Fecal Occult Blood Test Cards Research Articles

Stability of the Fecal and Oral Microbiome over 2 Years at -80°C for Multiple Collection Methods.

In prospective cohorts, biological samples are generally stored over long periods before an adequate number of cases have accrued. We investigated the impact of sample storage at -80°C for 2 years on the stability of the V4 region of the 16S rRNA gene across seven different collection methods (i.e., no additive, 95% ethanol, RNAlater stabilization solution, fecal occult blood test cards, and fecal immunochemical test tubes for feces; OMNIgene ORAL tubes and Scope mouthwash for saliva) among 51 healthy volunteers. Intraclass correlation coefficients (ICC) were calculated for the relative abundance of the top three phyla, the 20 most abundant genera, three alpha-diversity metrics, and the first principal coordinates of three beta-diversity matrices. The subject variability was much higher than the variability introduced by the sample collection type, and storage time. For fecal samples, microbial stability over 2 years was high across collection methods (range, ICCs = 0.70-0.99), except for the samples collected with no additive (range, ICCs = 0.23-0.83). For oral samples, most microbiome diversity measures were stable over time with ICCs above 0.74; however, ICCs for the samples collected with Scope mouthwash were lower for two alpha-diversity measures, Faith's phylogenetic diversity (0.23) and the observed number of operational taxonomic units (0.23). Fecal and oral samples in most used collection methods are stable for microbiome analyses after 2 years at -80°C, except for fecal samples with no additive. This study provides evidence that samples stored for an extended period from prospective studies are useful for microbiome analyses.

A Pilot Study to Assess Stool Sample Collection Methods for Gut Microbiome Research in Large Prospective Cohort Studies (FS07-01-19)

ObjectivesColonic microbiota can be modified by diet and other environmental exposures that are associated with risk of cancer and other diseases. In addition, the stool metabolome represents products formed by gut microbial utilization of foods, nutrients, and other compounds. The collection of stool samples for analyses of the microbiome and metabolome in prospective cohort studies may lead to a better understanding of diet and other factors in disease etiology.Most studies of the gut microbiome and metabolome have been small clinical studies and relied on the collection of stool samples that were quickly flash-frozen and stored with no preservative. However, this method of collection is not feasible in large epidemiologic studies in which participants would self-collect and ship samples to a central repository. Other methods may preclude metabolomic analyses or result in a limited amount of stool. MethodsWe designed a pilot study to inform stool collection procedures for participants enrolled in a nationwide prospective cohort study. In this pilot study, stool samples will be collected by 10 volunteers who will aliquot their sample into: 1) OMNIgene Gut collection kit, 2) 95% ethanol collection kit, (3) Fecal Occult Blood Test cards, and (4) a vial for fresh-frozen sample with no solution (i.e., the gold standard in this analysis). Fresh-frozen samples will be shipped overnight on dry ice to a central biorepository. The remaining samples will be: 1) shipped overnight on cold packs; 2) shipped overnight at ambient temperature; 3) shipped overnight after 4 days at ambient temperature; and 4) shipped overnight at ambient temperature, followed by 4-day incubation at 50 °C to mimic maximum shipment temperature. The reproducibility, stability, and accuracy of 16S sequencing and metabolomics in stool will be compared among the collection kits, and shipping and storage conditions. ResultsInitial results are anticipated by June 2019. ConclusionsThe findings of this pilot study will inform future stool collection among Cancer Prevention Study-3 (CPS-3) participants, which, when analyzed with food frequency questionnaire data, will broaden our understanding of the role of diet in cancer risk. Funding SourcesThe American Cancer Society funds the creation, maintenance, and updating of CPS-3.

Gut Microbiome in Survivors of Childhood Acute Lymphoblastic Leukemia

PurposeAcute lymphoblastic leukemia (ALL) is the most common cancer in childhood and has a high treatment success rate. However, survivors of childhood ALL have a high prevalence of chronic medical illnesses, such as metabolic syndrome. Dysbiosis in the gut microbiome is associated with metabolic derangement and disease risk. Chemotherapy and antibiotics increase gut microbiome dysbiosis. We tested the hypothesis that ALL treatment can cause alterations in the gut microbiome that persist in survivorship.MethodStool samples were collected on fecal occult blood test cards from 38 survivors between 2-18 years of age who were >1 year off therapy for ALL. 16 stool samples from healthy siblings age 2-18 years were collected from 14 families as controls. Clinical data including anthropometrics, antibiotic use, and probiotic use were collected. DNA was extracted and sequenced using a modified Illumina 16S Metagenomics Sequencing Library Preparation protocol for analysis of hypervariable region V4. A single rarefaction was performed at 4,897 removing 2 samples with low mapped read counts. Alpha and beta (Bray) diversities were calculated; Wilcoxon rank-sum test was used to compare the alpha diversities between groups, as well as the beta diversities within and between groups. Wilcoxon signed-rank test was used to compare the alpha diversity between survivors and their matched siblings. Finally, read counts for each Operational Taxonomic Unit (OTU) was normalized and tested for differential abundance using edgeR, assuming a negative binomial model.ResultsSignificant differences in the abundance of taxa were found, with the most notable being the depletion of Faecalibacterium in survivors (FDR= 0.0004). Figure 1 shows a heatmap with the complete linkage clustering method on the Euclidean distance using the 13 OTUs with statistically significant (FDR<0.05) differences between survivors and siblings (Table 1). When compared to their respective siblings, survivors exhibited decreased alpha diversity using four metrics (Observed, Shannon, Simpson, Fisher), but these results did not meet statistical significance. Significant differences were not observed in alpha diversity within survivors between different clinical categories (antibiotic usage, probiotic usage, disease risk, age at diagnosis and time off treatment). Stool microbiome was more similar within a family than between families (P = 0.00079).ConclusionDifferences in the relative abundance of certain taxa were found between survivors and siblings. Specifically, Fecalibacterium was depleted in survivors, which has also been previously observed in older populations of childhood ALL survivors. This study shows that these microbiome changes are present in ALL survivors during childhood, and should be evaluated longitudinally for association with the chronic medical illnesses seen in ALL survivors in adulthood. Early interventions to restore the gut microbiome in ALL patients may potentially ameliorate the risk of long-term adverse health outcomes. [Display omitted] DisclosuresNo relevant conflicts of interest to declare.

Collection of non-meconium stool on fecal occult blood cards is an effective method for fecal microbiota studies in infants

BackgroundEffective methods are needed to collect fecal samples from children for large-scale microbiota studies. Stool collected on fecal occult blood test (FOBT) cards that can be mailed provides an effective solution; however, the quality of sequencing resulting from this method is unknown.The aim of this study is to compare microbiota metrics of 16S ribosomal RNA (rRNA) gene sequencing from stool and meconium collected on FOBT cards with stool collected in an Eppendorf tube (ET) under different conditions.MethodsEight stool samples from children in diapers aged 0 month–2 years and three meconium samples were collected and stored as follows: (1) ≤ 2 days at room temperature (RT) in an ET, (2) 7 days at − 80 °C in an ET, (3) 3–5 days at RT on a FOBT card, (4) 7 days at RT on a FOBT card, and (5) 7 days at − 80 °C on a FOBT card. Samples stored at − 80 °C were frozen immediately. Each specimen/condition underwent 16S rRNA gene sequencing with replicates on the Illumina MiSeq. Alpha and beta diversity measures and relative abundance of major phyla were compared between storage conditions and container (ET vs. FOBT card), with pairwise comparison between different storage conditions and the “standard” of 7 days at − 80 °C in an ET and fresh stool in an ET.ResultsStool samples clustered mainly by individual diaper (P < 10−5, Adonis), rather than by storage condition (P = 0.42) or container (P = 0.16). However, meconium samples clustered more by container (P = 0.002) than by individual diaper (P = 0.009) and storage condition (P = 0.02).Additionally, there were no differences in alpha diversity measures and relative abundance of major phyla after Bonferroni correction between stool stored on a FOBT card at RT for 7 days with stool stored in an ET tube at − 80 °C; differences in alpha diversity were seen however when compared to fresh stool in an ET. Overall, based on the intraclass correlation coefficient (ICC), the different storage containers/conditions are reliable in preserving the microbial memberships and slightly less reliable in preserving the alpha diversity and relative microbial composition of infant stool.ConclusionsAcknowledging certain limitations, FOBT cards may be a useful tool in large-scale stool microbiota studies in children requiring outpatient follow-up where only small amounts of stool can be obtained, but should not be used when studying meconium.

Adherence to Competing Strategies for Colorectal Cancer Screening Over 3 Years.

We have shown that, in a randomized trial comparing adherence to different colorectal cancer (CRC) screening strategies, participants assigned to either fecal occult blood testing (FOBT) or given a choice between FOBT and colonoscopy had significantly higher adherence than those assigned to colonoscopy during the first year. However, how adherence to screening changes over time is unknown. In this trial, 997 participants were cluster randomized to one of the three screening strategies: (i) FOBT, (ii) colonoscopy, or (iii) a choice between FOBT and colonoscopy. Research assistants helped participants to complete testing only in the first year. Adherence to screening was defined as completion of three FOBT cards in each of 3 years after enrollment or completion of colonoscopy within the first year of enrollment. The primary outcome was adherence to assigned strategy over 3 years. Additional outcomes included identification of sociodemographic factors associated with adherence. Participants assigned to annual FOBT completed screening at a significantly lower rate over 3 years (14%) than those assigned to colonoscopy (38%, P<0.001) or choice (42%, P<0.001); however, completion of any screening test fell precipitously, indicating the strong effect of patient navigation. In multivariable logistic regression analysis, being randomized to the choice or colonoscopy group, Chinese language, homosexuality, being married/partnered, and having a non-nurse practitioner primary care provider were independently associated with greater adherence to screening (P<0.01). In a 3-year follow-up of a randomized trial comparing competing CRC screening strategies, participants offered a choice between FOBT and colonoscopy continued to have relatively high adherence, whereas adherence in the FOBT group fell significantly below that of the choice and colonoscopy groups. Patient navigation is crucial to achieving adherence to CRC screening, and FOBT is especially vulnerable because of the need for annual testing.

Abstract B95: Barriers to completion of a free colorectal cancer screening program in a low-income population

Abstract Colorectal cancer (CRC) is the fourth most common cancer in the US. Screening is effective to prevent and detect CRC, but is underutilized in underserved populations. We assessed a free CRC screening program intended for the underserved population in central Illinois to determine what factors (demographics, medical history, risk factors, perceived barriers, rurality) prevented eligible patients from completing CRC screening. Methods: Potential participants were recruited to the Vince Demuzio Colorectal Screening Initiative via postcard mailing, media advertising and physician referral from July 2010 to June 2012. Interested participants called a toll-free number for an eligibility assessment, which required: being due for a CRC screening, age of 50-64 years, uninsured/underinsured, ≤250% of the federal poverty level, and residence in the 22 county (1 urban and 21 rural counties) catchment area. Eligible participants then completed a questionnaire via phone about their demographics, screening history, risk factors, and screening barriers, and were sent documents to sign for enrollment. Once signed documents were returned, patients chose to complete a fecal occult blood test (FOBT) or schedule a pre screening appointment and colonoscopy at 1 of 13 participating local hospitals. Analysis of 22 factors associated with screening was performed comparing residency (rural vs. urban) and screening completion (completers vs. non-completers) using Fisher's exact tests and independent t-tests. Results: There were 352 eligible participants, and they were: 86 % white, 57% female, 90% with at least a high school education, 60 % rural and 37 % current smokers. 245 participants (69.6%) completed CRC screenings (233 colonoscopies and 12 FOBTs). Ultimately, 107 (30.4%) eligible individuals did not complete screening due to the following: unreturned enrollment documents (54), loss to follow-up or withdrawal (44), did not return FOBT card (4) or were later deemed ineligible (5). Overall, rural participants were more likely than urban to be female (66.2% vs.44.4%, p&amp;lt;0.001), white (98.6% vs.68.3%, p&amp;lt;0.001), to have had a past blood stool test (25.8% vs. 9.4%, p=0.013) and to have a history of polyps (12.9% vs. 4.9%, p=0.016). Screening completion rates did not differ between urban and rural participants (65.5 % vs. 72.4%, p=0.19). The only factor significantly different between completers (C) and non-completers (NC) was report of a past blood stool test (42.4% vs. 29.9%, p=0.03), and among those reporting a past test, having a test within the past year (23.1% vs. 7.5%; p=0.04). Rural NC were more likely to note fear of discomfort as a barrier than urban NC (28.6% vs. 10.6%; p=0.03). There were no other significant differences at these stratifications. Conclusions: Despite meeting eligibility criteria, roughly a third of interested patients did not receive CRC screening. Rural NC differed from urban NC. Rural NC were more often female, white (anticipated in rural Illinois) and reported procedure discomfort as a screening barrier. However, most examined patient-related factors did not differ between groups and stratifications. Patient anecdotes indicated that more efficient processes, such as reduction in enrollment and screening steps and assistance with scheduling, may improve completion rates. Also, efforts should be made to both address gender and race differences that might impact screening in rural populations and develop better survey tools to identify screening barriers. Citation Format: Whitney Zahnd, David Steward, Wiley Jenkins, Jennifer Andoh, Georgia Mueller, Sandra Puczynski. Barriers to completion of a free colorectal cancer screening program in a low-income population. [abstract]. In: Proceedings of the Sixth AACR Conference: The Science of Cancer Health Disparities; Dec 6–9, 2013; Atlanta, GA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2014;23(11 Suppl):Abstract nr B95. doi:10.1158/1538-7755.DISP13-B95

Adherence to Colorectal Cancer Screening

Despite evidence that several colorectal cancer (CRC) screening strategies can reduce CRC mortality, screening rates remain low. This study aimed to determine whether the approach by which screening is recommended influences adherence. We used a cluster randomization design with clinic time block as the unit of randomization. Persons at average risk for development of CRC in a racially/ethnically diverse urban setting were randomized to receive recommendation for screening by fecal occult blood testing (FOBT), colonoscopy, or their choice of FOBT or colonoscopy. The primary outcome was completion of CRC screening within 12 months after enrollment, defined as performance of colonoscopy, or 3 FOBT cards plus colonoscopy for any positive FOBT result. Secondary analyses evaluated sociodemographic factors associated with completion of screening. A total of 997 participants were enrolled; 58% completed the CRC screening strategy they were assigned or chose. However, participants who were recommended colonoscopy completed screening at a significantly lower rate (38%) than participants who were recommended FOBT (67%) (P<.001) or given a choice between FOBT or colonoscopy (69%) (P<.001). Latinos and Asians (primarily Chinese) completed screening more often than African Americans. Moreover, nonwhite participants adhered more often to FOBT, while white participants adhered more often to colonoscopy. The common practice of universally recommending colonoscopy may reduce adherence to CRC screening, especially among racial/ethnic minorities. Significant variation in overall and strategy-specific adherence exists between racial/ethnic groups; however, this may be a proxy for health beliefs and/or language. These results suggest that patient preferences should be considered when making CRC screening recommendations. Trial Registration clinicaltrials.gov Identifier: NCT00705731.

Results of National Colorectal Cancer Screening Program in Croatia (2007-2011)

To study the epidemiologic indicators of uptake and characteristic colonoscopic findings in the Croatian National Colorectal Cancer Screening Program. Colorectal cancer (CRC) was the second leading cause of cancer mortality in men (n = 1063, 49.77/100,000), as well as women (n = 803, 34.89/100,000) in Croatia in 2009. The Croatian National CRC Screening Program was established by the Ministry of Health and Social Welfare, and its implementation started in September, 2007. The coordinators were recruited in each county institute of public health with an obligation to provide fecal occult blood testing (FOBT) to the participants, followed by colonoscopy in all positive cases. The FOBT was performed by hypersensitive guaiac-based Hemognost card test (Biognost, Zagreb). The test and short questionnaire were delivered to the home addresses of all citizens aged 50-74 years consecutively during a 3-year period. Each participant was required to complete the questionnaire and send it together with the stool specimen on three test cards back to the institute for further analysis. About 4% FOBT positive cases are expected in normal risk populations. A descriptive analysis was performed. A total of 1,056,694 individuals (born between 1933-1945 and 1952-1957) were invited to screening by the end of September 2011. In total, 210,239 (19.9%) persons returned the envelope with a completed questionnaire, and 181,102 of them returned it with a correctly placed stool specimen on FOBT cards. Until now, 12,477 (6.9%), FOBT-positive patients have been found, which is at the upper limit of the expected values in European Guidelines for Quality Assurance in CRC Screening and Diagnosis [European Union (EU) Guidelines]. Colonoscopy was performed in 8541 cases (uptake 66%). Screening has identified CRC in 472 patients (5.5% of colonoscopied, 3.8% of FOBT-positive, and 0.26% of all screened individuals). This is also in the expected range according to EU Guidelines. Polyps were found and removed in 3329 (39% of colonoscopied) patients. The largest number of polyps were found in the left half of the colon: 64% (19%, 37% and 8% in the rectum, sigma, and descendens, respectively). The other 36% were detected in the proximal part (17% in the transverse colon and 19% in ceco-ascending colon). Small polyps in the rectum (5-10 mm in diameter), sigmoid and descending colon were histologically found to be tubular adenomas in 60% of cases, with a low degree of dysplasia, and 40% were classified as hyperplastic. Polyps of this size in the transverse or ceco-ascending colon in almost 20% had a histologically villous component, but still had a low degree of dysplasia. Polyps sized 10-20 mm in diameter were in 43% cases tubulovillous, and among them, 32% had areas with a high degree of dysplasia, especially those polyps in the ceco-ascending or transverse part. The characteristics of the Croatian CRC Screening National Program in the first 3 years were as follows: relatively low percentage of returned FOBT, higher number of FOBT-positive persons but still in the range for population-based programs, and higher number of pathologic findings (polyps and cancers). These results suggest a need for intervention strategies that include organizational changes and educational activities to improve awareness of CRC screening usefulness and increase participation rates.

Colorectal Cancer Testing in the National Veterans Health Administration

Colorectal cancer (CRC) screening is a priority for the Veteran's Health Administration (VHA). Optimizing fecal occult blood testing (FOBT) is integral to CRC screening in health care systems. The purpose of this study was to characterize the utilization of CRC testing in a large integrated health care system (VHA), determine current rates of CRC testing by FOBT and examine factors associated with lack of FOBT card return. The VHA Office of Quality and Performance (OQP) collected data from a national sample of Veterans from October 2008 to September 2009. Rates and modality of CRC testing for eligible Veterans were calculated. Among those offered FOBT, bivariate analyses were performed to describe population characteristics by FOBT return. Logistic regression was used to determine factors independently associated with lack of FOBT return. A total of 36,336 Veterans were included. On weighted analysis, 80.4% of Veterans received a form of CRC screening. The majority underwent colonoscopy in the prior 10 years (71.6%), followed by FOBT in the prior year (24.0%). A total of 31.0% did not return FOBT cards that were provided. Factors associated with a lack of FOBT return included: younger age, female gender, non-Caucasian race, living in the Northeast, current smoking and lack of influenza vaccination. Overall rates of CRC screening in VHA are high. Systems-based practices within VHA likely play a role in successful CRC screening. CRC screening is most often via colonoscopy, followed by FOBT. Characteristics associated with non-adherence with FOBT may inform future quality improvement initiatives in health care systems.

Cost-effectiveness of a mailed educational reminder to increase colorectal cancer screening.

BackgroundColorectal cancer (CRC) screening rates are low in many areas and cost-effective interventions to promote CRC screening are needed. Recently in a randomized controlled trial, a mailed educational reminder increased CRC screening rates by 16.2% among U.S. Veterans. The aim of our study was to assess the costs and cost-effectiveness of a mailed educational reminder on fecal occult blood test (FOBT) adherence.MethodsIn a blinded, randomized, controlled trial, 769 patients were randomly assigned to the usual care group (FOBT alone, n = 382) or the intervention group (FOBT plus a mailed reminder, n = 387). Ten days after picking up the FOBT cards, a 1-page reminder with information related to CRC screening was mailed to the intervention group. Primary outcome was number of returned FOBT cards after 6 months. The costs and incremental cost-effectiveness ratio (ICER) of the intervention were assessed and calculated respectively. Sensitivity analyses were based on varying costs of labor and supplies.ResultsAt 6 months after card distribution, 64.6% patients in the intervention group returned FOBT cards compared with 48.4% in the control group (P < 0.001). The total cost of the intervention was $962 or $2.49 per patient, and the ICER was $15 per additional person screened for CRC. Sensitivity analysis based on a 10% cost variation was $13.50 to $16.50 per additional patient screened for CRC.ConclusionsA simple mailed educational reminder increases FOBT card return rate at a cost many health care systems can afford. Compared to other patient-directed interventions (telephone, letters from physicians, mailed reminders) for CRC screening, our intervention was more effective and cost-effective.

A Survey of Indian Health Service and Tribal Health Providers' Colorectal Cancer Screening Knowledge, Perceptions, and Practices

Provider recommendation is critical for colorectal cancer (CRC) screening participation, yet few data exist on practices of providers serving American Indians and Alaska Natives. We examined Indian Health Service (IHS) and tribal provider practices, beliefs about screening efficacy, and perceptions of barriers. We developed a Web-based questionnaire and recruited respondents via electronic distribution lists. We generated descriptive statistics by region, provider type, and workplace setting. Most respondents (77%) recommend starting CRC screening of average-risk patients at age 50; however, 22% recommend flexible sigmoidoscopy and 43% colonoscopy at intervals inconsistent with national guidelines. Of those recommending fecal occult blood test (FOBT), 23% use a single, in-office FOBT card as their only FOBT method. Respondents reported barriers to screening to include underutilized reminder systems and inadequate resources. Indian Health Service/tribal providers are knowledgeable about when to begin CRC screening; however, education about the appropriate use and frequency of CRC tests is needed.

Effectiveness of a clinic‐based colorectal cancer screening promotion program for underserved Hispanics

Hispanics in the United States are less likely than other groups to receive screening services for colorectal cancer. The authors conducted a clinic-based individual randomized trial that enrolled Hispanic patients ages 50 to 79 years who had been seen in the Seattle-based community clinic in the past 5 years. A total of 501 patients met the eligibility criteria and were randomized to 1 of 3 conditions: 1) usual care; 2) mailed fecal occult blood test (FOBT) card and instructions on how to complete the test (mailed FOBT only); and 3) mailed FOBT card and instructions on how to complete the test, telephone reminders, and home visits (mailed FOBT and outreach). The authors assessed postintervention differences in rates of FOBT screening in intervention and usual care groups using computerized medical records reviewed from June 2007 to March 2008. Data analysis occurred between November 2008 and September 2009. Nine-month postintervention screening rates were 26% among patients who received the mailed packet only intervention (P < .001 compared with usual care) and 31% in the group that received the mailed packet and outreach intervention (P < .001 compared with usual care). This compared with 2% in the group that received usual care. Screening rates in the mailed FOBT only group and in the mailed FOBT and outreach group were not significantly different (P = .28). Culturally appropriate clinic-based interventions may increase colorectal cancer screening among underserved Hispanics.

Lack of Follow-up After Fecal Occult Blood Testing in Older Adults

It is unclear whether lack of follow-up after screening fecal occult blood testing (FOBT) in older adults is due to screening patients whose comorbidity or preferences do not permit follow-up vs failure to complete follow-up in healthy patients. A prospective cohort study of 2410 patients 70 years or older screened with FOBT was conducted at 4 Veteran Affairs (VA) medical centers from January 1 to December 31, 2001. The main outcome measure was receipt of follow-up within 1 year of FOBT based on national VA and Medicare data. For patients with positive FOBT results, age and Charlson comorbidity scores were evaluated as potential predictors of receiving a complete colon evaluation (colonoscopy or sigmoidoscopy plus barium enema), and medical records were reviewed to determine reasons for lack of follow-up. A total of 212 patients (9%) had positive FOBT results; 42% received a complete colon evaluation within 1 year. Age and comorbidity were not associated with receipt of a complete follow-up, which was similar among patients 70 to 74 years old with a Charlson score of 0 compared with patients 80 years or older with a Charlson score of 1 or higher (48% vs 41%; P=.28). The VA site, number of positive FOBT cards, and number of VA outpatient visits were predictors. Of 122 patients who did not receive a complete follow-up within 1 year, 38% had documentation that comorbidity or preferences did not permit follow-up, and over the next 5 years 76% never received a complete follow-up. While follow-up after positive FOBT results was low regardless of age or comorbidity, screening patients in whom complete evaluation would not be pursued substantially contributes to lack of follow-up. Efforts to improve follow-up should address the full chain of decision making, including decisions to screen and decisions to follow up.

Systematic Review: Enhancing the Use and Quality of Colorectal Cancer Screening

National guideline groups recommend screening and discussion of screening options for persons at average risk for colorectal cancer (CRC). However, emerging evidence suggests that CRC screening is simultaneously underused, overused, and misused and that adequate patient-provider discussions about screening are infrequent. To summarize evidence on factors that influence CRC screening and strategies that increase the appropriate use and quality of CRC screening and CRC screening discussions. MEDLINE, the Cochrane Library, and the Cochrane Central Register of Controlled Trials were searched for English-language publications describing studies conducted in the United States from January 1998 through September 2009. Two reviewers independently selected studies that addressed the study questions and met eligibility criteria. Information on study design, setting, intervention, outcomes, and quality were extracted by one reviewer and double-checked by another. Reviewers assigned a strength-of-evidence grade for intervention categories by using criteria plus a consensus process. Reviewers found evidence of simultaneous underuse, overuse, and misuse of CRC screening as well as inadequate clinical discussions about CRC screening. Several patient-level factors were independently associated with lower screening rates, including having low income or less education, being uninsured, being Hispanic or Asian, being less acculturated into the United States, or having limited access to care. Evidence that interventions that included patient reminders or one-on-one interactions (that is, between patients and nonphysician clinic staff), eliminated structural barriers (for example, simplifying access to fecal occult blood test cards), or made system-level changes (for example, using systematic screening as opposed to opportunistic screening) were effective in enhancing use of CRC screening was strong. Evidence on how best to enhance discussions about CRC screening options is limited. No studies focused on reducing overuse, and very few focused on misuse. Reporting and publication bias may have affected our findings. The independent effect of individual elements of multicomponent interventions was often uncertain. Although CRC screening is underused overall, important problems of overuse and misuse also exist. System- and policy-level interventions that target vulnerable populations are needed to reduce underuse. Interventions aimed at reducing barriers by making the screening process easier are likely to be effective. Studies aimed at reducing overuse and misuse and at enhancing the quality and frequency of discussions about CRC screening options are needed. Agency for Healthcare Research and Quality.

Fecal Occult Blood Test in Patients on Low-Dose Aspirin, Warfarin, Clopidogrel, or Non-steroidal Anti-inflammatory Drugs

To determine the effect of anticoagulants and antiplatelet medications on the positive-predictive-value of fecal occult blood test (FOBT). All patients who underwent a colonoscopy at our institution from 1995 to 2006 for a positive FOBT were identified. Medical records were searched, and patients were stratified into five groups selected a priori: low-dose aspirin, NSAIDs, warfarin, clopidogrel, or controls. The positive-predictive-value of FOBT for advanced colonic neoplasia was computed for each group. During the study period, 1,126 patients underwent colonoscopy for a positive FOBT and met entry criteria. The average age of study participants was 69 years and most were men. The positive-predictive-value of FOBT for advanced colon neoplasia was significantly higher in the control group (30.5%) when compared to those on low-dose aspirin (20.5%; p = 0.003), NSAIDs (19.7%; p = 0.003), clopidogrel (7.3%; p = 0.002), or warfarin (20%; p = 0.05). The positive-predictive-value of FOBT was significantly lower for those on clopidogrel than those on low-dose aspirin (p = 0.04) and NSAIDs (p = 0.05), but not warfarin (p = 0.08). The positive-predictive-value for FOBT was similar for those on aspirin, NSAIDs, and warfarin. There was a linear trend between the number of number of positive FOBT cards and prevalence of advanced colon neoplasia (p = 0.01). Anticoagulants and antiplatelet medications lower the positive-predictive-value of FOBT for advance colonic neoplasia and should be stopped if clinically feasible prior to stool collection.

Improving Fecal Occult Blood Testing Compliance Using a Mailed Educational Reminder

BACKGROUNDColorectal cancer (CRC) is one of the leading causes of cancer-related deaths in the United States. Randomized controlled trials have shown that annual screening fecal occult blood testing (FOBT) reduces CRC mortality and incidence. However, patient compliance with FOBT is low.OBJECTIVETo determine whether a mailed educational reminder increases FOBT card return rates and to examine predictors of FOBT compliance.DESIGNBlinded, randomized, controlled trial at the Veteran Affairs Medical Center, San Diego, California.PATIENTSSeven hundred and seventy-five consecutive patients ≥50 years of age referred by their primary care physicians for FOBT.INTERVENTIONPatients were randomly assigned to the usual care group or the intervention group. Ten days after picking up the FOBT cards, a 1-page reminder with information related to CRC screening was mailed to the intervention group only.MEASUREMENTSThe primary outcome was proportion of returned FOBT cards after 6 months. Patient demographic, clinical characteristics and prior FOBT completed were collected for multivariate regression analysis.RESULTSAt 6 months after card distribution, 64.6% of patients in the intervention group returned cards compared with 48.4% in the control group (P < 0.001). Patients who received a mailed reminder (OR 2.02; 95% CI: 1.48–2.74) or have a prior history of returning the FOBT cards (OR 1.87; 95% CI: 1.29–2.70) were more likely to return the FOBT cards. Patients with current or recent illicit drug use were less likely to return the FOBT cards (OR 0.26; 95% CI: 0.13–0.50).CONCLUSIONA simple mailed educational reminder significantly increases compliance with FOBT for CRC screening.Electronic supplementary materialThe online version of this article (doi:10.1007/s11606-009-1087-5) contains supplementary material, which is available to authorized users.

Colonoscopy Completion in a Large Safety Net Health Care System

Anecdotally, patients in safety net health care systems have difficulty completing screening and diagnostic colonoscopies, but this is poorly characterized. It is important to understand this phenomenon to improve low rates of colorectal cancer screening in vulnerable populations and to ensure that patients with signs and symptoms complete medically indicated colonoscopic evaluations. We performed a 6-month retrospective review of outpatient endoscopy laboratory scheduling and procedure logs and electronic medical records at Denver Health Medical Center (DHMC), a large safety net health care system, to describe rates and sociodemographic predictors of colonoscopy nonattendance and inadequate (fair/poor) bowel preparation. Predictor variables included patient age, gender, race/ethnicity, procedure indication, and insurance type. The nonattendance rate was 41.7% for all scheduled outpatient colonoscopies without difference between screening and diagnostic procedures. Consistent with non-safety net systems, the rate of inadequate bowel preparation was 30.2%; however, the rate of poor bowel preparation that absolutely precluded an exam was 9.9%. Correctional care patients had markedly higher rates of nonattendance and inadequate bowel preparation compared with other groups. A very large proportion of patients scheduled for colonoscopy in a large safety net health care system do not attend their procedures, and among those who do, there is a high rate of inadequate bowel preparation leading to incomplete and aborted evaluations. Interventions are needed to promote the more efficient use of a limited and expensive resource and to achieve higher rates of screening and medically indicated diagnostic colonoscopies in vulnerable patient populations.

Detecting K- ras mutations in stool from fecal occult blood test cards in multiphasic screening for colorectal cancer

Fecal occult blood testing (FOBT) is proven an efficient way of reducing mortality from colorectal cancer but has a relatively low positive predictive value (PPV). This study evaluated the ability to detect K- ras mutations in stool DNA from FOBT cards and to improve the PPV of the screening process. Two hundred and five consecutive positive FOBT cards and an arbitrary sample of 38 negative cards from a population-based screening program were included. K- ras mutations in FOBT card stool were sought using allele-specific hybridization. DNA was successfully amplified from 87.2% of cards. In 130 cases with positive FOBT and amplifiable DNA 23 malignancies and 25 adenomas were detected. In 34.8% of the malignancies, a mutation in K- ras was detected. The PPV for malignancies increased from 17.7% (all positive cards) to 60.0% if cards with four or more fields were positive and K- ras was positive (RR = 2.66, 95% CI: 1.2–6.1). Testing for K- ras mutations in DNA extracted from stool from positive FOBT cards is feasible. Sequential detection of cancer-associated genetic markers from FOBT-based stool samples may potentially help separate true from false positives in a FOBT-based screening process.

Promoting culturally appropriate colorectal cancer screening through a health educator

Colorectal cancer (CRC) is a leading cause of cancer mortality in the US. Surveys reveal low CRC screening levels among Asians in the US, including Chinese Americans. A randomized controlled trial was conducted with Chinese patients to evaluate a clinic-based, culturally and linguistically appropriate intervention promoting fecal occult blood test (FOBT) screening. The multifaceted intervention included a trilingual and bicultural health educator, bilingual materials (a video, a motivational pamphlet, an informational pamphlet, and FOBT instructions), and three FOBT cards. Patients in the control arm received usual care. Our primary outcome measure was FOBT screening within 6 months after randomization. The proportion of FOBT completion in the intervention and control arms was compared by using a chi-square test, and logistic regression analysis was performed to adjust for the effects of sociodemographic variables and prior screening history. Potential effect modifications were also tested by using logistic regression models. Our intervention had a strong effect on FOBT completion (intervention group, 69.5%; control group, 27.6%), and the adjusted odds of FOBT slightly increased to over 6-fold greater in the intervention arm compared with the control arm. No effect modification by age, gender, language, insurance, or prior FOBT was found. The authors' multifaceted, culturally appropriate intervention significantly increased FOBT screening in a group of low-income and less-acculturated minority patients. Given the large effect size, future research should determine the effective core component(s) that can increase CRC screening in both the general and minority populations.

Predictors of fecal occult blood test (FOBT) completion among low-income adults

Background. Fecal occult blood testing (FOBT) can reduce colorectal cancer (CRC) mortality. Unfortunately, CRC screening is underutilized. Sociocultural mediators of FOBT adherence have not been extensively studied in lower income, minority populations. This study prospectively studied FOBT return in a low-income, multiethnic population. Methods. Participants ( N = 298), aged ≥40 years, were surveyed and given FOBT kits with instructions. Those not returning kits within 30 days received a reminder telephone call. Bivariate and multivariate analyses assessed predictors of FOBT card return at 90 days. Results. Participants (median age = 48) were predominately African American (69%), without private insurance (88%), and of low income. The largest group of participants preferred FOBT alone (46%), followed by whatever my doctor recommends (19%), endoscopy + annual FOBT (16%), endoscopy alone (14%), and no screening (5%). In multivariate analyses, FOBT return was predicted by age (OR = 1.05) and lack of reported FOBT barriers (OR = 3.81). Among those ≥50 and not up-to-date with screening, FOBT return was predicted by cancer fatalism (OR = 0.83). FOBT barriers were associated with age (OR = 0.96), less than high school education (OR = 2.05), and less physician trust (OR = 2.12). Endoscopy barriers were associated with age (OR = 0.93), less physician trust (OR = 1.95), and female gender (OR = 3.45). Conclusions. Younger individuals and those with less education, less trust in health care providers, and more fatalistic beliefs are at risk for CRC screening non-adherence. Strategies addressing common misconceptions should improve CRC screening rates in low-income, multiethnic populations.