Population-based Colorectal Cancer Screening Research Articles

Perspectives of international experts and the Danish citizens on the ‘relevant knowledge’ that citizens need for making informed choices about participation in cancer screening: Qualitative study

ObjectivesThis study aimed to investigate the perspectives of international experts and Danish citizens on relevant knowledge about population-based breast, colorectal and cervical cancer screening. MethodsThis was a qualitative interview study with focus group interviews with experts and Danish citizens eligible for breast, colorectal and/or cervical cancer screening. Data were collected using semi-structured interview guides, audio-recorded and transcribed verbatim. A thematic analysis was conducted. ResultsParticipants were nine international experts from Germany, Canada, the USA, Sweden, the Netherlands and Australia, and 54 citizens from Denmark. Most citizens had 'adequate' or 'problematic' levels of health literacy. Themes that experts and citizens agreed on were: knowledge about the disease and symptoms, practical information about screening, benefits of screening, the option of non-participation and the importance of having numeric information of possible screening outcomes. Experts agreed on the importance of knowledge about the harms of screening, but only a minority of citizens considered this important. ConclusionsThe experts and citizens disagreed on the relevance of knowledge about harms of screening and agreed on other relevant knowledge. Practice implicationsWhat experts and citizens find important may not align when making informed decisions. Therefore, experts and citizens needs to be involved when developing questionnaires.

Effectiveness of colorectal cancer screening strategies: a review of current scientific evidence

Colorectal cancer is one of the most common malignancies in the world. Its incidence and mortality could be reduce through primary prevention activities, which include healthy lifestyle behavior and avoidance of risk factors, and through screening (secondary prevention). Understanding the strengths and weaknesses of different colorectal cancer screening strategies is within the scope of interest of different health professionals. Therefore, the aim of this review is to synthesis the current scientific evidence that addresses the issues of effectiveness of population-based colorectal cancer screening programs and new methods for its early diagnosis.

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 to 2.94; V3: RR, 1.56; 95% CI, 1.15 to 2.13; V4: RR, 1.18; 95% CI, 0.83 to 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 CRC, this issue should be addressed by monitoring endoscopist volumes and variations in performances.

Participation and Yield in Multiple Rounds of Colorectal Cancer Screening Based on Fecal Immunochemical Test: A Systematic Review and Meta-Analysis.

The evidence on the cumulative participation and yield in multiple rounds of colorectal cancer (CRC) screening based on fecal immunochemical test is sparse. We aimed to assess the trends in participation and detection for advanced colorectal neoplasm under different screening intervals in multiround fecal immunochemical testing-based CRC screening by synthesizing the current available evidence. PubMed, Embase, and Cochrane were retrieved from January 1, 2002, to April 16, 2024, for potential eligible studies, and then, we synthesized participation and advanced colorectal neoplasm detection rates for each screening round, along with their respective 95% confidence intervals (CIs). Nineteen studies involving a total of 2,296,071 individuals were included. As screening rounds increased, participation exhibited a gradual consistent increase, reaching 78.45% and 74.97% for annual and biennial screening strategies. For annual screening, the cumulative detection rates for 3 rounds were 1.38% (95% CI: 1.18%-1.63%), 1.95% (95% CI: 1.72%-2.21%), and 2.50% (95% CI: 2.29%-2.72%), respectively. For biennial screening, the cumulative detection rates for 4 rounds were 2.22% (95% CI: 1.22%-3.22%), 3.44% (95% CI: 2.06%-4.82%), 4.26% (95% CI: 2.70%-5.83%), and 5.10% (95% CI: 3.28%-7.29%), respectively. Notably, the per-round detection rate of advanced colorectal neoplasms declined yet as the screening progressed. In population-based CRC screening programs, the participation exhibited a slow upward trend for both screening strategies, but the incremental benefits in CRC detection gradually diminished. Tailored strategies, such as extending intervals for individuals with multiple negative fecal immunochemical testing results, might optimize effectiveness and cost-efficiency in population-based CRC screening.

A Stool DNA-Based SDC2 Methylation Test for the Early Detection of Colorectal Cancer in an Asymptomatic, High-Risk Population: A Multicenter Prospective Randomized Trial.

Noninvasive stool DNA-based methylation testing has emerged as an effective strategy for the early colorectal cancer (CRC) detection. Syndecan-2 (SDC2) methylation frequently occurs in all stages of CRC; therefore, the aim of this study was to evaluate the clinical performance of a stool DNA-based SDC2 methylation test for detecting CRC in asymptomatic or high-risk CRC populations. This multicenter prospective study was conducted to determine the clinical performance of the SDC2 methylation test on stool DNA using real-time polymerase chain reaction. Stool samples were collected from asymptomatic individuals before colonoscopy, and the test results were independently analyzed through comparison with colonoscopic findings and pathological outcomes as reference standards. Of the 1,124 evaluable participants, 20 had CRC, 73 had advanced adenomatous polyps (≥1.0 cm), 469 had nonadvanced adenomatous polyps (<1.0 cm), 178 had non-neoplastic polyps, and 384 had negative colonoscopy results. The stool SDC2 methylation test had a sensitivity and specificity of 95.0% and 81.5%, respectively, for detecting CRC, while the sensitivity for detecting advanced adenomatous polyps and CRC was 58.1%. The rate of adenoma detection increased with polyp size (P < 0.01), and sensitivity was not associated with CRC stage (P = 0.864). The stool DNA-based SDC2 methylation test attained a high sensitivity for CRC detection in an asymptomatic high-risk population. Further large-scale clinical studies are required to validate the clinical utility of this test as a population-based CRC screening tool.

The challenge of colorectal cancer (CRC) screening in low and middle-income countries (LMIC): Acceptance, knowledge, and preferences in Brazil.

153 Background: Presenting an increasing incidence and high mortality rates, CRC is a challenge that many LMIC face and struggle to establish an effective screening strategy. Brazil is one of the few Latin American countries and LMIC that have a population-based CRC screening program, targeting ages 50-74 and performing a fecal occult blood test (FT) every 2 years and colonoscopy/sigmoidoscopy as a confirmatory test. Methods: We conducted a survey in patients visiting the primary care unit in the months of January and March 2024 in three distinct settings (Rural, Suburban, and Urban) aiming to estimate acceptance, knowledge, and preferences regarding FT and colonoscopy. Patients aged 50-74 were invited to join this study, excluding those with a history of CRC, and we used the integrated digital charting platform to set demographic variables. At the end of the survey, participants were invited to undergo CRC screening. Those who refuse to screen would select the main reason. Results: A total of 1,031 individuals responded the survey, which 52% were females and the median age was 62 years. A total of 763 (74%) accepted to undergo CRC screening with an overall preference for FT (72%) compared to colonoscopy (53,5%). FT acceptance remained somewhat constant in both gender subgroups (70-75%), and a lower colonoscopy acceptance in the male subgroup (46%). In the subdivided geographic setting groups, the rural population (12%) had the lowest knowledge score and the lowest overall acceptance rate (65%), ranking “No symptoms” as the main reason for not screening. The suburban and urban subgroups showed an equivalent overall acceptance rate (74-75%), ranking “Busy schedule” and “Healthy lifestyle” as the main reasons for not screening. Conclusions: Data suggests that an effective CRC screening depends on multiple factors. While literature sustains the weight of cost and long waiting times, this study contributes adding a new, more granular perspective. Efforts in patient education, and clarification of misconceptions and anxieties could prove to be an important step in the right direction. A closer contact between patient and healthcare provider could make the difference between screening or not. A leave of absence or mailed FT might be of great benefit for those with a busy schedule, while interaction with CRC survivors seems to drastically increase colonoscopy acceptance, an important intervention that should be encouraged and widespread. Although this study has its limitations due to sample size and geographic characteristics, it lays down a new layer in understanding the individuals and planning actions to prevent the advance of CRC in LMIC.

Improving Colorectal Cancer Screening via Mailed Fecal Immunochemical Testing in a Veterans Affairs Health System.

Colorectal cancer screening rates at the Veterans Affairs Connecticut Healthcare System (VACHS) decreased during the COVID-19 pandemic. Fecal immunochemical testing is recognized as a tier 1 preferred screening method by the US Multi-Society Task Force on Colorectal Cancer. The VACHS implemented a program that mailed fecal immunochemical testing kits to patients to improve colorectal cancer screening rates. This article describes the components of the VACHS patient aligned care team-based mailed fecal immunochemical testing program. Fecal immunochemical testing utilization, completion, and colorectal cancer screening rates at VACHS substantially increased after the implementation of this project. Through a proactive, population-based colorectal cancer screening program centered on mailed fecal immunochemical testing kits outside of a traditional patient visit, VACHS substantially increased the utilization of fecal immunochemical testing kits as well as colorectal cancer screening rates.

Pattern of Participation in Colorectal Cancer Screening from a Population-Based Screening Program in Iran.

In Isfahan, the fecal immunochemical test (FIT) has been used since January 2016 as part of the Iran's Package of Essential Non-communicable Diseases (IraPEN) program for colorectal cancer (CRC) screening. The test is recommended for people who are 50-70 years old. Then, those with positive results would be referred for colonoscopy. This study aims to describe the uptake of the program and its outcome. A retrospective observational study was performed by collecting data from Isfahan Vice-Chancellor for Health database for this study purpose. The number of participators, the number of positive FIT, and the number of detected polyps or cancers were determined. Between 2016 and 2019, the number of participants in the program reached 345 207 individuals (nearly 40% of the eligible population of 874 674). Totally, 21 264 participants (6.1%) had positive tests, of whom about 20% underwent the recommended colonoscopy with available reports, and 971 (24%) and 110 (3%) patients were diagnosed with polyps and CRC, respectively. Over four years of screening with FIT in Isfahan, 40% of the eligible population participated. Among those with positive FIT results, 20% underwent colonoscopy, and approximately 26% of these individuals were identified as having polyps or cancer. This study provides valuable insights into the uptake and outcomes of a population-based CRC screening program in Isfahan, Iran. The findings highlight the need for targeted interventions to increase participation rates and improve the detection of polyps and CRC cases.

Enhancing Colorectal Cancer Screening with Droplet Digital PCR Analysis of Fusobacterium nucleatum in Fecal Immunochemical Test Samples.

Fecal immunochemical test (FIT) followed by colonoscopy in positive cases is commonly used for population-based colorectal cancer screening. However, specificity of FIT for colorectal cancer is not ideal and has poor performance for advanced adenoma detection. Fecal Fusobacterium nucleatum (Fn) detection has been proposed as a potential noninvasive biomarker for colorectal cancer and advanced adenoma detection. We aimed to evaluate the diagnostic performance of Fn detection using droplet digital PCR (ddPCR) in FIT samples from individuals enrolled in a colorectal cancer screening program with colorectal adenoma or cancer. We evaluated Fn presence in DNA isolated from FIT leftover material of 300 participants in a colorectal cancer screening program using ddPCR. The Fn DNA amount was classified as Fn-low/negative and Fn-high, and the association with patients' clinicopathological features and accuracy measurements was calculated. Fn-high levels were more prevalent in FIT-positive (47.2%, n = 34 of 72) than FIT-negative samples (28.9%, n = 66 of 228; P < 0.04). Among FIT-positive samples, high Fn levels were significantly more frequent in patients with cancer (CA, n = 8) when compared to normal (NT, n = 16; P = 0.02), non-advanced adenomas (NAA, n = 36; P = 0.01), and advanced adenomas (AA, n = 12; P = 0.01). Performance analysis of Fn in FIT-positive samples for colorectal cancer detection yielded an AUC of 0.8203 [confidence interval (CI), 0.6464-0.9942], with high sensitivity (100%) and specificity of 50%. Concluding, we showed the feasibility of detecting Fn in FIT leftovers using the ultrasensitive ddPCR technique. Furthermore, we highlighted the potential use of Fn levels in fecal samples to ameliorate colorectal cancer detection. Prevention Relevance: Fusobacterium nucleatum detection by droplet digital PCR could prioritize the selection of fecal immunochemical test-positive individuals who might benefit the most from the colonoscopy procedure.

Developing an optimal stratification model for colorectal cancer screening and reducing racial disparities in multi-center population-based studies

BackgroundEarly detection of colorectal neoplasms can reduce the colorectal cancer (CRC) burden by timely intervention for high-risk individuals. However, effective risk prediction models are lacking for personalized CRC early screening in East Asian (EAS) population. We aimed to develop, validate, and optimize a comprehensive risk prediction model across all stages of the dynamic adenoma-carcinoma sequence in EAS population.MethodsTo develop precision risk-stratification and intervention strategies, we developed three trans-ancestry PRSs targeting colorectal neoplasms: (1) using 148 previously identified CRC risk loci (PRS148); (2) SNPs selection from large-scale meta-analysis data by clumping and thresholding (PRS183); (3) PRS-CSx, a Bayesian approach for genome-wide risk prediction (PRSGenomewide). Then, the performance of each PRS was assessed and validated in two independent cross-sectional screening sets, including 4600 patients with advanced colorectal neoplasm, 4495 patients with non-advanced adenoma, and 21,199 normal individuals from the ZJCRC (Zhejiang colorectal cancer set; EAS) and PLCO (the Prostate, Lung, Colorectal, and Ovarian Cancer Screening Trial; European, EUR) studies. The optimal PRS was further incorporated with lifestyle factors to stratify individual risk and ultimately tested in the PLCO and UK Biobank prospective cohorts, totaling 350,013 participants.ResultsThree trans-ancestry PRSs achieved moderately improved predictive performance in EAS compared to EUR populations. Remarkably, the PRSs effectively facilitated a thorough risk assessment across all stages of the dynamic adenoma-carcinoma sequence. Among these models, PRS183 demonstrated the optimal discriminatory ability in both EAS and EUR validation datasets, particularly for individuals at risk of colorectal neoplasms. Using two large-scale and independent prospective cohorts, we further confirmed a significant dose–response effect of PRS183 on incident colorectal neoplasms. Incorporating PRS183 with lifestyle factors into a comprehensive strategy improves risk stratification and discriminatory accuracy compared to using PRS or lifestyle factors separately. This comprehensive risk-stratified model shows potential in addressing missed diagnoses in screening tests (best NPV = 0.93), while moderately reducing unnecessary screening (best PPV = 0.32).ConclusionsOur comprehensive risk-stratified model in population-based CRC screening trials represents a promising advancement in personalized risk assessment, facilitating tailored CRC screening in the EAS population. This approach enhances the transferability of PRSs across ancestries and thereby helps address health disparity.Graphical

Development of an algorithm combining blood-based biomarkers, fecal immunochemical test, and age for population-based colorectal cancer screening

Implementation of screening modalities have reduced the burden of colorectal cancer (CRC), but high false positive rates pose a major problem for colonoscopy capacity. We aimed to create a tailored screening algorithm that expands the fecal immunochemical test (FIT) with a blood specimen and current age to improve selection of individuals for diagnostic colonoscopy. In this prospective multi-center study, eight blood-based biomarkers (CEA, Ferritin, hsCRP, HE4, Cyfra21-1, Hepsin, IL-8 and OPG) were investigated in 1,977 FIT positive individuals from the Danish national CRC screening program undergoing follow-up colonoscopy. Specimens were analyzed on ARCHITECT i2000®, ARCHITECT c8000® or Luminex xMAP® machines. FIT analyses and blood-based biomarker data were combined with clinical data (i.e., age and colonoscopy findings) in a cross-validated logistic regression model (algorithm) benchmarked against a model solely using the FIT result (FIT model) applying different cutoffs for FIT positivity. The cohort included individuals with CRC (n = 240), adenomas (n = 938) or no neoplastic lesions (n = 799). The cross-validated algorithm combining the eight biomarkers, quantitative FIT result and age performed superior to the FIT model in discriminating CRC versus non-CRC individuals (AUC 0.77 versus 0.67, p < 0.001). When discriminating individuals with either CRC or high- or medium-risk adenomas versus low-risk adenomas or clean colorectum, the AUCs were 0.68 versus 0.64 for the algorithm and FIT model, respectively. The algorithm presented here can improve patient allocation to colonoscopy, reducing colonoscopy burden without compromising cancer and adenomas detection rates or vice versa.

Optimizing colorectal cancer screening outreach: A probability-based strategy by Temple University Hospital.

e13502 Background: Temple University Hospital has created an initiative to increase colorectal cancer (CRC) screening to a historically underserved population in Northern Philadelphia through the administration of Fecal Immunochemical Tests (FIT). FIT testing possesses the advantage of being inexpensive and easy to use. Moreover, FIT testing serves as an additional opportunity for underserved patients to be integrated into a health network to receive lifesaving care when utilized by a large health system such as Temple Health. This study demonstrates how healthcare institutions, such as Temple Health, can employ probability-based modeling created from empiric data to navigate uncertainty and establish goals for the number of colonoscopies they aim to perform per a specific quantity of FIT tests distributed within the community. By doing so, they can significantly enhance the overall screening efforts in Northern Philadelphia and provide an essential service to those who need it most. Methods: FIT tests were distributed to the participants at community engagement events. FIT response rates, positivity rates, and progression to colonoscopy rates were determined and fit to a binomial distribution in Palisades @Risk software and underwent a Monte Carlo simulation of 10,000 iterations to determine the different probabilities of response rates, positivity rate, and colonoscopies performed per 1000 FIT tests distributed. Results: A total of 292 tests were distributed with a response rate of 56.5% (165 patients) and a positivity rate of 8.9% (26 patients). Out of 292 patients, 2.4% (7 patients) have had a colonoscopy or are scheduled to have a colonoscopy at Temple University Hospital. Probability curves were created to demonstrate the probability of number of responses, number of positive tests, and number of colonoscopies performed per 1000 FIT tests administered to the community. Lastly, we modeled the number of FIT tests that need to be administered to the community to perform at least 100 colonoscopies with different levels of certainty (Table). Conclusions: Here we show how hospital systems, like Temple Health, can use probability distributions based on empiric data to set tangible goals regarding their community engagement efforts to increase access to CRC screening. Through the utilization of probability distributions, healthcare organizations can gain deeper insights into resource allocation needs and strategically direct their initiatives, ultimately fostering a more inclusive and equitable approach to population-based CRC screening. [Table: see text]

Is annual screening by fecal immunochemical test necessary after a recent colonoscopy?

The population-based colorectal cancer screening guidelines in Japan recommend an annual fecal immunochemical test (FIT). However, there is no consensus on the need for annual FIT screening for patients who recently performed a total colonoscopy (TCS). Therefore, we evaluated the repeated TCS results for patients with positive FIT after a recent TCS to assess the necessity of an annual FIT. We reviewed patients with positive FIT in opportunistic screening from April 2017 to March 2022. The patients were divided into two groups: those who had undergone TCS within the previous 5 years (previous TCS group) and those who had not (non-previous TCS group). We compared the detection rates of advanced neoplasia and colorectal cancer between the two groups. Of 671 patients, 151 had received TCS within 5 years and 520 had not. The detection rates of advanced neoplasia in the previous TCS and non-previous TCS groups were 4.6% and 12.1%, respectively (p < 0.01), and the colorectal cancer detection rates were 0.7% and 1.5%, respectively (no significant difference). The adenoma detection rates were 33.8% in the previous TCS group and 40.0% in the non-previous TCS group (no significant difference). Only a few patients were diagnosed with advanced neoplasia among the patients with FIT positive after a recent TCS. For patients with adenomatous lesions on previous TCS, repeated TCS should be performed according to the surveillance program without an annual FIT. The need for an annual FIT for patients without adenomatous lesions on previous TCS should be prospectively assessed in the future.

Evaluation of the “Burgenland PREvention trial of colorectal cancer Disease with ImmunologiCal Testing” (B-PREDICT)—a population-based colorectal cancer screening program

BackgroundThe colorectal cancer (CRC) screening program B-PREDICT is a population based invited two stage screening project using a faecal immunochemical test (FIT) for initial screening followed by a colonoscopy for those with a positive FIT. B-PREDICT was compared with the opportunistic screening colonoscopy (OPP-COL), performed in course of the nationwide screening program.MethodsWithin B-PREDICT all residents of the Austrian federal state Burgenland, aged between 40 and 80 are annually invited to FIT testing. All individuals who underwent initial colonoscopy in Burgenland between 01/2003 and 12/2014, were included in this study. Individuals from the FIT-triggered invited screening program B-PREDICT were compared with those from the non-FIT triggered OPP-COL.Results15 133 individuals from B-PREDICT were compared to 10 045 individuals with OPP-COL. CRC detection rates were 1.34% (CI-95%, [1.15; 1.52]) in B-PREDICT compared to 0.54% in OPP-COL (95%-CI, [0.39; 0.68] p < 0.001). The decrease in the age standardized incidence rates of CRC was more pronounced in the population screened with FIT than in the general population screened with colonoscopy. Changes in incidence rates per year were -4.4% (95%-CI, [-5.1; -3.7]) vs. -1.8% (95%-CI, [-1.9; -1.6] p < 0.001).ConclusionsB-PREDICT shows a two-fold higher detection rate of CRC as well as HRA compared to OPP-COL.

Association between time to colonoscopy after positive fecal testing and colorectal cancer outcomes in Alberta, Canada.

To quantify the associations between time to colonoscopy after a positive fecal immunochemical test (FIT+) and colorectal cancer (CRC)-related outcomes in the context of a provincial, population-based CRC screening program. Population-based, retrospective cohort study in Alberta, Canada, including Albertans aged 50-74 with at least one FIT+ in 2014-2017. Study outcomes were CRC diagnosis after a FIT+ and a diagnostic follow-up colonoscopy in 2014-2019 and CRC stage at diagnosis. Multivariable logistic regression models were used to evaluate the relative risk of any CRC or advanced-stage CRC. Results were presented as crude odds ratio (OR) and adjusted OR (aOR) with 95% confidence intervals (CIs). Of the 787,967 participants who had a FIT, 63,232 (8%) had a FIT+ and met the study's eligibility criteria. The risk of any CRC or advanced-stage CRC stayed high and was relatively consistent for follow-up colonoscopies performed within 1-12 months of the FIT+. After 12 months, the risk of CRC was considerably higher, particularly for advanced-stage CRC. The OR and aOR for any CRC were 1.40 (95% CI: 1.13-1.73; p < 0.05) and 1.20 (95% CI: 0.96-1.49), respectively, and the OR and aOR for advanced-stage CRC were 1.42 (95% CI: 0.98-2.08) and 0.88 (95% CI: 0.59-1.32), respectively, for colonoscopy follow-up within 12-18 months versus 1-2 months. For Albertans who used FIT for CRC screening, a longer time interval between a FIT+ and follow-up colonoscopy, particularly over 12 months, increases the risk of having CRC and decreases the effectiveness of CRC screening programs.

Population-based screening for colorectal cancer in Wuhan, China.

https://www.chictr.org.cn/showproj.html?proj=192838, identifier ChiCTR2300070520.

Routine Fecal Occult Blood Screening and Colorectal Cancer Mortality in Sweden

Population-based colorectal cancer (CRC) screening programs are implemented worldwide, but there are difficulties evaluating their effectiveness. The magnitude of routine CRC screening effectiveness regarding cancer-specific mortality is unclear. To evaluate cancer-specific mortality associated with early vs late or no invitation for routine CRC screening using fecal occult blood testing. This prospective cohort study was performed in the region of Stockholm-Gotland, Sweden, between January 1, 2008, and December 31, 2021. All individuals of the target population of screening born from 1938 to 1954 were included. Data were analyzed from December 12, 2022, to June 25, 2023. Individuals were invited early (2008-2012), late (2013-2015), or not at all to screening with biennial guaiac-based fecal occult blood test. The early invitation group was considered the exposure group and the late or no invitation group was considered the control group. The main outcome was cancer-specific mortality, defined as CRC registered in the Cancer Register with CRC as underlying cause of death in the Cause of Death Register. Excess mortality was calculated as all-cause deaths among the individuals with CRC subtracted from the expected number of deaths had they not had CRC. Poisson regression analysis based on deaths and person-years was used to estimated mortality rate ratio (RR) with 95% CIs, adjusted for follow-up years and attained age. In total, 379 448 individuals (193 436 [51.0%] female) were invited for CRC screening, including 203 670 individuals in the exposure group and 175 778 in the control group. The mean screening participation rate was 63.3%, and there was a maximum of 14 years follow-up. There were 834 CRC deaths in 2 190 589 person-years in the exposure group, compared with 889 CRC deaths in 2 249 939 person-years in the control group. Individuals who underwent early CRC screening had reduced adjusted risk of CRC mortality (RR, 0.86; 95% CI, 0.78-0.95) and excess mortality (RR, 0.84; 95% CI, 0.75-0.93). This prospective cohort study of routine screening with fecal occult blood testing found a 14% decrease in CRC mortality associated with screening. The true association of screening with reduced mortality is expected to be higher due to some coexistence of testing in the control group and CRC deaths diagnosed more than 2 years after screening.

A Roadmap to Developing a Population-Based Colorectal Cancer Screening Program in Oman

Colorectal cancer (CRC) is a major public health problem worldwide, as it is the third most common disease and the second leading cause of cancer-related fatalities. In recent years, Oman, like many other countries, has seen an epidemiological shift from communicable diseases to noncommunicable diseases, including colorectal cancer, necessitating comprehensive planning to address the root cause of the problem as well as a comprehensive screening program to detect diseases at an early stage and thus improve health outcomes. Colorectal cancer is the second most frequent cancer in Oman, with the highest mortality rate, inflicting considerable public health and economic consequences; nevertheless, there is no population-based CRC screening programme in place to minimise the disease's incidence, mortality, and severe health outcomes. This review highlights the epidemiology of colorectal cancer in Oman, the Wilson and Junger criteria, operational readiness, and recommendations for implementing a population-based colorectal cancer screening program.

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.

Value of fecal immunochemical test in colorectal cancer screening

Screening and early diagnosis and treatment have been proven effective in reducing the incidence and mortality of colorectal cancer. Colonoscopy combined with pathological examination is the gold standard for colorectal cancer screening. However, due to the invasiveness, high cost and the need for professional endoscopists of colonoscopy, it is not feasible to directly use this method for mass population screening. Fecal immunochemical test (FIT) is one of the screening techniques recommended by authoritative international guidelines for colorectal cancer screening, and has been widely used in population-based colorectal cancer screening programs in countries around the world. This paper elaborates on the value of FIT in colorectal cancer screening from different aspects, such as the technical principles, the screening efficiency, the screening strategies, and the population effects and benefits. Additionally, it describes the current situation of colorectal cancer screening in China and summarizes the challenges faced in colorectal cancer screening in order to optimize the FIT-based colorectal cancer screening strategies in the population and provide theoretical reference for effective colorectal cancer screening.