Organized Colorectal Cancer Screening Research Articles

Association between Endoscopist Volume and Interval Cancers after Colonoscopy: Results from the National Colorectal Cancer Screening Program in Korea.

The rate of interval colorectal cancer (iCRC) is now accepted as a key performance indicator of organized colorectal cancer (CRC) screening programs. We aimed to examine the association between endoscopist volumes and the rate of iCRC among individuals with a positive fecal immunochemical test (FIT) within a nationwide population-based CRC screening program. Individuals aged ≥50 years who underwent colonoscopy after a positive FIT from January 1, 2019 until December 31, 2020 in the Korean National Cancer Screening Program (KNCSP) were enrolled. We converted the data into per-endoscopist screening results, calculated the iCRC rates per endoscopist, and compared them to the previous year's annual volume that was divided into five groups (V1, 1-9; V2, 10-29; V3, 30-59; V4, 60-119; V5, ≥120). A total of 10,412 endoscopists performed 216,907 colonoscopies. Overall, the average rate of iCRC per endoscopist was 8.46 per 1,000 examinations. Compared with the group with the highest volume (V5 group), the rate of iCRC was 2.21 times higher in the V1 group. Similar trends were observed in the other groups (V2: Relative risks [RR], 2.15; 95% Confidence Interval [CI], 1.57-2.94; V3: RR, 1.56, 95% CI, 1.15-2.13; V4: RR, 1.18; 95% CI, 0.83-1.67). The findings emphasize that endoscopists with lower procedure volumes have higher risks of interval cancer being missed or undetected. To maximize the preventative impact of colonoscopy for colorectal cancer, this issue should be addressed by monitoring endoscopist volumes and variations in performances.

Colorectal Cancer Screening After Sequential Outreach Components in a Demographically Diverse Cohort

Organized screening outreach can reduce differences in colorectal cancer (CRC) incidence and mortality between demographic subgroups. Outcomes associated with additional outreach, beyond universal outreach, are not well known. To compare CRC screening completion by race and ethnicity, age, and sex after universal automated outreach and additional personalized outreach. This observational cohort study included screening-eligible individuals aged 50 to 75 years assessed during 2019 in a community-based organized CRC screening program within the Kaiser Permanente Northern California (KPNC) integrated health care delivery setting. For KPNC members who are not up to date with screening by colonoscopy, each year the program first uses automated outreach (mailed prescreening notification postcards and fecal immunochemical test [FIT] kits, automated telephone calls, and postcard reminders), followed by personalized components for nonresponders (telephone calls, electronic messaging, and screening offers during office visits). Data analyses were performed between November 2021 and February 2023 and completed on February 5, 2023. Completed CRC screening via colonoscopy, sigmoidoscopy, or FIT. The primary outcome was the proportion of participants completing an FIT or colonoscopy after each component of the screening process. Differences across subgroups were assessed using the χ2 test. This study included 1 046 745 KPNC members. Their mean (SD) age was 61.1 (6.9) years, and more than half (53.2%) were women. A total of 0.4% of members were American Indian or Alaska Native, 18.5% were Asian, 7.2% were Black, 16.2% were Hispanic, 0.8% were Native Hawaiian or Other Pacific Islander, and 56.5% were White. Automated outreach significantly increased screening participation by 31.1%, 38.1%, 29.5%, 31.9%, 31.8%, and 34.5% among these groups, respectively; follow-up personalized outreach further significantly increased participation by absolute additional increases of 12.5%, 12.4%, 13.3%, 14.4%, 14.7%, and 11.2%, respectively (all differences P < .05 compared with White members). Overall screening coverage at the end of the yearly program differed significantly among members who were American Indian or Alaska Native (74.1%), Asian (83.5%), Black (77.7%), Hispanic (76.4%), or Native Hawaiian or Other Pacific Islander (74.4%) compared with White members (82.2%) (all differences P < .05 compared with White members). Screening completion was similar by sex; older members were substantially more likely to be up to date with CRC screening both before and at the end of the screening process. In this cohort study of a CRC screening program, sequential automated and personalized strategies each contributed to substantial increases in screening completion in all demographic groups. These findings suggest that such programs may potentially reduce differences in CRC screening completion across demographic groups.

Effectiveness of tailored talks between a cancer screening specialist and general practitioners to improve the uptake of colorectal cancer screening in Ancona (Italy) during the pandemic period

Background Colorectal cancer (CRC) screening uptake in many countries has been low and further impacted by the COVID-19 pandemic. General Practitioners (GPs) are key facilitators, however research on their impact on organised CRC screening is still limited. Objectives To evaluate the effectiveness of tailored talks with GPs to increase population uptake of the long-established CRC screening programme in Ancona province, Italy. Methods In this prospective cohort study, one-to-one tailored talks were organised in January 2020 between the GPs of one county of the province (with GPs from other counties as controls) and the screening programme physician-in-chief to discuss the deployment and effectiveness of organised screening. Data was extracted from the National Healthcare System datasets and linear regression was used to assess the potential predictors of CRC screening uptake. Results The mean CRC screening uptake remained stable from 39.9% in 2018–19 to 40.8% in 2020–21 in the 22 GPs of the intervention county, whereas it statistically significantly decreased from 38.7% to 34.7% in the 232 control GPs. In multivariate analyses, belonging to the intervention county was associated with an improved uptake compared to the control counties (+5.1%; 95% Confidence Intervals – CI: 2.0%; 8.1%). Conclusion Persons cared for by GPs who received a tailored talk with a cancer screening specialist avoided a drop in CRC screening adherence, which characterised all other Italian screening programmes during the COVID-19 emergency. If future randomised trials confirm the impact of tailored talks, they may be incorporated into existing strategies to improve population CRC screening uptake.

Access to colorectal cancer screening in populations in China, 2020: A coverage-focused synthesis analysis.

In populations in China, colorectal cancer (CRC) screening can be mainly accessed through organized screening, opportunistic screening, and physical examination. This screening intervention is found to be effective but the exact coverage rate is difficult to measure. Based on data from published articles, official websites, and available program reports, the screening coverage rate and related indicators were quantified. A rapid review was then conducted to estimate the overall and the breakdown coverage rates of the sub-type screening services, by leveraging the numbers of articles and the by-type median sample sizes. Up to 2020, two central government-funded and four provincial/municipal-level organized CRC screening programs have been initiated and included in this analysis. For populations aged 40-74, the estimated coverage rate of organized programs in China was 2.7% in 2020, and the 2-year cumulative coverage rate in 2019-2020 was 5.3% and the 3-year cumulative coverage rate in 2018-2020 was 7.7%. The corresponding coverage rates of 50-74-year-olds were estimated to be 3.4%, 7.1%, and 10.3%, respectively. Based on the rapid review approach, the overall screening coverage rate for 40-74 years, considering organized screening programs, opportunistic screening, and physical examinations, was then estimated to be 3.0% in China in 2020. However, comparing the findings of this study with the number of health check-ups reported in the local national health statistics yearbooks suggeststhat the number of CRC physical examinations may be underestimated in this study. The findings suggest that further efforts are needed to improve population access to CRC screening in China. Furthermore, evidence for access to opportunistic CRC screening and physical examination is limited, and more quantitative investigation is needed.

The association between organised colorectal cancer screening strategies and reduction of its related mortality: a systematic review and meta-analysis

BackgroundTo assess the long-term association between organised colorectal cancer (CRC) screening strategies and CRC-relate mortality.MethodsWe systematically reviewed studies on organised CRC screening through PubMed, Ovid Medline, Embase and Cochrane from the inception. We retrieved characteristics of organised CRC screening from included literature and matched mortality (over 50 years) of those areas from the International Agency for Research on Cancer in May 2023. The variations of mortality were reported via the age-standardised mortality ratio. A random-effects model was used to synthesis results.ResultsWe summarised 58 organised CRC screening programmes and recorded > 2.7 million CRC-related deaths from 22 countries where rollout screening programmes were performed. The CRC screening strategy with faecal tests (guaiac faecal occult blood test (gFOBT) or faecal immunochemical tests (FIT)) or colonoscopy as the primary screening offer was associated with a 41.8% reduction in mortality, which was higher than those offered gFOBT (4.4%), FIT (16.7%), gFOBT or FIT (16.2%), and faecal tests (gFOBT or FIT) or flexible sigmoidoscopy (16.7%) as primary screening test. The longer duration of screening was associated with a higher reduction in the pooled age-standardised mortality ratio. In particular, the pooled age-standardised mortality ratio became non-significant when the screening of FIT was implemented for less than 5 years.ConclusionsA CRC screening programme running for > 5 years was associated with a reduction of CRC-related mortality. Countries with a heavy burden of CRC should implement sustainable, organised screening providing a choice between faecal tests and colonoscopy as a preferred primary test.

Efficient organized colorectal cancer screening in Shenzhen: a microsimulation modelling study

BackgroundColorectal cancer (CRC) is a global health issue with noticeably high incidence and mortality. Microsimulation models offer a time-efficient method to dynamically analyze multiple screening strategies. The study aimed to identify the efficient organized CRC screening strategies for Shenzhen City.MethodsA microsimulation model named CMOST was employed to simulate CRC screening among 1 million people without migration in Shenzhen, with two CRC developing pathways and real-world participation rates. Initial screening included the National Colorectal Polyp Care score (NCPCS), fecal immunochemical test (FIT), and risk-stratification model (RS model), followed by diagnostic colonoscopy for positive results. Several start-ages (40, 45, 50 years), stop-ages (70, 75, 80 years), and screening intervals (annual, biennial, triennial) were assessed for each strategy. The efficiency of CRC screening was assessed by number of colonoscopies versus life-years gained (LYG).ResultsThe screening strategies reduced CRC lifetime incidence by 14–27 cases (30.9–59.0%) and mortality by 7–12 deaths (41.5–71.3%), yielded 83–155 LYG, while requiring 920 to 5901 colonoscopies per 1000 individuals. Out of 81 screening, 23 strategies were estimated efficient. Most of the efficient screening strategies started at age 40 (17 out of 23 strategies) and stopped at age 70 (13 out of 23 strategies). Predominant screening intervals identified were annual for NCPCS, biennial for FIT, and triennial for RS models. The incremental colonoscopies to LYG ratios of efficient screening increased with shorter intervals within the same test category. Compared with no screening, when screening at the same start-to-stop age and interval, the additional colonoscopies per LYG increased progressively for FIT, NCPCS and RS model.ConclusionThis study identifies efficient CRC screening strategies for the average-risk population in Shenzhen. Most efficient screening strategies indeed start at age 40, but the optimal starting age depends on the chosen willingness-to-pay threshold. Within insufficient colonoscopy resources, efficient FIT and NCPCS screening strategies might be CRC initial screening strategies. We acknowledged the age-dependency bias of the results with NCPCS and RS.

Effect of colorectal cancer screening on colorectal cancer surgery outcomes: nationwide cohort study.

National colorectal cancer screening commenced in Denmark in 2014. Little is known about the effects of organized colorectal cancer screening on intraoperative and postoperative events. The aim of this nationwide cohort study was to evaluate the difference in intraoperative and postoperative outcomes between patients with screen-detected colorectal cancer and non-screen-detected colorectal cancer within the first 90 days after surgery. National register data were collected for Danish residents diagnosed with colorectal cancer between January 2014 and March 2018. Outcomes for the two cohorts were reported as relative risk or weighted mean difference. Intraoperative outcomes were blood loss, blood transfusion, tumour perforation, and organ lesion. Postoperative outcomes were complications (surgical and non-surgical) and 90-day mortality. Discrete data estimates were calculated from a general linear model. Analyses were adjusted for potential healthy user bias with respect to sex, age, location of the cancer (colon/rectum), and Charlson co-morbidity index. In total, 10 606 patients were included. Compared with patients in the non-screen-detected colorectal cancer group (4497 patients), patients in the screen-detected colorectal cancer group (6109 patients) had reduced intraoperative blood loss (-52 mL, 95% c.i. -67 to -37, P < 0.001), a shorter duration of hospitalization (-2.3 days, 95% c.i. -2.8 to -1.8, P < 0.001), and reduced rates of intraoperative organ lesion (0.76, 95% c.i. 0.59 to 0.99, P = 0.042), surgical complications (0.79, 95% c.i. 0.73 to 0.87, P < 0.001), non-surgical complications (0.68, 95% c.i. 0.60 to 0.78, P < 0.001), and 90-day mortality (0.29, 95% c.i. 0.21 to 0.39, P < 0.001). In comparison with non-screen-detected colorectal cancer, surgery for screen-detected colorectal cancer remains associated with improvement in several intraoperative and early postoperative outcomes after considering healthy user bias.

Multilevel Interventions to Improve Colorectal Cancer Screening in an Urban Native American Community: A Pilot Randomized Clinical Trial

Native Americans have the highest burden of colorectal cancer (CRC) and the lowest rates of CRC screening across the United States.1 The disparities in CRC screening were made worse during the pandemic, creating an unmet need to implement evidence-based, multilevel interventions to improve CRC screening uptake. This can be achieved through an organized outreach program with identification of screen-eligible individuals using health records from the clinic; and a screening program with the following: (1) a mailed invitation, (2) a package of materials so patients can complete a fecal immunochemical test (FIT) kit from their homes, (3) reminder calls and a letter, and (4) navigation to a diagnostic colonoscopy.2-5 We conducted a pilot randomized controlled trial of a program of outreach vs usual care for completion of CRC screening at an urban clinic serving the Native American community. Applying the Consolidated Framework for Implementation Research (CFIR),6 we also conducted patient and provider interviews to understand barriers and facilitators to the organized program and CRC screening in general.

Feasibility and Colonoscopy Yield Using the Fecal Immunochemical Test (FIT)-Based Colorectal Cancer Screening in a Latin America Country

Background and aimsOrganized colorectal cancer (CRC) is not widely practiced in Latin America and the results of regional studies may help overcome barriers for implementation of national screening programs. We aimed to describe the implementation and findings of a fecal immunochemical test (FIT)-based program in Brazil. MethodsIn a prospective population-based study, asymptomatic individuals (50 to 75 years-old) from Sao Paulo city were invited to undergo FIT for CRC screening. Participants with positive FIT (>10 μg Hb/g feces) were referred for colonoscopy. Subjects were classified into groups according to the presence of CRC, precursor lesions, and other benign findings, possibly related to bleeding. ResultsOf a total of 9,881 subjects, 7.8% had positive FIT and colonoscopy compliance was 68.9% (n=535). Boston scale was considered adequate in 99% and cecal intubation rate was 99.4%. CRC was diagnosed in 5.9% of the cases, adenoma in 63.2%, advanced adenoma (AA) in 31.4%, and advanced neoplasia (AN) in 33.0%. Age was positively associated with CRC (p=0.03). Higher FIT concentrations were associated with increased detection of CRC (p<0.008), AA (p<0.001), and AN (p<0.001). ConclusionImplementation of a FIT-based CRC screening program was feasible in a low-resource setting, and there was a high yield for neoplasia in individuals with a positive FIT. This approach could be used as a model to plan and disseminate organized CRC screening more broadly in Brazil and Latin America.

Implementing an Organized Colorectal Cancer Screening Program: Lessons Learned From an Academic–Community Practice

IntroductionThe effectiveness of mailed fecal immunochemical test (FIT) outreach might be enhanced through an organized colorectal cancer (CRC) screening program, yet published real-world experiences are limited. We synthesized the process of implementing a CRC screening program which used mailed FIT outreach in a large integrated academic-community practice. Materials and MethodsData from a pilot mailed FIT program were shared with healthcare system leadership which inspired the creation of a cross-institutional organized CRC Screening Program. In partnership with a centralized Population Health Team and Primary Care, we defined: 1) the institutional approach to CRC screening, 2) the target population and method for screening, 3) the team responsible for implementation, 4) the healthcare team responsible for decisions and care, 5) a quality assurance structure, and 6) a method for identifying cancer occurrence. ResultsThe Fred Hutch/UW Medicine Population Health CRC Screening Program began in September 2021. The workflow for mailed FIT outreach included a mailed postcard, a MyChart message from the patient's primary care provider (PCP), a FIT kit with a letter signed by the PCP and program director, and up to three bi-weekly reminders. Patients without a colonoscopy 3 months after an abnormal FIT result received navigation through the program. In the first program year, we identified 9,719 patients eligible for outreach and in an intention to treat analysis, 32% of patients completed CRC screening by FIT or colonoscopy. ConclusionsReal-world experiences detailing how to implement organized CRC screening programs might increase adoption. In our experience, broadly disseminating pilot data, early institutional support, robust data management and strong cross-departmental relationships were critical to successfully implementing a CRC screening program that benefits all patients.

Impact of organised colorectal cancer screening on age-specific population incidences: evidence from a quasi-experimental study in Sweden

Colorectal cancer (CRC) incurs a significant disease burden globally. Organised CRC screening programmes have been widely implemented for early detection and prevention. To understand the public health impact of these programmes, quantitative evidence of changes in overall and age-specific population incidences is fundamental. We aimed to provide such evidence by exploiting a time lag in the implementation of organised screening in Sweden: two out of 21 regions (these two regions comprise nearly 20% of the total Swedish population) have offered organised screening since 2008; the other regions have offered CRC screening since 2021. Using registry data on diagnosed CRC cases and socio-demographics for all regions in Sweden over the period 1970–2019, Bayesian structural time series modelling and difference-in-differences were applied to analyse the impact of screening on age-specific population incidences over time (CRC cases per 100.000 persons/year). After inviting birth-year cohorts aged 60–69 years for stool-based testing, the incidence rate in the 70–74-year age group decreased significantly over time, with an average reduction of − 44·40 (95% CI − 58·15 to − 31·31) from 2011 to 2019 in the intervention regions. In the overall population aged 60–74 years, there was a net incidence decrease of − 7·99 (95% CI − 13·85 to − 2·39) since the initiation of organised screening in the intervention regions (2008–2019). Organised CRC screening for 60–69-year-olds generated a change in age-specific incidence patterns with a long-lasting incidence decrease in the 70–74-year-old population, implying reductions in the excess mortality and burden of the disease.

Integration of community pharmacies in an Italian colorectal cancer screening program: insights from the Local Health Authority of Bologna

In Italy, a nationwide population-based colorectal cancer (CRC) screening initiative has been in place since 2006. In recent years, there has been a growing interest in involving community pharmacies in this activity. This commentary provides an insightful analysis of the integration between the screening program of the Local Health Authority (LHA) of Bologna (Northern Italy) and community pharmacies. A horizontal integration at the micro level with service and clinical integrations supported by meso-level policy (regional authority) was applied. Four types of integration such as normative, informational, financial and functional serving as enablers were implemented. A high level of depth of consensus, connectivity, communication, and trust was pursued. The program achieved large participation from community pharmacies, with 91.1% (n = 234) of pharmacies in the LHA territory actively participating. On average, each pharmacy served 1,228 (range, 1,021-1,519) target citizens. Between 2021 (the first full year under the community pharmacy model) and 2022, pharmacies delivered an annual mean of 68,295 kits (range, 12-840). In 2021, there was a remarkably high level of screening completion, with 93.7% of fecal immunochemical tests being returned to pharmacies. This percentage increased by 3.3% in 2022. In our setting, pharmacy involvement improved service quality by introducing complete traceability of kits and specimen flow, as well as temperature control. It also led to a 4.6% increase in attendance rates compared to the previous organizational model (61.6% vs. 57%; P &lt; 0.001). Finally, additional European experiences involving community pharmacies in organized CRC screening programs, resembling the Bologna setting, are reported.

Association Between Socioeconomic Status and Adherence to Fecal Occult Blood Tests in Colorectal Cancer Screening Programs: Systematic Review and Meta-Analysis of Observational Studies.

Screening adherence is important in reducing colorectal cancer (CRC) incidence and mortality. Disparity in CRC screening adherence was observed in populations of different socioeconomic status (SES), but the direction and strength of the association remained unclear. We aimed to systematically review all the observational studies that have analyzed the association between SES and adherence to organized CRC screening based on fecal occult blood tests. We systematically reviewed the studies in PubMed, Embase, and Web of Science and reference lists of relevant reviews from the inception of the database up until June 7, 2023. Individual SES, neighborhood SES, and small-area SES were included, while any SES aggregated by geographic areas larger than neighbors were excluded. Studies assessing SES with any index or score combining indicators of income, education, deprivation, poverty, occupation, employment, marital status, cohabitation, and others were included. A random effect model meta-analysis was carried out for pooled odds ratios (ORs) and relative risks for adherence related to SES. Overall, 10 studies, with a total of 3,542,379 participants and an overall adherence rate of 64.9%, were included. Compared with low SES, high SES was associated with higher adherence (unadjusted OR 1.73, 95% CI 1.42-2.10; adjusted OR 1.53, 95% CI 1.28-1.82). In the subgroup of nonindividual-level SES, the adjusted association was significant (OR 1.57, 95% CI 1.26-1.95). However, the adjusted association was insignificant in the subgroup of individual-level SES (OR 1.46, 95% CI 0.98-2.17). As for subgroups of the year of print, not only was the unadjusted association significantly stronger in the subgroup of early studies (OR 1.97, 95% CI 1.59-2.44) than in the subgroup of late studies (OR 1.43, 95% CI 1.31-1.56), but also the adjusted one was significantly stronger in the early group (OR 1.86, 95% CI 1.43-2.42) than in the late group (OR 1.26, 95% CI 1.14-1.39), which was consistent and robust. Despite being statistically insignificant, the strength of the association seemed lower in studies that did not adjust for race and ethnicity (OR 1.31, 95% CI 1.21-1.43) than the overall estimate (OR 1.53, 95% CI 1.28-1.82). The higher-SES population had higher adherence to fecal occult blood test-based organized CRC screening. Neighborhood SES, or small-area SES, was more competent than individual SES to be used to assess the association between SES and adherence. The disparity in adherence between the high SES and the low SES narrowed along with the development of interventions and the improvement of organized programs. Race and ethnicity were probably important confounding factors for the association.

Impact of the COVID-19 Pandemic on the Diagnosis of Colorectal Cancer within a Population-Based Organized Screening Program.

The interruption of the activity of population-based organized colorectal cancer (CRC) screening programs due to the COVID pandemic may have affected their results in terms of the detection of preneoplastic lesions and CRC. We evaluated the impact of the COVID pandemic on the delays, participation, adherence to colonoscopies, lesions detected, and CRC stage at diagnosis in a CRC screening program. We analyzed all the invitations between 1 January 2019 and 31 December 2021. We defined the pandemic period as the period after 12 March 2020. We calculated the delay intervals (successive and all rounds), the rates of participation, adherence to colonoscopy after a positive fecal immunochemical test (FIT), and the diagnostic yield of colonoscopy, specifically of CRC and colorectal neoplasia (CRC and/or adenoma), as well as the CRC stage at diagnosis. In the period analyzed, 976,187 invitations were sent (61.0% in the pandemic period), 439,687 FIT were returned (62.4% in the pandemic period) and 23,092 colonoscopies were performed (59.1% in the pandemic period). The colonoscopies were normal in 7378 subjects (32.4%) and CRC was detected in 916 subjects (4.0%). In successive rounds, the delay increased significantly by seven months during the pandemic period (p < 0.001). In all the invitations, the delay from the invitation to the colonoscopy increased significantly by 8 days (p < 0.001). Once adjusted for the confounding variables, the participation in the screening program increased significantly (OR = 1.1; 95% CI = 1.09-1.11), with no changes in the adherence to colonoscopy (OR = 0.9; 95% CI = 0.8-1.0). We found no differences in the diagnostic yield of colonoscopy in terms of CRC (OR = 0.90; 95% CI = 0.78-1.02) or colorectal neoplasia (OR = 0.98; 95% CI = 0.92-1.03) detection. Finally, we found no differences in the CRC stage at diagnosis (p = 0.2). Although the interruption of the CRC screening program due to the COVID pandemic increased the delays, it did not reduce participation, adherence to colonoscopy, or the diagnostic yield of colonoscopy.

Socioeconomic inequality in organized and opportunistic screening for colorectal cancer: results from the Korean National Cancer Screening Survey, 2009-2021.

This study aimed to investigate socioeconomic status (SES)-based inequality in colorectal cancer (CRC) screening in Korea. We assessed whether the rates of opportunistic and organized CRC screening differed according to income and education levels. We analyzed data from the Korean National Cancer Screening Survey of 27,654 cancer-free individuals, aged 50-74 years, from 2009 to 2021. The weighted cancer screening rates with trends were estimated with the average annual percentage change using joinpoint regression. Inequality was calculated in both relative and absolute terms, based on a Poisson regression model. The organized screening rate increased significantly from 22.1% in 2009 to 53.1% in 2020 and 50.6% in 2021, with an average annual change of 8.6% (95% confidence interval [CI], 4.9 to 12.5). In contrast, no significant trend was observed for opportunistic screening. The SES inequality in opportunistic screening uptake was indicated by a slope index of inequality (SII) of 9.74% (95% CI, 6.36 to 13.12), relative index of inequality (RII) of 2.18 (95% CI, 1.75 to 2.70) in terms of education level; and an SII of 7.03% (95% CI, 4.09 to 9.98), RII of 1.81 (95% CI, 1.41 to 2.31) in terms of measured income. Although there was an increasing trend in income inequality, no significant SES inequalities were observed in the overall estimates for organized screening. Organized CRC screening is effective in improving the participation rate, regardless of SES. However, significant inequalities were found in opportunistic screening, suggesting room for improvement in the overall equity of CRC screening.

Less Invasive Primary Treatment for Colorectal Cancer After Implementation of National Screening: A Nationwide Cohort Study.

The effect of organized colorectal cancer (CRC) screening on type of primary treatment remains sparsely investigated. This study evaluated the difference in primary treatment strategy between patients diagnosed with screen-detected (SD-CRC) and non-screen-detected colorectal cancer (NSD-CRC) in a national CRC screening program. This was a retrospective national register-based cohort study. Data on patients aged between 50 and 75years and diagnosed with SD-CRC or NSD-CRC were retrieved from the national colorectal cancer screening database and the Danish Colorectal Cancer Group database. Outcomes related to surgical invasiveness were compared between the two cohorts. Differences were expressed as relative risks using log-binomial generalized linear regression models. UICC stage IV specific outcomes were analyzed using the same method. All analyses were adjusted for sex, age, type of cancer (colonic/rectal), and Charlson comorbidity index. The study included 4707 patients with SD-CRC and 7328 with NSD-CRC. Therapeutic flexible endoscopy (SD-CRC: n = 636 vs. NSD-CRC: n = 334, RR: 2.50, P < 0.001), (robotic-assisted) laparoscopic resection ((n = 616 vs. n = 773, RR: 1.27, P < 0.001), n = 2759 vs. n = 3471, RR: 1.11, P < 0.001), and radical resection (n = 3890 vs. n = 4834, RR: 1.02, P = 0.002) were significantly more frequent in the SD-CRC group. The rates of emergency priority (n = 32 vs. n = 562, RR: 0.09, P < 0.001), open surgery (n = 391 vs. n = 1410, RR: 0.53, P < 0.001), supplementary organ resection (n = 259 vs. n = 860, RR: 0.56, P < 0.001), and stoma formation (n = 526 vs. n = 1040, RR: 0.89, P = 0.007) were significantly lower in the SD-CRC group. The rate of patients undergoing surgery with UICC stage IV disease was significantly higher in the SD-CRC group (SD-CRC: n = 262, NSD-CRC: n = 994, RR: 1.43, P < 0.001). SD-CRC remained associated with less invasive primary surgical treatment following adjustment for potential healthy user bias. UICC stage IV disease may be less advanced in patients with SD-CRC.

Potential global loss of life expected due to COVID-19 disruptions to organised colorectal cancer screening

Screening for colorectal cancer (CRC) decreases cancer burden through removal of precancerous lesions and early detection of cancer. The COVID-19 pandemic has disrupted organised CRC screening programs worldwide, with some programs completely suspending screening and others experiencing significant decreases in participation and diagnostic follow-up. This study estimated the global impact of screening disruptions on CRC outcomes, and potential effects of catch-up screening. Organised screening programs were identified in 29 countries, and data on participation rates and COVID-related changes to screening in 2020 were extracted where available. Four independent microsimulation models (ASCCA, MISCAN-Colon, OncoSim, and Policy1-Bowel) were used to estimate the long-term impact on CRC cases and deaths, based on decreases to screening participation in 2020. For countries where 2020 participation data were not available, changes to screening were approximated based on excess mortality rates. Catch-up strategies involving additional screening in 2021 were also simulated. In countries for which direct data were available, organised CRC screening volumes at a country level decreased by an estimated 1.3-40.5% in 2020. Globally, it is estimated that COVID-related screening decreases led to a deficit of 7.4 million fewer faecal screens performed in 2020. In the absence of any organised catch-up screening, this would lead to an estimated 13,000 additional CRC cases and 7,900 deaths globally from 2020 to 2050; 79% of the additional cases and 85% of additional deaths could have been prevented with catch-up screening, respectively. COVID-19-related disruptions to screening will cause excess CRC cases and deaths, but appropriately implemented catch-up screening could have reduced the burden by over 80%. Careful management of any disruption is key to improving the resilience of colorectal cancer screening programs. The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This work was supported by Cancer Council New South Wales, Health Canada, and Dutch National Institute for Public Health and Environment.

Screening for colorectal cancer : Arecommendation statement of the Austrian National Committee for Cancer Screening.

Colorectal cancer is the fourth most common cancer in Austria. To date, colorectal cancer screening in Austria remains opportunistic and includes colonoscopy or stool-based blood tests. The Austrian National Committee for Cancer Screening developed evidence-based recommendations for anationwide organized colorectal cancer screening program. The methodological framework followed the approach of the United States Preventive Services Task Force. The evidence base underlying the newly developed recommendations comprised areview of the existing published evidence and adecision analytic model tailored to the Austrian context. Using astructured process, committee members considered 1)the magnitude of the net benefit of each screening strategy, 2)the certainty of evidence, and 3)the level of acceptance of the interventions among the target population. The Austrian National Committee for Cancer Screening recommends the implementation of anationwide organized colorectal cancer screening program for all adults aged 45-75years. For persons 65years or older, screening decisions should occur on an individual basis in accordance with aperson's overall health, prior screening history, and preferences. Specifically, the committee recommends either a10-year screening colonoscopy or biennial fecal immunochemical tests with colonoscopy following apositive result, with both screening strategies considered equivalent. Each citizen should be able to make an informed decision about their preferred screening method. Switching between the two screening strategies should be possible. Following an unremarkable colonoscopy, screening by fecal immunochemical test (FIT) is only required after 10years. Screening recommendations apply only to asymptomatic persons at average risk for colorectal cancer. The screening program must be pilot tested, and accompanied by apublic information campaign, formative evaluation, quality assurance, and data collection.

Implementing organized colorectal cancer screening programs in Europe—protocol for a systematic review of determinants and strategies

BackgroundWith a high mortality of 12.6% of all cancer cases, colorectal cancer (CRC) accounts for substantial burden of disease in Europe. In the past decade, more and more countries have introduced organized colorectal cancer screening programs, making systematic screening available to entire segments of a population, typically based on routine stool tests and/or colonoscopy. While the effectiveness of organized screening in reducing CRC incidence and mortality has been confirmed, studies continuously report persistent program implementation challenges. This systematic review will synthesize the literature on organized CRC screening programs. Its aim is to understand what is currently known about the barriers and facilitators that influence the implementation of these programs and about the implementation strategies used to navigate these determinants.MethodsA systematic review of primary studies of any research design will be conducted. CENTRAL, CINAHL, EMBASE, International Clinical Trials Registry Platform, MEDLINE, PsycINFO, and Scopus will be searched. Websites of (non-)government health care organizations and websites of organizations affiliated with authors of included studies will be screened for unpublished evaluation reports. Existing organized CRC screening programs will be contacted with a request to share program-specific grey literature. Two researchers will independently screen each publication in two rounds for eligibility. Included studies will focus on adult populations involved in the implementation of organized CRC screening programs and contain information about implementation determinants/ strategies. Publications will be assessed for their risk of bias. Data extraction will include study aim, design, location, setting, sample, methods, and measures; program characteristics; implementation stage, framework, determinants, strategies, and outcomes; and service and other outcome information. Findings will be synthesized narratively using the three stages of thematic synthesis.DiscussionWith its sole focus on the implementation of organized CRC screening programs, this review will help to fill a central knowledge gap in the literature on colorectal cancer screening. Its findings can inform the decision-making in policy and practice needed to prioritize resources for establishing new and maintaining existing programs in the future.Systematic review registrationPROSPERO (CRD42022306580).

Implementation of an organized colorectal cancer screening program through quantitative fecal immunochemical test followed by colonoscopy in an urban low-income community: Guidance and strategies

Fecal Immunochemical Test (FIT) followed by a colonoscopy is an efficacious strategy to improve the adenoma detection rate and Colorectal Cancer (CRC). There is no organized national screening program for CRC in Brazil. The aim of this research was to describe the implementation of an organized screening program for CRC through FIT followed by colonoscopy, in an urban low-income community of São Paulo city. The endpoints of the study were: FIT participation rate, FIT positivity rate, colonoscopy compliance rate, Positive Predictive Values (PPV) for adenoma and CRC, and the rate of complications. From May 2016 to October 2019, asymptomatic individuals, 50–75 years old, received a free kit to perform the FIT. Positive FIT (≥ 50 ng/mL) individuals were referred to colonoscopy. 10,057 individuals returned the stool sample for analysis, of which (98.2%) 9,881 were valid. Women represented 64.8% of the participants. 55.3% of individuals did not complete elementary school. Positive FIT was 7.8% (776/9881). The colonoscopy compliance rate was 68.9% (535/776). There were no major colonoscopy complications. Adenoma were detected in 63.2% (332/525) of individuals. Advanced adenomatous lesions were found in 31.4% (165/525). CRC was diagnosed in 5.9% (31/525), characterized as adenocarcinoma: in situ in 3.2% (1/31), intramucosal in 29% (9/31), and invasive in 67.7% (21/31). Endoscopic treatment with curative intent for CRC was performed in 45.2% (14/31) of the cases. Therefore, in an urban low-income community, an organized CRC screening using FIT followed by colonoscopy ensued a high participation rate, and high predictive positive value for both, adenoma and CRC.