Participation In Colorectal Cancer Screening Research Articles

Cross-sectional adherence with the multi-target stool DNA test for colorectal cancer screening in a medicaid population

Colorectal cancer (CRC) is the third leading cause of cancer death in the US. Early detection improves CRC outcomes and multiple options are endorsed for CRC screening; however, adherence remains challenging. Among Medicaid enrollees, the fecal immunochemical test (FIT) is often used for average-risk CRC screening, with suboptimal adherence rates reported (12.3–23.2 %). The navigation-supported (personalized outreach by phone, mail, email and text), at home collection, multi-target stool DNA (mt-sDNA) test represents a relatively recent and broadly accessible option for average-risk CRC screening in Medicaid enrollees. We assessed cross-sectional mt-sDNA adherence in a national sample of Medicaid patients. Data from Exact Sciences Laboratories LLC (ESL; Madison, WI) were retrospectively analyzed. Participants included individuals 45 + years covered by Fee-For-Service (FFS)- or Managed-Medicaid. Primary analysis focused on the 50–74 age cohort and included those with valid mt-sDNA orders between January 1–December 31, 2018. Data from 25,794 individuals who received valid orders for mt-sDNA were included in analysis (61.2 % women; mean age at order 57.5 years). Overall adherence – completion of an ordered test – was 51.3 %. Adherence was 54.6 % in Managed-Medicaid and 38.9 % in FFS-Medicaid. Adherence by age was: 51.5 % for 50–64 years and 47.7 % for 65–74 years. Mt-sDNA tests ordered by gastroenterologists had higher adherence (60.5 %) compared with primary care clinicians (51.3 %). These data from a large, national sample of Medicaid-insured patients substantiate mt-sDNA testing as a viable patient-supported, home-based option to improve average-risk CRC screening participation in Medicaid enrollees.

Type and Severity of Mental Illness and Participation in Colorectal Cancer Screening

The effectiveness of colorectal cancer screening programs depends on the participation rate. This study examined the association between type and severity of mental illness and colorectal cancer screening participation. Between 2012 and 2017, a total of 46,919 individuals were invited to sigmoidoscopy screening in Norway, and 70,019 were invited to fecal immunochemical testing. In 2022, logistic regression was used to evaluate the association between the use of antipsychotics, anxiolytics, hypnotics, and antidepressants in the year preceding the screening invitation and screening participation, adjusted for demographic and socioeconomic factors. Defined daily doses of individual drugs were used to assess dose‒response relationships. Overall, 19.2% (24.8% of women, 13.4% of men) of all invitees used at least 1 psychotropic medication. Nonparticipation in the 2 arms combined was associated with the use of anxiolytics (60.7% in users vs 43.2% in nonusers; OR=1.53; 95% CI=1.45, 1.62) and antipsychotics (64.3% vs 43.8%; OR=1.41; 95% CI=1.30, 1.53) and increased with higher doses for both drugs. Hypnotics and antidepressants were only weakly associated with nonparticipation in higher doses. Participation rates were 57.3%, 52.3%, 42.9%, and 35.4% in those prescribed 0, 1, 2, and 3-4 classes of psychotropic medications, respectively. The associations between the use of psychotropic medications and nonparticipation were similar for the 2 screening tests. These findings show significant disparities in colorectal cancer screening participation for individuals with mental illness, independent of the screening method. Moreover, screening participation varied depending on the type and severity of mental illness. Targeted interventions are warranted to ensure that people with mental illness are supported to access the benefits of colorectal cancer screening.

Addressing social determinants of health for colorectal cancer in the African American population: STAT (Screen, Trust, Access, Treat) phase I study.

143 Background: Colorectal cancer (CRC) is the third most common cancer and third leading cause of cancer deaths among African Americans, who have the highest CRC rates compared to other racial/ethnic groups, in the United States. STAT (Screen, Trust, Access, Treat) is a three-phase study assessing attitudes and perceptions related to disparities in CRC screening, treatment and clinical trial participation in the African American population. STAT Phase I surveyed attitudes/perceptions among health care providers (HCPs) and Phase II is ongoing to survey African American patients with CRC; in Phase III, data collected from Phases I/II will be used to design and test multiple interventions to reduce CRC disparities among African Americans. Here we present findings from STAT Phase I. Methods: Using non-probability and convenience sampling methodology, a survey link was exposed to over 3,000 HCPs through partnering non-profit health care organizations. The 20-item survey evaluated practitioner views on strategies for overcoming social determinants of health (SDOH), improving CRC outcomes among African Americans, and barriers/motivators for clinical trial enrolment. Results: Respondents (n = 109) comprised oncologists (53%), primary care providers (29%), gastroenterologists (2%), and representatives from other specialties (16%). They were predominantly White/Caucasian (65%); 22% were Asian/Asian American, 11% were African American/Black, and 6% were Hispanic/Latino. To overcome SDOH disparities, most HCPs used translation/interpreter services (83%), offered patients information in multiple languages (76%), and asked them to repeat back care instructions (73%); however, fewer offered provisions such as SDOH assessments (50%), access to financial assistance (66%), and transportation services (45%). Most HCPs agreed or strongly agreed they were prepared to care for patients from cultures differing from their own (91%), with health beliefs conflicting with Western medicine (71%), and with limited health literacy (83%). Increased community-based education (85%), community access to stool-based cancer screening tests (71%), and improved access to primary care physicians (69%) were viewed by HCPs as the favoured approaches to improve CRC outcomes among African Americans. Lack of awareness (43%) was reported as the predominant barrier to clinical trial enrolment, and HCPs agreed or strongly agreed that a patient eligibility screening system (86%) or clinical trial alert system (73%) would be a motivator to engage in clinical trials. Conclusions: Results from STAT Phase I reveal opportunities for HCPs to overcome inequities due to SDOH. Together with ongoing/planned research in STAT Phases II and III, these findings could inform strategies to reduce existing disparities in CRC care and improve outcomes for the African American population.

S255 Assessing the Impact of a Multi-Component Health System Intervention to Address Low Colorectal Cancer Screening Participation in Patients With a Family History of Colorectal Cancer

Introduction: In the United States, 3-10% of individuals have a family history of colorectal cancer (CRC). Population health strategies to increase CRC screening often exclude these individuals, and interventions to increase screening participation in this high-risk group are rare. We designed and implemented a multi-component health system intervention to increase CRC screening uptake among individuals with a family history of CRC that were excluded from mailed fecal immunochemical test (FIT) outreach in our health system. Methods: The study was performed in a large academic medical center with biannual mailed FIT outreach for individuals at average-risk for CRC. We included patients who did not receive mailed FIT outreach in 2021 due to a family history of CRC. We excluded patients with a personal history of inflammatory bowel disease, colectomy, or CRC. The intervention included both primary care provider (PCP) and patient components. The PCP component was sent via the electronic health record (EHR) and included CRC screening guidelines for patients with a family history of CRC and a pended colonoscopy order for each patient overdue for screening. The patient component was delivered via the EHR patient portal and a mailed letter and included education about familial risk and colonoscopy, and a prompt to schedule a colonoscopy. Preliminary outcomes were measured 2-months post-intervention and were whether: (1) the PCP signed the pended colonoscopy order and (2) the patient scheduled colonoscopy. We used descriptive statistics to describe the study cohort and paired t-tests to compare the study outcomes pre- and post-intervention. The primary outcome of colonoscopy completion will be measured 6 months post-intervention. Results: 152 patients received the intervention. The mean age was 61.3 years (s.d 7.0), 32.9% were male, and 42.1% were non-Hispanic White (Table). Colonoscopy orders increased from 32 (21.1%) to 92 (60.5%) from pre- to post-intervention (p< 0.0001) (Figure). Colonoscopies scheduled increased from 0 to 9 (5.9%) (p=0.002). Conclusion: We designed and evaluated the preliminary results of a health system intervention that aims to increase screening participation among individuals with a family history of CRC. There was a significant increase in both colonoscopies ordered and colonoscopies scheduled. This study demonstrates a successful population health strategy to increase provider and patient intention to screen in this high-risk population.Figure 1.: Screening colonoscopies ordered and screening colonoscopies scheduled pre- intervention versus post- intervention, n= 152 Table 1. - Intervention population characteristics, n= 152 Patient Characteristic Study Population (n=152) Age [years, mean (SD)] 61.3 (7.0) Male Sex [n (%)] 50 (32.9) White Race [n (%)] 72 (47.4) Non-Hispanic Ethnicity [n (%)] 116 (76.3) Private Insurance [n (%)] 149 (98.0) Married [n (%)] 83 (54.6) English Language Preference [n (%)] 147 (96.7) Social Vulnerability Index [median (IQR)] 25.9 (11.8-47.8) Current or Former Tobacco Use Disorder [n (%)] 38 (25.0) Current or Former Alcohol Use Disorder [n (%)] 13 (8.6) Body Mass Index ≥ 25 [n (%)] 100 (66.2) Hemoglobin A1c ≥ 5.7 [n (%)] 75 (52.8) Family Members with Documented CRC [median (IQR)] 1 (1-1) 1st Degree Family Members with Documented CRC [median (IQR)] 1 (1-1) Years since Last PCP Visit [median (IQR)] 1.01 (0.75-1.62) Years since Last GI Visit [median (IQR)] 2.3 (2.5-9.2) Breast Cancer Screening Up-To-Date [n (%)] 47 (47) Cervical Cancer Screening Up-To-Date [n (%)] 61 (83.6)

Concurrent participation in breast, cervical, and colorectal cancer screening in the Netherlands

BackgroundMany European countries offer organised population-based breast, cervical, and colorectal cancer screening programmes. Around age 55 and 60, Dutch women are invited to all three screening programmes. We examined the extent to which participation concurs and identified factors influencing concurrent participation. Materials and methodsIndividual level data from breast, cervical, and colorectal cancer screening invitations between 2017 and 2019 were extracted from the Dutch screening registry. The percentages of women participating in all three, two, one, or none of the programmes around age 55 and 60, and before subsequent round invitation were determined. Multivariate ordinal regression analyses were performed to estimate whether population density, socio-economic status (SES) per postal code area, and time between the three invitations (<3, 3–6, >6 months) were associated with concurrent participation. ResultsData from 332,484 women were analysed. At age 55, 53.7% participated in all three programmes, 22.1% in two, 11.7% in one, and 12.6% did not participate at all. At age 60, a similar participation pattern was observed. Women living in areas with higher population density were less likely (odds ratios 0.75–0.94) and women in higher SES groups were more likely (odds ratios 1.12–1.60) to participate in more screening programmes, although this positive association was smaller for the highest SES group. No substantial association was found between concurrent participation and timing of invitations. ConclusionsMore than half of Dutch women participated in all three screening programmes and around 12% did not participate in any. Concurrent participation was lower in cities and lower SES groups.

Three birds with one stone: a protocol for a randomised intervention study to increase participation in cervical and colorectal cancer screening among women attending breast cancer screening

IntroductionThe participation rate is higher in breast cancer screening than in cervical cancer (CCU) and colorectal cancer (CRC) screening. In this cluster-randomised study, we aim to evaluate an intervention offering...

The impact of pre-notifications and reminders on participation in colorectal cancer screening – A randomised controlled trial

This study aimed to test whether participation in colorectal cancer (CRC) screening can be increased by combining the standard invitation procedure with a pre-notification and/or an extra reminder.In a non-blinded randomised controlled trial nested in a population-based CRC screening programme employing the faecal immunochemical test, Group I received a three-staged invitation procedure (pre-notification, invitation and one reminder), Group II received a three-staged invitation procedure (invitation and two reminders) and Group III received a four-staged invitation procedure (pre-notification, invitation and two reminders). The control group received the invitation and one reminder (usual procedure).A total of 59,041 participants were included in the analyses. Overall participation rates increased from 66.9% in the control group to 69.8% in the four-staged invitation procedure corresponding to an increase in overall participation rate of 2.9% (95% CI: 1.8 to 4.0). In the age group 50–59 years, the four-staged invitation procedure increased the participation rate by 4.0% (95% CI: 2.4 to 5.6). An extra reminder increased participation with 2.7% (95% CI: 1.1; 4.2) for males compared to 1.1% (95% CI: −0.3; 2.5) for females.In conclusion, the four-staged invitation procedure was the most effective invitation procedure indicating that multiple invitation procedures are most effective, especially in the youngest age group. If a three-staged invitation procedure is applied, a second reminder should be preferred over a pre-notification.Trial registrationThe project was registered at ClinicalTrials.gov on 26 February 2020 and patient enrolment began in August 2020.ClinicalTrials.gov Identifier: NCT04292366.

The impact of driving time on participation in colorectal cancer screening with sigmoidoscopy and faecal immunochemical blood test

BackgroundHigh participation rates are important for a colorectal cancer (CRC) screening programme to be effective. Having a long travelling distance to screening centres may impede participation. MethodsWe analysed the association between driving time from home address to screening centre and participation among individuals invited to screening with faecal immunochemical test (FIT) (n = 68,624) or sigmoidoscopy (n = 46,076) in a randomized trial in Norway in 2012–17. Two screening centres were involved. We fitted multiple logistic regression models, adjusted for demographic, socioeconomic and health characteristics, and reported odds ratios (OR) with 95% confidence intervals (CI). ResultsParticipation rates were 58.9 % (n = 40,445) for FIT and 51.9 % (n = 23,911) for sigmoidoscopy. In sigmoidoscopy, participation was 56.9 % and 47.9 % in those living < 20 and > 60 min by car from the screening centres, respectively. For each 10 min driving time increase, OR for participating in sigmoidoscopy screening was 0.93 (95 % CI 0.91–0.95). There was a significant difference between the two screening centres (p-value for heterogeneity <0.001). Participation in FIT screening were 61.2 % and 57.1 % in those with < 20 and > 60 min driving time, respectively, and the OR was 0.98 (95 % CI 0.96–0.99) for each 10 min increase (heterogeneity between screening methods, P-value <0.001). Among those with a positive FIT, compliance to colonoscopy was higher in those living < 20 compared to > 60 min from the centres (95.1 % vs. 92.9 %, respectively, OR 0.86; 95 % CI 0.77–0.93 for each 10 min increase). ConclusionsDriving time to screening centre was a significant predictor of participation, mainly in sigmoidoscopy. There were local differences in the impact of driving time on participation. Driving time also affected compliance to colonoscopy after a positive FIT. When planning a CRC screening programme, one should consider offering people living far from screening sites special assistance to facilitate their participation.

Coronavirus Disease 2019 Pandemic–related Colorectal Cancer Screening Delays Impact Unscreened Older Adults the Most, But Mitigation Strategies Exist

Colorectal cancer (CRC) screening between ages 50 and 75 years is a US Preventive Services Task Force Grade A recommendation.1 The coronavirus disease 2019 (COVID-19) pandemic initially decreased CRC screening participation by as much as 82%,2 and new variants continue to disrupt preventive care. Screening colonoscopy is more vulnerable to pandemic-related delays than the fecal immunochemical test (FIT).2 We estimated the potential clinical impact of pandemic-related interruptions in CRC screening on the US population.

A Randomized Controlled Trial to Increase Cancer Screening and Reduce Depression Among Low-Income Women.

Low-income women of color receive fewer cancer screenings and have higher rates of depression, which can interfere with cancer screening participation. This study assessed the comparative effectiveness of two interventions for improving colorectal, breast, and cervical cancer screening participation and reducing depression among underserved women in Bronx, NY, with depression. This comparative effectiveness randomized controlled trial (RCT) with assessments at study entry, 6, and 12 months utilized an intent-to-treat statistical approach. Eligible women were aged 50 to 64, screened positive for depression, and were overdue for ≥ 1 cancer screening (colorectal, breast, and/or cervical). Participants were randomized to a collaborative depression care plus cancer screening intervention (CCI + PCM) or cancer screening intervention alone (PCM). Interventions were telephone-based, available in English or Spanish, delivered over 12 months, and facilitated by a skilled care manager. Cancer screening data were extracted from electronic health records. Depression was measured with a validated self-report instrument (PHQ-9). Seven hundred fifty seven women consented and were randomized (CCI + PCM, n = 378; PCM, n = 379). Analyses revealed statistically significant increases in up-to-date status for all three cancer screenings; depression improved in both intervention groups. There were no statistically significant differences between the interventions in improving cancer screening rates or reducing depression. CCI and PCM both improved breast, cervical, and colorectal cancer screening and depression in clinical settings in underserved communities; however, neither intervention showed an advantage in outcomes. Decisions about which approach to implement may depend on the nature of the practice and alignment of the interventions with other ongoing priorities and resources.

Participation in Colorectal Cancer Screening among Migrants and Non-Migrants in Germany: Results of a Population Survey

Colorectal cancer screening can contribute to reducing colorectal cancer incidence and mortality. Findings on disparities in the utilization of colorectal cancer screening between migrants and non-migrants have been inconsistent, with some studies reporting lower, and some higher utilization among migrants. The aim of the present study was to examine potential disparities in fecal occult blood testing and colonoscopy among migrants in Germany. Data from a population survey on 11,757 men and women aged ≥50 years is used. Using multivariable logistic regression, the utilization of fecal occult blood testing and colonoscopy was compared between non-migrants, migrants from EU countries and migrants from non-EU countries, adjusting for socio-economic factors and also taking into account intersectional differences by sex and age. The study shows that migrants from the EU (adjusted OR = 0.73; 95%-CI: 0.57, 0.94) and from non-EU countries (adjusted OR = 0.39; 95%-CI: 0.31, 0.50) were less likely to utilize fecal occult blood testing than non-migrants. No disparities for the use of colonoscopy were observed. The findings are in line with studies from other countries and can be indicative of different barriers migrants encounter in the health system. Adequate strategies taking into account the diversity of migrants are needed to support informed decision-making among this population group.

No Increase in Colorectal Cancer Screening in 2019 After American Cancer Society Recommends Starting Screening at Age 45

In May 2018, the American Cancer Society (ACS) updated guidelines to recommend colorectal cancer (CRC) screening at age 45 years for persons at average risk. 1 Wolf A.M.D. et al. CA Cancer J Clin. 2018; 68: 250-281 Crossref PubMed Scopus (780) Google Scholar Fedewa et al 2 Fedewa S.A. et al. Cancer. 2020; 126: 1351-1353 Crossref PubMed Scopus (17) Google Scholar reported that CRC screening participation among adults aged 45–49 years increased from 4.8% in early 2018 to 11.7% in late 2018, coincident with updated ACS guidelines. It is unknown whether this initial increase persisted as guidelines were implemented. To address this gap, we examined trends in CRC screening participation through 2019 in a nationally representative sample.

Patients’ acceptability and implementation outcomes of a case management approach to encourage participation in colorectal cancer screening for people with schizophrenia: a qualitative secondary analysis of a mixed-method randomised clinical trial

ObjectivesWe examined the efficacy of case management (CM) interventions to encourage participation in colorectal cancer screening for patients with schizophrenia. This study aimed to clarify patients’ acceptability of the intervention...

AI Diagnostic Technologies and the Gap in Colorectal Cancer Screening Participation.

AI augmented clinical diagnostic tools are the latest research focus in colorectal cancer (CRC) detection. While the opportunity presented by AI-enhanced CRC diagnosis is sound, this paper highlights how its effectiveness with respect to reducing CRC-related mortality and enhancing patient outcomes may be limited by the fact that patient participation remains extremely low globally. This paper builds a foundation to consider how human factors tend to contribute to low participation rates and suggests that a more nuanced socio-technical approach to the development, implementation and evaluation of AI systems that is sensitive to the psycho-social and cultural dimension of CRC may lead to tools that increase screening uptake.

Perceived barriers and benefits in the participation in faecal occult blood test colorectal cancer screening programme

BackgroundColorectal cancer is the second cancer-related cause of death in the world. Tumour stage at diagnosis is the principal prognosis factor of survival. However, the participation in the programme is around 50%. The aim of the study was to identify the benefits and barriers perceived by the population when participating in a colorectal cancer screening programme with faecal occult blood test. MethodsWe carried out a cases–controls study with 408 participants. We analyzed epidemiological and social variables associated with lifestyle and behavioural factors based in the Health Belief Model. We conducted a descriptive analysis, and identified variables associated to adherence by a logistic regression. ResultsVariables independently associated with the participation in a colorectal cancer screening programme were age (OR 1.06; 95% CI: 1.01–1.11), having a stable partner (OR 1.96; 95% CI: 1.20–3.18), the level of education (OR 1.59; 95% CI: 1.02–2.47) and two of the barriers to participate in the faecal occult blood test screening: “you don’t know how to do one” (OR=0.46; 95% CI: 0.23–0.93) and “it is not that important right now” (OR=0.43; 95% CI: 0.24–0.78). ConclusionThe existing barriers for screening with faecal occult blood test are the best factor predicting. This is relevant when designing the intervention programmes, as they should focus on reducing perceived barriers to increase the participation in colorectal cancer screening, thereby reducing colorectal cancer mortality.

Colorectal cancer screening participation among citizens not recommended to be screened: a cohort study

BackgroundGuidelines on colorectal cancer (CRC) screening recommend screening of average-risk adults only. In addition, screening of individuals with active inflammatory bowel disease (IBD) might result in too many false-positive cases. However, the organisers of CRC screening programmes are often uninformed of whom to exclude due to an elevated CRC risk or active IBD. It is therefore unknown how often high-risk individuals (i.e. individuals with a previous diagnosis of CRC or polyps associated with hereditary CRC syndromes and certain patient groups with a diagnosis of inflammatory bowel disease (IBD) or multiple polyps) and individuals with active IBD participate in CRC screening following invitation.Materials and methodsWe used data from the first two years of the Danish CRC screening programme (2014–2015). Information on invitations, participations and FIT test results were obtained from the national screening database, while information on previous CRC, hereditary CRC syndromes, IBD or multiple polyps diagnoses were obtained from the Danish Cancer Registry and the Danish Patient Register. Screening participation rates and FIT-positive rates were calculated and compared for high-risk invitees, invitees having IBD and an average risk group of remaining invitees not diagnosed with colorectal polyps in 10 years preceding the invitation.ResultsWhen invited to CRC screening, 28–48% of high-risk residents (N: 29; 316; 5584) and 55% of residents with IBD (N: 2217; 6927) chose to participate. The participation rate was significantly higher (67%) among residents without previous colorectal disease, i.e. the average risk group (N = 585,624). In this average group 6.7% of the participants had a positive FIT test. The proportion of positive FIT results was higher among all disease groups (7.7–14.8%), though not statistically significant for participants with prior CRC diagnosis and participants with high-risk IBD.ConclusionWhen high-risk residents and residents with IBD receive an invitation to CRC screening, many participate despite being recommended not to. The screening program was not intended for these groups and further research is needed as several of these groups have a higher rate of positive screening result than the average risk population.

Characteristics of nonparticipants in a randomised colorectal cancer screening trial comparing sigmoidoscopy and faecal immunochemical testing.

Public health systems should guarantee universal access to health care services, including cancer screening. We assessed whether certain population subgroups were underrepresented among participants in colorectal cancer screening with sigmoidoscopy and faecal immunochemical testing (FIT). Between 2012 and 2019, about 140 000 individuals aged 50 to 74 years were randomly invited to once‐only sigmoidoscopy or first round of FIT screening. Our study included 46 919 individuals invited to sigmoidoscopy and 70 019 to FIT between 2012 and 2017. We used logistic regression models to evaluate if demographic and socioeconomic factors and use of certain drugs were associated with participation. Twenty‐four thousand one hundred and fifty‐nine (51.5%) individuals attended sigmoidoscopy and 40 931 (58.5%) FIT screening. Male gender, young age, low education and income, being retired or unemployed, living alone, being an immigrant, long driving time to screening centre, and use of antidiabetic and psychotropic drugs were associated with low participation in both screening groups. Many of these factors also predicted low acceptance of colonoscopy after positive FIT. While male gender, young age and living alone were more strongly associated with nonparticipation in FIT than sigmoidoscopy, low education and income, being retired or immigrant and long driving time were more strongly associated with nonparticipation in sigmoidoscopy than FIT. In conclusion, participation was lower in sigmoidoscopy than FIT. Predictors of nonparticipation were similar between arms. However, low socioeconomic status, being an immigrant and long driving time affected participation more in sigmoidoscopy screening, suggesting that FIT may guarantee more equal access to screening services than sigmoidoscopy.

Mailed fecal testing and patient navigation versus usual care to improve rates of colorectal cancer screening and follow-up colonoscopy in rural Medicaid enrollees: a cluster-randomized controlled trial

BackgroundScreening reduces incidence and mortality from colorectal cancer (CRC), yet US screening rates are low, particularly among Medicaid enrollees in rural communities. We describe a two-phase project, SMARTER CRC, designed to achieve the National Cancer Institute Cancer MoonshotSM objectives by reducing the burden of CRC on the US population. Specifically, SMARTER CRC aims to test the implementation, effectiveness, and maintenance of a mailed fecal test and patient navigation program to improve rates of CRC screening, follow-up colonoscopy, and referral to care in clinics serving rural Medicaid enrollees.MethodsPhase I activities in SMARTER CRC include a two-arm cluster-randomized controlled trial of a mailed fecal test and patient navigation program involving three Medicaid health plans and 30 rural primary care practices in Oregon and Idaho; the implementation of the program is supported by training and practice facilitation. Participating clinic units were randomized 1:1 into the intervention or usual care. The intervention combines (1) mailed fecal testing outreach supported by clinics, health plans, and vendors and (2) patient navigation for colonoscopy following an abnormal fecal test result. We will evaluate the effectiveness, implementation, and maintenance of the intervention and track adaptations to the intervention and to implementation strategies, using quantitative and qualitative methods. Our primary effectiveness outcome is receipt of any CRC screening within 6 months of enrollee identification. Our primary implementation outcome is health plan- and clinic-level rates of program delivery, by component (mailed FIT and patient navigation). Trial results will inform phase II activities to scale up the program through partnerships with health plans, primary care clinics, and regional and national organizations that serve rural primary care clinics; scale-up will include webinars, train-the-trainer workshops, and collaborative learning activities.DiscussionThis study will test the implementation, effectiveness, and scale-up of a multi-component mailed fecal testing and patient navigation program to improve CRC screening rates in rural Medicaid enrollees. Our findings may inform approaches for adapting and scaling evidence-based approaches to promote CRC screening participation in underserved populations and settings.Trial registrationRegistered at clinicaltrial.gov (NCT04890054) and at the NCI’s Clinical Trials Reporting Program (CTRP #: NCI-2021-01032) on May 11, 2021.

Cancer Prevention in a Postpandemic World: A One-Stop-Shop Approach

Cancer Prevention in a Postpandemic World: A One-Stop-Shop Approach

Urban density differences in colorectal cancer screening participation and screening yield in The Netherlands

Lower socioeconomic status has been associated with higher colorectal cancer incidence and lower participation in population-based screening with faecal immunochemical testing (FIT) but regional variations in participation may also exist. We analysed differences in participation and yield in colorectal cancer screening by urban density level.Data of all invitees to the Dutch colorectal cancer screening programme in 2014–2015 were included. Primary outcomes were participation (returning FIT), FIT positive predictive value, and screening yield (advanced neoplasia detected in invitees). Differences were explored across five levels of urban density.In total 1,873,639 screening invitees were included. FIT participation was 77.3% in the lowest versus 62.8% in the highest urban areas (RR 1.23; 95%CI 1.23–1.24). FIT positive predictive value was 58.6% in the lowest versus 55.2% in the highest urban areas (RR 1.06; 95% CI 1.04–1.09). Screening yield was also higher in the lowest (2.1%-2.3%) compared to the highest urban areas (1.8%). Compared to socioeconomic status, differences in urban density were associated with larger differences in screening participation.In conclusion, participation is lower and fewer cases of advanced neoplasia are detected in areas with a high urban density in the Dutch colorectal cancer screening programme. Differences in urban density could be used in tailoring regional strategies to target barriers in colorectal cancer screening.