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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).

Green BB, Coronado GD, Schwartz M, et al.
Using a continuum of hybrid effectiveness-implementation studies to put research-tested colorectal screening interventions into practice.
Implement Sci. 2019; 14(1):53 [PubMed] Free Access to Full Article Related Publications
BACKGROUND: Few previous studies have applied the hybrid effectiveness-implementation design framework to illustrate the way in which an intervention was progressively implemented and evaluated across multiple studies in diverse settings.
METHODS: We describe the design components and methodologies of three studies that sought to improve rates of colorectal cancer (CRC) screening using mailed outreach, and apply domains put forth by Curran et al.: research aims, research questions, comparison conditions, sample, evaluation methods, measures, and potential challenges. The Hybrid 1 study (emphasis on effectiveness) was a patient-level randomized trial of a mailed fecal test and stepped phone-outreach intervention program delivered in an integrated healthcare system (21 clinics, 4673 patients). The primary outcome was effectiveness (CRC screening uptake). Implementation outcomes included cost-effectiveness and acceptability. The Hybrid 2 study (shared emphasis on effectiveness and implementation) was a pragmatic cluster-randomized trial of mailed fecal immunochemical test (FIT) outreach implemented at safety net clinics (26 clinics, 41,000 patients). The intervention used electronic health record tools (adapted from Hybrid 1) and clinic personnel to deliver the intervention. Outcomes included effectiveness (FIT completion) and implementation (FIT kits delivered, clinic barriers and facilitators, cost-effectiveness). Hybrid 3 study (emphasis on implementation) is a demonstration project being conducted by two Medicaid/Medicare insurance plans (2 states, 12,000 patients) comparing two strategies for implementing mailed FIT programs that addressed Hybrid 2 implementation barriers. Outcomes include implementation (activities delivered, barriers) and effectiveness (FIT completion).
RESULTS: The effectiveness-implementation typology successfully identified a number of distinguishing features between the three studies. Two additional features, program design and program delivery, varied across our studies, and we propose adding them to the current typology. Program design and program delivery reflect the process by which and by whom a program is designed and delivered (e.g., research staff vs. clinic/health plan staff).
CONCLUSIONS: We describe three studies that demonstrate the hybrid effectiveness to implementation continuum and make recommendations for expanding the hybrid typology to include new descriptive features. Additional comparisons of Hybrid 1, 2, and 3 studies may help confirm whether our hybrid typology refinements are generalizable markers of the pipeline from research to practice.

Moskowitz DA, Rahman M, Li DH
Exploring anal self-examination as a screening tool for women at risk for anal cancer: awareness, interest, and barriers to behavioral uptake.
Cancer Causes Control. 2019; 30(6):559-568 [PubMed] Related Publications
PURPOSE: Anal cancer is the second most common human-papillomavirus-related cancer in women, with women also at an elevated risk of incidence relative to men. Anal self-examination (ASE) is an efficient way for women to screen between provider visits for potential anal masses. While studied in male populations, no research has explored women's awareness of the self-test.
METHODS: In response, 345 women recruited from online advertisements and listservs were surveyed to assess their experiences using health care, history of Pap smears, knowledge of anal cancer, awareness and attitudes surrounding ASEs, and potential educational modalities to promote ASE enactment.
RESULTS: Results indicated the sample failed two key anal cancer knowledge tests (receiving a 68%/100% for risk factors and 61%/100% for signs/symptoms), and only 2.3% of participants had ever heard of ASEs before the survey. Most thought ASEs would be somewhat helpful as a screening tool, but little interest was shown towards future performance. Analyses revealed this disinterest was due to lack of knowledge, perceived discomfort with performing ASEs, and perceived irrelevance of ASEs.
CONCLUSIONS: Future interventions should push for a stronger role of providers (e.g., gynecologists) in anal health, education, and screening. Additionally, campaigns should be crafted to promote the ASE as an easy, at-home screening tool that could trigger an early warning for anal disease.

Steele RJC, Digby J, Chambers JA, O'Carroll RE
The impact of personalised risk information compared to a positive/negative result on informed choice and intention to undergo colonoscopy following colorectal Cancer screening in Scotland (PERICCS) - a randomised controlled trial: study protocol.
BMC Public Health. 2019; 19(1):411 [PubMed] Free Access to Full Article Related Publications
BACKGROUND: In Scotland a new, easier to complete bowel screening test, the Faecal Immunochemical Test (FIT), has been introduced. This test gives more accurate information about an individual's risk of having colorectal cancer (CRC), based on their age and gender, and could lead to fewer missed cancers compared to the current screening test. However, there is no evidence of the effect on colonoscopy uptake of providing individuals with personalised risk information following a positive FIT test. The objectives of the study are: 1) To develop novel methods of presenting personalised risk information in an easy-to-understand format using infographics with involvement of members of the public 2) To assess the impact of different presentations of risk information on informed choice and intention to take up an offer of colonoscopy after FIT 3) To assess participants' responses to receiving personal risk information (knowledge, attitudes to screening/risk, emotional responses including anxiety).
METHODS: Adults (age range 50-74) registered on the Scottish Bowel Screening database will be invited by letter to take part. Consenting participants will be randomised to one of three groups to receive hypothetical information about their risk of cancer, based on age, gender and faecal haemoglobin concentration: 1) personalised risk information in numeric form (e.g. 1 in 100) with use of infographics, 2) personalised information described as 'highest', 'moderate' or 'lowest' risk with use of infographics, and 3) as a 'positive' test result, as is current practice. Groups will be compared on informed choice, intention to have a colonoscopy, and satisfaction with their decision. Follow-up semi-structured qualitative interviews will be conducted, by telephone, with a small number of consenting participants (n = 10 per group) to explore the acceptability/readability and any potential negative impact of the risk information, participants' understanding of risk factors, attitudes to the different scenarios, and reasons for reported intentions.
DISCUSSION: Proving personalised risk information and allowing patient choice could lead to improved detection of CRC and increase patient satisfaction by facilitating informed choice over when/whether to undergo further invasive screening. However, we need to determine whether/how informed choice can be achieved and assess the potential impact on the colonoscopy service.
TRIAL REGISTRATION: The trial is registered on www.isrctn.com on 08/12/2017. Registration no: ISRCTN14254582.

Phillipson L, Pitts L, Hall J, Tubaro T
Factors contributing to low readiness and capacity of culturally diverse participants to use the Australian national bowel screening kit.
Public Health Res Pract. 2019; 29(1) [PubMed] Related Publications
OBJECTIVES: Bowel screening is an effective way to promote early detection of bowel cancer. Culturally and linguistically diverse (CALD) people face considerable barriers to screening. This qualitative study explored perceptions towards, and usability of, Australia's national bowel screening kit with members of two migrant communities.
METHODS: Thirty-three people (aged 50-79 years) from Serbian and Macedonian communities in the Illawarra region in New South Wales, Australia, participated in one of five interactive focus group sessions. Sessions used innovative 'customer journey' techniques to understand participants' experience of each step of the faecal occult blood test process. Participants discussed knowledge of bowel cancer and attitudes to screening, and participated in a collective mock use of a test kit. Sessions were audio recorded, transcribed and thematically analysed by two researchers in collaboration with bicultural health workers.
RESULTS: Multiple factors contributed to low readiness and capacity to use the kit, including limited promotion of the program in community languages, complicated and poorly sequenced kit instructions, and confusion around the order and labelling of kit components. Participants suggested several ways to improve kits to improve uptake by CALD communities.
CONCLUSION: Simplified and targeted promotion of bowel screening programs in community languages, and improved kit design, may support participation of CALD populations in screening programs.

Kroupa R, Ondrackova M, Kovalcikova P, et al.
Viewpoints of the target population regarding barriers and facilitators of colorectal cancer screening in the Czech Republic.
World J Gastroenterol. 2019; 25(9):1132-1141 [PubMed] Free Access to Full Article Related Publications
BACKGROUND: Public awareness of colorectal cancer (CRC) and uptake of CRC screening remain challenges. The viewpoints of the target population (asymptomatic individuals older than 50) regarding CRC screening information sources and the reasons for and against participation in CRC screening are not well known in the Czech Republic. This study aimed to acquire independent opinions from the target population independently on the health system.
AIM: To investigate the viewpoints of the target population regarding the source of information for and barriers and facilitators of CRC screening.
METHODS: A survey among relatives (aged 50 and older) of university students was conducted. Participants answered a questionnaire about sources of awareness regarding CRC screening, reasons for and against participation, and suggestions for improvements in CRC screening. The effect of certain variables on participation in CRC screening was analyzed.
RESULTS: Of 498 participants, 478 (96%) respondents had some information about CRC screening and 375 (75.3%) had participated in a CRC screening test. General practitioners (GPs) (
CONCLUSION: GPs and other specialists play crucial roles in the successful uptake of CRC screening. Reduction of the fear of colonoscopy and simple equipment for stool sampling might assist in improving the uptake of CRC screening.

Azulay R, Valinsky L, Hershkowitz F, Magnezi R
CRC Screening Results: Patient Comprehension and Follow-up.
Cancer Control. 2019 Jan-Dec; 26(1):1073274819825828 [PubMed] Free Access to Full Article Related Publications
BACKGROUND:: Fecal occult blood tests are recommended for colorectal cancer screening, but are only effective if colonoscopy follows positive results. Patients with positive results often do not complete follow-up. This study examined the association between patient comprehension and adherence to colonoscopy after positive FIT (Fecal Immunochemical Test).
METHODS:: Five hundred twenty-two patients completed a telephone questionnaire regarding the FIT and its implications 120 days after a positive result. Patients were asked whether they had the test, received the results, and required follow-up. These questions were used to identify the degree to which patients understood medical information. A participant who answered "no" to any question was defined as having "low comprehension" regarding the FIT, and participants who answered "yes" to all 3 questions, as having "high comprehension".
RESULTS:: Comprehension and colonoscopy adherence were significantly associated. Adherence to colonoscopy was significantly higher among participants with high comprehension, after adjusting for gender, age, education, ethnicity, and socio-economic status.
CONCLUSIONS:: This study demonstrates a link between health comprehension and patient follow-up after positive FIT and contributes to understanding the implications of health comprehension in terms of health promotion. We recommend patients undergoing screening tests receive clear explanations regarding need for follow-up of positive results thus reducing health disparities associated with health comprehension.

Karsenti D, Tharsis G, Burtin P, et al.
Adenoma and advanced neoplasia detection rates increase from 45 years of age.
World J Gastroenterol. 2019; 25(4):447-456 [PubMed] Free Access to Full Article Related Publications
BACKGROUND: Colonoscopy is considered a valid primary screening tool for colorectal cancer (CRC). The decreasing risk of CRC observed in patients undergoing colonoscopy is correlated with the adenoma detection rate (ADR). Due to the fact that screening programs usually start from the age of 50, very few data are available on the risk of adenoma between 40 and 49 years. However, the incidence of CRC is increasing in young populations and it is not uncommon in routine practice to detect adenomas or even advanced neoplasia during colonoscopy in patients under 50 years.
AIM: To compare the ADR and advanced neoplasia detection rate (ANDR) according to age in a large series of patients during routine colonoscopy.
METHODS: All consecutive patients who were scheduled for colonoscopy were included. Exclusion criteria were as follows: patients scheduled for partial colonoscopy or interventional colonoscopy (for stent insertion or stenosis dilation). Colonoscopies were performed in our unit by a team of 30 gastroenterologists in 2016. We determined the ADR and ANDR in each age group in the whole population and in the population with an average risk of CRC (excluding patients with personal or family history of advanced adenoma or cancer).
RESULTS: 6027 colonoscopies were performed in patients with a median age of 57 years (range, 15-96). The ADR and ANDR were 28.6% and 9.7%, respectively, in the whole population. When comparing patients aged 40-44 (
CONCLUSION: This study shows a significant two-fold increase in the ADR and ANDR in patients aged 45 years and over.

Jangsirikul S, Promratpan W, Aniwan S, et al.
Overweight as an Additional Risk Factor for Colorectal Neoplasia in Lean Population
Asian Pac J Cancer Prev. 2019; 20(1):105-111 [PubMed] Free Access to Full Article Related Publications
Background: Overweight in Thailand is not as common as in Western countries. We sought to evaluate overweight as the additional risk factor that can increase the prediction of colorectal neoplasia (CRN) detection in Thais apart from the Asia-Pacific Colorectal Screening (APCS) score. Methods: We prospectively enrolled asymptomatic 338 subjects who underwent screening colonoscopy between November 2016 and September 2017. All risk factors according to APCS, BMI and the presence of metabolic syndrome were collected. Overweight was defined as BMI ≥23 kg/m2. By APCS score, subjects were categorized into 1) high-risk and 2) average-risk. Using the combination of APCS score and overweight, subjects were stratified into 4 groups; high-risk with overweight (G1), average-risk with overweight (G2), high-risk with normal weight (G3) average-risk and with normal weight (G4). Logistic regression analysis was used to estimate the risk of detecting CRN. Results: The prevalence of CRN in the high-risk subjects was higher than that of in the average-risk subjects (49%vs.32%; OR, 2.00; 95%CI, 1.17-3.41). After adjustment for APCS risk factors and metabolic syndrome, overweight significantly increased the risk of detecting CRN (OR, 2.52; 95%CI, 1.57-4.05). Among the 4 groups, the detection rates of CRN were significantly different (G1=64%, G2=40%, G3=32% and G4=21%, p<0.01). The relative risk of detecting CRN increased when G1 (OR 6.49; 95%CI, 2.87-14.67), and G2 (2.42; 1.39-4.21) were compared with G4. Conclusions: In addition to the APCS score, overweight is an independent risk factor for detecting CRN. In Thai population, combining overweight and APCS score may be useful to improve the prediction for CRN.

Asombang AW, Madsen R, Simuyandi M, et al.
Descriptive analysis of colorectal cancer in Zambia, Southern Africa using the National Cancer Disease Hospital Database.
Pan Afr Med J. 2018; 30:248 [PubMed] Free Access to Full Article Related Publications
Introduction: Colon cancer is preventable. There is a plethora of data regarding epidemiology and screening guidelines, however this data is sparse from the African continent. Objective: we aim to evaluate the trends of colorectal cancer (CRC) in a native African population based on age at diagnosis, gender and stage at diagnosis.
Methods: We conducted a retrospective analysis of the Cancer Disease Hospital (CDH) registry in Zambia, Southern Africa.
Results: 377 charts were identified in the CDH registry between 2007 and 2015, of which 234 were included in the final analysis. The mean age at diagnosis was 48.6 years and 62% are males. Using descriptive analysis for patterns: mode of diagnosis was surgical in 195 subjects (84%), histology adenocarcinoma in 225 (96.5%), most common location is rectum 124 (53%) followed by sigmoid 31 (13.4%), and cecum 26 (11%). 122 subjects (54%) were stage 4 at diagnosis. Using the Spearman rank correlation, we see no association between year and stage at diagnosis (p = 0.30) or year and age at diagnosis (p = 0.92).
Conclusion: Colorectal cancer was diagnosed at a young age and late stage in the Zambian patients.

Almadi MA, Alghamdi F
The gap between knowledge and undergoing colorectal cancer screening using the Health Belief Model: A national survey.
Saudi J Gastroenterol. 2019 Jan-Feb; 25(1):27-39 [PubMed] Free Access to Full Article Related Publications
Background/Aims: Colorectal cancer (CRC) is a public health issue, and before the initiation of a national cancer screening program, there is a need to examine the acceptance of the public to undergo CRC screening and explore potential barriers.
Materials and Methods: A nationwide survey was conducted using an electronic platform to collect demographic variables and using the Health Belief Model to assess attitudes and behavior of participants as well as the knowledge about and intent to undergo CRC screening. At the end of the survey, participants from Riyadh were invited to get screened for CRC.
Results: Responses from 5720 individuals covering all the 13 jurisdictions of Saudi Arabia were collected. Males represented 71.53% of the respondents; the mean age was 43.28 years and 15.24% had already undergone CRC screening using various methods, mostly colonoscopy (72.73%). The mean knowledge score was 11.05 (standard deviation 4.4, range 1-23), with no difference between genders, jurisdictions of the Kingdom, between those who expressed interest in screening and those who did not, and between those who accepted the invitation to undergo CRC screening and those who did not. Participants displayed positive attitudes toward both CRC screening and colonoscopy as a screening tool, and 73% expressed willingness to undergo screening. On multivariate analysis, male gender was the only factor associated with a higher probability of accepting screening, whereas neither knowledge nor willingness to undergo screening predicted accepting the invitation to screening.
Conclusion: Although the majority of participants were willing to undergo screening, no significant correlation between knowledge and willingness to undergo screening were predictors of screening uptake. Other areas that could be targeted in the promotion of CRC screening uptake to bridge the gap between "knowing" and "doing" should be explored.

Keränen A, Ghazi S, Carlson J, et al.
Testing strategies to reduce morbidity and mortality from Lynch syndrome.
Scand J Gastroenterol. 2018; 53(12):1535-1540 [PubMed] Related Publications
OBJECTIVE: Lynch syndrome (LS) has an autosomal dominant inheritance pattern and is associated with increased risk for colorectal cancer (CRC) and other cancers. Various strategies are used to identify patients at risk and offer surveillance and preventive programs, the cost effectiveness of which is much dependent on the prevalence of LS in a population. Universal testing (UT) is proposed as an effective measure, targeting all newly diagnosed CRC patients under a certain age.
MATERIALS AND METHODS: LS cases were identified in a cohort of 572 consecutive CRC patients. Immunohistochemistry was performed in 539 cases, using antibodies against mismatch repair proteins MLH1, PMS2, MSH2, and MSH6. Microsatellite instability and gene mutation screening were performed in 57 cases.
RESULTS: In total 11 pathogenic variants were detected, identifying LS in 1.9% of new CRC cases. Comparing the results with current clinical methods, 2 pathogenic variants were found with Amsterdam criteria and 9 when using either Bethesda guidelines or our institution's prior clinical criteria. Pathogenic variants in MSH6 were the most common in our series. We also found different outcomes using different age cut offs.
CONCLUSION: Our study demonstrates that UT of tumors before age on onset at 75 years would most likely be cost-efficient and essentially equivalent to applying the Bethesda guidelines or our institution's prior clinical criteria on all new CRC.

Tangka FKL, Subramanian S, Hoover S, et al.
Identifying optimal approaches to scale up colorectal cancer screening: an overview of the centers for disease control and prevention (CDC)'s learning laboratory.
Cancer Causes Control. 2019; 30(2):169-175 [PubMed] Free Access to Full Article Related Publications
Use of recommended screening tests can reduce new colorectal cancers (CRC) and deaths, but screening uptake is suboptimal in the United States (U.S.). The Centers for Disease Control and Prevention (CDC) funded a second round of the Colorectal Cancer Control Program (CRCCP) in 2015 to increase screening rates among individuals aged 50-75 years. The 30 state, university, and tribal awardees supported by the CRCCP implement a range of multicomponent interventions targeting health systems that have low CRC screening uptake, including low-income and minority populations. CDC invited a select subset of 16 CRCCP awardees to form a learning laboratory with the goal of performing targeted evaluations to identify optimal approaches to scale-up interventions to increase uptake of CRC screening among vulnerable populations. This commentary provides an overview of the CRCCP learning laboratory, presents findings from the implementation of multicomponent interventions at four FQHCs participating in the learning laboratory, and summarizes key lessons learned on intervention implementation approaches. Lessons learned can support future program implementation to ensure scalability and sustainability of the interventions as well as guide future implementation science and evaluation studies conducted by the CRCCP learning laboratory.

Vitellius C, Laly M, Banaszuk AS, et al.
Contribution of the OC Sensor
Eur J Epidemiol. 2019; 34(2):163-172 [PubMed] Related Publications
Colorectal cancer (CRC) is a major cause of cancer-related death of worldwide with high incidence and mortality rate, accessible to a screening program in France, first with guaiac- based fecal occult blood test (g-FOBT) then with fecal immunochemical tests (FIT), since 2015, because of better accuracy. The aim of our study was to compare the characteristics of screen-detected lesions in two successive CRC screening campaigns, using two different tests (Hemoccult II

Jiang W, Cai MY, Li SY, et al.
Universal screening for Lynch syndrome in a large consecutive cohort of Chinese colorectal cancer patients: High prevalence and unique molecular features.
Int J Cancer. 2019; 144(9):2161-2168 [PubMed] Related Publications
The prevalence of Lynch syndrome (LS) varies significantly in different populations, suggesting that ethnic features might play an important role. We enrolled 3330 consecutive Chinese patients who had surgical resection for newly diagnosed colorectal cancer. Universal screening for LS was implemented, including immunohistochemistry for mismatch repair (MMR) proteins, BRAF

Hilsden RJ, Heitman SJ, Mizrahi B, et al.
Prediction of findings at screening colonoscopy using a machine learning algorithm based on complete blood counts (ColonFlag).
PLoS One. 2018; 13(11):e0207848 [PubMed] Free Access to Full Article Related Publications
Adenomatous polyps are a common precursor lesion for colorectal cancer. ColonFlag is a machine- learning-based algorithm that uses basic patient information and complete blood cell counts (CBC) to identify individuals at elevated risk of colorectal cancer for intensified screening. The purpose of this study was to determine whether ColonFlag is also able to predict the presence of high risk adenomatous polyps at colonoscopy. This study was conducted at a large colon cancer screening center in Calgary, Alberta. The study population included asymptomatic individuals between the ages of 50 and 75 who underwent a screening colonoscopy between January 2013 and June 2015. All subjects had at least one CBC result within the year prior to colonoscopy. Based on age, sex, red blood cell parameters, inflammatory cells and platelets, the ColonFlag algorithm generated a score from 0 to 100. We compared the ability of the ColonFlag test result to discriminate between individuals who were found to have a high risk polyp and those with a normal colonoscopy. Among the 17,676 individuals who underwent a screening colonoscopy there were 1,014 found to have a high risk precancerous lesion (5.7%) and 60 were found to have colorectal cancer (0.3%). At a specificity of 95%, the odds ratio for a positive ColonFlag was 2.0 for those with an advanced precancerous lesion compared with those with a normal colonoscopy. The odds ratio did not vary according to patient subgroup, colorectal cancer location or stage. ColonFlag is a passive test that can use routine blood test results to help identify individuals at elevated risk for high risk precancerous polyps as well as frank colorectal cancer. These individuals may be targeted in an effort to achieve greater compliance with conventional screening tests.

Almadi MA, Allehibi A, Aljebreen MA, et al.
Findings during screening colonoscopies in a Middle Eastern cohort.
Saudi J Gastroenterol. 2019 Jan-Feb; 25(1):20-26 [PubMed] Free Access to Full Article Related Publications
Background/Aims: Colorectal cancer is the most common cancer in males and the third most common cancer in females. We aim to determine the polyp and adenoma prevalence in a cohort of patients who underwent opportunistic screening colonoscopies.
Patients and Methods: A retrospective cohort study was conducted using an endoscopic reporting database of individuals seen at three tertiary care hospitals (two public hospitals and one private) in Riyadh, Saudi Arabia. Consecutive patients who were 45 years of age and older and underwent opportunistic screening colonoscopies between November 2016 and October 2017 were included. We excluded those with a history of colon cancer or colonic resection for any reason, inflammatory bowel disease, gastrointestinal bleeding, or anemia.
Results: Around 1180 patients were included in the study with a mean age of 58.6 years (SD = 7.3), with males representing 53.6% and an overall cecal intubation rate of 92.4%. Masses were found in 1.6% of the study population (50% in the sigmoid or rectosigmoid, 37.5% in the rectum). The polyp detection rate in colonoscopies was 24.8% and the adenoma detection rate was 16.8%. The histology of removed polyps was tubular adenomas in 56.6%, hyperplastic polyps in 32.7%, tubulovillous adenomas in 8.2%, and villous adenomas in 2.5%. The majority of the polyps were in the sigmoid colon (28.3%) and rectum (22.0%), followed by the ascending colon (11.2%) and cecum (10.3%), then the transverse colon and descending colon (9.4% each), and multiple locations in the remainder.
Conclusion: The prevalence of polyps and adenomas in this cohort is less than that reported in the Western populations.

Erben V, Carr PR, Holleczek B, et al.
Strong associations of a healthy lifestyle with all stages of colorectal carcinogenesis: Results from a large cohort of participants of screening colonoscopy.
Int J Cancer. 2019; 144(9):2135-2143 [PubMed] Related Publications
The risk of developing colorectal cancer (CRC) is associated with a wide range of dietary and lifestyle factors. The individual contribution of single modifiable factors, such as alcohol consumption, physical activity, smoking, body mass index (BMI) or dietary components, to the development of CRC has been investigated extensively, but evidence on their combined effect at various stages of colorectal carcinogenesis is sparse. The aim of our study was to analyze the association of a healthy lifestyle pattern with prevalence of early and advanced colorectal neoplasms. A total of 13,600 participants of screening colonoscopy in Saarland/Germany (mean age 62.9 years) who were enrolled in the KolosSal study (Effektivität der Früherkennungs-Koloskopie: eine Saarland-weite Studie) from 2005 until 2013 were included in this cross-sectional analysis. Dietary and lifestyle data were collected and colonoscopy results were extracted from physicians' reports. The association of an a priori defined healthy lifestyle score-including dietary intake, alcohol consumption, physical activity, smoking and BMI-with early and advanced colorectal neoplasms was assessed by multiple logistic regression analyses with comprehensive adjustment for potential confounders. Strong inverse dose-response relationships were observed between an overall healthier lifestyle pattern and presence of advanced colorectal neoplasms, nonadvanced adenomas and hyperplastic polyps (p value <0.0001 in all cases), with adjusted odds ratios (95% CI) for the highest compared to the lowest category of the healthy lifestyle score of 0.41 (0.30-0.56), 0.42 (0.33-0.54) and 0.39 (0.29-0.54) respectively. A healthy lifestyle is strongly associated with lower risk of all stages of colorectal neoplasms.

Kasi PM, Shahjehan F, Cochuyt JJ, et al.
Rising Proportion of Young Individuals With Rectal and Colon Cancer.
Clin Colorectal Cancer. 2019; 18(1):e87-e95 [PubMed] Related Publications
BACKGROUND: Recent trends have identified increasing number of young individuals with rectal and colon cancers. These individuals, who are younger than 50 years old, in most instances would not meet screening guidelines. We aimed to report the characteristics and trend of the rising proportion of young individuals being diagnosed with rectal and colon cancers at our institutions.
PATIENTS AND METHODS: This study included 3381 rectal and colon cancer patients from the Mayo Clinic cancer registry from 1972 to 2017 who were diagnosed with rectal or colon cancer and who were < 50 years old. Patient and cancer characteristics are described. The Cochran-Armitage trend test was used to see if the change in percentage diagnosed at age < 50 years had a significant trend over the years. A linear regression model was fit to estimate the percentage change per year when the trend was approximately linear.
RESULTS: The percentage of patients diagnosed with rectal or colon cancer in different age categories over the years showed a rising trend for individuals aged < 50. Most of these tumors were distal (rectum, left-sided colon, and right-sided colon were 49.8%, 28.8%, and 21.4%, respectively). This was more so for patients < 50 diagnosed with rectal cancer, which showed a linear increase at a rate of 0.26% per year (P < .001).
CONCLUSION: Our study affirms the rising proportion of colorectal cancers found in young individuals, with a linear ongoing rise of rectal cancers in particular. This may have implications for the current screening recommendations for colorectal cancers, which are already being revised.

Zhou Q, Li Y, Liu HZ, et al.
Willingness to pay for colorectal cancer screening in Guangzhou.
World J Gastroenterol. 2018; 24(41):4708-4715 [PubMed] Free Access to Full Article Related Publications
AIM: To measure the willingness to pay for colorectal cancer screening in Guangzhou, and to identify those factors associated with it.
METHODS: A face-to-face questionnaire survey for pre-screening population from free and non-free colonoscopy districts was used to collect information on demographic characteristics, health behaviours, the intention of the cancer screenings and willingness to pay for colorectal cancer screening. A total of 1243 participants who took part in the pre-screening for colorectal cancer in Guangzhou were collected in the study. Categorical data were compared using the χ
RESULTS: The percentage of participants willing to pay for colorectal cancer screening was 91.7%. "Unnecessary" was the dominant reason that participants gave for their unwillingness, accounting for 63.1%. Of those who were willing to pay, 29.2%, 20.7%, 14.8%, 13.0% and 22.4% of participants were willing to pay less than \100, \100-\199, \200-299, \300-\399 and more than \400, respectively. Non-logistic regression analysis showed that respondents who were male, had a high level of education, were from the family with more children/older to raise, and accepted colorectal cancer screening were willing to pay for this screening. Multi-class logistic regression analysis showed that respondents with higher annual household income per capita, from government and private enterprises, government agency/institution and peasants, and less family medical expenditure were willing to pay more.
CONCLUSION: Willingness to pay for colorectal cancer screening in Guangzhou is high, but the amount of willing to pay is not much.

Sali L, Ventura L, Grazzini G, et al.
Patients' experience of screening CT colonography with reduced and full bowel preparation in a randomised trial.
Eur Radiol. 2019; 29(5):2457-2464 [PubMed] Related Publications
OBJECTIVES: To assess patients' experience of bowel preparation and procedure for screening CT colonography with reduced (r-CTC) and full cathartic preparation (f-CTC) that showed similar detection rate for advanced neoplasia in a randomised trial.
METHODS: Six hundred seventy-four subjects undergoing r-CTC and 612 undergoing f-CTC in the SAVE trial were asked to complete two pre-examination questionnaires-(1) Life Orientation Test - Revised (LOT-R) assessing optimism and (2) bowel preparation questionnaire-and a post-examination questionnaire evaluating overall experience of CTC screening test. Items were analysed with chi-square and t test separately and pooled.
RESULTS: LOT-R was completed by 529 (78%) of r-CTC and by 462 (75%) of f-CTC participants and bowel preparation questionnaire by 531 (79%) subjects in the r-CTC group and by 465 (76%) in the f-CTC group. Post-examination questionnaire was completed by 525 (78%) subjects in the r-CTC group and by 453 (74%) in the f-CTC group. LOT-R average score was not different between r-CTC (14.27 ± 3.66) and f-CTC (14.54 ± 3.35) (p = 0.22). In bowel preparation questionnaire, 88% of r-CTC subjects reported no preparation-related symptoms as compared to 70% of f-CTC subjects (p < 0.001). No interference of bowel preparation with daily activities was reported in 80% of subjects in the r-CTC group as compared to 53% of subjects in the f-CTC group (p < 0.001). In post-examination questionnaire, average scores for discomfort of the procedure were not significantly different between r-CTC (3.53 ± 0.04) and f-CTC (3.59 ± 0.04) groups (p = 0.84).
CONCLUSIONS: Reduced bowel preparation is better tolerated than full preparation for screening CT colonography.
KEY POINTS: • Reduced bowel preparation is better tolerated than full preparation for screening CT colonography. • Procedure-related discomfort of screening CT colonography is not influenced by bowel preparation. • Males tolerate bowel preparation and CT colonography screening procedure better than females.

Chen H, Li N, Ren J, et al.
Participation and yield of a population-based colorectal cancer screening programme in China.
Gut. 2019; 68(8):1450-1457 [PubMed] Related Publications
OBJECTIVE: Colorectal cancer (CRC) screening has been widely implemented in many countries. However, evidence on participation and diagnostic yield of population-based CRC screening in China is sparse.
DESIGN: The analyses were conducted in the context of the Cancer Screening Program in Urban China, which recruited 1 381 561 eligible participants aged 40-69 years from 16 provinces in China from 2012 to 2015. 182 927 participants were evaluated to be high risk for CRC by an established risk score system and were subsequently recommended for colonoscopy. Participation rates and detection of colorectal neoplasms in this programme were reported and their associated factors were explored.
RESULTS: 25 593 participants undertook colonoscopy as recommended, with participation rate of 14.0%. High level of education, history of faecal occult blood test, family history of CRC and history of colonic polyp were found to be associated with the participation in colonoscopy screening. Overall, 65 CRC (0.25%), 785 advanced adenomas (3.07%), 2091 non-advanced adenomas (8.17%) and 1107 hyperplastic polyps (4.33%) were detected. Detection rates of colorectal neoplasms increased with age and were higher for men. More advanced neoplasms were diagnosed in the distal colon/rectum (65.2%). Several factors including age, sex, family history of CRC, dietary intake of processed meat and smoking were identified to be associated with the presence of colorectal neoplasms.
CONCLUSION: The diagnostic yield was not optimal using colonoscopy screening in high-risk populations given the relatively low participation rate. Our findings will provide important references for designing effective population-based CRC screening strategies in the future.

Jenkins MA, Ait Ouakrim D, Boussioutas A, et al.
Revised Australian national guidelines for colorectal cancer screening: family history.
Med J Aust. 2018; 209(10):455-460 [PubMed] Related Publications
INTRODUCTION: Screening is an effective means for colorectal cancer prevention and early detection. Family history is strongly associated with colorectal cancer risk. We describe the rationale, evidence and recommendations for colorectal cancer screening by family history for people without a genetic syndrome, as reported in the 2017 revised Australian guidelines. Main recommendations: Based on 10-year risks of colorectal cancer, people at near average risk due to no or weak family history (category 1) are recommended screening by immunochemical faecal occult blood test (iFOBT) every 2 years from age 50 to 74 years. Individuals with moderate risk due to their family history (category 2) are recommended biennial iFOBT from age 40 to 49 years, then colonoscopy every 5 years from age 50 to 74 years. People with a high risk due to their family history (category 3) are recommended biennial iFOBT from age 35 to 44 years, then colonoscopy every 5 years from age 45 to 74 years. Changes in management as a result of the guidelines: By 2019, the National Bowel Cancer Screening Program will offer all Australians free biennial iFOBT screening from age 50 to 74 years, consistent with the recommendations in these guidelines for category 1. Compared with the 2005 guidelines, there are some minor changes in the family history inclusion criteria for categories 1 and 2; the genetic syndromes have been removed from category 3 and, as a consequence, colonoscopy screening is now every 5 years; and for categories 2 and 3, screening begins with iFOBT for people aged 40 and 35 years, respectively, before transitioning to colonoscopy after 10 years.

Mai TTX, Lee YY, Suh M, et al.
Socioeconomic Inequalities in Colorectal Cancer Screening in Korea, 2005-2015: After the Introduction of the National Cancer Screening Program.
Yonsei Med J. 2018; 59(9):1034-1040 [PubMed] Free Access to Full Article Related Publications
PURPOSE: This study aimed to investigate inequalities in colorectal cancer (CRC) screening rates in Korea and trends therein using the slope index of inequality (SII) and relative index of inequality (RII) across income and education groups.
MATERIALS AND METHODS: Data from the Korean National Cancer Screening Survey, an annually conducted, nationwide cross-sectional survey, were utilized. A total of 17174 men and women aged 50 to 74 years were included for analysis. Prior experience with CRC screening was defined as having either a fecal occult blood test within the past year or a lifetime colonoscopy. CRC screening rates and annual percentage changes (APCs) were evaluated. Then, SII and RII were calculated to assess inequality in CRC screening for each survey year.
RESULTS: CRC screening rates increased from 23.4% in 2005 to 50.9% in 2015 (APC, 7.8%; 95% CI, 6.0 to 9.6). Upward trends in CRC screening rates were observed for all age, education, and household income groups. Education inequalities were noted in 2009, 2014, and overall pooled estimates in both indices. Income inequalities were inconsistent among survey years, and overall estimates did not reach statistical significance.
CONCLUSION: Education inequalities in CRC screening among men and women aged 50 to 74 years were observed in Korea. No apparent pattern, however, was found for income inequalities. Further studies are needed to thoroughly outline socio-economic inequalities in CRC screening.

Lam TH, Wong KH, Chan KK, et al.
Recommendations on prevention and screening for colorectal cancer in Hong Kong.
Hong Kong Med J. 2018; 24(5):521-526 [PubMed] Related Publications
Colorectal cancer is the commonest cancer in Hong Kong. The Cancer Expert Working Group on Cancer Prevention and Screening was established in 2002 under the Cancer Coordinating Committee to review local and international scientific evidence, assess and formulate local recommendations on cancer prevention and screening. At present, the Cancer Expert Working Group recommends that average-risk individuals aged 50 to 75 years and without significant family history consult their doctors to consider screening by: (1) annual or biennial faecal occult blood test, (2) sigmoidoscopy every 5 years, or (3) colonoscopy every 10 years. Increased-risk individuals with significant family history such as those with a first-degree relative diagnosed with colorectal cancer at age ≤60 years; those who have more than one first-degree relative diagnosed with colorectal cancer irrespective of age at diagnosis; or carriers of genetic mutations associated with familial adenomatous polyposis or Lynch syndrome should start colonoscopy screening earlier in life and repeat it at shorter intervals.

Zorzi M, Hassan C, Capodaglio G, et al.
Divergent Long-Term Detection Rates of Proximal and Distal Advanced Neoplasia in Fecal Immunochemical Test Screening Programs: A Retrospective Cohort Study.
Ann Intern Med. 2018; 169(9):602-609 [PubMed] Related Publications
Background: Short-term studies have reported that the fecal immunochemical test (FIT) is less accurate in detecting proximal than distal colorectal neoplasia.
Objective: To assess the long-term detection rates for advanced adenoma and colorectal cancer (CRC), according to anatomical location.
Design: Retrospective study.
Setting: Population-based, organized screening program in the Veneto region of Italy.
Participants: Persons aged 50 to 69 years who completed 6 rounds of FIT screening.
Measurements: At each screening round, the detection rates for advanced adenoma and cancer, as well as the proportional interval cancer rate (PICR), were calculated by anatomical location (proximal colon, distal colon, or rectum).
Results: Between 2002 and 2014, a total of 123 347 participants had 441 647 FITs. The numbers of advanced adenomas and cancer cases detected, respectively, were 1704 and 200 in the proximal colon, 3703 and 324 in the distal colon, and 1220 and 209 in the rectum. Although the detection rate for proximal colon cancer declined only from the first to the second screening round (0.63 to 0.36 per 1000 screenees), the rate for both distal colon and rectal cancer steadily decreased across 6 rounds (distal colon, 1.65 in the first round to 0.17 in the sixth; rectum, 0.82 in the first round to 0.17 in the sixth). Similar trends were found for advanced adenoma (proximal colon, 5.32 in the first round to 4.22 in the sixth; distal colon, 15.2 in the first round to 5.02 in the sixth). Overall, 150 cases of interval cancer were diagnosed. The PICR was higher in the proximal colon (25.2% [95% CI, 19.9% to 31.5%]) than the distal colon (6.0% [CI, 3.9% to 8.9%]) or rectum (9.9% [CI, 6.9% to 13.7%]).
Limitations: Participants with irregular attendance were censored. Those who had a false-positive result on a previous FIT but negative colonoscopy results were included in subsequent rounds.
Conclusion: This FIT-based, multiple-round, long-term screening program had a negligible reduction in detection rates for neoplastic lesions in the proximal versus the distal colon after the first round. This was related to a higher PICR in the proximal colon and suboptimal efficacy in preventing the age-related proximal shifting of CRC.
Primary Funding Source: None.

Ghai NR, Jensen CD, Corley DA, et al.
Colorectal Cancer Screening Participation Among Asian Americans Overall and Subgroups in an Integrated Health Care Setting with Organized Screening.
Clin Transl Gastroenterol. 2018; 9(9):186 [PubMed] Free Access to Full Article Related Publications
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.

Bie AKL, Brodersen J
Why do some participants in colorectal cancer screening choose not to undergo colonoscopy following a positive test result? A qualitative study.
Scand J Prim Health Care. 2018; 36(3):262-271 [PubMed] Free Access to Full Article Related Publications
OBJECTIVE: Our aim was to investigate why participants opted out of colonoscopy following a positive screening result for colorectal cancer.
DESIGN: Semi-structured, qualitative, single interviews. We audio-recorded and transcribed all interviews verbatim and used Strauss and Corbin's concept of open, axial, and selective coding to identify the main categories shared across all interviews. These formed the basis of our findings.
SETTING: A Danish national colorectal cancer screening programme.
SUBJECTS: Single interviews with 13 participants who declined to have a colonoscopy.
MAIN OUTCOME MEASURES: Reasons to decline colonoscopy after positive screening test.
RESULTS: Participants gave 42 different reasons for deciding not to have a colonoscopy and we coded them into nine main categories; Practical barriers, Discomfort of the examination, Personal integrity, Multimorbidity, Feeling healthy, Not having the energy, Belief that cancer is not present, Risk of complications, and Distrust in the accuracy of the iFOBT.
CONCLUSIONS: Our findings suggest that some practical barriers could be quite easily addressed, by offering the participants alternative management and procdures.
IMPLICATIONS: Further research is needed to examine how widely our findings are represented in the general population, and how general practitioners should consult with patients who have opted out of colonoscopy, despite a positive screening result. Key points   Some screening participants are reluctant to proceed with further diagnostic tests for colorectal cancer following a positive screening result.   • Interviews with people, who had refused a follow-up colonoscopy, discovered nine categories (42 reasons) of reasons for refusal.   • Reluctance can be addressed by offering support with pre-procedure preparations and alternatives to colonoscopy.   • General practitioners face ethical dilemmas and challenges, when patients at risk of colorectal cancer decline to proceed with screening.

Kościelniak-Merak B, Radosavljević B, Zając A, Tomasik PJ
Faecal Occult Blood Point-of-Care Tests.
J Gastrointest Cancer. 2018; 49(4):402-405 [PubMed] Free Access to Full Article Related Publications
BACKGROUND: Early detection of colorectal cancer decreases the risk of mortality. Faecal occult blood tests (FOBT) are recognised as a useful tool for colorectal cancer screening. These non-invasive, rapid, and easy-to-carry assays are very often used as a point-of-care test and for self-testing. On the market, there are various types of FOB tests available, including chemical and immunochromatographic tests, which are based on different detection methods and differ in their sensitivity and specificity.
CONCLUSIONS: Clinicians should be aware of the causes of false-negative and false-positive test results, which can vary depending on the test. Additionally, stool sampling bias may be a source of error and must be considered by the clinician. The current FOBT methods are subject to various interfering factors; items such as proper preparation of the patient prior to testing or the clinician's knowledge of testing limitations are key in correct interpreting results. Novel technologies such as FOBT DNA tests, micro RNA tests, and biochips equipped with bacteria can indicate bleeding from the gastrointestinal tract and improve diagnostics process.

Jäntti M, Heinävaara S, Malila N, Sarkeala T
The effect of colorectal cancer screening on health status in a survey study.
Acta Oncol. 2018; 57(12):1605-1610 [PubMed] Related Publications
BACKGROUND: Colorectal cancer (CRC) screening has been found to reduce mortality from CRC but it may have adverse effects on other aspects of health. Our aim was to evaluate the effect of CRC screening on overall health status among men and women within a randomized health-services study in Finland.
MATERIAL AND METHODS: A random sample of 10,648 men and women born in 1951 received a questionnaire on health and lifestyle. They were randomized for CRC screening or controls (1:1) in 2011 (N = 10,271). The current study population consisted of those who responded to the questionnaire both before and after screening (n = 4895). Self-rated health (SRH), perceived healthiness of diet and perceived physical fitness were used to determine health status, and assessed with logistic and ordered logistic models using calendar time (2010, 2012), screening randomization and demographic characteristics as covariates.
RESULTS: SRH, healthiness of diet and physical fitness improved over time (OR 1.32, CI 1.17-1.48, OR 1.23, CI 1.08-1.41 and OR 1.44, CI 1.28-1.60, respectively). Compared to non-invited controls, CRC screening invitation had no effect on these measures (OR 0.91, CI 0.74-1.12, OR 0.95, CI 0.75-1.20, and OR 1.09, CI 0.87-1.37, respectively). Women reported better health status than men. However, among those who attended screening, women reported weaker, and men better health status than the respective controls.
CONCLUSIONS: CRC screening did not have any effect on health status measured using self-rated health, healthiness of diet, and physical fitness. Thus, screening for colorectal cancer can be recommended as a health policy.

Gandilhon C, Soler-Michel P, Vecchiato L, et al.
A motivational phone call improves participation to screening colonoscopy for those with a positive FIT in a national screening programme (NCT 03276091).
Dig Liver Dis. 2018; 50(12):1309-1314 [PubMed] Related Publications
BACKGROUND: A large proportion of individuals with a positive faecal immunologic test (FIT) will never undergo the recommended colonoscopy despite a full sequence of reminders.
AIMS: This prospective study aimed to recruit refractory individuals by a motivational personalised phone call given by a screening physician.
METHODS: We evaluated the impact of a motivational phone call given by a physician of the screening organisation in order to convince patients with positive FIT to undergo a colonoscopy.
RESULTS: 115 individuals with a positive FIT were targeted. After GP phone call, it was ascertained that 15 had had a colonoscopy, one died, one moved outside the region, and the GP refused the study phone call for 13. Finally, we attempted to call 85 individuals; 24 could not be reached, 5 colonoscopies had been performed, and thus 56 individuals were included. The main reason for colonoscopy refusal (33.9%) was wrong advice from the GP or the gastroenterologist. Among those included, 33.9% (19/56) underwent the colonoscopy within 22.7 months after FIT; 1 invasive cancer, 18 adenomas and 9 serrated sessile lesions were found.
CONCLUSION: Motivational phone call performed by a physician from the screening organisation is effective to recruit a third of refractory individuals. Education for GPs and gastroenterologists is necessary to increase participation to colonoscopy and to avoid the performance of an inappropriate secondary FIT.

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