Organized Colorectal Cancer Screening Program 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.

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.

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.

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.

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.

Testing behavioral economics messages to increase non-responders' participation in organized colorectal cancer-screening programs: A randomized controlled trial

This study aimed to evaluate the impact of behavioral economic-inspired messages on participation in colorectal cancer (CRC) screening programs. We conducted a randomized-controlled trial involving 11,505 non-responders to the CRC screening programs in Florence, Rome, and Turin in 2020.Participants aged 54–70 years were randomly assigned to four conditions. Individuals in the control conditions received a standard invitation letter while the three intervention groups included an additional paragraph featuring either i. normative feedback [F] message (giving feedback that invited subjects did not participate); ii. Minority norm [MN] message (only a minority did not participate); iii. F+ MN message (combining both messages). The primary outcome was the screening participation rate 90 days after the invitation was completed. A multivariate analysis was conducted adjusting for gender, age and birthplace.Overall, screening participation rates were 5.3% in the control condition, 7.0% in the F, 8.2% in the MN, and 7.4% in the F + MN arms (p = 0.002). Invited subjects in the MN arm were more likely to participate (adjusted Odds Ratio[aOR] = 1.38; 95% Confidence Interval [95%CI,1.13–1.68]), particularly those aged 54–59 years (aOR = 1.52; 95%CI:1.16–1.98), and 60–64 (aOR = 1.57; 95%CI:1.62-; 95%CI: 1.06–2.48). Additionally, individuals aged 60–64 invited in F and F + MN arms demonstrated a higher likelihood of participation (aOR for F arm = 1.60; 95%CI: 1.06–2.41; aOR for F + MN arm = 1.99; 95%CI: 1.35–2.92).The inclusion of MN and/or F messages in the invitation letter increased participation among previous non-responders <65 years. Behavioral economics is a promising area of interest for enhancing CRC screening participation. Trial registrationISRCTN registration number: ISRCTN11841256.

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).

A Colorectal Cancer Screening Programs in Middle-Income Countries: A Scoping Review

Background: Colorectal cancer (CRC) is the 3rd most common cancer worldwide, and a major contributor to cancer-related mortality. In contrast to declining CRC incidence and mortality rates across high-income countries, the CRC burden is increasing in low- and middle-income countries. Although CRC screening has been shown to be a cost-effective intervention that decreases CRC incidence and mortality, screening programs remain an unmet need in most low- and middle-income countries. This article reviews evidence on existing CRC screening efforts in middle income countries, where the majority of new CRC cases and deaths are projected to occur over the next decade. Aims: The aim of this study was to identify and describe opportunistic and organized CRC screening programs in middle income countries and to identify barriers and facilitators of such programs. Methods: We identified countries defined as middle income countries by the World Bank and conducted a scoping literature review using PubMed, Google Scholar, and ScienceDirect. For each country, we identified whether CRC screening guidelines or programs exist on the national, regional, or local levels, and summarized data on screening methods and uptake, when this information was available. We also summarized published literature describing barriers and facilitators to CRC screening in middle income countries. Results: Of the 108 countries defined as middle income countries by the World Bank, we identified CRC screening programs in six lower-middle income countries and 23 upper-middle income countries. Most countries have opportunistic CRC screening guidelines/programs. Countries with organized CRC screening programs had higher screening uptake rates, although very few have achieved CRC screening coverage rates of &gt;50% of the eligible population. Most programs were initiated less than 10 years ago, limiting ability to evaluate effect on CRC incidence and mortality. Several barriers to CRC screening were identified, including lack of physician buy in, participant knowledge and resources, and participant fear of screening. Conclusions: While there has been growth of CRC screening programs in the last decade with the initiation of both opportunistic and organized screening programs in middle income countries, there remain significant barriers to the uptake and implementation of such programs.

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.

Проблемы и перспективы скрининга колоректального рака

Colorectal cancer (CRC) is a widespread malignancy that is asymptomatic in the early stages, and late diagnosis is associated with poor outcome. Several levels of CRC risk exist. Thus, 80% of CRCs are sporadic (medium risk), and the rate of their detection increases with age, in particular, after 50 years. 15% of CRCs are caused by familial predisposition or pre-existing colon disease (high risk). 5% of CRCs are associated with genetic diseases (very high risk). Methods for preventing CRC are tailored to these levels of risk. If a patient is classified as having high or very high risk, colonoscopy is the first-line choice depending on the level of risk and age. In very high risk, patients are also referred for genetic counseling. Medium-risk patients are the target group for an organized CRC screening program. Regular screening identifies the disease even at the precancer stage. Noninvasive screening tests for CRC detect blood in the stool. These include stool guaiac test and fecal immunochemical tests. Colonoscopy is the "gold standard" for CRC screening. In addition to colonoscopy, flexible sigmoidoscopy is used for CRC screening. In recent years, molecular genetic tests to identify CRC biomarkers, computed tomography colonography, magnetic resonance colonography, and colon capsule endoscopy have emerged. This paper reviews current issues of CRC screening, i.e., age and gender structure of risk groups, the rate and algorithms used in different countries for CRC early detection, and ways to improve screening efficacy, including artificial intelligence technologies. KEYWORDS: colorectal cancer, age, screening, methods, algorithms, artificial intelligence. FOR CITATION: Radygina L.V., Mochalova L.V. Challenges and prospects of colorectal cancer screening. Russian Medical Inquiry. 2023;7(6):359–365 (in Russ.). DOI: 10.32364/2587-6821-2023-7-6-4.

Change in colorectal cancer (CRC) testing rates associated with the introduction of the first organized screening program in canton Uri, Switzerland: Evidence from insurance claims data analyses from 2010 to 2018

The first canton in Switzerland to implement an organized colorectal cancer screening program (OSP) was Uri. Starting in 2013, it offered 50–69-year-olds free testing with colonoscopy every 10 years or fecal occult blood test (FOBT) every 2 years. We tested the association between the OSP and testing rates over time.We analyzed claims data of 50–69-year-olds from Uri and neighboring cantons (NB) provided by a large health insurance and complemented it with data from the OSP. We fitted multivariate adjusted logistic regression models to compare overall testing rates and by method (colonoscopy or FOBT/both) We computed the 2018 rate of the population up-to-date with testing (colonoscopy within 9 years/FOBT within 2 years).Yearly overall testing rates in Uri increased from 8.7% in 2010 to 10.8% in 2018 and from 6.5% to 7.9% in NB. In Uri, the proportion tested with FOBT/both increased from 4.7% to 6.0% but decreased from 2.8% to 1.1% in NB. Testing by FOBT/both increased more between 2015 and 2018 than 2010–2012 in Uri than in NB (OR:2.1[95%CI:1.8–2.4]), it increased less for colonoscopy (OR:0.60[95%CI:0.51–0.70]), with no change in overall CRC testing (OR:0.91[95%CI:0.81–1.02]). In 2018 in Uri, 42.5% were up-to-date with testing (FOBT/both:9.2%, colonoscopy:35.7%); in NBs, 40.7% (FOBT/both:2.7%, colonoscopy:39%).Yearly FOBT rates in Uri were always higher than in NB. Though the OSP in Uri was not associated with a greater increase in overall testing rates, the OSP was associated with increased FOBT.

Declining Colectomy Rates for Nonmalignant Colorectal Polyps in a Large, Ethnically Diverse, Community-Based Population.

INTRODUCTION:Despite studies showing improved safety, efficacy, and cost-effectiveness of endoscopic resection for nonmalignant colorectal polyps, colectomy rates for nonmalignant colorectal polyps have been increasing in the United States and Europe. Given this alarming trend, we aimed to investigate whether colectomy rates for nonmalignant colorectal polyps are increasing or declining in a large, integrated, community-based healthcare system with access to advanced endoscopic resection procedures.METHODS:We identified all individuals aged 50–85 years who underwent a colonoscopy between 2008 and 2018 and were diagnosed with a nonmalignant colorectal polyp(s) at the Kaiser Permanente Northern California integrated healthcare system. Among these individuals, we identified those who underwent a colectomy for nonmalignant colorectal polyps within 12 months after the colonoscopy. We calculated annual colectomy rates for nonmalignant colorectal polyps and stratified rates by age, sex, and race and ethnicity. Changes in rates over time were tested by the Cochran-Armitage test for a linear trend.RESULTS:Among 229,730 patients who were diagnosed with nonmalignant colorectal polyps between 2008 and 2018, 1,611 patients underwent a colectomy. Colectomy rates for nonmalignant colorectal polyps decreased significantly from 125 per 10,000 patients with nonmalignant polyps in 2008 to 12 per 10,000 patients with nonmalignant polyps in 2018 (P < 0.001 for trend). When stratified by age, sex, and race and ethnicity, colectomy rates for nonmalignant colorectal polyps also significantly declined from 2008 to 2018.DISCUSSION:In a large, ethnically diverse, community-based population in the United States, we found that colectomy rates for nonmalignant colorectal polyps declined significantly over the past decade likely because of the establishment of advanced endoscopy centers, improved care coordination, and an organized colorectal cancer screening program.

A Modified Implementation Mapping Methodology for Evaluating and Learning From Existing Implementation.

When empirically supported interventions are implemented in real-world practice settings, the process of how these interventions are implemented is highly relevant for their potential success. Implementation Mapping is a method that provides step-by-step guidance for systematically designing implementation processes that fit the respective intervention and context. It includes needs assessments among relevant stakeholders, the identification of implementation outcomes and determinants, the selection and design of appropriate implementation strategies, the production of implementation protocols and an implementation outcome evaluation. Implementation Mapping is generally conceptualized as a tool to prospectively guide implementation. However, many implementation efforts build on previous or ongoing implementation efforts, i.e., “existing implementation.” Learnings from existing implementation may offer insights critical to the success of further implementation activities. In this article, we present a modified Implementation Mapping methodology to be applied when evaluating existing implementation. We illustrate the methodology using the example of evaluating ongoing organized colorectal cancer screening programs in Switzerland. Through this example, we describe how we identify relevant stakeholders, implementation determinants and outcomes as well as currently employed implementation strategies. Moreover, we describe how we compare the types of strategies that are part of existing implementation efforts with those that implementation science would suggest as being suited to address identified implementation determinants. The results can be used for assessing the current state of implementation outcomes, refining ongoing implementation strategies, and informing future implementation efforts.

Colonoscopy-Related Adverse Events in Patients With Abnormal Stool-Based Tests: A Systematic Review of Literature and Meta-analysis of Outcomes.

Colorectal cancer (CRC) screening programs based on the fecal immunochemical test (FIT) and guaiac-based fecal occult blood (gFOBT) are associated with a substantial reduction in CRC incidence and mortality. We conducted a systematic review and comprehensive meta-analysis to evaluate colonoscopy-related adverse events in individuals with a positive FIT or gFOBT. A systematic and detailed search was run in January 2021, with the assistance of a medical librarian for studies reporting on colonoscopy-related adverse events as part of organized CRC screening programs. Meta-analysis was performed using the random-effects model, and the results were expressed for pooled proportions along with relevant 95% confidence intervals (CIs). A total of 771,730 colonoscopies were performed in patients undergoing CRC screening using either gFOBT or FIT across 31 studies. The overall pooled incidence of severe adverse events in the entire patient cohort was 0.42% (CI 0.20-0.64); I2 = 38.76%. In patients with abnormal gFOBT, the incidence was 0.2% (CI 0.1-0.3); I2 = 24.6%, and in patients with a positive FIT, it was 0.4% (CI 0.2-0.7); I2 = 48.89%. The overall pooled incidence of perforation, bleeding, and death was 0.13% (CI 0.09-0.21); I2 = 22.84%, 0.3% (CI 0.2-0.4); I2 = 35.58%, and 0.01% (CI 0.00-0.01); I2 = 33.21%, respectively. Our analysis shows that in colonoscopies performed after abnormal stool-based testing, the overall risk of severe adverse events, perforation, bleeding, and death is minimal.

Two randomized controlled trials for colorectal cancer screening invitations developed using a behavioral science approach

The effectiveness of behaviorally informed, targeted invitations to standard invitations and to no invitation (control arm, primary analysis) were compared in the context of an organized colorectal cancer (CRC) screening program. Two multi-arm, pragmatic randomized controlled trials in men (arms: male-specific, unisex, standard invitation, or no invitation) and in women (arms: unisex, standard invitation, or no invitation), were conducted in Ontario, Canada. Eligible persons aged 50–74, due for CRC screening, were randomized. Primary and secondary outcomes were completion of the guaiac fecal occult blood test (gFOBT) and uptake of any colorectal test, respectively, within 5 months of mailing. Impact of invitation type was assessed using logistic regression. Letters were mailed to 75,810 men and women; 38,673 males and 34,453 females were included in the analyses. Men who received the male-specific letter were most likely to screen with gFOBT compared to controls (odds ratio (OR) 7·24, 95% CI: 5·77, 9·09), followed by those receiving the unisex letter (OR 6·75, 95% CI: 5·37, 8·47) and the standard letter (OR 5·99, 95% CI: 4·76, 7·53). Women who received the unisex letter were most likely to be screened with gFOBT compared to controls (OR 7·07, 95% CI: 5·83, 8·59), followed by those receiving the standard letter (OR 6·76, 95% CI: 5·56, 8·21). In both trials, the findings were similar for the secondary outcome. Mailed invitations were effective for both men and women. With greater targeting using the behaviorally informed invitations, the magnitude of benefit relative to no invitation appeared to increase. (ClinicalTrials.gov, NCT02364895).

Impact of COVID-19 Related Disruptions to Colorectal Cancer Screening Programs in Three Countries: A Comparative Modelling Study

Background: Colorectal cancer (CRC) screening programs worldwide have been disrupted during the COVID-19 pandemic. This study aimed to estimate the impact of hypothetical disruptions to organized CRC screening programs on short- and long-term CRC incidence and mortality in three countries using microsimulation modelling.Methods: Using CRC microsimulation models for Australia (Policy1-Bowel), Canada (OncoSim) and the Netherlands (ASCCA and MISCAN-Colon) participating in the COVID-19 and Cancer Global Modelling Consortium (CCGMC), we simulated a range of scenarios to assess the potential impact of disruptions to screening on CRC incidence and mortality. Modelled scenarios varied by disruption duration (3-, 6- and 12-months), post-disruption participation decreases, and catch-up screening strategy.Findings: Without catch-up screening, CRC deaths could increase by 0·2-0·5%, 0·4-1·0%, and 0·8-2·0% over 2020-2050 among individuals aged 50 years and older in the three modelled countries after 3-, 6-, and 12- month disruptions, respectively, compared to undisrupted screening. A 6-month disruption would result in an estimated 1,964, 1,319, and 676-856 additional CRC deaths in Australia, Canada and the Netherlands, respectively, compared to undisrupted screening. Providing catch-up screening could minimize the impact of the disruption, while a post-disruption decrease in participation could increase CRC deaths by 1·8-3·7% compared to undisrupted screening.Interpretation: Although the relative impact of the modelled CRC screening disruptions due to the COVID-19 pandemic is modest, there is a clear impact on absolute CRC deaths over the period 2020-2050. It is crucial that, if disrupted, screening programs ensure participation rates return to previously observed rates and provide catch-up screening wherever possible, as the impact of any disruption could be considerably larger otherwise.Funding Statement: The secretariat for the COVID-19 and Cancer Global Modelling Consortium (CCGMC) working group 2 is funded through Cancer Council New South Wales.Declaration of Interests: KC: Dr. Canfell reports and is co-principal investigator of an unrelated investigator-initiated trial of cervical screening in Australia (Compass; ACTRN12613001207707 and NCT02328872), which is conducted and funded by the VCS Foundation (VCS), a government-funded health promotion charity. The VCS Foundation received equipment and a funding contribution from Roche Molecular Systems USA. However, neither KC nor her institution on her behalf (Cancer Council NSW) receives direct funding from industry for this trial or any other project. All other authors declare no conflict of interest.

A63 REFINING THE CANADIAN ASSOCIATION OF GASTROENTEROLOGY GUIDELINE ON SCREENING IN PERSONS WITH A FAMILY HISTORY OF NONHEREDITARY COLORECTAL CANCER OR ADENOMA: A MODIFIED DELPHI PROCESS

Abstract Background In 2018, the Canadian Association of Gastroenterology (CAG) published an extensive systematic review and guideline on screening in persons with a family history (FHx) of nonhereditary colorectal cancer (CRC) and adenoma. While CAG’s recommendations were evidence-based, some recommendations lacked precision (e.g. ranges for some start ages &amp; intervals) and screening cessation age was not addressed, leading to implementation challenges for practitioners and CRC screening programs. Aims To review and update the evidence since the 2018 guideline and to formulate implementable recommendations in the Ontario context that are aligned with the CAG guideline. Methods ColonCancerCheck (Ontario’s organized CRC screening program) conducted a modified version of the literature search used by CAG (Jan 2017 - Sept 2019). A 19-member expert panel with Canadian and international representatives from endoscopy, primary care, epidemiology, organized CRC screening programs, Ontario’s cancer system and the general public refined the recommendations of the CAG guideline for the purposes of implementation in an organized CRC screening program using a modified Delphi process. This iterative process involved a series of webinars and anonymous survey rounds where the panel reviewed evidence materials and provided online feedback to develop, refine &amp; achieve consensus on screening recommendations in persons with a FHx of CRC/adenoma. Consensus was achieved if ≥75% of members agreed or strongly agreed with the statement. Results Six new systematic reviews and 2 new guidelines were identified. New evidence included data on the absolute risk (10 year &amp; lifetime risk) of CRC by type of FHx, as well as the performance of fecal immunochemical testing (FIT) and barriers to CRC screening in persons with a FHx of CRC. The expert panel participated in 3 webinars and 4 online surveys to arrive at consensus. Panel recommendations and level of consensus will be reported for the 6 statements (Table). Conclusions Building from the CAG guideline, we derived evidence-based and implementable recommendations for screening persons with a FHx of CRC or adenoma. Funding Agencies Ontario Health (Cancer Care Ontario)

The Performance of Colorectal Cancer Screening in Brazil: The First Two Years of the Implementation Program in Barretos Cancer Hospital.

Colorectal cancer is the second most common cancer in Brazil. Yet, a nationally organized colorectal screening program is not implemented. Barretos Cancer Hospital (BCH) is one of the largest Brazilian institution that cares for underserved patients. BCH developed a fecal immunochemical test (FIT)-based organized colorectal cancer screening program to improve colorectal cancer outcomes.This study aims to present the quality/performance measures of the first 2 years of the FIT-based colorectal cancer screening program and its impact on the colorectal cancer disease stage. Between 2015 and 2017, a total of 6,737 individuals attending the Outpatient Department of Prevention or the Mobile Unit of BCH, which visits 18 cities of Barretos county, ages 50 to 65 years, were personally invited by a health agent/nurse practitioner. Exclusion criteria were personal history of colorectal cancer, adenomatous polyps, inflammatory bowel disease, and colonoscopy, or flexible sigmoidoscopy performed in the past 5 years. European Union (EU) guidelines for colorectal cancer screening programs were evaluated. Overall, 92.8% returned the FIT, with an inadequate examination rate of 1.5%. Among the 6,253 adequately tested, 12.5% had a positive result. The colonoscopy compliance and completion rates were 84.6 and 98.2%, respectively. The PPVs were 60.0%, 16.5%, and 5.6% for adenoma, advanced adenoma, and cancer, respectively. Stage distribution of screen-detected cancers shows earlier stages than clinically diagnosed colorectal cancer cancers reported at BCH and Brazilian cancer registries. Our colorectal cancer screening program achieved desirable quality metrics, aligned with the EU guidelines. The observed shift toward earlier colorectal cancer stages suggests an exciting opportunity to improve colorectal cancer-related cancers in Brazil.