25.2% (612/2430) for f-CTC, and 14.8% (153/1036) for OC. All differences between groups were statistically significant (P = .047 for r-CTC vs f-CTC; P < .001 for all others). DRs for advanced neoplasia were 1.7% (79/4677) for first-round FIT, 5.5% (37/674) for r-CTC, 4.9% (30/612) for f-CTC, and 7.2% (11/153) for OC. Differences in DR between CTC groups and FIT were statistically significant (P < .001), but not between r-CTC and f-CTC (P = .65).
CONCLUSIONS: Reduced preparation increases participation in CTC. Lower attendance and higher DR of CTC as compared with FIT are key factors for the optimization of its role in population screening of CRC.

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