Biennial Faecal Occult Blood Testing Research Articles

The Impact of CT Colonography for Colorectal Cancer Screening on the UK NHS

Biennial faecal occult blood testing (FOBT) for individuals aged 60-69 years is the primary screening tool for colorectal cancer (CRC) in the UK NHS, despite a large number of patients undergoing an unnecessary optical colonoscopy (OC) and evidence from modelling studies to suggest that more cost-effective technologies exist. CT colonography (CTC) is an emerging CRC screening technology with the potential to prevent CRC by detecting pre-cancerous polyps and to detect cancer at an earlier stage. to assess the impact of introducing CTC into the UK NHS screening programme for CRC on key health outcomes as well as the NHS budget and healthcare resource capacity. a discrete Markov model was used to reflect the natural history of CRC and the impact of three screening scenarios (biennial FOBT with and without CTC triage of patients referred to OC, and CTC every 5 years) on a range of health outcomes, including the incidence and prevalence of CRC, in a hypothetical cohort of individuals. The yearly costs, health outcomes and healthcare resource capacity requirements were estimated over a 10-year period (2009-18). using CTC to follow up FOBT-positive patients (scenario 2) was less costly than directing all FOBT-positive patients to OC (scenario 1); saving £776 283 over 10 years for 100 000 individuals invited for screening (year 2007 values), primarily by avoiding approximately 1700 OCs, but was estimated to require 2200 additional CT scans. Implementing a programme of 5-yearly CTC as a primary screen is expected to be more expensive than FOBT screening over the short term (driven by high screening and diagnosis costs), despite substantial savings in treatment costs for CRC over the 10-year time horizon of the model and improved health outcomes. adding CTC into the existing NHS Bowel Cancer Screening Programme as part of a preventive screening strategy could be less costly to the NHS over the longer term when used to triage FOBT-positive patients to appropriate follow-up. Increased demand for radiology services may be compensated for by reduced demand in endoscopy units.

Costs and cost-effectiveness of full implementation of a biennial faecal occult blood test screening program for bowel cancer in Australia

Costs and cost-effectiveness of full implementation of a biennial faecal occult blood test screening program for bowel cancer in Australia

Programme of screening for colorrectal cancer in the Valencia community, Spain: results of the first round (2005-2008)

Several studies evaluating colorectal cancer (CRC) screening with fecal occult blood testing (FOBT) have reported a significant reduction in mortality from this tumor. The study aims to describe the results of the first round of the CRC screening program in medium-risk population of Valencia and assessing their feasibility and acceptability. Colorectal cancer screening pilot study using biennial FOBT. All residents (106,000 Inhabitants) between 50 and 69 years old (a subgroup of 70-74 years), from 3 selected health departments (04, 07 and 13) were invited by mail to participate. The individuals with FOBT positive were referred to hospital for colonoscopy. The following rates were calculated as indicators of program quality: the participation rate, positive FOBT rate, acceptance rate of colonoscopy, and detection rate of low and high-risk adenomas and invasive cancers, and positive predictive value of FOBT. The participation was 35,231 individuals (35.70%). The number of FOBT positive was 579 (1.64% of total analyzed test), 548 people agreed colonoscopy (acceptance rate: 94.69%). 61 CRC were detected, 61 and 153 High-Risk and Low-Risk Adenomas (rates of 1.77, 1.77 and 4.46% per 1,000 participants). The positive predictive values for cancer, low-risk and high risk adenomas were 10.95%, 10.95%, and 27.46% respectively. The program indicators suggest that a population program of colorectal cancer is feasible in our community as the process indicators obtained are similar to those given in other programs in Spain and Europe.

Abstract PR-01: Inequalities in colorectal cancer screening uptake: Results from the first 2.6 million invitations in the organized screening program in the U.K

Abstract Background: An organized, population-based colorectal cancer (CRC) screening program was initiated in England in 2006, offering biennial Fecal Occult Blood testing (FOBt) to adults aged 60 to 69 years, with abnormal results followed up by colonoscopy. Because organized programs use population records to contact all eligible adults by mail, and there are no costs associated with screening or follow-up in the UK National Health Service, barriers to access for lower SES groups should be minimized. However, socioeconomic (SES) differences have been observed across a range of early detection behaviors, making it important to monitor the implementation of a new screening program. The aim of this analysis was to identify the extent of inequalities in uptake by SES, ethnic diversity, gender, and age in the English screening program. Methods: Between October 2006 and January 2009, over 2.6 million adults aged 60-69 years were mailed a first FOBt kit by one of the five regional “Hubs.” Area-level SES was indexed with a composite indicator (the Index of Multiple Deprivation) based on census-derived indicators of income, education, employment, environment, and housing for each postcode sector (containing an average of 3,000 addresses). Area-level ethnic diversity was based on the proportion of nonwhite residents in each postcode sector. Gender and age data were obtained from the Hubs. Screening uptake was defined as return of a test kit within 13 weeks, recorded by the Hub. We used multivariate generalized linear regression to examine variation in uptake by deprivation, ethnicity, gender, and age. Results: Over the study period, 2,658,859 FOBt kits were mailed out, of which 54% were returned. Uptake rates showed a linear gradient across quintiles of deprivation, ranging from 35% in the most deprived quintile to 61% in the least deprived. Multivariate analyses confirmed a significant independent effect of deprivation after adjusting for ethnicity, gender, age and Hub. The association between deprivation and uptake was stronger in women and older people. The most ethnically diverse quintile of areas also had lower uptake rates (38%) than other areas (52% to 58%), independent of SES, age, gender, and Hub. Ethnic disparities were more pronounced in men but equivalent across age groups. More women than men returned a kit (56% vs. 51%). Uptake increased with age in men (49% at 60-64 years; 53% at 65-69 years) but not in women (57% vs. 56%). Conclusion: Uptake of FOBt in the new national CRC screening program in England is encouraging, but these results demonstrate that even though organized programs provide equitable delivery of the opportunity to screen, they do not eradicate inequalities in uptake. The lower uptake associated with ethnic diversity was apparent only in the most diverse quintile, which predominantly comprised inner city areas. In contrast, SES inequalities not only meant dramatically reduced uptake in the most deprived quintile but also showed a linear gradient in uptake across the entire SES spectrum. Reducing inequalities in uptake will require understanding how SES influences screening decision making. Organized programs do not obviate the need for action to promote equality of uptake if they are to avoid creating increased inequalities in cancer mortality. Citation Information: Cancer Prev Res 2010;3(12 Suppl):PR-01.

Longitudinal Adherence With Fecal Occult Blood Test Screening in Community Practice

Although screening with fecal occult blood testing (FOBT) reduces colorectal cancer (CRC) mortality, its effectiveness may diminish if patients do not adhere with repeated screenings. Among patients who had previously engaged in FOBT screening, we assessed subsequent adherence with FOBT screening. We assessed longitudinal adherence with biennial FOBT screening (every other year) within a cohort of patients enrolled in an integrated Washington State health plan. Among 11,110 patients who participated in FOBT screening during a 2-year baseline period (2000-2001), we ascertained CRC screening use during a subsequent 2-year observation period (2002-2003). We used multinomial logistic regression to identify patient characteristics associated with higher incidence of repeat CRC screening (with or without FOBT) relative to patients who received no CRC screening. Despite prior participation in FOBT screening, less than one-half of patients (44.4%; 95% CI, 42.9%-45.8%) completed FOBT screening during the 2-year observation period. Although 8.8% of patients (95% CI, 8.0%-9.7%) received other CRC tests without FOBT during the observation period, nearly one-half, 46.8% (95% CI, 45.3%-48.4%), received no CRC screening. After adjustment for other patient characteristics, receipt of a preventive health examination was strongly associated with FOBT adherence relative to no CRC screening (adjusted relative rate ratio = 11.16; 95% CI, 9.61-12.96). Longitudinal adherence with FOBT screening was low in this insured population, potentially compromising its effectiveness in population CRC mortality reduction. Interventions to promote adherence may be necessary to achieve high effectiveness in population-based FOBT screening programs.

Effect of Gender, Age and Deprivation on Key Performance Indicators in a Fobt-based Colorectal Screening Programme

To assess the effect of gender, age and deprivation on key performance indicators in a colorectal cancer screening programme. Between March 2000 and May 2006 a demonstration pilot of biennial guaiac faecal occult blood test (gFOBT) colorectal screening was carried out in North-East Scotland for all individuals aged 50-69 years. The relevant populations were subdivided, by gender, into four age groups and into five deprivation categories according to the Scottish Index of Multiple Deprivation (SIMD), and key performance indicators analysed within these groups. In all rounds, uptake of the gFOBT increased with age (P < 0.001), decreased with increasing deprivation in both genders (P < 0.001), and was consistently higher in women than in men in all age and all SIMD groups. In addition, increasing deprivation was negatively associated with uptake of colonoscopy in men with a positive gFOBT (P < 0.001) although this effect was not observed in women. Positivity rates increased with age (P < 0.001) and increasing deprivation (P < 0.001) in both genders in all rounds, although they were higher in men than in women for all age and SIMD categories. Cancer detection rates increased with age (P < 0.001), were higher in men than in women in all age and SIMD categories, but were not consistently related to deprivation. In both genders, the positive predictive value (PPV) for cancer increased with age (P < 0.001) and decreased with increasing deprivation (P < 0.001) in all rounds and was consistently higher in men than in women in all age and SIMD categories. In this population-based colorectal screening programme gender, age, and deprivation had marked effects on key performance indicators, and this has implications both for the evaluation of screening programmes and for strategies designed to reduce inequalities.

Cost Effectiveness of CT Colonography for UK NHS Colorectal Cancer Screening of Asymptomatic Adults Aged 60–69 Years

Screening of populations at risk for colorectal cancer (CRC) allows the detection and successful treatment of tumours and their precursor polyps. The current UK CRC screening programme is faecal occult blood testing (FOBT), despite evidence from modelling studies to suggest that more cost-effective technologies exist. To assess the cost effectiveness of CT colonography (CTC) for colorectal cancer screening from the perspective of the UK NHS. A state-transition Markov model was constructed to estimate lifetime costs and health outcomes of a cohort of individuals screened at age 60-69 years using four different CRC screening technologies: FOBT, flexible sigmoidoscopy, optical colonoscopy and CTC. CTC screening offered every 10 years was cost saving compared with the current UK programme of biennial FOBT screening. This strategy also yielded greater health benefits (QALYs and life-years) than biennial FOBT screening. The model fit observed CRC epidemiology data well and was robust to changes in underlying parameter values. CTC remained cost effective under a range of assumptions in the univariate sensitivity analysis. However, in the probabilistic sensitivity analysis, CTC dominated FOBT in only 5.9% of simulations and was cost effective at a threshold of pound30,000 per QALY gained in 48% of simulations. CTC has the potential to provide a cost-effective option for CRC screening in the UK NHS and may be cost saving compared with the current programme of biennial FOBT. Further analysis is required to assess the impact of introducing CTC to the UK CRC screening programme on the NHS budget and capacity.

What is a Reasonable Screening Test for Colorectal Cancer

See Article on Page 420-423 The methods of screening tests are stool examinations, such as the fecal occult blood test (FOBT) and the fecal DNA test, and evaluations of images, such as flexible sigmoidoscopy, colonoscopy, double-contrast barium enema and computed tomographic colonography. The advantages and the disadvantages of different screening tests have been the subject of intense debate. An accurate screening test would have high sensitivity when an adenomatous polyp or cancer is present and high specificity in their absence. Randomized controlled trials using the FOBT as the screening strategy have shown a reduction in mortality due to colorectal cancer. The fecal DNA panel (k-ras, APC, p53 and BAT-26) was more sensitive than the FOBT for invasive cancer and adenomas, but its cost effectiveness is controversial [1]. Colonoscopy has theoretical advantages over other screening tests, including direct visualization of the entire colon and, more importantly, removal of precancerous adenomatous lesions. Colonoscopy has averted the greatest number of deaths from colorectal cancer (31%), followed by annual fecal occult blood testing (29%), flexible sigmoidoscopy (21%) and biennial fecal occult blood testing (19%) [2, 3]. The FOBT was preferred as a screening test by 70.2% of the participants and colonoscopy by 9.3% because colonoscopy was significantly more time consuming, was disturbing, painful, and annoying, and involved risks [4]. In conclusion, screening based on stool tests with colonoscopic follow-up of positive test results might offer a high potential for early detection or prevention of colorectal cancer.

Tamización de cáncer colorrectal en población adulta asintomática: revisión sistemática

ObjectiveTo identify the best strategy for colorectal cancer screening among population over 50 years of age. MethodsA systematic review was performed were main outcomes corresponded to colorectal cancer mortality and incidence as well as side effects os screening. MedLine, Embase, Cochrane, DARE, Clinical Evidence, CINAHL, LILACS and University of York databases were reviewed from January 1st 2001 to December 31th 2009. ResultsThe fecal occult blood test (FOBT) reduces colorectal cancer mortality about 20% to 33% but not the overall mortality (RR: 1.00, IC 95%: 0.98-1.01). There is no difference between annual (RR: 0.84, IC 95%: 0.78-0.90) or biennial FOBT screening (RR: 0.85, IC 95%: 0.78-0.92). Sigmoidoscopy, sigmoidoscopy plus FOBT, or colonoscopy are not supported on strong evidence (randomized controlled trials) as screening strategies for reducing colorectal cancer mortality. The evidence is controversial about performance of test guaiaco or immunochemical tests as FOBT screening tests. ConclusionBased on the best available evidence FOBT should be used for colorectal cancer screening among population over 50 years.

Variations between endoscopists in rates of detection of colorectal neoplasia and their impact on a regional screening program based on colonoscopy after fecal occult blood testing

There are few data about the performance variability among endoscopists participating to nationwide or regionwide colorectal cancer screening programs. To assess the variability of neoplasia detection rates among endoscopists participating in a regional colorectal cancer screening program based on colonoscopy after biennial fecal occult blood testing (FOBT). Two rounds of colonoscopy were performed: round 1 took place in 2003 and 2004, and round 2 took place in 2005 and 2006. Secondary analysis of colonoscopy findings from the first 2 rounds was performed by using data drawn from all endoscopists who performed more than 30 colonoscopies in each round. Detection rates were adjusted for patient age and sex, and logistic regression analyses were conducted including these 2 variables and round number (1 or 2). District of Ille-et-Vilaine in Brittany (population >900,000) between 2003 and 2007. The per-endoscopist adjusted rates of colonoscopies with at least 1, 2, or 3 adenomas, 1 adenoma 10 mm or larger, or a cancer. Among the 18 endoscopists who performed 3462 colonoscopies, the adjusted detection rates were in the following ranges: at least 1 adenoma, 25.4% to 46.8%; 2 adenomas, 5.1% to 21.7%; 3 adenomas, 2.7% to 12.4%; 1 adenoma 10 mm or larger, 14.2% to 28.0%; and cancer, 6.3% to 16.4%. Multivariate analyses showed that the endoscopist was not an independent predictor of cancer detection, but was an independent predictor of detecting adenomas, regardless of category; the R(2) of the models ranged from 6% to 13% only. Other factors known to influence colorectal neoplasia occurrence and withdrawal time could not be taken into account. In a screening program with a high compliance rate with colonoscopy after FOBT, interendoscopist variability had no effect on cancer detection, but did influence identification of adenomas. The clinical impact of such findings merits further evaluation.

Comparing Different Strategies for Colorectal Cancer Screening in Italy: Predictors of Patients' Participation

The objective of this study was to study predictors of patients' participation in colorectal cancer (CRC) screening. Men and women, aged 55-64 years, were randomized to the following: (i) biennial fecal occult blood test (FOBT) delivered by mail (n=2,266); (ii) FOBT delivered by a general practitioner (GP)/screening facility (n=5,893); (iii) "once-only" sigmoidoscopy (FS) (n=3,650); (iv) FS followed by FOBT for screenees with negative FS (n=10,867); and (v) patient's choice between FS and FOBT (n=3,579). A stratified (by screening arm) random sample of attenders and nonattenders was contacted by trained interviewers 4 months after the initial invitation. Subjects giving their consent were administered a questionnaire (available online) investigating perceptions of individual CRC risk, attitudes toward prevention, adoption of health protective behaviors, and reasons for attendance/nonattendance. Adjusted prevalence odds ratios (ORs) were computed by multivariable logistic regression. The response rate was 71.9% (701 of 975) among nonattenders and 88.9% (773 of 870) among attenders. Adjusting for screening arm, center, gender, age, and education, participation was significantly higher among people who consulted their GP before undergoing screening (OR: 4.24; 95% confidence interval (CI): 3.11-5.78), who mentioned one first-degree relative with CRC (OR: 3.62; 95% CI: 2.02-6.49), who reported regular physical activity (OR: 1.85; 95% CI: 1.33-2.55), and who read the mailed information (letter only: OR: 1.85; 95% CI: 1.23-2.78; letter+leaflet: OR: 3.18; 95% CI: 2.12-4.76). People who considered screening to be ineffective (OR: 0.12; 95% CI: 0.08-0.19), those who considered it to be effective but reported even moderate levels of anxiety (OR: 0.32; 95% CI: 0.23-0.45), and those who mentioned previous knowledge of CRC screening tests were less likely to accept the invitation (OR: 0.49; 95% CI: 0.34-0.70). Adoption of health protective behaviors is associated with a higher attendance rate, whereas anxiety represents a strong barrier, even among people who deemed screening to be effective. Increasing the proportion of people who consult their GP when making a decision regarding screening might enhance participation.

Faecal occult blood test-based screening programme with high compliance for colonoscopy has a strong clinical impact on colorectal cancer

The results of a pilot colorectal cancer screening programme by biennial immunochemical faecal occult blood test (FOBT) are reported. All residents aged between 50 and 69 years in the Italian province of Lecco were invited to have a FOBT. Those with a positive result were offered colonoscopy. FOBT uptake and compliance with colonoscopy were assessed. Detection rate and positive predictive value (PPV) for cancer and adenoma were calculated. Tumour stages were compared between screen-detected cancers and other colorectal cancers diagnosed within the target age group. Some 38,693 (49.6 per cent) of 78,083 individuals had a FOBT and 2392 (6.2 per cent) had a positive result. Colorectal cancer was diagnosed in 4.6 per cent and advanced adenoma in 32.7 per cent. PPVs were 4.0 per cent for cancer, 28.1 per cent for advanced adenoma and 36.6 per cent for any adenoma. There was a significant difference in incidence of stage III/IV disease between screened and non-screened cohorts. Compliance for colonoscopy was 92.0 per cent. Major determinants of compliance were age less than 59 years, female sex, high education level and non-manual work. These results justify extension of colorectal cancer screening to other regions of Italy.

The Appropriateness of Colonoscopy in the Screening Programme of Colorectal Cancer Based On Fecal Occult Blood Test (FOBT): The Outcomes Expected and Surprising

Introduction: The incidence of colorectal cancer in the Czech Republic is continuously increasing. A national screening programme based on the biennial FOBT and colonoscopy, in the event of FOBT positivity, was launched in 2000. The total number of colonoscopies increased by 50%, reaching approximately 130,000 (3.5% of the eligible population) per year. The number of FOBT has multiplied. The aim of this prospective multicenter study was to assess the potential role of colonoscopy in the diagnosis and screening of colorectal cancer in the conditions of the screening programme. Results: A total of 3827 colonoscopic records were analyzed. The mean rate of caecum intubation was 87.6%. The most frequent indication for colonoscopy was enterorrhage (32.4%) followed by pain (27.5%) and changes in stool habits (21.3%). Overall, 542 (14.1%) colonoscopies were performed as an official screening method following either positive (395) or negative (147) FOBT. A total of 385 (10.1%) colonoscopies were performed as a primary screening procedure without previous FOBT (altogether 927 - 24.2% - screening procedures). 2251 polyps in 1172 patients (30.5%), 334 advanced adenomas in 269 patients (7,0%), and 143 (3.7%) carcinomas were found. In 479 patients reporting a positive family history, carcinoma was detected in 7 (1.5%) and advanced adenoma in 19 (4.0%) of them, which was lower than in 3348 patients without a positive family history (136 cancers: 4.1%, 315 advanced adenomas: 9.4%), but 212 procedures were done as part of the screening (44.2% vs. 21.3% in patients without positive family history). Among 1395 patients reporting blood in the stool, 141 patients underwent FOBT (106 positive, 35 negative). In patients with enterorrhage, carcinomas were found in 75 (5.4%) patients, which is higher than their occurrence in 2432 other patients (69 cancers: 2.8%). Altogether, ninety four (37.1%) of advanced adenomas and 51 (36.7%) carcinomas were detected by screening. Conclusions: We proved yield of the screening programme based on FOBT and colonoscopy, since a relatively high proportion of all colonoscopies was indicated either after FOBT or as primary screening procedures, and a relatively high proportion of advanced lesions was detected by screening. Surprisingly, in patients with a positive family history, the detection rate of significant lesions was rather low, which could be explained by the relatively high rate of screening procedures in this group. The consequences of the screening process have to be analyzed with caution.

Endoscopists Are Independent Predictors of Adenoma Detection Rates in a Colorectal Cancer Screening Program Based On Biennial Fecal Occult Blood Test (FOBT): A Population-Based Study

Background and Aim: Whilst the prevalence of neoplasia is known to be high at colonoscopy performed after a positive FOBT result, little is known about putative variations in neoplasia detection rates between endoscopists in such cases. We therefore aimed to assess the differences between endoscopists in a population-based study (938,947 inhabitants) with a high (>50%) compliance rate for screening. Patients and Methods: We calculated the detection rates for cancer, any adenoma, ≥ 2 adenomas, ≥ 3 adenomas, adenoma ≥ 10 mm for each of the 18 endoscopists enrolled in the study: those who participated to the two first rounds of the screening program and performed at least 30 colonoscopies at each screening round. Crude neoplasia detection rates and adjusted rates to patients' age and gender were calculated for each endoscopist. Odds ratios were calculated for each endoscopist by comparing him to the endoscopist with the lowest adjusted neoplasia detection rate. Differences between endoscopists were determined at each round and after pooling data of both rounds. Differences were assessed by multivariate analysis for each round (results not shown) and for pooled data. Results: the 18 endoscopists performed 3462 of 4136 (84%) colonoscopies following FOBT (1936 and 1526 at 1st and 2nd round, respectively). At 1st round, adjusted detection rates ranged among endoscopists from 7.0% to 17.8% for cancer, 6.0% to 48.3% for any adenoma, 4.9% to 24.4% for ≥2 adenomas, 2.8% to 13.3% for ≥3 adenomas and 8.2% to 30.4% for large adenoma. Similar findings were depicted at 2nd round. Regarding pooled data, odds ratios ranged among endoscopists from 1.21 to 2.85 for cancer (4/17 significantly > 1) and from 1.19 to 2.77 for any adenoma detection (8/17 significantly > 1). No statistical correlation was observed between endoscopists' performances and either their age or colonoscopy volume. Multivariate analysis indicated that endoscopists (besides patients' age and gender) were independent predictors of all categories of adenoma detection including large adenomas (p = 0.015), but not of cancer detection (p = 0.38). Conclusions: This study shows for the first time that performances in detecting all categories of adenomas, including large adenomas, but not cancer vary greatly among endoscopists participating to a nationwide colorectal cancer screening program based on FOBT. While assuming that most endoscopists performed careful examinations after a positive FOBT result, these findings emphasize the need for understanding the reasons for observed differences in the real life and for defining quality indicators of colonoscopy following FOBT.

Population screening for colorectal cancer: the implications of an ageing population

Population screening for colorectal cancer (CRC) has recently commenced in the United Kingdom supported by the evidence of a number of randomised trials and pilot studies. Certain factors are known to influence screening cost-effectiveness (e.g. compliance), but it remains unclear whether an ageing population (i.e. demographic change) might also have an effect. The aim of this study was to simulate a population-based screening setting using a Markov model and assess the effect of increasing life expectancy on CRC screening cost-effectiveness. A Markov model was constructed that aimed, using a cohort simulation, to estimate the cost-effectiveness of CRC screening in an England and Wales population for two timescales: 2003 (early cohort) and 2033 (late cohort). Four model outcomes were calculated; screened and non-screened cohorts in 2003 and 2033. The screened cohort of men and women aged 60 years were offered biennial unhydrated faecal occult blood testing until the age of 69 years. Life expectancy was assumed to increase by 2.5 years per decade. There were 407 552 fewer people entering the model in the 2033 model due to a lower birth cohort, and population screening saw 30 345 fewer CRC-related deaths over the 50 years of the model. Screening the 2033 cohort cost £96 million with cost savings of £43 million in terms of detection and treatment and £28 million in palliative care costs. After 30 years of follow-up, the cost per life year saved was £1544. An identical screening programme in an early cohort (2003) saw a cost per life year saved of £1651. Population screening for CRC is costly but enables cost savings in certain areas and a considerable reduction in mortality from CRC. This Markov simulation suggests that the cost-effectiveness of population screening for CRC in the United Kingdom may actually be improved by rising life expectancies.

Endoscopic requirements of colorectal cancer screening programs in average-risk population. Estimation according to a Markov model

BackgroundAlthough colorectal cancer (CRC) screening strategies are quite common in the United States, their systematic introduction in Europe has been delayed until the year 2008. To estimate endoscopic requirements of four different CRC screening strategies (annual and biennial fecal occult blood testing (FOBT), flexible sigmoidoscopy every 5 years, and colonoscopy every 10 years) in an average-risk population. MethodsA long-term Markov process model was designed combining three adherence rates for the four above-mentioned screening strategies in individuals aged from 50 to 74. Estimations included endoscopic procedures performed for both screening and surveillance purposes. Models were adjusted for age-related adenoma and CRC incidence rates, life expectancy, and cancer-related survival. ResultsThe mean number of annual colonoscopies per 100,000 individuals aged 50-74 ranged from 100 to 271 for annual FOBT, from 75 to 203 for biennial FOBT, from 222 to 601 for sigmoidoscopy, and from 903 to 2449 for colonoscopy-based strategies, depending on the adherence rate. According to these estimations, annual and biennial FOBT strategies would generate a slight decrease of current endoscopic activity (1.4-3.8% and 2.7-7.2%, respectively), whereas sigmoidoscopy and colonoscopy-based strategies would induce a 4.7-12.8% and 32-87% increase, respectively, with respect to a non-screening scenario. The model confirmed a 3-16% mean reduction of CRC incidence depending on the strategy and adherence rate. ConclusionWhereas endoscopic capacity exists for widespread CRC screening with annual or biennial FOBT, implementation of potentially more effective strategies, such as flexible sigmoidoscopy or colonoscopy, would result in a significant increase of current endoscopic resources.

Nonmedical Costs of Colorectal Cancer Screening With the Fecal Occult Blood Test and Colonoscopy

The nonmedical costs of colorectal cancer screening are unknown. However, they might influence screening uptake and impact the cost-effectiveness of colorectal cancer screening modalities. Consecutive individuals presenting for colorectal cancer screening in the Calgary Health Region were recruited from 4 community laboratory collection sites (fecal occult blood test) and 2 endoscopy units (colonoscopy). Subjects completed a questionnaire including items on time off work for the subject and any accompanying caregiver, travel details, and direct out-of-pocket expenses (bowel prep). Time costs were valued at Government of Canada wage rates. Travel costs included estimated costs for travel by car and actual parking costs and taxi and public transportation fares. Car users' costs were calculated by using a Canadian Automobile Association estimate of motoring costs per kilometer. Costs are in 2006 Canadian dollars. The final sample included 604 subjects who underwent fecal occult blood test (mean age, 62 years; 51% male; 43% employed) and 723 who underwent colonoscopy (mean age, 56; 49% male; 66% employed). Eighty percent of colonoscopy subjects required an accompanying caregiver, compared with only 5% for fecal occult blood test. The nonmedical costs (subject +/- caregiver) averaged $308 for colonoscopy and $36 for fecal occult blood test. The nonmedical costs of colorectal cancer screening are substantial, especially for colonoscopy. However, the costs are similar with repeated fecal occult blood tests. These costs might be one factor accounting for low colorectal cancer screening uptake rates. Nonmedical costs should be incorporated into economic analyses of colorectal cancer screening.

Randomized trial of a self-administered decision aid for colorectal cancer screening

Previous studies have not assessed whether evidence-based information about the outcomes of colorectal cancer screening increases informed choice among people from a range of socioeconomic backgrounds nor have they assessed whether this can be administered away from a health-care provider. Randomized controlled trial in six primary care locations. Three hundred and fourteen people aged 50-74 years received a self-administered decision aid (DA) booklet about outcomes of biennial faecal occult blood testing (FOBT) screening or government consumer guidelines (G). Significantly more DA recipients (20.9%) were 'informed' compared with G recipients (5.8%) (P = 0.0001, OR 4.32; 95% CI 2.49 to 7.52); the DA did not affect values clarity (61.9% clear after DA versus 59.1% after G) nor screening decisions overall (87.3% would screen after DA versus 90.5% after G). Test uptake at one month was uniformly low (5.2% DA versus 6.6% G); mostly due to being 'too busy'. DA recipients were more likely to make decisions 'integrating' knowledge with values (10.4% DA versus 1.5% G). Decisions not to screen were equally uncommon in both groups but more likely to be uninformed in G (P = 0.03). More DA recipients from all education levels were 'informed' (P = 0.02), particularly in lower education (50.0% DA versus 17.8% G) and university-educated groups (79.4% DA versus 32.1% G). Detailed absolute risk and benefit information about FOBT screening can be effectively used at home by people to increase informed choice. The DA was effective in people with lower education levels. Unique Protocol ID 211705 ClinicalTrials.gov ID NCT 00148226.

Hallazgos colonoscópicos del estudio piloto de cribado de cáncer colorrectal realizado en Cataluña

to evaluate lesions detected in two screening rounds performed in a pilot screening programme for colorectal cancer in Catalonia, Spain. a colorectal cancer screening programme was initiated in 2000. The target population included men and women aged 50-69 years. Screening consisted of biennial guaiac-based fecal occult blood testing (FOBT), and colonoscopy for participants with a positive FOBT. Any polyps found were removed, and biopsies were performed for any masses. colonoscopies were performed in 442 of 495 people with positive FOBT. In 213 (48.2%), 36 invasive cancers, 121 high-risk adenomas, 29 low-risk adenomas, and 27 hyperplastic polyps were diagnosed. Lesion size was smaller than 10 mm in 25.8% of cases. Most detected lesions (37.2%) were located in the distal colon, followed by the proximal colon (5.7%) and both locations (5.2%). Advanced neoplasm was significantly associated with male gender and distal location. The prevalence of advanced proximal neoplasms among patients with no distal polyps was 5.1%. the most common lesions detected by colonoscopy were high-risk adenomas located in the distal colon. FOBT is a suitable method for detecting small precancer lesions during population screening, and is thus a key factor in reducing the incidence of colorectal cancer.

Screening for Rectal Cancer – Will it Improve Cure Rates?

Here we give an overview of colorectal cancer screening strategies with an emphasis on the diagnosis and management of rectal cancer. We review the published studies on screening in the high-risk population, including patients with a history of colorectal cancer, inflammatory bowel disease and inherited conditions. In the average-risk population, the evidence base for a number of screening strategies is evaluated, including endoscopy, contrast studies and faecal occult blood testing. Screening guidelines in the high-risk population are predominantly based on case–control studies comparing the incidence of colorectal cancer in screened and control groups. Screening the average-risk population for colorectal cancer reduces cancer-specific mortality by 15% after biennial guaiac faecal occult blood testing and 50–80% after flexible sigmoidoscopy. All of the screening strategies outlined have a greater sensitivity for distal lesions than proximal lesions.