Patient Preferences for a Blood-Based Colorectal Cancer Screening Test: Insights From a Conjoint Analysis Survey.

Is this the end of colonoscopy screening for colorectal cancer? An Asia-Pacific perspective.

COVID-19: An Opportunity to Reimagine Colorectal Cancer Diagnostic Testing—A New Paradigm Shift

FIT to be Tried

Screening and Surveillance Colonoscopy and COVID-19: Avoiding More Casualties

PURPOSE: We partnered with the largest FQHC in New Haven, CT to address overdue colorectal cancer screening with evidence-based interventions (EBI). We report on the 12-month follow up of a cohort of 3,127 patients overdue for CRC screening who received 1 or more evidence based interventions (EBIs) in October, 2021. BACKGROUND: Sociocultural and medical concerns are barriers to colonoscopy uptake contributing to disparities in CRC screening. An additional barrier is system level capacity. COVID-19 associated delays exacerbated the existing backlog of individuals overdue for CRC screening, underscoring the need to expand Fecal Immunochemical Testing (FIT) screening capacity. At the time of the study, colonoscopy was the front-line cancer screening strategy in this and other primary care settings in this region. METHODS: We tested the unique and additive value of multiple EBIs for increasing CRC screening in this low-income urban population. The EBIs included: medical reminder to all recipients (Arms 1-4), supplemented with information to address social determinants of health [SDOH]) barriers (Arm 2), offer of assistance from trained community health workers (CHW) to address SDOH barriers (Arm 3), and offer of educational intervention (video and pre- and post- survey) (Arm 4). Twelve-month outcomes include: 1) CRC screening test ordered; 2) CRC screening completed. RESULTS: Of the 3,127 randomized patients, ages 50-75, 77% were Hispanic (33%) or Black (44%). At 12 months post-intervention, 1,692 (54.1%) of the cohort received an order for CRC screening, and 541 (17.3%) of the cohort completed screening. With no path to CRC screening other than a provider order, among patients for whom CRC screening was ordered, nearly one-third (32%) completed screening within 12 months of the intervention. There were no differences in either outcome based on intervention Arm. DISCUSSION: Among the 3,127 individuals who were due or overdue for screening at the time of intervention, only 9 had documented CRC cancer screening in the 5 years before randomization. The promotion of stool-based testing may have brought individuals into CRC screening. There were no differences in CRC screening (colonoscopy or FIT) orders or completed tests across the 4 arms of the study, suggesting that the provider endorsed mailed screening reminder with information on in-home, stool-based testing option (FIT), and notice that CRC screening is now recommended beginning at age 45 was key to behavior change. Provider engagement and post-pandemic care-seeking on part of patients, as well as increased awareness of CRC screening following the death of high-profile actor at age 43 likely contributed to increased uptake of CRC screening. SUMMARY: A mailed reminder is a cost effective, scalable intervention that may be effective in safety net primary care settings that serve high-risk individuals. Closing the screening gap in CRC screening should include educating patients about their CRC screening options as well as the change in recommended age to begin CRC screening. Citation Format: Beth A. Jones, Sakinah C. Suttiratana, Sarah A. DeGiovanni, Levita Robinson, Michael Couturie, Steven J. Parra, Louie M. Gangcuangco, Laney Zhang, Denise Stevens, Margarita Vargas-Torres. Implementing on overdue colorectal cancer (CRC) screening in the Federally Qualified Health Center (FQHC) primary care setting: 12-month post intervention results [abstract]. In: Proceedings of the 16th AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2023 Sep 29-Oct 2;Orlando, FL. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2023;32(12 Suppl):Abstract nr C117.

Optimizing Colorectal Cancer Screening by Getting FIT Right

Reduced Incidence of Colorectal Cancers With Repeated Screening With Fecal Immunochemical Tests

Colorectal cancer (CRC) screening has been shown to be more effective in preventing deaths from this common cancer, but current methods are suboptimal. Because of limitations and barriers, interval cancers occur, and many people (25%-40%) are not compliant with colorectal cancer screening. Advances over the past year, which have led to a blood-based screening test and more accurate stool tests, address the limitations of current tests. Three clinical trials published in the past year have led to a novel blood-based test, a multitarget stool eRNA test, and an improved multitarget stool DNA test for colorectal cancer screening. The multitarget eRNA stool-based test and multitarget stool DNA test are 94.4% sensitive (87.9% specificity) and 93.5% sensitive (90.6% specificity) for CRC and 45.9% sensitive and 43.4% sensitive for advanced polyps, respectively. The blood test uses cell free DNA to detect CRC and is 83% sensitive for CRC (89.6% specificity) and 13% sensitive for advanced adenomas. These advances provide a novel effective blood-based test for CRC screening, which promises to increase compliance, and more accurate stool-based tests, which promise to lead to fewer interval CRCs.

Colon Cancer Screening Models: Lessons and Challenges

INTRODUCTION: Colonoscopy (COL) non-adherence following a positive non-invasive colorectal cancer (CRC) screening test (e.g., multitarget stool DNA [mt-sDNA], fecal immunochemical test [FIT]) undermines the achievable benefits of screening. Given wide variations in the limited data reporting COL adherence after a positive non-invasive test, microsimulation modeling was used to estimate the clinical implications of this understudied input. METHODS: An average-risk US population cohort free of diagnosed CRC at age 40 that underwent triennial mt-sDNA or annual FIT screening from ages 50 to 75 was simulated using the validated CRC-AIM model. Three scenarios were modeled: (S1) assumed 100% adherence for initial screening and COL follow-up; (S2) reported adherence rates for initial mt-sDNA (71%) or FIT (43%) screening, with assumed 100% adherence to COL follow-up; and (S3) reported adherence rates for initial mt-sDNA or FIT screening and reported adherence rates for COL follow-up after positive mt-sDNA (73%) or FIT (47%). Sensitivity analyses were performed using 100% and reported adherence rates for mt-sDNA and FIT screening, with COL follow-up adherence ranging from 40%-100%. Patients without a COL follow-up were assumed to be non-adherent until CRC symptom onset. Outcomes for each scenario are per 1000 individuals. RESULTS: S1, S2, and S3 each yielded life-years gained (LYG) and reductions in CRC incidence and CRC mortality with either mt-sDNA or FIT screening vs no CRC screening (Table 1). Estimated LYG for mt-sDNA and FIT were 297 and 316 for S1, 284 and 245 for S2, and 203 and 113 for S3, respectively. Reductions in CRC incidence for mt-sDNA and FIT were 64% and 68% for S1, 61% and 50% for S2, and 43% and 23% for S3, respectively; reductions in CRC mortality were 72% and 76% for S1, 69% and 59% for S2, and 49% and 27% for S3, respectively. With assumed 100% adherence to mt-sDNA or FIT screening, the LYG transition was at 45% (LYG = 128) and 40% (LYG = 119) adherence for COL follow-up, respectively (Figure 1). At reported adherence for stool-tests, the additional LYG for mt-sDNA vs FIT ranged from 12 to 188 as follow-up COL adherence increased from 40% to 100% (Figure 2). CONCLUSION: These modeling analyses demonstrate that the inclusion of more realistic estimates for mt-sDNA, FIT, and COL follow-up adherence has substantial impact on the predicted outcomes. Using reported adherence rates, rather than assuming 100% adherence, mt-sDNA yields greater CRC screening benefits vs FIT.Table 1.: Predicted life-years gained (LYG), colorectal cancer (CRC) incidence reduction, and CRC mortality reduction for triennial multitarget stool DNA (mt-sDNA) and annual fecal immunochemical test (FIT) in 3 different adherence scenarios per 1000 individuals free of diagnosed colorectal cancer at age 40 and screened between 50–75 yearsFigure 1.: Percent difference in predicted life-years gained (LYG) per 1000 individuals assuming 100% adherence for triennial multitarget stool DNA (mt-sDNA) and annual fecal immunochemical test (FIT) at assumed adherence rate intervals for follow-up colonoscopy (COL) in individuals free of diagnosed colorectal cancer at age 40 and screened between 50–75 years. White boxes indicate 10% positive difference with mt-sDNA versus FIT. Dark gray boxes indicate >10% negative difference with mt-sDNA versus FIT.Figure 2.: Percent difference in predicted life-years gained (LYG) per 1000 individuals by reported adherence rates for triennial multitarget stool DNA (mt-sDNA) and annual fecal immunochemical test (FIT) at assumed adherence rate intervals for follow-up colonoscopy (COL) in individuals free of diagnosed colorectal cancer at age 40 and screened between 50–75 years. White boxes indicate 10% positive difference with mt-sDNA versus FIT. Dark gray boxes indicate >10% negative difference with mt-sDNA versus FIT.

CN14-06: Screening for colorectal cancer: 2009

Quantitation of Hemoglobin Improves Fecal Immunochemical Tests for Noninvasive Screening

The colorectal cancer (CRC) screening landscape has rapidly evolved, introducing new technologies alongside established methods. The lack of head-to-head observational studies comparing these diverse options impairs clinicians’ and patients’ ability to make informed choices in CRC screening test selection. This manuscript aims to provide a comprehensive review of existing and emerging CRC screening technologies and develop a practical framework for informed decision-making. We conducted a systematic review of current literature on CRC screening methods, including colonoscopy, fecal immunochemical test (FIT), multi-target stool DNA test (mt-sDNA), the next-generation multi-target stool DNA test, multi-target stool RNA test (mt-sRNA), and blood-based tests. We summarized performance characteristics, adherence rates, follow-up colonoscopy rates, accessibility, and costs for each method. Our review revealed significant variations in test performance, patient adherence, and implementation factors across screening modalities. Blood-based tests showed promise in terms of patient acceptance but currently have lower sensitivity for early-stage cancers with a higher participant adherence when screening navigation is provided. Our review led to the development of a comprehensive framework for evaluating CRC screening options, addressing the critical need for informed decision-making in this area. The framework encompasses five key dimensions: test performance (sensitivity and specificity for CRC and precancerous lesions), patient considerations (invasiveness, preparation, and location preferences), adherence and follow-up (real-world rates and diagnostic colonoscopy completion rates), accessibility and cost (insurance coverage, out-of-pocket expenses, and system integration), and screening interval (recommended frequency and long-term impact). By synthesizing data, the framework enables healthcare providers and patients to navigate the complex landscape of screening options, facilitating personalized recommendations tailored to individual risk factors, preferences, and healthcare system constraints. Future research should validate this framework in diverse clinical settings and update it as new technologies emerge, ensuring continued improvement in CRC screening participation, effectiveness, and outcomes.

Introduction: Asian Americans are the fastest growing major racial/ethnic group in the US, with Filipinos comprising the 3rd largest group. While >80% of Filipinos are proficient in English, and have insurance rates, education levels, and incomes that exceed the general US population, they have lower CRC screening rates and worse CRC outcomes vs. non-Hispanic Whites. To begin to address this disparity, we used conjoint analysis to understand Filipinos’ preferences for the different CRC screening test options. Methods: To quantify Filipinos’ preferences for CRC screening tests, we conducted a choice-based conjoint analysis survey for individuals ≥40yo at average risk for CRC who had not undergone prior screening. From 4/29-11/7/21, we recruited Filipinos at an academic medical center and through a national survey research firm (Cint). Using the conjoint data, we performed simulations to determine each individual’s preferred screening test; for this analysis, we focused on the proportion of people who preferred annual FIT or colonoscopy every 10 years as both are tier 1 tests according to the US Multi-Society Task Force (MSTF) on CRC. We then performed logistic regression to explore whether demographics predicted decision making on FIT vs colonoscopy; variables with p< .20 from bivariate analyses were included as covariates in the regression model. Results: Overall, 105 participants completed the survey; most respondents were female (74.3%) and aged 40-49y (84.8%). Moreover, 64.8% of participants stated they planned to get screened for CRC and they reported high self-perceived benefits of CRC screening (median 4.4, IQR 3.8-4.8; 1-5 scale, higher=more beneficial). When performing simulations using the conjoint data for the US MSTF tier 1 tests, we found that 66.7% of respondents preferred an annual FIT while 33.3% preferred a colonoscopy every 10 years (Figure). In a regression analysis that accounted for sex, marital status, household income, employment status, and geographic region, no variables were significantly associated with individual's preference for FIT over colonoscopy (Table). Conclusion: We found that 2 in 3 Filipinos prefer annual FIT over colonoscopy for their CRC screening and that demographics poorly predict individual decision making. To improve CRC screening uptake in the Filipino community, our data suggest that community-based interventions should either focus primarily on FIT or employ a choice-based approach (ie, FIT or colonoscopy).Figure 1.: Data from simulations using conjoint analysis data assessing the proportion of respondents who would prefer each MSTF tier 1-recommended test (N=105) Table 1. - Regression analysis on preferring FIT every year over colonoscopy every 10 years for CRC screening; screening test preferences were determined through simulations from conjoint analysis-derived data (N=105) Variable Prefers FIT every year for CRC screening n (% of row) aOR [95% CI] Sex: Male 21 (77.8%) Reference Female 49 (62.8%) 0.61 (0.20, 1.86) Marital status: Married or living with a partner 53 (62.4%) Reference Not married 17 (85.0%) 2.65 (0.61, 11.44) Total household income: ≤$100,000 34 (79.1%) reference >$100,000 31 (62.0%) 0.72 (0.24, 2.20) Prefer not to say 5 (41.7%) 0.23 (0.05, 1.12) Employment status: Unemployed, on disability, on leave of absence from work, retired, or a homemaker 19 (82.6%) reference Employed or student 51 (62.2%) 0.36 (0.10, 1.31) US region: Northeast/South/ Midwest 15 (83.3%) reference West 55 (63.2%) 0.70 (0.15, 3.21) Has non-first degree relative or friend diagnosed with CRC 11 (44.0%) 0.42 (0.15, 1.16)

88 Background: There are an estimated 60 million individuals in the US who are not up-to-date with average-risk colorectal cancer (CRC) screening, as screening rates and adherence have remained stubbornly below the national target of 80%. Efforts are ongoing to improve CRC screening performance and participation, including the development of new blood-based tests. Despite high expectations for these tests, performance remains lower than other guideline-recommended strategies, particularly with respect to advanced precancerous lesion (APL) sensitivity. We conducted a simulation study of estimated clinical and economical outcomes for CRC screening with a blood-based test (at perfect adherence) compared to the multi-target stool-DNA (mt-sDNA) test (at published adherence rates). Methods: Utilizing CRC-AIM, a calibrated and validated microsimulation model, CRC screening outcomes were calculated for 1 million average-risk individuals screened between ages 45-75 years with triennial blood-based versus mt-sDNA testing. CRC and APL sensitivity and specificity inputs were derived from two large clinical validation studies for these screening modalities: ECLIPSE (NCT04136002) and DeeP-C (NCT01397747), respectively. To demonstrate the maximum benefits and burdens of blood-based screening, adherence to initial screening and follow-up colonoscopy after a positive blood test was modeled at 100%, while real-world adherence estimates of 65.6% were used for the mt-sDNA test. Outcomes of interest included life years-gained (LYG) and CRC cases missed by the blood-based test compared to the stool-based test, additional treatment costs imposed by theblood-based test, and additional CRC-related deaths per 1 million screened. Results: Compared to triennial screening with mt-sDNA at real-world adherence, blood-based screening at perfect adherence resulted in a higher number of incident (n=18,464) and fatal (n=6,483) CRC cases that would been avoided with the mt-sDNA test. Over a lifetime, screening with blood-based tests required 1,276,310 more tests (21% more) and 52,942 additional follow-up colonoscopies (7% more) compared to mt-sDNA screening. This increased testing burden did not generate additional benefits and instead reduced life-years gained by 67,645 per 1 million screened, resulting in an additional $1.6 billion in treatment costs compared to the mt-sDNA strategy. Conclusions: Data from this CRC-AIM modeling study show that even with perfect adherence, blood-based screening yields inferior clinical and economic benefits compared to mt-sDNA screening, due to suboptimal APL detection with the former test.