Colorectal Cancer Screening Outcomes Research Articles

Costs and Projected Effect of a Federally Qualified Health Center-Based Mailed Colorectal Cancer Screening Program in Texas.

Mailed stool testing for colorectal cancer (CRC) may improve screening uptake and reduce the incidence and mortality of CRC, especially among patients at federally qualified health centers (FQHCs). To expand screening programs it is important to identify cost-effective approaches. We developed a decision-analytic model to estimate the cost, effects on screening and patient outcomes (CRCs detected, CRCs prevented, CRC deaths prevented), and cost-effectiveness of implementing a state-wide mailed stool testing program over 5 years among unscreened, age-eligible (aged 50-75 y) patients at FQHCs in Texas. We compared various outreach strategies and organizational structures (centralized, regional, or a hybrid). We used data from our existing regional mailed stool testing program and recent systematic reviews to set parameters for the model. Costs included start-up and ongoing activities and were estimated in 2022 US dollars from the perspective of a hypothetical third-party payer. Cost-effectiveness was assessed by using both incremental and average cost-effectiveness ratios. Using either a statewide centralized or hybrid organizational configuration to mail stool tests to newly eligible FQHC patients and patients who have responded at least once since program inception is likely to result in the best use of resources over 5 years, enabling more than 110,000 additional screens, detecting an incremental 181 to 194 CRCs, preventing 91 to 98 CRCs, and averting 46 to 50 CRC deaths, at a cost of $10 million to $11 million compared with no program. A statewide mailed stool testing program for FQHC patients can be implemented at reasonable cost with considerable effects on CRC screening outcomes, especially when its structure maximizes program efficiency while maintaining effectiveness.

Estimated impact and value of blood-based colorectal cancer screening at varied adherence compared with stool-based screening

Objective This analysis estimated the outcomes of triennial blood-based colorectal cancer (CRC) screening at various adherence, including perfect adherence, compared with triennial multi-target stool DNA (mt-sDNA) screening at the reported real-world adherence rate. Methods The validated CRC-AIM model simulated a US cohort of average-risk individuals receiving triennial screening with mt-sDNA or blood-based test from ages 45 to 75 years. Modeled specificity and sensitivity were based on reported data. Adherence was set at a real-world rate of 65.6% for mt-sDNA and at 65.6%, relative 10% incremental increases from 65.6%, or 100% for the blood-based test. Costs of mt-sDNA and the blood-based test were based on prices for clinically available tests ($508.87 and $895, respectively). Value-based pricing was estimated at a willingness-to-pay threshold of $100,000. Results Both tests resulted in life-years gained (LYG), reduced CRC cases, and reduced deaths versus no screening. With adherence for mt-sDNA set at 65.6% and for blood-based test set at 100%, mt-sDNA resulted in 30% more LYG, 52% more averted CRC cases, and 32% more averted CRC deaths. At reported sensitivity and specificity rates, mt-sDNA at 65.6% adherence dominates (is more effective and less costly) the blood-based test at any adherence. There was no price at which triennial screening with the blood-based test at any adherence was cost-effective compared with mt-sDNA at 65.6% adherence. Conclusions Triennial screening with mt-sDNA resulted in better clinical outcomes at a lower cost compared with the modeled blood-based test even at perfect adherence, supporting application of blood-based tests only as a secondary screening option.

Racial/ethnic disparities in colorectal cancer screening methods: Unveiling patterns and implications.

124 Background: Colorectal cancer screening (CRC) is crucial for reducing morbidity and mortality of CRC. The type of screening method chosen is important for accessibility, compliance, and effectiveness. Colonoscopy and sigmoidoscopy are considered the gold standard while fecal occult blood tests (FOBT) are non-invasive, inexpensive, and more available. Our study examined the racial/ethnic disparities associated with various CRC screening methods. Methods: We utilized the cross-sectional nationally representative data from the 2018-2021 Behavioral Risk Factor Surveillance System (BRFSS). The sample included individuals between 50-75 years, the recommended age for CRC screening. Logistic regression analysis was performed to investigate up-to-date CRC screening rates and the choice of CRC screening method in related to race/ethnicity, after controlling for confounding factors. Results: Among the weighted population of 119,841,048 individuals aged 50-75 years, 44.6% reported having an up-to-date colonoscopy/sigmoidoscopy only, 5.0% had only FOBT in the past year, and 5.8% had both tests. The logistic regression models revealed that Asians and Pacific Islanders (APIs; adjusted odds ratio [aOR]: 0.59; 95%CI: 0.49-0.69), American Indians and Alaska Natives (AIs/ANs; aOR: 0.73; 95%CI: 0.59-0.90), and Hispanic individuals (aOR: 0.76; 95%CI: 0.69-0.84) were less likely to undergo colonoscopy/sigmoidoscopy only compared to non-Hispanic White (NHW) peers. Conversely, APIs (aOR: 1.46; 95%CI: 0.98-2.17) and Hispanic individuals (aOR: 1.46; 95%CI: 1.20-1.79) were associated with a higher rate of recent FOBT only compared to their NHW individuals. Regarding the combination of up-to-date colonoscopy/sigmoidoscopy and FOBT, non-Hispanic Blacks (NHB; aOR: 1.66; 95%CI: 1.44-1.92) and Hispanic individuals (aOR: 1.61; 95CI: 1.33-1.95) were more likely to have both tests compared to NHW individuals. Conclusions: Our findings highlight the significant variations in CRC screening preferences among different racial/ethnic groups, which are likely influenced by cultural backgrounds, health literacy and access, and language barriers. It is crucial for healthcare providers to acknowledge these differences, as they can significantly impact patient engagement and compliance with CRC screening recommendations. Emphasizing culturally informed approaches to CRC screening is essential for fostering trust, promoting equitable healthcare, and ultimately reducing disparities in CRC outcomes.

Evaluating the Effectiveness of a Modified Colorectal Cancer Screening Program in Almaty, Kazakhstan.

This study aimed to evaluate the effectiveness of a modified colorectal cancer (CRC) screening program, incorporating culturally tailored strategies to increase screening uptake and compliance, in Almaty, Kazakhstan. A cross-sectional study was conducted in Almaty between 2019-2022, involving 5370 participants aged 50-70 from diverse settings. Participants were assigned to the main (modified method) and comparison (standard method) groups based on the parity of their ID number digits. Variables of interest included demographics, somatic comorbidities, disability degree, and CRC screening results. The modified screening emphasized healthcare prioritization, optimized nursing resources, enhanced accessibility, and preparedness for the second screening stage. In the study 2702 patients in the main group (modified method), and 2668 patients in the comparison group (standard method). Comorbidity data showed that the majority of participants in both groups had between 1-10 comorbidities, with an average of 8.2 in the main group and 8.1 in the comparison group. Screening response rates at stage I were higher in the main group, with 82.6% of subjects undergoing screening, compared to 78.9% in the comparison group (χ2=12.12, p=0.001). The response rates were higher among females in both groups, and no significant differences were found across age groups. At stage II, the response rate was again higher in the main group (56.2%) than in the comparison group (47.2%) (χ2=4.217, p=0.040), with no significant differences noted in relation to sex or age. However, the main group showed a higher response rate at stage I among respondents with 6-10 comorbidities (87.1% vs 82.5%, χ2 =7.820, p=0.009). The study demonstrates that the modified program significantly outperformed the traditional one, achieving higher response rates at both the initial and subsequent stages of screening. These findings emphasize the value of revisiting and refining current CRC screening methods to maximize early detection rates.

Costs and outcomes of colorectal cancer screening program in Isfahan, Iran

BackgroundColorectal cancer is one of the most prevalent gastrointestinal cancers in Iran i.e., the fourth and the second prevalent cancer among Iranian males and females, respectively. A routine screening program is effective in the early detection of disease which can reduce the cancer burden both for individuals and society. In 2015, Iran’s Package of Essential Non- communicable Diseases program had been piloted in Shahreza city in Isfahan province. Colorectal cancer screening for the population aged 50–70 was a part of this program. So far, there was no study about the cost and outcomes of that program. Thus, this study aimed to analyze the costs and outcomes of colorectal cancer screening done from 2016 to 2019 in Shahreza.MethodsThis cost-outcome description study used the data of 19,392 individuals who were 50–70 years old experienced a fecal immunochemical test (FIT) and had an electronic health record. All direct costs including personnel, building space, equipment, training, etc. were extracted from the financial documents existing in the Isfahan province Health Center. The outcome was defined as positive FIT, detection of adenoma or malignancy as recorded in the E-integrated health system.ResultsThe results of this study indicated that the direct costs of the colorectal cancer screening program during the years 2016–2019 were 7,368,707,574 Rials (321,029 PPP$) in Shahreza, Isfahan province. These costs resulted in identifying 821 people with a positive FIT test, of those 367 individuals were undergone colonoscopy. Of whom 8 cases of colorectal cancer, and 151 cases with polyps were diagnosed.ConclusionThis study showed that by paying a small amount of 320 thousand international dollars we could prevent 151 cases of polyps to be progressed to colorectal cancer,resulting in a significant reduction in colorectal cancer incidence.

Abstract A105: Participants with lower socioeconomic status or lacking access to health care benefited more from a decision support navigation trial to increase colorectal cancer screening: Study of Chinese and Korean American primary care patients

Abstract Background: Although colorectal cancer (CRC) is the second most common cancer among Asian Americans, cancer screening rates among Chinese- and Korean Americans are lower than in other racial/ethnic groups in the United States. To address this disparity, we designed, implemented, and evaluated the effectiveness of a culturally adapted decision support navigation trial. Methods: Twenty-four Chinese and Korean primary care physicians (PCPs) from Maryland and northern Virginia were recruited to the STOP CRC (Screening TO Prevent CRC) program, a cluster randomized controlled trial. The PCPs’ clinics were randomized into intervention or control group. Then, 400 Chinese and Korean Americans were recruited through the PCPs’ clinics. Participants randomized to a decision support navigation intervention group (n=200) received an informational booklet, instructions to access colonoscopy screening, and a free fecal immunochemical test (FIT) kit at baseline. A bilingual patient navigator also guided them through an exercise to facilitate screening test choices. Six months after enrollment, participants randomized to the control group (n=200) received the informational booklet, colonoscopy instructions, and a FIT kit. Participants were offered a choice to select between the FIT or colonoscopy. Screening (completion of FIT or colonoscopy) was measured at 6 and 12 months after enrollment by medical record review and self-report. Generalized estimating equations (GEE) models with an exchangeable working correlation matrix to account for clustering effects at the PCP level were employed to examine intervention effects on CRC screening outcomes. Results: Intervention and control participants were comparable in their socio-demographic background and access to healthcare at baseline. At 12 months, screening adherence in the intervention group was (93%) substantially higher than in the control group (63%) (Prevalence Ratio: 1.51, 95% confidence interval: 1.37-1.66). Interestingly, the effect of the intervention on CRC screening was significantly higher among those with less than or equal to high school education (PR=1.95; 95% CI: 1.89-2.02) compared to those with higher than high school education (PR=1.37; 95% CI: 1.37; 95% CI: 1.22-1.54). Moreover, the impact of the intervention on CRC screening was higher among participants with lower income (<$100,000: PR=1.60; 95% CI: 1.56-1.65) than the participants with higher income (≥$100,000: PR=1.18; 96% CI: 0.85-1.64). The same impact was higher among those without health insurance (PR=1.70; 95% CI: 1.28-2.25) and those with Medicare/Medicaid (PR=1.80, 95% CI: 1.29-2.52) compared to those who have private health insurance (PR=1.35, 95% CI: 1.19-1.53). Conclusions: The STOP CRC program, a culturally and linguistically adapted decision support navigation intervention, is effective in increasing CRC screening among Chinese and Korean American primary care patients who are not up-to-date with the screening. This impact is more pronounced among participants with lower socioeconomic status or lacking access to health care. Citation Format: Sunmin Lee, Soomin Ryu, Carissa Kwan, Ronald E. Myers, Yuxi Shi, Luohua Jiang, Brittany N. Morey. Participants with lower socioeconomic status or lacking access to health care benefited more from a decision support navigation trial to increase colorectal cancer screening: Study of Chinese and Korean American primary care patients [abstract]. In: Proceedings of the 15th AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2022 Sep 16-19; Philadelphia, PA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2022;31(1 Suppl):Abstract nr A105.

S290 Is Fecal Immunochemical Test (FIT) the Answer to Increasing Colorectal Cancer Screening (CRC) Uptake in the Filipino Community? Results From a Conjoint Analysis Survey

Introduction: Asian Americans are the fastest growing major racial/ethnic group in the US, with Filipinos comprising the 3rd largest group. While >80% of Filipinos are proficient in English, and have insurance rates, education levels, and incomes that exceed the general US population, they have lower CRC screening rates and worse CRC outcomes vs. non-Hispanic Whites. To begin to address this disparity, we used conjoint analysis to understand Filipinos’ preferences for the different CRC screening test options. Methods: To quantify Filipinos’ preferences for CRC screening tests, we conducted a choice-based conjoint analysis survey for individuals ≥40yo at average risk for CRC who had not undergone prior screening. From 4/29-11/7/21, we recruited Filipinos at an academic medical center and through a national survey research firm (Cint). Using the conjoint data, we performed simulations to determine each individual’s preferred screening test; for this analysis, we focused on the proportion of people who preferred annual FIT or colonoscopy every 10 years as both are tier 1 tests according to the US Multi-Society Task Force (MSTF) on CRC. We then performed logistic regression to explore whether demographics predicted decision making on FIT vs colonoscopy; variables with p< .20 from bivariate analyses were included as covariates in the regression model. Results: Overall, 105 participants completed the survey; most respondents were female (74.3%) and aged 40-49y (84.8%). Moreover, 64.8% of participants stated they planned to get screened for CRC and they reported high self-perceived benefits of CRC screening (median 4.4, IQR 3.8-4.8; 1-5 scale, higher=more beneficial). When performing simulations using the conjoint data for the US MSTF tier 1 tests, we found that 66.7% of respondents preferred an annual FIT while 33.3% preferred a colonoscopy every 10 years (Figure). In a regression analysis that accounted for sex, marital status, household income, employment status, and geographic region, no variables were significantly associated with individual's preference for FIT over colonoscopy (Table). Conclusion: We found that 2 in 3 Filipinos prefer annual FIT over colonoscopy for their CRC screening and that demographics poorly predict individual decision making. To improve CRC screening uptake in the Filipino community, our data suggest that community-based interventions should either focus primarily on FIT or employ a choice-based approach (ie, FIT or colonoscopy).Figure 1.: Data from simulations using conjoint analysis data assessing the proportion of respondents who would prefer each MSTF tier 1-recommended test (N=105) Table 1. - Regression analysis on preferring FIT every year over colonoscopy every 10 years for CRC screening; screening test preferences were determined through simulations from conjoint analysis-derived data (N=105) Variable Prefers FIT every year for CRC screening n (% of row) aOR [95% CI] Sex: Male 21 (77.8%) Reference Female 49 (62.8%) 0.61 (0.20, 1.86) Marital status: Married or living with a partner 53 (62.4%) Reference Not married 17 (85.0%) 2.65 (0.61, 11.44) Total household income: ≤$100,000 34 (79.1%) reference >$100,000 31 (62.0%) 0.72 (0.24, 2.20) Prefer not to say 5 (41.7%) 0.23 (0.05, 1.12) Employment status: Unemployed, on disability, on leave of absence from work, retired, or a homemaker 19 (82.6%) reference Employed or student 51 (62.2%) 0.36 (0.10, 1.31) US region: Northeast/South/ Midwest 15 (83.3%) reference West 55 (63.2%) 0.70 (0.15, 3.21) Has non-first degree relative or friend diagnosed with CRC 11 (44.0%) 0.42 (0.15, 1.16)

Modelling cost-effective strategies for minimising socioeconomic inequalities in colorectal cancer screening outcomes in England

Colorectal cancer (CRC) incidence and mortality is higher in socioeconomically deprived groups for a variety of reasons, but is exacerbated by poorer screening uptake. However, many strategies for improving screening participation exist. This analysis aimed to model the impact of screening on CRC inequalities in England and then compare different strategies for increasing participation, to determine the most cost-effective methods for reducing screening-induced inequalities. An existing health economic model, Microsimulation Model in Cancer of the Bowel was adapted. Screening-eligible individuals were simulated to investigate the impact of screening on CRC inequalities. Following this, four strategies for promoting screening participation were compared: 1) annual re-invitation of screening non-participants; 2) a national media advertising campaign; 3) text message reminders for non-participants; 4) health promotion in deprived populations. Cost-effectiveness, CRC outcomes, resource impacts and effects on CRC inequalities were assessed. Inequalities analysis was based on age-standardised CRC mortality by socioeconomic group. Screening was found to be highly cost-effective but CRC inequalities increased as screening effectiveness improved. Annual re-invitation of non-participants was most cost-effective for promoting particiption (incremental cost-effectiveness ratio = £4404 per quality-adjusted life-year), reducing CRC mortality (11,129 deaths averted), and reducing screening-induced inequality (slope of inequalities reduced from 20.80 to 19.38), although it required 42% more screening kits to be sent out. Other strategies were cost-effective compared with screening alone, and improved CRC outcomes, but had varying impacts on inequalities. Whilst bowel cancer screening increases socioeconomic inequalities in CRC mortality, effective and cost-effective strategies are available for mitigating screening-induced inequalities.

Abstract CT164: A culturally adapted decision support navigation trial to increase colorectal cancer screening among Chinese and Korean American primary care patients

Abstract Background: Colorectal cancer (CRC) is the second most common cancer among Asian Americans. However, cancer screening rates among Chinese- and Korean Americans are lower than other racial/ethnic groups in the United States. To address this disparity, we tested the effectiveness of a culturally adapted decision support navigation trial. Methods: The STOP CRC (Screening TO Prevent CRC) program, a cluster randomized controlled trial, recruited 24 Chinese and Korean primary care physicians (PCP) from Maryland and northern Virginia. Then, 400 Chinese and Korean Americans were recruited through the PCPs’ clinics. Participants randomized to a decision support navigation intervention group (n=200) received an informational booklet, instructions to access colonoscopy screening, and a free fecal immunochemical test (FIT) kit at baseline. A bilingual patient navigator also guided them through an exercise to facilitate screening test choices. Six months after enrollment, participants randomized to the control group (n=200) received the informational booklet, colonoscopy instructions, and a FIT kit. Participants selected a method of CRC screening between the FIT or colonoscopy. Screening (completion of FIT or colonoscopy) was measured at 6 and 12 months after enrollment by medical record review and self-report. Generalized estimating equations (GEE) models with an exchangeable working correlation matrix to account for clustering effects at the PCP level were employed to examine intervention effects on CRC screening outcomes. Results: Intervention and control participants were comparable on socio-demographic background and access to healthcare at baseline. The mean age of participants was 58 years, and 53% of participants were female. The majority of participants (85%) were married, 34% had less than or equal to high school education, 32% had annual household income less than $40,000, and 21% did not have health insurance. At 6 months, screening adherence in the intervention group was (91%) predominantly greater than in the control group (8%) (Prevalence Ratio: 11.31, 95% confidence interval: 6.95-18.43). At 12 months, although the gap between the two groups was reduced, the screening adherence in the intervention group was (93%) still substantially higher than in the control group (63%) (Prevalence Ratio: 1.51, 95% confidence interval: 1.37-1.66). Conclusions: The STOP CRC program, a culturally and linguistically adapted decision support navigation intervention, is effective in increasing CRC screening among Chinese and Korean American primary care patients who are not up-to-date with the screening. This program can potentially be adapted and implemented for other Asian Americans who are not up-to-date with the CRC screening in the U.S. Citation Format: Sunmin Lee, Soomin Ryu, Carissa Kwan, Ronald E. Myers, Yuxi Shi, Luohua Jiang, Brittany N. Morey. A culturally adapted decision support navigation trial to increase colorectal cancer screening among Chinese and Korean American primary care patients [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2022; 2022 Apr 8-13. Philadelphia (PA): AACR; Cancer Res 2022;82(12_Suppl):Abstract nr CT164.

Diabetes mellitus and colorectal cancer screening in the population of the Italian region Friuli Venezia Giulia

&#x0D; Aims: Colorectal cancer is the most common cancer in Italy, where screening programs are now in place all over the country. We conducted a research to assess whether the use and outcomes of colorectal cancer screening are different between diabetics, who are at increased risk of developing colorectal cancer, and non-diabetics in the Italian Northeastern region Friuli Venezia Giulia.&#x0D; Methods: This was a retrospective population-based study which used the administrative databases of the regional health information system as the sources of information. For the two screening rounds 2010-2011 and 2012-2013, we compared adherence to the program and the results of the fecal occult blood tests and of the colonoscopy among diabetic and non-diabetic residents.&#x0D; Results: Overall, more than 300,000 persons were invited for the colorectal cancer screening in each round. Of them, approximately 8.8% were diabetic. In the regional population, adherence to the screening program was significantly lower among diabetics than among non-diabetics. The proportion of positive fecal occult blood tests was higher among diabetics than among non-diabetics. Among diabetics, the detection rate for initial and advanced adenomas was higher than among non-diabetics, whereas no clear pattern was observed for the detection of cancers.&#x0D; Conclusion: In Friuli Venezia Giulia, efforts should be directed at improving the management of diabetic patients and at reducing the inequalities in access to care due to this comorbidity.&#x0D;

Racism Is a Modifiable Risk Factor: Relationships Among Race, Ethnicity, and Colorectal Cancer Outcomes

Racism Is a Modifiable Risk Factor: Relationships Among Race, Ethnicity, and Colorectal Cancer Outcomes

Polygenic risk score across distinct colorectal cancer screening outcomes: from premalignant polyps to colorectal cancer

BackgroundDifferent risk-based colorectal cancer (CRC) screening strategies, such as the use of polygenic risk scores (PRS), have been evaluated to improve effectiveness of these programs. However, few studies have previously assessed its usefulness in a fecal immunochemical test (FIT)-based screening study.MethodsA PRS of 133 single nucleotide polymorphisms was assessed for 3619 participants: population controls, screening controls, low-risk lesions (LRL), intermediate-risk (IRL), high-risk (HRL), CRC screening program cases, and clinically diagnosed CRC cases. The PRS was compared between the subset of cases (n = 648; IRL+HRL+CRC) and controls (n = 956; controls+LRL) recruited within a FIT-based screening program. Positive predictive values (PPV), negative predictive values (NPV), and the area under the receiver operating characteristic curve (aROC) were estimated using cross-validation.ResultsThe overall PRS range was 110–156. PRS values increased along the CRC tumorigenesis pathway (Mann-Kendall P value 0.007). Within the screening subset, the PRS ranged 110-151 and was associated with higher risk-lesions and CRC risk (ORD10vsD1 1.92, 95% CI 1.22–3.03). The cross-validated aROC of the PRS for cases and controls was 0.56 (95% CI 0.53–0.59). Discrimination was equal when restricted to positive FIT (aROC 0.56), but lower among negative FIT (aROC 0.55). The overall PPV among positive FIT was 0.48. PPV were dependent on the number of risk alleles for positive FIT (PPVp10-p90 0.48–0.57).ConclusionsPRS plays an important role along the CRC tumorigenesis pathway; however, in practice, its utility to stratify the general population or as a second test after a FIT positive result is still doubtful. Currently, PRS is not able to safely stratify the general population since the improvement on PPV values is scarce.

Comparing Colorectal Cancer Screening Outcomes in the International Cancer Screening Network: A Consortium Proposal

Randomized trials have shown that stool testing for occult blood and flexible sigmoidoscopy reduce colorectal cancer (CRC) incidence and mortality, and based on observational evidence of its effectiveness, colonoscopy is also frequently used as a screening modality.1 Opportunistic and organized CRC screenings are now available in many countries, presenting opportunities for knowledge exchange and data sharing that could improve the delivery of screening and further reduce CRC morbidity and mortality worldwide.

Colorectal Cancer Screening Outcomes of 2412 Prostate Cancer Patients Considered for Carbon Ion Radiotherapy.

Simple SummaryColorectal cancer (CRC) screening is effective for cancer detection in average-risk adults. For prostate cancer (PCa) patients considered for carbon ion radiotherapy (CIRT), pre-treatment CRC screening is performed empirically to avoid post-treatment colonoscopic manipulation. However, the outcomes of screening remain unclear. To address this, we analyzed the outcomes of 2412 PCa patients at average risk for CRC who underwent routine pre-CIRT CRC screening and found that the estimated CRC prevalence was greater than that reported by 17 previous large-scale screening studies analyzing average-risk adults. These data indicate the possibility that the prevalence of CRC in PCa patients is greater than that in general average-risk adults, warranting further research.Colorectal cancer (CRC) screening is effective for detecting cancer in average-risk adults. For prostate cancer (PCa) patients considered for carbon ion radiotherapy (CIRT), pre-treatment CRC screening is performed empirically to avoid post-treatment colonoscopic manipulation. However, the outcomes of screening this population remain unclear. Here, we compared the outcomes of routine pre-CIRT CRC screening of 2412 PCa patients at average risk for CRC with data from two published datasets: the Japan National Cancer Registry (JNCR) and a series of 17 large-scale screening studies analyzing average-risk adults. The estimated prevalence rate was calculated using the pooled sensitivity elucidated by a previous meta-analysis. Consequently, 28 patients (1.16%) were diagnosed with CRC. CRC morbidity was significantly associated with high pre-treatment levels of prostate-specific antigen (p = 0.023). The screening positivity rate in this study cohort exceeded the annual incidence reported in the JNCR for most age brackets. Furthermore, the estimated prevalence rate in this study cohort (1.46%) exceeded that reported in all 17 large-scale studies, making the result an outlier (p = 0.005). These data indicate the possibility that the prevalence of CRC in PCa patients is greater than that in general average-risk adults, warranting further research in a prospective setting.

Black and White Differences in Colorectal Cancer Screening and Screening Outcomes: A Narrative Review.

Racial disparities in colorectal cancer incidence are widely documented. There are two potential mechanisms for these disparities: differences in access to screening, including screening follow-up, and differences in underlying risk of colorectal cancer. We reviewed the literature for evidence of these two mechanisms. We show that higher colorectal cancer incidence in blacks relative to whites emerged only after the dissemination of screening and describe evidence of racial disparities in screening rates. In contrast to the strong evidence for differences in colorectal cancer screening utilization, there is limited evidence for racial differences in adenoma prevalence. In general, black and white patients who are screened have similar adenoma prevalence, though there is some evidence that advanced adenomas and adenomas in the proximal colon are somewhat more likely in black than white patients. We conclude that higher rates of colorectal cancer incidence among black patients are primarily driven by lower rates of colorectal cancer screening. Our findings highlight the need to increase black patients' access to quality screening to reduce colorectal cancer incidence and mortality.

Impact of screening and follow-up colonoscopy adenoma sensitivity on colorectal cancer screening outcomes in the CRC-AIM microsimulation model.

BackgroundReal‐world data for patients with positive colorectal cancer (CRC) screening stool‐tests demonstrate that adenoma detection rates are lower when endoscopists are blinded to the stool‐test results. This suggests adenoma sensitivity may be lower for screening colonoscopy than for follow‐up to a known positive stool‐based test. Previous CRC microsimulation models assume identical sensitivities between screening and follow‐up colonoscopies after positive stool‐tests. The Colorectal Cancer and Adenoma Incidence and Mortality Microsimulation Model (CRC‐AIM) was used to explore the impact on screening outcomes when assuming different adenoma sensitivity between screening and combined follow‐up/surveillance colonoscopies.MethodsModeled screening strategies included colonoscopy every 10 years, triennial multitarget stool DNA (mt‐sDNA), or annual fecal immunochemical test (FIT) from 50 to 75 years. Outcomes were reported per 1000 individuals without diagnosed CRC at age 40. Base‐case adenoma sensitivity values were identical for screening and follow‐up/surveillance colonoscopies. Ranges of adenoma sensitivity values for colonoscopy performance were developed using different slopes of odds ratio adjustments and were designated as small, medium, or large impact scenarios.ResultsAs the differences in adenoma sensitivity for screening versus follow‐up/surveillance colonoscopies became greater, life‐years gained (LYG) and reductions in CRC‐related incidence and mortality versus no screening increased for mt‐sDNA and FIT and decreased for screening colonoscopy. The LYG relative to screening colonoscopy reached >90% with FIT in the base‐case scenario and with mt‐sDNA in a “medium impact” scenario.ConclusionsAssuming identical adenoma sensitivities for screening and follow‐up/surveillance colonoscopies underestimate the potential benefits of stool‐based screening strategies.

Abstract PO-035: Factors associated with colorectal cancer screening in a peer-counseling intervention study in partnership with African American churches

Abstract Background: Colorectal cancer (CRC) mortality is 47% higher in African American men and 34% higher in African American women compared to non-Hispanic white men and women. Methods: Nine African American churches in Los Angeles (LA) participated in a one-group pre/post-test pilot study to promote cancer screening (2015-2018). Each church identified 5 Community Health Advisors (CHAs) who received training to recruit study participants ages 50 to 75; assess participants’ adherence to cancer screening guidelines of the U.S. Preventive Services Task Force; and provide one-on-one counseling for participants who were not adherent. Participants completed telephone surveys 3 months after the intervention. The goal of this analysis was to understand CRC screening outcomes among 163 African American participants who were baseline non-adherent to CRC screening guidelines. We fit bivariate and multivariate mixed effects logistic regression models to assess correlates of (1) discussion of CRC screening with provider and (2) receipt of CRC screening during follow-up. Results: 49% of respondents reported that they discussed CRC screening with a provider during the follow-up period and 28% of respondents reported receipt of CRC screening. Respondents who reported that they were counseled by a CHA were more than twice as likely to discuss CRC screening with their provider as those who reported that they did not receive the intervention (54% versus 24%, p&amp;lt;0.005). Those who had a regular doctor, who had more than 3 health care visits in the past 3 months and who had a routine check-up in the past 12 months were also significantly more likely to discuss CRC screening with a provider (all p&amp;lt;.001). Females were almost twice as likely as males to receive CRC screening during the follow-up period than males (35% versus 18%, p&amp;lt;.02) and South LA residents were significantly less likely to receive CRC screening than participants outside of South LA (22% versus 38%, p&amp;lt;.02). Those who had a routine check-up in the past 12 months were also significantly more likely to report receipt of CRC testing during the follow-up period (all p&amp;lt;0.01). Those who had discussed CRC screening with a provider were significantly more likely to obtain CRC screening (p&amp;lt;.001). Knowledge of CRC screening guidelines was low overall but significantly higher among those who received CRC screening than among their counterparts who did not receive screening (p&amp;lt;.02). In multivariable analyses, receipt of CHA counseling (OR 3.77) was significantly associated with discussing CRC screening with a provider during follow-up but not with CRC screening. Residence in South LA (OR 0.38) was significantly associated with lack of CRC screening. Conclusions: Findings confirm the important role of health care providers and suggest that residence in South LA constitutes an additional barrier to CRC screening. Further research and additional resources are needed to address disparities in the uptake of CRC screening among African Americans, especially in South LA. Citation Format: Annette E. Maxwell, Aziza Lucas-Wright, Cindy Chang, Rhonda Santifer, Catherine M. Crespi. Factors associated with colorectal cancer screening in a peer-counseling intervention study in partnership with African American churches [abstract]. In: Proceedings of the AACR Virtual Conference: Thirteenth AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2020 Oct 2-4. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2020;29(12 Suppl):Abstract nr PO-035.

Framework and Strategies to Eliminate Disparities in Colorectal Cancer Screening Outcomes

Preventable differences in colorectal cancer (CRC) mortality across racial/ethnic, economic, geographic, and other groups can be eliminated by assuring equitable access and quality across the care continuum, but few interventions have been demonstrated to do so. Multicomponent strategies designed with a health equity framework may be effective. A health equity framework takes into account social determinants of health, multilevel influences (policy, community, delivery, and individual levels), screening processes, and community engagement. Effective strategies for increasing screening uptake include patient navigation and other interventions for structural barriers, reminders and clinical decision support, and data to continuously track metrics and guide targets for improvement. Community resource gaps should be addressed to assure high-quality services irrespective of racial/ethnic and socioeconomic status. One model combinespopulation-based proactive outreach screening with screening delivery at in-person or virtual points of contact, as well as community engagement. Patient- and provider-based behavioral interventions may be considered for increasing screening demand and delivery. Providing a choice of screening tests is recommended for CRC screening, and access to colonoscopy is required for completion of the CRC screening process.

Do we know the effects of colorectal cancer screening? A short communication on selective uptake and differential effects of colorectal cancer screening in Scandinavia.

Colorectal cancer (CRC) contributes extensively to the overall cancer burden, with substantial and increasing social inequality in both incidence and survival. In several countries, this social inequality in incidence and survival has been increasing over time, and the increase is expected to continue. To overcome this, it is advised to implement nationwide CRC screening programmes, as these are effective in detecting possible signs of CRC, hence identifying earlier-stage cancer and reducing mortality. However, little is known about the distribution of these effects across population groups. It is possible that the outcomes of CRC screening are not equally distributed among participants, but rather that the screening programme serves some population groups better than others. The aim of this short communication based on published data is to describe the status of selective uptake according to sociodemographic and economic factors in CRC screening in Scandinavia. Furthermore, we raise questions that need to be addressed in future research in order to grasp the full effects of the screening programme and ultimately to ensure high uptake as well as participation in subsequent diagnostic procedures across population groups.

Abstract B103: Racial and geographic disparities in stage of presentation in the colorectal cancer hotspot region of North Carolina

Abstract Background: Despite improvements in colorectal cancer (CRC) screening, treatment, and long-term outcomes, recent epidemiological studies have demonstrated that geographic disparities in CRC persist. Spatial mapping has identified distinct hotspots of increased CRC death rates, including 11 rural counties in eastern North Carolina (NC). The primary aim of this study was to (1) measure CRC incidence by stage in the NC hotspot and non-hotspot regions, and (2) determine if racial disparities exist in stage-stratified incidence and overall mortality rates by geographic region. Methods: CRC diagnosis and death data from 2008-2016 were obtained from the NC Central Cancer Registry and analyzed by hotspot and non-hotspot regions by summary cancer stage at diagnosis and race. The non-hotspot region was defined as 71 NC counties outside of eastern NC. Death rates (95% CI) were expressed per 100,000 person-years and age-adjusted to the 2000 U.S. standard population. Regional rates were calculated for the 8-year interval. Results: Within the hotspot region in eastern NC, the overall incidence rate of CRC is higher than non-hotspot NC [43.7 (95% CI 39.2-48.8) vs 38.4 (95% CI 37.6-39.2)]. Within the hotspot counties, overall incidence rates are higher among African American (AA) compared to White patients [51.1 (95% CI 43.4-59.9) vs. 39.1 (95% CI 33.6-45.4)], and this disparity persists across all stage categories. The incidence among AA and White patients with localized disease is 18.4 and 14.4, respectively; for regional disease, 16.7 vs. 13.9; and for distant disease, 11.4 and 7.8. Similar racial disparities in CRC incidence are also observed within the non-hotspot counties (localized 16.1 vs. 13.5, regional 15.2 vs. 13.5, and distant 11.3 vs. 7.8). CRC mortality rates in the hotspot counties are higher among both AA and White patients (21.7 and 15.5, respectively) compared to non-hotspot NC (19.1 and 12.8, respectively), although the absolute difference by race is similar (6.2 vs. 6.3, respectively). Conclusions: Patients residing within the 11 rural hotspot counties in NC have higher age-adjusted incidence of localized, regional, and distant CRC and higher mortality rates than patients in non-hotspot counties. Noteworthy racial disparities exist in both stage at presentation and mortality rates; however, absolute racial disparities appear similar in both geographic regions. Future work should investigate the underlying etiology for both increased CRC incidence and mortality among AA and White patients in the NC hotspot counties. Citation Format: Tyler Hinshaw, Suzanne Lea, Justin Arcury, Alexander A Parikh, Rebecca A Snyder. Racial and geographic disparities in stage of presentation in the colorectal cancer hotspot region of North Carolina [abstract]. In: Proceedings of the Twelfth AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2019 Sep 20-23; San Francisco, CA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2020;29(6 Suppl_2):Abstract nr B103.