Bowel Screening Research Articles

Improved use of faecal immunochemical tests for haemoglobin in the Scottish bowel screening programme.

This study aimed to develop a risk-scoring model in the Scottish Bowel Screening Programme incorporating faecal haemoglobin concentration with other risk factors for colorectal cancer. Data were collected for all individuals invited to participate in the Scottish Bowel Screening Programme between November 2017 and March 2018 including faecal haemoglobin concentration, age, sex, National Health Service Board, socioeconomic status, and screening history. Linkage with The Scottish Cancer Registry identified all screening participants diagnosed with colorectal cancer. Logistic regression was performed to identify which factors demonstrated significant association with colorectal cancer and could be used in the development of a risk-scoring model. Of 232,076 screening participants, 427 had colorectal cancer: 286 diagnosed following a screening colonoscopy and 141 arising after a negative screening test result giving an interval cancer proportion of 33.0%. Only faecal haemoglobin concentration and age showed a statistically significant association with colorectal cancer. Interval cancer proportion increased with age and was higher in women (38.1%) than men (27.5%). If positivity in women were mirrored in men at each age quintile interval cancer proportion would still have remained higher in women (33.2%). Moreover, an additional 1201 colonoscopies would be required to detect 11 colorectal cancers. Development of a risk scoring model using early data from the Scottish Bowel Screening Programme was not feasible due to most variables showing insignificant association with colorectal cancer. Tailoring the faecal haemoglobin concentration threshold according to age could help to diminish some of the disparity in interval cancer proportion between women and men. Strategies to achieve sex equality using faecal haemoglobin concentration thresholds depend considerably on which variable is selected for equivalency and this requires further exploration.

Risk stratification for the detection of metachronous polyps after bowel screening polypectomy: clinical outcomes from the Integrated Technologies for Improved Polyp Surveillance (INCISE) study cohort.

After colorectal polypectomy, 20-50 per cent of patients develop metachronous polyps and some have increased colorectal cancer risk. British Society of Gastroenterology (BSG) 2020 guidelines recommend surveillance colonoscopy for high-risk patients based on index pathology. The aim of this study was to evaluate metachronous lesion outcome using BSG 2020 criteria. A retrospective, multicentred study was conducted including patients who had polypectomy during screening colonoscopy (2009-2016) followed by surveillance. Demographics, index pathology, and BSG 2020 risk criteria were compared with regard to metachronous lesion pathology (non-advanced versus advanced lesions) and timing of detection (early versus late). Advanced lesions were defined as adenomas/serrated polyps greater than or equal to 10 mm, high-grade dysplasia, serrated polyps with dysplasia, or colorectal cancer, and late lesions those detected greater than 2 years after the index procedure. Of 3090 eligible patients, 2643 were included. Among these, retrospective BSG 2020 application would have excluded 51.5 per cent from surveillance. After a median of 36 months, the advanced polyp/colorectal cancer rate in BSG 2020 high-risk patients was 16.3 versus 13.0 per cent in low-risk patients. Older age (P = 0.008) correlated with advanced metachronous lesions. Male sex, greater than five polyps, and BSG 2020 high-risk criteria correlated with non-advanced and advanced lesions (P < 0.001). Older age (P < 0.001), villous features (P = 0.006), advanced index polyp (P = 0.020), and greater than five polyps (P < 0.001) correlated with early metachronous lesions. Male sex and BSG 2020 high-risk criteria correlated with early and late lesions (P < 0.001). On multivariable regression, increased polyp number (odds ratio (OR) 1.15 (95 per cent c.i. 1.07 to 1.25); P < 0.001) and villous features (OR 1.49 (95 per cent c.i. 1.05 to 2.10); P = 0.025) independently correlated with early advanced lesions. The rate of non-advanced and advanced metachronous polyps was higher in BSG 2020 high- versus low-risk patients (44.4 versus 35.4 per cent for non-advanced and 15.7 versus 11.8 per cent for advanced; P < 0.001), but the colorectal cancer rate was similar (0.6 versus 1.2 per cent). However, when examining only lesions detected greater than 2 years after the index colonoscopy in high- versus low-risk patients, no significant differences were observed (P = 0.140). BSG 2020 criteria correlated with metachronous polyps, but did not differentiate advanced and non-advanced lesions and were not predictive of late lesions.

Inequalities in cancer screening participation between adults with and without severe mental illness: results from a cross-sectional analysis of primary care data on English Screening Programmes

BackgroundPeople with severe mental illness (SMI) are 2.5 times more likely to die prematurely from cancer in England. Lower participation in screening may be a contributing factor.MethodsClinical Practice Research Datalink data for 1.71 million, 1.34 million and 2.50 million adults were assessed (using multivariate logistic regression) for possible associations between SMI and participation in bowel, breast and cervical screening, respectively.ResultsScreening participation was lower among adults with SMI, than without, for bowel (42.11% vs. 58.89%), breast (48.33% vs. 60.44%) and cervical screening (64.15% vs. 69.72%; all p < 0.001). Participation was lowest in those with schizophrenia (bowel, breast, cervical: 33.50%, 42.02%, 54.88%), then other psychoses (41.97%, 45.57%, 61.98%), then bipolar disorder (49.94%, 54.35%, 69.69%; all p-values < 0.001, except cervical screening in bipolar disorder; p-value > 0.05). Participation was lowest among people with SMI who live in the most deprived quintile of areas (bowel, breast, cervical: 36.17%, 40.23%, 61.47%), or are of a Black ethnicity (34.68%, 38.68%, 64.80%). Higher levels of deprivation and diversity, associated with SMI, did not explain the lower participation in screening.ConclusionsIn England, participation in cancer screening is low among people with SMI. Support should be targeted to ethnically diverse and socioeconomically deprived areas, where SMI prevalence is greatest.

Increasing uptake of FIT colorectal screening: protocol for the TEMPO randomised controlled trial testing a suggested deadline and a planning tool

IntroductionScreening can reduce deaths from colorectal cancer (CRC). Despite high levels of public enthusiasm, participation rates in population CRC screening programmes internationally remain persistently below target levels. Simple behavioural interventions...

The Barriers to Bowel Cancer Screening Scale: Examining Structural Validity, Measurement Invariance, and Criterion Validity.

The success of national cancer screening programs, such as the National Bowel Cancer Screening Program (NBCSP) in Australia, depends on public participation, which is currently an alarming 43.5% for the NBCSP. Understanding the barriers that impede screening participation requires valid measurement instruments. This study aims to cross-validate such an instrument with a new, large, and varied sample, as well as assess measurement invariance across subsamples at a greatest risk of nonparticipation (ie, testing whether the scale functions in similar ways across groups). A cross-sectional sample of 1158 participants from the target screening population (50-74 years) provided demographic information, responses to the Barriers to Home Bowel Screening (BB-CanS) scale, and information on their previous screening participation. Both the full and the brief versions of the BB-CanS scale showed good model fit for the full sample and for gender and age subsamples. Despite the inter-factor correlations being high, the unidimensional and bi-factor models exhibited poorer fit. Improvement in fit was observed with scale refinement involving the removal of 7 items. All versions of the BB-CanS scale were invariant across gender and age subsamples. Age and gender differences emerged across several barriers and variance in all 4 barriers significantly predicted prior screening participation. The BB-CanS scale is a valid measure of 4 highly correlated barriers to home bowel cancer screening: disgust relating to screening, avoidance of test outcomes, practical difficulty (or challenges), and the need for a sense of greater autonomy. All versions of the instrument measure the equivalent construct across age and gender groups. Observed differences in barriers across at-risk groups provide targets for future intervention.

Inequalities in colorectal cancer screening uptake in Wales: an examination of the impact of the temporary suspension of the screening programme during the COVID-19 pandemic

BackgroundResponse to the early stages of the COVID-19 pandemic resulted in the temporary disruption of cancer screening in the UK, and strong public messaging to stay safe and to protect NHS capacity. Following reintroduction in services, we explored the impact on inequalities in uptake of the Bowel Screening Wales (BSW) programme to identify groups who may benefit from tailored interventions.MethodsRecords within the BSW were linked to electronic health records (EHR) and administrative data within the Secured Anonymised Information Linkage (SAIL) Databank. Ethnic group was obtained from a linked data method available within SAIL. We examined uptake for the first 3 months of invitations (August to October) following the reintroduction of BSW programme in 2020, compared to the same period in the preceding 3 years. Uptake was measured across a 6 month follow-up period. Logistic models were conducted to analyse variations in uptake by sex, age group, income deprivation quintile, urban/rural location, ethnic group, and clinically extremely vulnerable (CEV) status in each period; and to compare uptake within sociodemographic groups between different periods.ResultsUptake during August to October 2020 (period 2020/21; 60.4%) declined compared to the same period in 2019/20 (62.7%) but remained above the 60% Welsh standard. Variation by sex, age, income deprivation, and ethnic groups was observed in all periods studied. Compared to the pre-pandemic period in 2019/20, uptake declined for most demographic groups, except for older individuals (70–74 years) and those in the most income deprived group. Uptake continues to be lower in males, younger individuals, people living in the most income deprived areas and those of Asian and unknown ethnic backgrounds.ConclusionOur findings are encouraging with overall uptake achieving the 60% Welsh standard during the first three months after the programme restarted in 2020 despite the disruption. Inequalities did not worsen after the programme resumed activities but variations in CRC screening in Wales associated with sex, age, deprivation and ethnic group remain. This needs to be considered in targeting strategies to improve uptake and informed choice in CRC screening to avoid exacerbating disparities in CRC outcomes as screening services recover from the pandemic.

P896 Inflammatory Bowel Disease in the elderly, a survey of elderly patient demographics, disease-related complications and compliance with vaccination and screening services

Abstract Background Inflammatory Bowel Disease (IBD) in the elderly (&amp;gt;60yrs) is becoming more prevalent in concordance with the ageing population and the rising incidence of IBD. An increasing number of patients are receiving a diagnosis of IBD in later years in addition to those with known IBD transitioning to elderly. The presentation, disease course, risk of complications and choice of medical therapies differ in this group from younger cohorts. We aimed to examine patient demographics and the incidence of adverse effects/complications amongst elderly IBD patients. We also sought to identify appropriate vaccination rates and uptake with screening services. Methods In a single tertiary centre, IBD patients aged &amp;gt;60 attending the outpatient clinic or admitted acutely were invited to complete an anonymous written survey. Results 28 patients surveyed to date. 61% (n=17) had a diagnosis of UC. 54% were female (n=15). Mean age was 67.5, while mean age at diagnosis was 50 (range 19-65). 25% (n=7) received a diagnosis of IBD after 60 years, of which 57% were female. Mean BMI was 25.9. 25% (n=7) reported an infection in the last 6 months, all of whom required treatment with antibiotics. There was only one case of infection requiring hospitilisation, a patient on biologic therapy who developed a clostridium difficile infection. COVID-19 affected 39% (n=11), none required hospitilisation. 21% (n=6) report 2 or more comorbidities, of which 50% report a recent infection requiring treatment. All patients who required IBD surgery (n=5) had a high BMI. 57% (n=16) had a smoking history, with 14% (n=4) being active smokers. Infliximab and salofalk granules were the most prescribed IBD treatments. 46% were on biologics (n=13), with anti-TNF being the most common (29%). 25% (n=7) reported steroid use in the last year while 14% were not currently on IBD treatment. 21.4% (n=6) reported prior malignancy, skin cancer being most common. 50% of cancer sufferers were smokers. 100% have had a minimal of two COVID-19 vaccines. 64% (n=18) have had a flu-vaccine in the last 12 months with 75% (n=21) report annual flu-vaccine uptake. 61% (n=17) had the pneumococcal vaccine. Bowel screening participation was 46.5% (n=13). Conclusion Smoking, high BMI and multiple comorbidities were common in elderly IBD patients. Infections were common in this cohort and typically required treatment with antibiotics, however, were rarely severe or required hospitalisation. Severe infections were seen in those on biologic therapy. Biologics were commonly prescribed to elderly IBD patients. Skin cancer was the most common malignancy. There was suboptimal uptake with vaccinations and bowel screening.

Colonoscopy Colorectal Cancer Screening Programme in Southern Iraq: Challenges, Knowledge Gaps and Future Potential.

Data on current colorectal cancer screening practices in Iraq are limited. This study aimed to better understand the current colorectal cancer screening practice and perceived barriers. The project also aimed to use UK expertise to introduce Bowel Cancer Screening Programme (BCSP) in Basra, Iraq. The study consisted of two parts: A pre-visit online survey of clinicians to test the project's feasibility. A public survey was conducted to understand and gauge the general knowledge and perceived barriers to having colorectal cancer screening. The second phase included a short visit to Basra and the delivery of a multidisciplinary meeting for bowel screening colonoscopists. Fifty healthcare providers completed the survey. Basra has no established bowel cancer screening programme, let alone the country. Opportunistic colonoscopy surveillance is done on an ad hoc base. A total of 350 individuals completed the public survey. The survey showed that more than 50% of participants were not familiar with the concept of a BCSP and less than 25% were aware of "red flag" symptoms of bowel cancer. The short visit to Basra included a roundtable discussion and delivered a training workshop for screening colonoscopists using UK training materials in conjunction with the Iraqi Medical Association. Feedback from the course was extremely positive. Several potential barriers were identified to participate in BCSP. The study highlighted potential barriers, including a lack of public awareness and insufficient training resources to be addressed in future screening programmes. The study has identified several potential areas for future collaboration to support the development of a BCSP centre in Basra.

Geographical and spatial variations in bowel cancer screening participation, Australia, 2015-2020.

Participation in bowel cancer screening programs remains poor in many countries. Knowledge of geographical variation in participation rates may help design targeted interventions to improve uptake. This study describes small-area and broad geographical patterns in bowel screening participation in Australia between 2015-2020. Publicly available population-level participation data for Australia's National Bowel Cancer Screening Program (NBCSP) were modelled using generalized linear models to quantify screening patterns by remoteness and area-level disadvantage. Bayesian spatial models were used to obtain smoothed estimates of participation across 2,247 small areas during 2019-2020 compared to the national average, and during 2015-2016 and 2017-2018 for comparison. Spatial heterogeneity was assessed using the maximized excess events test. Overall, screening participation rates was around 44% over the three time-periods. Participation was consistently lower in remote or disadvantaged areas, although heterogeneity was evident within these broad categories. There was strong evidence of spatial differences in participation over all three periods, with little change in patterns between time periods. If the spatial variation was reduced (so low participation areas were increased to the 80th centile), an extra 250,000 screens (4% of total) would have been conducted during 2019-2020. Despite having a well-structured evidence-based government funded national bowel cancer screening program, the substantial spatial variation in participation rates highlights the importance of accounting for the unique characteristics of specific geographical regions and their inhabitants. Identifying the reasons for geographical disparities could inform interventions to achieve more equitable access and a higher overall bowel screening uptake.

Methodological reflections on the recruitment and engagement of people for cancer screening research in Wales.

Cancer is a major threat to public health and the second leading cause of death globally. Population-based cancer screening is an effective way to improve the early detection of a cancer and reduce mortality. Factors associated with participation in cancer screening have been increasingly explored in research. The challenges to undertaking such research are evident, but there is little discussion about how to address such challenges. This article discusses methodological issues associated with the recruitment and engagement of participants in research, drawing upon our experience of undertaking research exploring the support needs of people residing in Newport West, Wales, to participate in breast, bowel, and cervical screening programs. Four key areas were addressed: sampling issues, language barriers, IT issues, and time demand for participation. The paper highlights the importance of ongoing community engagement, the provision of appropriate study materials, and the adaption to different data collection modes to meet participants' needs to participate in research, thus enabling people who are usually excluded from research to have a voice and make a significant contribution to research.

Long-term benefits for lower socioeconomic groups by improving bowel screening participation in South Australia: A modelling study.

The gap in bowel cancer screening participation rates between the lowest socioeconomic position (SEP) groups and the highest in Australia is widening. This study estimates the long-term health impacts and healthcare costs at current colorectal cancer (CRC) screening participation rates by SEP in South Australia (SA). A Markov microsimulation model for each socioeconomic quintile in SA estimated health outcomes over the lifetime of a population aged 50-74 years (total n = 513,000). The model simulated the development of CRC, considering participation rates in the National Bowel Cancer Screening Program and estimated numbers of cases of CRC, CRC deaths, adenomas detected, mean costs of screening and treatment, and quality adjusted life years. Screened status, stage of diagnosis and survival were obtained for patients diagnosed with CRC in 2006-2013 using data linked to the SA Cancer Registry. We predict 10915 cases of CRC (95%CI: 8017─13812) in the lowest quintile (Q1), 17% more than the highest quintile (Q5) and 3265 CRC deaths (95%CI: 2120─4410) in Q1, 24% more than Q5. Average costs per person, were 29% higher in Q1 at $11997 ($8754─$15240) compared to Q5 $9281 ($6555─$12007). When substituting Q1 screening and diagnostic testing rates with Q5's, 17% more colonoscopies occur and adenomas and cancers detected increase by 102% in Q1. Inequalities were evident in CRC cases and deaths, as well as adenomas and cancers that could be detected earlier. Implementing programs to increase screening uptake and follow-up tests for lower socioeconomic groups is critical to improve the health of these priority population groups.

Psychosocial Predictors of Colorectal Cancer Screening Intention: An Experiment on the Invitation Letter.

In Italy, attendance rates for colorectal cancer (CRC) screening are suboptimal. The present work analysed cognitive and emotional predictors of CRC screening intention and tested an intervention on a real invitation letter to improve CRC screening intention, both directly and in interaction with the predictors of our model. Our model included variables from the theory of planned behaviour and the emotional barriers to bowel screening scale. We applied six changes to an invitation letter used in Italy to avoid the repetition of words like 'faeces', 'blood', or 'occult' and reduce the prompting of disgust. The 228 participants were randomly assigned to a between-participants design (original letter vs. manipulated letter). Disgust hindered CRC screening intention, while embarrassment, fear, and subjective norms (i.e., perception of the social pressures to attend CRC screening) were not associated with intention to screen. More positive attitudes towards CRC screening were associated with a higher intention to screen. The positive association between perceived behavioural control and CRC screening intention was stronger for participants who read the letter with fewer (vs. more) references to bodily waste. Letter manipulation did not affect intention to screen. The disgust associated with faecal matter is a critical factor in determining CRC screening attendance, and it should be acknowledged as such in public policies. Until new screening tests avoiding the activation of this emotional reaction are concretely available, public campaigns should improve CRC screening participation by boosting both positive attitudes towards screening and patients' perceived behavioural control.

Impact of the temporary suspension of the Bowel Screening Wales programme on inequalities during the COVID-19 pandemic: a retrospective register-based study

BackgroundResponse to the COVID-19 pandemic resulted in the temporary disruption of routine services in the UK National Health Service, including cancer screening. Following the reintroduction of services, we explored the impact on inequalities in uptake of the Bowel Screening Wales (BSW) programme to identify groups who might benefit from tailored intervention. MethodsBSW records were linked to electronic health record and administrative data within the Secured Anonymised Information Linkage (SAIL) Databank Trusted Research Environment. We examined uptake in the first 3 months (from August to October, 2020) of invitations following the reintroduction of the BSW programme compared with the same period in the preceding 3 years. We analysed inequalities in uptake by sex, age group, income deprivation quintile, urban and rural location, ethnic group, and uptake between different periods using logistic regression models. FindingsOverall uptake remained above the 60% Welsh standard during the COVID-19 pandemic period of 2020–21 but declined compared with the pre-pandemic period of 2019–20 (60·4% vs 62·7%; p<0·001). During the COVID-19 pandemic period of 2020–21, uptake declined for most demographic groups, except for older individuals (70–74 years) and those in the most deprived quintile. Variation by sex, age, income deprivation, and ethnic groups was observed in all periods studied. Among low-uptake groups, including males, younger individuals (60–64 years), those living in most deprived areas, and ethnic minorities, uptake remains below the 60% Welsh standard. InterpretationDespite the disruption, uptake remained above the Welsh standard and inequalities did not worsen after the programme resumed activities. However, variations associated with sex, age, deprivation, and ethnicity remain. These findings need to be considered in targeting strategies to improve uptake and informed choice in colorectal cancer screening such as co-producing information products with low-uptake groups and upscaling the use of GP-endorsed invitations and reminder letters for bowel screening. FundingHealth Data Research UK, UK Medical Research Council, Administrative Data Research UK, and Health and Care Research Wales.

Investigation of the New Advantages of Colonoscope Insertion with an Endoscopic Position Detection Unit.

The use of an endoscopic position detection unit (UPD) enables better and more objective understanding of the shape and position of the colonoscope. Here, we investigated the reproducibility of the insertion of a colonoscope with UPD. Study participants were 122 patients who received a colonoscopy with UPD twice for the purpose of large bowel screening and surveillance. The mean age of participants was 69.7 ± 10.4 years, and the male-to-female ratio was 9.2:1. The colonoscope insertion technique was primarily based on the shaft-holding, shortening insertion method. The cecal intubation time was recorded; the method used for passing through the sigmoid/descending colon junction (SDJ) and the hepatic flexure. The mean cecal intubation time was 990 ± 511 s. The cecal intubation time and the patterns for passing through the SDJ and hepatic flexure were significantly correlated between the first and second colonoscopies. Use of a UPD revealed good reproducibility of colonoscope insertion. This is the first time we have proved that both time and pattern are inserted in much the same way for the first and second times. In patients' conducted UPD combination TCS after the second time, it was suggested that individual tailor-made insertions are possible based on the information from the first time.

S1583 Surveillance With Double Balloon Enteroscopy in Adult Patients With Peutz-Jeghers Syndrome: A Single Center Experience

Introduction: Peutz-Jeghers syndrome (PJS) is an inherited polyposis syndrome caused by mutation in the STK11 gene, and characterized by hamartomatous polyps throughout the gastrointestinal tract, most often in the small bowel (60-90%) and colon (50-64%). Presenting symptoms in PJS are often related to symptomatic polyps, including intestinal obstruction, abdominal pain, and bloody stools. For PJS patients, current recommendations support screening upper endoscopy, colonoscopy, and video capsule endoscopy at age 8-10, and if no polyps identified then again at age 18. Small bowel screening is recommended every 2-3 years. Deep enteroscopy, via antegrade or retrograde balloon enteroscopy, is often required for clearance of larger polyps visualized on video capsule endoscopy (VCE). The optimal follow-up strategy and modality of screening and surveillance of small bowel polyps is controversial. We aimed to evaluate if proactively performing deep enteroscopy vs serial VCE in adult PJS patients reduces risk of requiring subsequent surgical intervention. Methods: We retrospectively collected data from adult patients over 18 years of age with Peutz-Jeghers syndrome who underwent deep balloon enteroscopy for small bowel surveillance. Patients within this subset underwent proactive screening with antegrade double balloon enteroscopy performed approximately every one to 2 years. Data collected included number of prior small bowel surgeries before onset of and during deep enteroscopy surveillance, and complications. Results: Thirteen patients underwent deep enteroscopy from 2010 through 2021. Average number of prior small bowel surgeries was 1.9 (SD 1.4), average number of balloon enteroscopies during surveillance period 2.8 (SD 1.4), and average number of surgeries during balloon enteroscopy surveillance 0.46 (SD 0.66). There was a significant difference between number of surgeries before and during surveillance period (P=0.002). Conclusion: The initial standard screening modality for small bowel polyps and malignancy, VCE, can be complicated by increased risk of capsule retention given likelihood of prior surgery and possibility of obstructing polyps. Additionally, within the PJS cohort, there is a high yield for pathology which may ultimately require therapeutic deep enteroscopy anyhow. Our study, though small, does indicate that on a proactive balloon enteroscopy surveillance protocol there is a significantly lower risk of requiring small bowel surgery.

What are common barriers and helpful solutions to colorectal cancer screening? A cross-sectional survey to develop intervention content for a planning support tool

ObjectiveColorectal screening using faecal immunochemical tests (FITs) can save lives if the people invited participate. In Scotland, most people intend to complete a FIT but this is not reflected in...

Do faecal test-based colorectal cancer screening pilots provide data that are reflected in subsequent programmes? Evidence from interval cancer proportions.

Guidelines on colorectal cancer (CRC) screening with guaiac faecal occult blood tests (gFOBTs) and faecal immunochemical tests (FITs) include the need for a pilot before a programme is introduced. Interval cancers (ICs), cancers arising after a negative screening test result but before the next scheduled invite, are important indicators of programme quality. Our aim was to compare IC in the gFOBT-based Scottish Bowel Screening Programme (SBoSP), a FIT-based pilot, and the FIT-based SBoSP, to assess if the pilot provided data that was reflected in the subsequent programme. The IC proportions (ICPs) data ([IC/(IC + screen detected CRC)] x 100) from the penultimate year of the gFOBT-based SBoSP, the 6-month pilot and the first year of the FIT-based SBoSP were compared. To ensure appropriate comparison, these data were only from the two pilot NHS Boards. For all participants, and females and males, the ICPs were very similar in the gFOBT-based SBoSP and the pilot. The faecal haemoglobin concentration (f-Hb) threshold for the pilot was set at ≥80μg Hb/g faeces. However, in marked contrast, in the FIT-based SBoSP, at the same threshold, the ICPs were lower. In all three groups, the ICPs were higher in females than in males. Data on variables in pilots, including ICP, can be informative, but only if variables such as FIT system are held consistent between pilot and programme. Lowering the f-Hb threshold for females to give the same ICP as males might be a strategy to minimise sex inequality.

Route to diagnosis of colorectal cancer and association with survival within the context of a bowel screening programme

ObjectivesBowel cancer screening has been introduced to improve colorectal cancer outcomes; however, a significant proportion of cases continue to present with TNM Stage III-IV disease and/or emergently. This study analyses the prior interaction with screening of patients diagnosed with colorectal cancer and factors associated with non-screening diagnosis. Study designThis was a retrospective observational study. MethodsAll patients diagnosed with colorectal cancer in the West of Scotland from 2011 to 2014 were identified. Through data linkage to the Scottish Bowel Cancer Screening Programme, we analysed patient interaction with screening within 2 years before cancer diagnosis. ResultsIn total, 6549 patients were diagnosed with colorectal cancer, 1217 (19%) via screening. Screening participation was associated with earlier TNM stage, reduced emergency presentations and improved 3-year survival (all P < 0.001). Failure to diagnose through screening was predominantly due to non-invitation (37%), non-return of screening test (29%) or negative test (13%). Three hundred fifty-one patients were below screening age, 79% of whom were aged 40–49 years and 2035 patients were above screening age. Factors associated with non-return of screening test included age, sex, SIMD (all P < 0.001) and raised Charlson score (P = 0.030). Factors associated with negative screening result included sex, anaemia, differentiation, right-sided tumours and venous invasion (P < 0.001). ConclusionWithin Scotland, <20% of colorectal cancer is diagnosed through screening despite the existence of a population screening programme. Measures must be taken to improve screening participation including encouragement of those of routine screening age and those age ≥75 years in good health to participate in screening with consideration given to extending screening to under 50s. A significant false-negative rate of testing was observed in the present study and this requires further investigation within a population undergoing screening through faecal immunochemical testing.

Cancer Prevention with Resistant Starch in Lynch Syndrome Patients in the CAPP2-Randomized Placebo Controlled Trial: Planned 10-Year Follow-up.

The CAPP2 trial investigated the long-term effects of aspirin and resistant starch on cancer incidence in patients with Lynch syndrome (LS). Participants with LS were randomized double-blind to 30 g resistant starch (RS) daily or placebo for up to 4 years. We present long-term cancer outcomes based on the planned 10-year follow-up from recruitment, supplemented by National Cancer Registry data to 20 years in England, Wales, and Finland. Overall, 463 participants received RS and 455 participants received placebo. After up to 20 years follow-up, there was no difference in colorectal cancer incidence (n = 52 diagnosed with colorectal cancer among those randomized to RS against n = 53 on placebo) but fewer participants had non-colorectal LS cancers in those randomized to RS (n = 27) compared with placebo (n = 48); intention-to-treat (ITT) analysis [HR, 0.54; 95% confidence interval (CI), 0.33-0.86; P = 0.010]. In ITT analysis, allowing for multiple primary cancer diagnoses among participants by calculating incidence rate ratios (IRR) confirmed the protective effect of RS against non-colorectal cancer LS cancers (IRR, 0.52; 95% CI, 0.32-0.84; P = 0.0075). These effects are particularly pronounced for cancers of the upper GI tract; 5 diagnoses in those on RS versus 21 diagnoses on placebo. The reduction in non-colorectal cancer LS cancers was detectable in the first 10 years and continued in the next decade. For colorectal cancer, ITT analysis showed no effect of RS on colorectal cancer risk (HR, 0.92; 95% CI, 0.62-1.34; P = 0.63). There was no interaction between aspirin and RS treatments. In conclusion, 30 g daily RS appears to have a substantial protective effect against non-colorectal cancer cancers for patients with LS. Regular bowel screening and aspirin reduce colorectal cancer among patients with LS but extracolonic cancers are difficult to detect and manage. This study suggests that RS reduces morbidity associated with extracolonic cancers. See related Spotlight, p. 557.

Participants' experiences of the management of screen-detected complex polyps within a structured bowel cancer screening programme.

The Bowel Screening Wales complex polyp removal service was introduced to address variations in surgery rates for screen-detected complex benign colorectal polyps, to improve the quality of the screening service and to make management of these polyps more equitable across Wales. Little is known about patient experiences and the potential impact on quality of life when undergoing complex polyp removal. This study is part of a wider research programme evaluating the decision-making, pathways and outcomes from complex polyp removal. This study aimed to understand experiences of having a complex polyp removed and how this may influence quality of life. Semi-structured telephone interviews were conducted, and a thematic approach was used for data analysis. All participants had a complex polyp removed after a positive stool test and review by Bowel Screening Wales' Network Multi-Disciplinary Team. Twenty-one participants were interviewed. Most participants had their complex polyps removed endoscopically and reported no or minor problems or negative outcomes following their procedure. For a small minority, worse problems (e.g., pain, bowel dysfunction) and negative outcomes (e.g., cancer) followed their procedures. Most participants felt supported and reassured throughout their procedures. Any physical and emotional changes to quality of life were mainly linked to procedure outcomes. Experiences of complex polyp removal were generally positive, with minimal changes in quality of life. While most people had a positive experience of having a complex polyp removed, support initiatives, such as counselling or signposting to coping strategies, may be helpful to reduce any potential negative effects of procedures on quality of life. Four patient and public involvement partners provided feedback on participant materials.