Population-based Colorectal Cancer Screening Research Articles

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

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

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.

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.

Colorectal neoplasia surveillance in inflammatory bowel disease

Performing colorectal neoplasia surveillance in persons with inflammatory bowel disease (IBD) that is both clinically effective and cost effective is among the greatest challenges facing endoscopists who care for this population. While heightened colorectal cancer (CRC) risk has long been recognized among persons with IBD, this risk has been declining over time, with recent reports suggesting no more than a 1.5–2-fold higher risk compared to age and sex matched members of the general population. Nonetheless, given that CRC still occurs at a higher rate in this population, current surveillance strategies are inadequate for some persons. Conversely, 80–90% of persons with IBD had no neoplastic lesions identified during colonoscopy surveillance, suggesting that many persons with IBD are unnecessarily exposed to the risks of colonoscopy, with society bearing these excess costs.&#x0D; The purpose of colorectal neoplasia surveillance is to reduce the burden of CRC and CRC-related death in the IBD population. Societal guidelines recommend initiating colorectal neoplasia screening with colonoscopy in all persons with colorectal IBD involving at least the rectosigmoid (or at least 1/3 of the colorectum if accompanied by discontinuous inflammation) at 8–10 years following disease diagnosis and continuing lifelong surveillance every 1–5 years. Major factors influencing surveillance frequency include historical disease severity, extent of colorectal inflammation, chronic post-inflammatory changes, family history of CRC, history of colorectal neoplasm, primary sclerosing cholangitis, prior colonoscopy findings, and adequacy of prior surveillance. All guidelines further recommend targeted sampling or resection of suspicious visible abnormalities, and some societies continue to recommend extensive non-targeted biopsies to detect “invisible” neoplasia, particularly if other adjunctive optical modalities, such as dye-spray chromoendoscopy (DCE) or virtual chromoendoscopy (VCE), are not performed, or if the mucosa is poorly visualized, such as in areas of significant inflammation, post-inflammatory polyposis, or poor bowel preparation. Most societies now advocate for DCE or VCE as primary screening tools for IBD neoplasia surveillance or, at a minimum, as alternative modalities to traditional white light colonoscopy with non-targeted biopsies where resources and expertise exists.&#x0D; However, there are no prospective studies demonstrating a reduction in the incidence of CRC or of death from CRC with current surveillance strategies in persons with IBD. Furthermore, observations from large retrospective studies are also conflicting. A Cochrane analysis of 3 studies in persons with UC did not find a significant mortality benefit for current surveillance strategies. Considering that IBD afflicts many persons at a young age, is rising in prevalence in Canada and globally, and requires intensive lifelong surveillance , the amount of endoscopy resources directed toward IBD surveillance is potentially enormous. Increasing demands on colonoscopy resources from expansion of population-based CRC screening programs and an aging population are likely to challenge the ability to continue to provide intensive surveillance to all persons with IBD. Optimizing delivery of limited colonoscopy resources will thus be essential to maintain effective CRC prevention programs in this population.&#x0D; Current standards for neoplasia surveillance in IBD have been recently updated. Shah and Itzkowitz authored a comprehensive review that includes epidemiology, pathogenesis, and management of colorectal neoplasia, along with a chart that compares surveillance recommendations put forward by multiple societies. The present review will highlight new evidence influencing neoplasia surveillance and provide practical approaches for surveillance and management of neoplastic lesions in the IBD population.

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

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

Colonoscopy compliance and diagnostic yield in a large population-based colorectal cancer screening programme

ObjectivesWith the intention of providing a reference for secondary prevention, our study provides some insight on diagnostic yield of factors influencing compliance with colonoscopy and the presence of advanced adenomas (AA).MethodsWe conducted large-scale CRC screening among local Tianjin residents aged 40–75 years between 2012 and 2019. A high-risk factor questionnaire (HRFQ) was distributed to each participant, followed by the performance of a fecal immunochemical test (FIT). Participants who tested positively for any of these items were advised to undergo a colonoscopy. Relevant basic information was collected from participants during CRC screening, and the screening data were sorted and analysed.ResultsA total of 5,670,924 people participated in CRC screening by the end of 2019, including 275,708 people in the high-risk group, and 74,685 (27.1%) people who underwent colonoscopy. The results of the logistic regression model demonstrated that participants with a history of mucous bloody stool (OR = 8.20, 95% CI: 7.92, 8.50, p < 0.001), chronic diarrhea (OR = 5.73, 95% CI: 5.57, 5.89, p < 0.001), and higher level of education (OR = 1.87, 95% CI: 1.80, 1.93, p < 0.001) were more likely to comply with a colonoscopy. Several factors including age (70–75 years old:OR = 3.72, 95% CI: 2.71, 5.10, p < 0.001), and FIT( +) (OR = 1.65, 95% CI: 1.42,1.90, p < 0.001) were identified to be associated with the presence of AA.ConclusionsIncreased compliance with colonoscopy is urgently needed. Our findings can inform the design of future effective large-scale population-based CRC screening programmes.

Knowledge, Compliance, and Inequities in Colon Cancer Screening in Spain: An Exploratory Study.

In Spain, inequities exist in implementing colorectal cancer (CRC) tests with the target population-adults aged 50 to 69-as part of population-based CRC screening programs. This research aims to further our understanding of the target population's awareness, attitudes, and perceptions of these test-based screening programs. A survey was carried out using an online panel representative of the target population, with a sample collected from 5313 individuals. Data collection took place in June 2022. Descriptive and bivariate analyses were carried out using contingency tables, the Chi-square test, and Cramer's V statistics. The sample was also segmented based on key variables. Finally, the results were analyzed using logistic regression. In the sample population, 62.5% had taken the fecal occult blood test (FOBT), 72.5% reported receiving the invitation letter to participate in the screening program, and 86.8% had prior knowledge of the FOBT. Noncompliance was mainly due to lack of symptoms (40%), non-receipt of invitation letters (39.7%), and forgetfulness or neglect (28.5%). On the contrary, receipt of the letter of invitation (OR 7.35, p < 0.01) and prior knowledge of FOBT (OR 6.32, p < 0.01) were the main variables that increased the probability of test uptake. Other significant variables included frequency of primary care visits (OR 1.71, p < 0.01) and being older (65-69 years old) (OR 1.52, p < 0.01) There is still a pressing need for greater awareness of both CRC risk factors and the benefits of early detection, as well as for overcoming the common misconception that detection should only be sought when symptoms are present.

The challenge of colorectal cancer (CRC) screening in low and middle-income countries (LMIC): The Brazilian ten year long experience.

129 Background: The increasing incidence of CRC seen in LMIC and the high mortality rates compared to high-income countries points towards the difficult implementation of an effective screening strategy in LMIC. Brazil is one of the few Latin American countries and LMIC that have a population-based CRC screening program, targeting ages 50 to 74 and performing a fecal occult blood test (FT) every 2 years and colonoscopy/sigmoidoscopy as a confirmatory test. Methods: We performed a cross-sectional study, which evaluated the prevalence of every stage of CRC/carcinoma in situ (CIS) at the time of its diagnosis from 2013 to 2022. Similar data regarding the Brazilian breast and cervical cancer screening programs was obtained. Each stage was evaluated by age targeted by their respective screening program using the national database (DATASUS). Results: In the analyzed decade there was a total of 87507 CRC/CIS cases in the overall studied population, which only 11% was of Stage I or less and 70% was of stage III or IV at the time of diagnosis. In the subdivided age groups, the prevalence of each stage remained somewhat constant through all groups (In situ/Stage 0 = 8-9%; Stage I = 3%; Stage II = 20-21%; Stage III = 35-36%; Stage IV = 32-34%) and the majority of cases occurred from age 60 to 64 (20549 cases). In 2022, a total of 2128168 RT was performed - corresponding to only 4,6% of the targeted population - and 408489 colonoscopies. When compared to other cancer screening programs, CRC presents indifferent to age group, sustaining constant rate of regional/distant stages, with at least 32% of patients presenting a &lt;17% 5-year survival rate (5-YSR), whereas cervical cancer presents approximately 80% of cases at &gt;91% 5-YSR at the first age group, and breast cancer with 89% of cases at &gt;86% 5-YSR at the first age group. Conclusions: Data suggests the inefficacy of CRC screening implementation, and literature sustains to be due to its poor acceptance by the population and the unavailability of confirmatory imaging tests due to long-waiting times and high cost, reducing its ability to detect early stage lesions, in contrast with the overall acceptance and high effectivity of cervical/breast cancer screening. The discrepancy between the guidelines and their implementation as a screening program in LMIC are in consonant. This study aims to be a launching point for new research and interventional studies evaluating the impact of better locally adjusted actions in the prevention of CRC such as screening invitations, in-community health education, and the developing of better cost-benefit confirmatory methods might hinder the advance of CRC in LMIC.[Table: see text]

Colorectal cancer screening with faecal immunochemical test: Patterns of participation.

To evaluate participation and participation patterns in a population-based screening programme for colorectal cancer (CRC) using the faecal immunochemical test (FIT). All individuals invited to three consecutive screening rounds in the population-based CRC screening between October 2015 and December 2020 in the Stockholm-Gotland Region, Sweden were included. Patterns of participation were assessed. The study included 26 541 individuals which resulted in 79 623 screening events. The overall uptake rate was 71.5% and women had a significantly higher participation rate. The participation rate increased significantly between the first and third screening round for both men and women, and the increase was larger among men than women (66.1 to 70.7% vs. 73.1 to 75.4%). In total, 80.9% participated at least once. Consistent participation was the most common participation pattern (61.0%). The probability of attending all three consecutive rounds after initial participation was 87.7%. Over the three rounds, 17.4% participated after a reminder letter. Screening individuals attending after a reminder letter had a higher proportion of drop-outs in the following screening round compared to initial participants (15.4% vs 6.2%). A constant and high participation rate was observed in population-based FIT-screening for CRC. Initial participation was a strong predictor for continuous participation. The need for a reminder letter before participation was a risk factor for subsequent drop-out.

Dilemmas in the Clinical Management of pT1 Colorectal Cancer.

Implementation of population-based colorectal cancer screening programs has led to increases in the incidence of pT1 colorectal cancer. These incipient invasive cancers have a very good prognosis and can be treated locally, but more than half of these cases are treated with surgery due to the presence of histological high-risk criteria. These high-risk criteria are suboptimal, with no consensus among clinical guidelines, heterogeneity in definitions and assessment, and poor concordance in evaluation, and recent evidence suggests that some of these criteria considered high risk might not necessarily affect individual prognosis. Current criteria classify most patients as high risk with an indication for additional surgery, but only 2-10.5% have lymph node metastasis, and the residual tumor is present in less than 20%, leading to overtreatment. Patients with pT1 colorectal cancer have excellent disease-free survival, and recent evidence indicates that the type of treatment, whether endoscopic or surgical, does not significantly impact prognosis. As a result, the protective role of surgery is questionable. Moreover, surgery is a more aggressive treatment option, with the potential for higher morbidity and mortality rates. This article presents a comprehensive review of recent evidence on the clinical management of pT1 colorectal cancer. The review analyzes the limitations of histological evaluation, the prognostic implications of histological risk status and the treatment performed, the adverse effects associated with both endoscopic and surgical treatments, and new advances in endoscopic treatment.

Assessing Risk for Gastrointestinal Cancers: Forewarned Is Forearmed…˙

Gastrointestinal cancers are an important cause of morbidity and mortality worldwide. The epidemiology of these diverse tumors is shifting. Colorectal cancer (CRC), historically a disease of older people in the Western hemisphere, has become a global problem affecting increasing numbers of younger individuals. Implementation of population-based CRC screening in many countries has decreased disease-related morbidity and mortality successfully in persons aged ≥50 years. However, the increasing incidence of CRC in young individuals raises questions about additional potential risk factors, beyond age and family history, that should be considered in assessing risk for gastrointestinal neoplasia and developing interventions to more effectively treat and prevent cancers.

Personalized colorectal cancer screening: study protocol of a mixed-methods study on the effectiveness of tailored intervals based on prior f-Hb concentration in a fit-based colorectal cancer screening program (PERFECT-FIT)

BackgroundIn 2014, the national population-based colorectal cancer (CRC) screening program was implemented in the Netherlands. Biennial fecal immunochemical testing (FIT) for hemoglobin (Hb) is used at a cut-off of 47 µg Hb per gram feces. The CRC screening program successfully started, with high participation rates and yield of screening. Now that the program has reached a steady state, there is potential to further optimize the program. Previous studies showed that prior fecal Hb (f-Hb) concentrations just below the FIT cut-off are associated with a higher risk for detection of advanced neoplasia (AN) at subsequent screening rounds. We aim to achieve a better balance between the harms and benefits of CRC screening by offering participants tailored invitation intervals based on prior f-Hb concentrations after negative FIT.MethodsThis mixed-methods study will be performed within the Dutch national CRC screening program and will consist of: (1) a randomized controlled trial (RCT), (2) focus group studies, and (3) decision modelling. The primary outcome is the yield of AN per screened individual in personalized screening vs. uniform screening. Secondary outcomes are perspectives on, acceptability of and adherence to personalized screening, as well as long-term outcomes of personalized vs. uniform screening. The RCT will include 20,000 participants of the Dutch CRC screening program; 10,000 in the intervention and 10,000 in the control arm. The intervention arm will receive a personalized screening interval based on the prior f-Hb concentration (1, 2 or 3 years). The control arm will receive a screening interval according to current practice (2 years). The focus group studies are designed to understand individuals’ perspectives on and acceptability of personalized CRC screening. Results of the RCT will be incorporated into the MISCAN-Colon model to determine long-term benefits, harms, and costs of personalized vs. uniform CRC screening.DiscussionThe aim of this study is to evaluate the yield, feasibility, acceptability and (cost-) effectiveness of personalized CRC screening through tailored invitation intervals based on prior f-Hb concentrations. This knowledge may be of guidance for health policy makers and may provide evidence for implementing personalized CRC screening in The Netherlands and/or other countries using FIT as screening modality.Trial registration: ClinicalTrials.gov, NCT05423886, June 21, 2022, https://clinicaltrials.gov/ct2/show/NCT05423886

Optimizing Screening for Colorectal Cancer: An Algorithm Combining Fecal Immunochemical Test, Blood-Based Cancer-Associated Proteins and Demographics to Reduce Colonoscopy Burden

BackgroundFecal Immunochemical Test (FIT) is widely used in population-based screening for colorectal cancer (CRC). This had led to major challenges regarding colonoscopy capacity. Methods to maintain high sensitivity without compromising the colonoscopy capacity are needed. This study investigates an algorithm that combines FIT result, blood-based biomarkers associated with CRC, and individual demographics, to triage subjects sent for colonoscopy among a FIT positive (FIT+) screening population and thereby reduce the colonoscopy burden. Materials and methodsFrom the Danish National Colorectal Cancer Screening Program, 4048 FIT+ (≥100 ng/mL Hemoglobin) subjects were included and analyzed for a panel of 9 cancer-associated biomarkers using the ARCHITECT i2000. Two algorithms were developed: 1) a predefined algorithm based on clinically available biomarkers: FIT, age, CEA, hsCRP and Ferritin; and 2) an exploratory algorithm adding additional biomarkers: TIMP-1, Pepsinogen-2, HE4, CyFra21-1, Galectin-3, B2M and sex to the predefined algorithm. The diagnostic performances for discriminating subjects with or without CRC in the 2 models were benchmarked against the FIT alone using logistic regression modeling. ResultsThe discrimination of CRC showed an area under the curve (AUC) of 73.7 (70.5-76.9) for the predefined model, 75.3 (72.1-78.4) for the exploratory model, and 68.9 (65.5-72.2) for FIT alone. Both models performed significantly better (P < .001) than the FIT model. The models were benchmarked vs. FIT at cutoffs of 100, 200, 300, 400, and 500 ng/mL Hemoglobin using corresponding numbers of true positives and false positives. All performance metrics were improved at all cutoffs. ConclusionA screening algorithm including a combination of FIT result, blood-based biomarkers and demographics outperforms FIT in discriminating subjects with or without CRC in a screening population with FIT results above 100 ng/mL Hemoglobin.

The role of defensive information processing in population-based colorectal cancer screening uptake.

Internationally, colorectal cancer screening participation remains low despite the availability of home-based testing and numerous interventions to increase uptake. To be effective, interventions should be based on an understanding of what influences individuals' decisions about screening participation. This study investigates the association of defensive information processing (DIP) with fecal immunochemical test (FIT)-based colorectal cancer screening uptake. Regression modeling of data from a cross-sectional survey within a population-based FIT screening program was conducted. The survey included the seven subdomains of the McQueen DIP measure. The primary outcome variable was the uptake status (screening user or nonuser). Multivariable logistic regression was used to estimate the odds ratio (OR) for screening nonuse by DIP (sub)domain score, with adjustments made for sociodemographic and behavioral factors associated with uptake. Higher scores (equating to greater defensiveness) on all DIP domains were significantly associated with lower uptake in the model adjusted for sociodemographic factors. In the model with additional adjustments for behavioral factors, the suppression subdomains of "deny immediacy to be tested" (OR, 0.53; 95% confidence interval [CI], 0.43-0.65; p<.001) and "self-exemption" (OR, 0.80; 95% CI, 0.68-0.96; p < .001) independently predicted nonuse of FIT-based screening. This is the first study outside the United States that has identified DIP as a barrier to colorectal cancer screening uptake, and it is the first focused specifically on FIT-based screening. The findings suggest that two suppression barriers, namely denying the immediacy to be tested and self-exempting oneself from screening, may be promising targets for future interventions to improve uptake.

Detection rates of adenomas, advanced adenomas, and colorectal cancers among the opportunistic colonoscopy screening population: a single-center, retrospective study.

Colorectal cancer (CRC) screening is effective in reducing CRC incidence and mortality. The aim of this study was to retrospectively determine and compare the detection rate of adenomas, advanced adenomas (AAs) and CRCs, and the number needed to screen (NNS) of individuals in an average-risk Chinese population of different ages and genders. This was a retrospective study performed at the Institute of Health Management, Chinese People's Liberation Army General Hospital. Colonoscopy results were analyzed for 53,152 individuals finally enrolled from January 2013 to December 2019. The detection rate of adenomas, AAs, or CRCs was computed and the characteristics between men and women were compared using chi-squared test. The average age was 48.8 years (standard deviation [SD], 8.5 years) for men and 50.0 years (SD, 9.0 years) for women, and the gender rate was 66.27% (35,226) vs. 33.73% (17,926). The detection rates of adenomas, AAs, serrated adenomas, and CRCs were 14.58% (7750), 3.09% (1641), 1.23% (653), and 0.59% (313), respectively. Men were statistically significantly associated with higher detection rates than women in adenomas (17.20% [6058/35,226], 95% confidence interval [CI] 16.74-17.53% vs. 9.44% [1692/17,926], 95% CI 8.94-9.79%, P < 0.001), AAs (3.72% [1309], 95% CI 3.47-3.87% vs. 1.85% [332], 95% CI 1.61-2.00%, P < 0.001), and serrated adenomas (1.56% [548], 95% CI 1.43-1.69% vs. 0.59% [105], 95% CI 0.47-0.70%, P < 0.001). The detection rate of AAs in individuals aged 45 to 49 years was 3.17% (270/8510, 95% CI 2.80-3.55%) in men and 1.69% (69/4091, 95% CI 1.12-1.86%) in women, and their NNS was 31.55 (95% CI 28.17-35.71) in men and 67.11 (95% CI 53.76-89.29) in women. The NNS for AAs in men aged 45 to 49 years was close to that in women aged 65 to 69 years (29.07 [95% CI 21.05-46.73]). The detection rates of adenomas, AAs, and serrated adenomas are high in the asymptomatic population undergoing a physical examination and are associated with gender and age. Our findings will provide important references for effective population-based CRC screening strategies in the future.