Abstract
BackgroundColorectal cancer leads to significant morbidity and mortality. Early detection and treatment are essential. Screening using fecal occult blood tests has increased significantly, but adherence to colonoscopy follow-up is suboptimal, increasing CRC mortality risk.The aim of this study was to identify barriers to colonoscopy following a positive FOBT at the level of the patient, physician, organization and policymakers.MethodsThis mixed methods study was conducted at two health care organizations in Israel. The study included retrospective analyses of 45,281 50–74 year-old members with positive fecal immunochemical tests from 2010 to 2014, and a survey of 772 patients with a positive test during 2015, with and without follow-up. The qualitative part of the study included focus groups with primary physicians and gastroenterologists and in-depth interviews with opinion leaders in healthcare.ResultsPatient lack of comprehension regarding the test was the strongest predictor of non-adherence to follow-up. Older age, Arab ethnicity, and lower socio economic status significantly reduced adherence. We found no correlation with gender, marital status, patient activation, waiting time for appointments or distance from gastroenterology clinics. Primary care physicians underestimate non-adherence rates. They feel responsible for patient follow-up, but express lack of time and skills that will allow them to ensure adherence among their patients. Gastroenterologists do not consider fecal occult blood an effective tool for CRC detection, and believe that all patients should undergo colonoscopy. Opinion leaders in the healthcare field do not prioritize the issue of follow-up after a positive screening test for colorectal cancer, although they understand the importance.ConclusionsWe identified important barriers that need to be addressed to improve the effectiveness of the screening program. Targeted interventions for populations at risk for non-adherence, specifically for those with low literacy levels, and better explanation of the need for follow-up as a routine need to be set in place. Lack of agreement between screening recommendations and gastroenterologist opinion, and lack of awareness among healthcare authority figures negatively impact the screening program need to be addressed at the organizational and national level.Trial registrationThis study was approved by the IRB in both participating organizations (Meuhedet Health Care Institutional Review Board #02–2–5-15, Maccabi Healthcare Institutional Review Board BBI-0025-16). Participant consent was waived by both IRB’s.
Highlights
Colorectal cancer leads to significant morbidity and mortality
We compiled a dataset of all members aged 50–75 who had a fecal immunochemical test (FIT) between the years 2010 and 2014 and had a positive result
Participants living in highly peripheral or highly centralised localities were less likely to adhere than those living in localities in the medium peripherality index. (p0.001>)
Summary
Colorectal cancer leads to significant morbidity and mortality. Early detection and treatment are essential. Recommended strategies for early detection for population screening are either fecal occult blood testing (FOBT) yearly or colonoscopy every 10 years from the age of 50 to 74 years [2]. Most screening programs are based on a fecal immunochemical test (FIT) for occult blood, with colonoscopy follow-up after a positive finding. In studies conducted in the US, only 49% of participants with a positive FOBT result completed a follow-up colonoscopy at 3 months, and 59% at 1 year [10, 11]. In Israel participation rates in the national CRC screening program are high (64%) the follow-up colonoscopy rate within the recommended 3 months are 40, and 70% at 1 year [8]
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