Colorectal cancer screening in Europe

Colorectal cancer (CRC) is the second most freq uent malignant disease in Europe. Every year, 412 000 people are diagnosed with this condition, and 207 000 patients die of it. In 2003, recommendations for screening programs were issued by the Council of the European Union (EU), and these currently serve as the basis for the preparation of European guidelines for CRC screening. The manner in which CRC screening is carried out varies significantly from country to country within the EU, both in terms of organization and the screening test chosen. A screening program of one sort or another has been implemented in 19 of 27 EU countries. The most frequently applied method is test - ing stool for occult bleeding (fecal occult blood test, FOBT). In recent years, a screening colonoscopy has been introduced, either as the only method (Poland) or the method of choice (Germany, Czech Republic).     

Lesiones detectadas en el programa de cribado de cáncer colorrectal en el País Vasco: primera ronda 2009-2011

Colorectal cancer (CRC) is a major public health problem due to its incidence and mortality. In May 2008, the Basque Country approved the implementation of a population-based colorectal cancer screening program, using the immunochemical fecal occult blood test (FOBT), in persons aged 50-69 years. Patients with a positive result were invited to undergo colonoscopy with sedation.     

Reduction in colorectal cancer mortality by fecal occult blood screening in a French controlled study

BACKGROUND & AIMS: Several randomized population-based studies have shown that screening for colorectal cancer (CRC) by fecal occult blood tests (FOBTs) can reduce CRC mortality. The aim of this French population-based study was to assess whether a similar benefit could be obtained in countries characterized by high performances in the diagnosis and management of CRC. METHODS: Small-sized geographic areas, including 91,199 individuals aged 45-74 years, were allocated to either FOBT screening or no screening. Six screening rounds were performed. The FOBT was performed without diet restriction and was sent to a central analysis center and processed without rehydration. Screening group participants who had a positive test result were offered a full colonoscopy. The entire population was followed up for 11 years after study entry. RESULTS: Acceptability of the test was 52.8% at the first screening round and varied between 53.8% and 58.3% in the successive rounds. Positivity rates were 2.1% initially and 1.4% on average in the successive rounds. CRC mortality was significantly lower in the screening population compared with the control population (mortality ratio, 0.84; 95% confidence interval, 0.71-0.99). The reduction in CRC mortality was more pronounced in those who participated at least once (mortality ratio, 0.67; 95% confidence interval, 0.56-0.81). CONCLUSIONS: Our findings, together with the results of other trials, suggest that biennial screening by FOBTs can reduce CRC mortality regardless of the quality of the health system and support attempts to introduce large-scale screening programs into the general population.     

Racial and ethnic colorectal cancer patterns affect the cost-effectiveness of colorectal cancer screening in the United States

BACKGROUND & AIMS: Colorectal cancer screening beginning at age 50 is recommended for all Americans considered at "average" risk for the development of colorectal cancer. METHODS: We used 1988-1995 California Cancer Registry data to compare the cost-effectiveness of two 35-year colorectal cancer screening interventions among Asians, blacks, Latinos, and Whites. RESULTS: Average annual age-specific colorectal cancer incidence rates were highest in blacks and lowest in Latinos. Screening beginning at age 50 was most cost-effective in blacks and least cost-effective in Latinos (measured as dollars spent per year of life saved), using annual fecal occult blood testing (FOBT) combined with flexible sigmoidoscopy every 5 years and using colonoscopy every 10 years. A 35-year screening program beginning in blacks at age 42, whites at age 44, or Asians at age 46 was more cost-effective than screening Latinos beginning at age 50. CONCLUSIONS: Colorectal cancer screening programs beginning at age 50, using either FOBT and flexible sigmoidoscopy or colonoscopy in each racial or ethnic group, are within the $40,000-$60,000 per year of life saved upper cost limit considered acceptable for preventive strategies. Screening is most cost-effective in blacks because of high age-specific colorectal cancer incidence rates.     

Population screening for colorectal cancer: advantages and drawbacks

Screening for colorectal cancer (CRC) has been shown to reduce mortality from the disease as well as incidence. Several methods for screening are available, but none are ideal. The present short review discusses the advantages and drawbacks using fecal occult blood tests (FOBTs), fecal DNA tests, flexible sigmoidoscopy (FS), colonoscopy, double contrast barium enema, and computed tomographic colonoscopy. The use of FOBTs with following colonoscopy in persons with a positive test has been shown to reduce mortality as well as the incidence of CRC in several randomized trials. It is likely that other methods will do the same, but it is not clear how large the benefit will be. Repeated testing is necessary for FOBTs and DNA tests as well as FS, and a high degree of acceptability is crucial for the effectivity of all tests in a national program. National services may be subject to variations in enthusiasm and expertise, resulting in varying acceptability and number of complications. It is recommended to perform pilot studies in limited populations (as in the UK) before embarking on a screening program on a national level.     

Colorectal cancer screening in the Czech Republic

The epidemiology of colorectal cancer (CRC) in the Czech Republic is extremely unfavourable. The alarmingly high rates of incidence (79/100,000) and mortality (45/100,000) (Fig.1) have practically remained unchanged in recent years. It is unclear to what extent this reflects a generally unfavourable genetic heritage, environmental factors or the dietary habits of the Czech population. The Czech Society of Gastroenterology launched a population-based CRC screening program in 2000. The FOBT became the standard procedure for a biannual screening examination performed by the general practitioners. A colonoscopy follows in the event of a positive FOBT result. In three screening rounds in 2001, 2002 and 2005, the FOBTs of 6.4% out of a total of 535,248 participants yielded positive results. 0.33% of all participants were diagnosed with a carcinoma, 1.9% with an adenoma. The acceptance and detection rates doubled between 2001 and 2005.     

Strategies in screening for colon carcinoma

Colorectal cancer is the second most common cancer in Europe and meets the criteria for population screening. Population screening should lead to a reduction in CRC-related mortality and incidence. Several options are available for CRC screening, which can be itemised as stool-based tests and structural exams. Stool-based tests include guaiac and immunochemical faecal occult blood tests and DNA -marker tests. Structural exams comprise endoscopic techniques (flexible sigmoidoscopy, colonoscopy and capsule endoscopy) and radiological exams (double contrast barium enema, CT colonography and MR colonography). Each test has its own test performance characteristics and acceptability profile, which affect the participation and effectiveness of the associated screening programmes. Faecal occult blood tests (FOBT ) and flexible sigmoidoscopy (FS) are the only methods with a demonstrated mortality reduction during a ten-year period (FOBT 16% and FS 31%) while flexible sigmoidoscopy is the only screening test with a demonstrated reduction in CRC incidence (23%). It is likely that other screening techniques such as colonoscopy and CT colonography will also be effective in the reduction of CRC-related mortality. DNA -marker tests, capsule endoscopy and MR colonography are possible options for the future.     

Fecal occult blood test in colorectal cancer screening

Colorectal cancer (CRC) is one of the leading causes of cancer‐related mortality worldwide. Cancer screening is known to decrease mortality from CRC. One important test for CRC screening is the fecal occult blood test (FOBT), which includes guaiac FOBT and fecal immunological tests. In this review we discussed the development and application of the FOBT in CRC screening.     

CT colonography: role in FOBT-based screening programs for colorectal cancer

Computed tomographic colonography (CTC) is a minimally invasive imaging examination for the colon, and is safe, well tolerated and accurate for the detection of colorectal cancer (CRC) and advanced adenoma. While the role of CTC as a primary test for population screening of CRC is under investigation, the fecal occult blood test (FOBT) has been recommended for population screening of CRC in Europe. Subjects with positive FOBT are invited to undergo total colonoscopy, which has some critical issues, such as suboptimal compliance, contraindications and the possibility of an incomplete exploration of the colon. Based on available data, the integration of CTC in FOBT-based population screening programs for CRC may fall into three scenarios. First, CTC is recommended in FOBT-positive subjects when colonoscopy is refused, incomplete or contraindicated. For these indications CTC should replace double-contrast barium enema. Second, conversely, CTC is not currently recommended as a second-level examination prior to colonoscopy in all FOBT-positive subjects, as this strategy is most probably not cost-effective. Finally, CTC may be considered instead of colonoscopy for surveillance after adenoma removal, but specific studies are needed.     

Tumor pyruvate kinase isoenzyme type M2 and immunochemical fecal occult blood test: performance in screening for colorectal cancer

OBJECTIVES: Immunochemical fecal occult blood test (FOBT) and determination of tumor pyruvate kinase isoenzyme type M2 (TuM2-PK) in stool samples may be valuable new screening tools for colorectal cancer (CRC). The aim of this study was to compare the accuracy of fecal TuM2-PK testing with immunochemical FOBT in patients with CRC or adenomas. METHODS: A total of 52 patients with CRC were analyzed, 47 with colorectal adenomas, and 63 matched controls with a normal colonoscopy. Nineteen additional patients with inflammatory bowel disease were tested to determine influence of inflammation. Stool samples were analyzed with two immunochemical FOBTs, Immo-care and OC-Light, and with a commercial enzyme-linked immunosorbent assay for TuM2-PK. RESULTS: In patients with CRC, the sensitivity of TuM2-PK, Immo-care and OC-Light was respectively 85, 92 and 94%. In patients with adenomas, the sensitivity was respectively 28, 40 and 34%. Specificity for these tests was 90% for TuM2-PK and 97% for both immunochemical FOBTs. All tests showed a high positivity rate in patients with inflammatory bowel disease (79% for TuM2-PK and Immo-care, and 89% for OC-Light). CONCLUSION: Both immunochemical FOBTs appear valuable and are sensitive tests for CRC screening. TuM2-PK does not have supplemental value for screening for CRC because of a lower sensitivity and specificity. None of these tests is sensitive enough for detection of advanced adenomas. Patients with inflammatory bowel disease should be excluded from CRC screening when using immunochemical FOBT or TuM2-PK.     

Asia Pacific consensus recommendations for colorectal cancer screening

Colorectal cancer (CRC) is rapidly increasing in Asia, but screening guidelines are lacking. Through reviewing the literature and regional data, and using the modified Delphi process, the Asia Pacific Working Group on Colorectal Cancer and international experts launch consensus recommendations aiming to improve the awareness of healthcare providers of the changing epidemiology and screening tests available. The incidence, anatomical distribution and mortality of CRC among Asian populations are not different compared with Western countries. There is a trend of proximal migration of colonic polyps. Flat or depressed lesions are not uncommon. Screening for CRC should be started at the age of 50 years. Male gender, smoking, obesity and family history are risk factors for colorectal neoplasia. Faecal occult blood test (FOBT, guaiac-based and immunochemical tests), flexible sigmoidoscopy and colonoscopy are recommended for CRC screening. Double-contrast barium enema and CT colonography are not preferred. In resource-limited countries, FOBT is the first choice for CRC screening. Polyps 5-9 mm in diameter should be removed endoscopically and, following a negative colonoscopy, a repeat examination should be performed in 10 years. Screening for CRC should be a national health priority in most Asian countries. Studies on barriers to CRC screening, education for the public and engagement of primary care physicians should be undertaken. There is no consensus on whether nurses should be trained to perform endoscopic procedures for screening of colorectal neoplasia.     

Better acceptance of Fecal Occult Blood Test (FOBT) for colorectal cancer screening during hospitalization

INTRODUCTION: Colorectal cancer (CRC) is a leading cause of illness and death in the Western world. Screening with fecal occult blood test (FOBT) significantly reduces the death rate and the incidence from CRC but these tests are not widely accepted. We investigated the possible contribution of hospitalization to a better acceptance of CRC screening. PATIENTS AND METHODS: From October 1998 through September 2000, 721 consecutive patients between 45 and 75 years of age admitted for various reasons were asked for participation in the study. They were asked to participate in FOBT-screening. In case of refusal of FOBT they were asked a second time after detailed information. In patients who accepted 3 consecutive FOBT's were performed. In case of positive FOBT results colonoscopy and gastroscopy were performed. RESULTS: 149 (82 male/67 female) patients were included. 94 (63.5%) of them agreed to undergo FOBT primarily and 10 (6.8%) secondarily after detailed information. The total acceptance rate of the FOBT was 69.8% (m/w : 69.1%/71.6%). In one of 5 cases with a positive FOBT result colorectal cancer (CRC) was diagnosed. Information on repetition of FOBT after one year could be obtained from 82 patients (55%). 37 patients (45%) had undergone repeated FOBT. None of the 37 patients was motivated by the FOBT screening during hospitalization. CONCLUSIONS: Staying in a hospital offers a good chance to achieve a higher acceptance of the FOBT. Therefore, hospitalization may contribute to a better colorectal cancer prevention. However, motivation to regularly repeat screening does not last in all patients. Therefore, public campaigns as well as medical counseling need to continuously stress the necessity of CRC screening procedures.     

Improving Fecal Occult Blood Testing Compliance Using a Mailed Educational Reminder

BACKGROUND  

Colorectal cancer (CRC) is one of the leading causes of cancer-related deaths in the United States. Randomized controlled trials have shown that annual screening fecal occult blood testing (FOBT) reduces CRC mortality and incidence. However, patient compliance with FOBT is low.     

Barriers to colorectal cancer screening： A case-control study

AIM： To investigate barriers to colorectal cancer （CRC） screening in a community population. METHODS： We conducted a community-based case-control study in an urban Chinese population by questionnaire. Cases were selected from those completing both a fecal occult blood test （FOBT） case and colonoscopy in a CRC screening program in 2004. Control groups were matched by gender, age group and community. Control 1 included those having a positive FOBT but refusing a colonoscopy. Control 2 included those who refused both an FOBT and colonoscopy. RESULTS： The impact of occupation on willingness to attend a colorectal screening program differed by gender. P for heterogeneity was 0.009 for case vs control group 1, 0.01 for case versus control group 2, and 0.80 for control group 1 vs 2. Poor awareness of CRC and its screening program, characteristics of screening tests, and lack of time affected thescreening rate. Financial support, fear of pain and bowel preparation were barriers to a colonoscopy as a screening test. Eighty-two percent of control group 1 and 87.1% of control group 2 were willing attend if the colonoscopy was free, but only 56.3% and 53.1%, respectively, if it was self-paid. Multivariate odds ratios for case vs control group 1 were 0.10 among those unwilling to attend a free colonoscopy and 0.50 among those unwilling to attend a self-paid colonoscopy. CONCLUSION： Raising the public awareness of CRC and its screening, integrating CRC screening into the health care system, and using a painless colonoscopy would increase its screening rate.     

Screening programs for sporadic colorectal carcinoma

In developed countries colorectal cancer (CRC) is the second most frequent organ malignancy of both genders. According to the world statistics Czech Republic occupies the top position in incidence of this disease. Approximately 75% of all CRC are the sporadic CRC in subjects with negative family or personal history of the disease. The low (average) risk factor in these subjects is age over 50 years, from which the incidence of CRC nearly doubles in each decade. The following options of screening are available for these subjects: 1. faecal occult blood test (FOBT), 2. flexible sigmoidoscopy, 3. combination of both previous procedures, 4. colonoscopy, 5. virtual colonography. FOBT is the mostly used programme in asymptomatic subjects over age 50 at one-year or at least two-years intervals. In FOBT-positive persons colonoscopy is considered the optimal diagnostic and in the case of polyps also therapeutic method. Prospective randomized studies proving a decrease of CRC-mortality in the range of 15-33% are available only for this type of programme. Screening of sporadic CRC was introduced on national basis in Federal Republic Germany in 1977 and in Czech Republic since the second half of the year 2000. With so many people dying of the disease, we cannot afford not to do its screening.     

Socioeconomic Disparities in Colorectal Cancer Screening in Korea: A Nationwide Cross-Sectional Study

Colorectal cancer (CRC) is a common cancer worldwide. The incidence and mortality rates of CRC are higher among lower socioeconomic status (SES) populations.We investigated the association between different indicators of SES and CRC screening rates in Korea. The eligible study population included males and females aged 50 to 74 years who participated in a nationwide cross-sectional survey (2010–2012). The “compliance with recommendation” category was applicable to participants who had undergone a fecal occult blood test (FOBT), double-contrast barium enema, or colonoscopy within 1, 5, or 10 years, respectively.In total, 6221 subjects (51.4% female, 55.6% aged 50 years) were included in the final analysis. Lower household income was significantly negatively related to compliance with screening recommendations (P for trend < 0.01) and marginally significantly related to noncompliance with recommendations (P for trend = 0.07). Older age and poor self-reported health were associated with the screening rate using the FOBT; male sex, older age, higher household income, having supplemental insurance, family history of cancer, and poor self-reported health were associated with a higher screening rate using colonoscopy.Lower household income was associated with a higher screening rate using the FOBT and with a lower screening rate using colonoscopy. To increase the rate of CRC screening using colonoscopy, efforts should be made toward improving the education and promotion of screening to the low household income target population.     

Potential impact of population-based colorectal cancer screening in Canada

Randomized controlled trials (RCT) have shown the efficacy of screening for colorectal cancer (CRC) using the faecal occult blood test (FOBT) with follow-up by colonoscopy. We evaluated the potential impact of population-based screening by FOBT followed by colonoscopy in Canada: mortality reduction, cost-effectiveness, and resource requirements. The microsimulation model POHEM was adapted to simulate CRC screening using Canadian data and RCT results about test sensitivity and specificity, participation, incidence, staging, progression, mortality and direct health care costs. In Canada, biennial screening of 67% of individuals aged 50-74 in the year 2000 resulted in an estimated 10-year CRC mortality reduction of 16.7%. The life expectancy of the cohort increased by 15 days on average and the demand for colonoscopy rose by 15% in the first year. The estimated cost of screening was $112 million per year or $11,907 per life-year gained (discounted at 5%). Potential effectiveness would depend on reaching target participation rates and finding resources to meet the demand for FOBT and colonoscopy. This work was conducted in support of the National Committee on Colorectal Cancer Screening.     

New era of colorectal cancer screening

Colorectal cancer（CRC） is the 2^nd most common cancer in women and 3^rd most common cancer in men worldwide. Most CRCs develop from adenomatous polyps arising from glandular epithelium. Tumor growth is initiated by mutation of the tumor suppressor gene APC and involves other genetic mutations in a stepwise process over years. Both hereditary and environmental factors contribute to the development of CRC. Screening has been proven to reduce the incidence of CRC. Screening has also contributed to the decrease in CRC mortality in the United States. However,CRC incidence and/or mortality remain on the rise in some parts of the world（Eastern Europe,Asia,and South America）,likely due to factors including westernized diet,lifestyle,and lack of healthcare infrastructure. Multiple screening options are available,ranging from direct radiologic or endoscopic visualization tests that primarily detect premalignant or malignant lesions such as flexible sigmoidoscopy,optical colonoscopy,colon capsule endoscopy,computed tomographic colonography,and double contrast barium enema- to stool based tests which primarily detect cancers,including fecal DNA,fecal immunochemical test,and fecal occult blood test. The availability of some of these tests is limited to areas with high economic resources. This article will discuss CRC epidemiology,pathogenesis,risk factors,and screening modalities with a particular focus on new technologies.     

Mass screening for colorectal cancer: compliance in Almopea Region

Colorectal cancer (CRC) is the second leading cause of cancer-related morbidity and mortality in Europe and the United States. Planning for a CRC screening began in co-operation with local authorities (Pella Prefecture sponsored test kits). Our aims were to develop a screening programme for colorectal cancer using the faecal occult blood test (FOBT) in Almopea province, and to investigate the compliance of local farmers population. Cancer statistics data from Almopea have been analysed and they showed higher colorectal cancer incidence compared to the rest of Greece. We designed a one-time FOBT screening programme on the Surgery Department computer Network, in which we listed 8963 subjects, over 50 years of age. From them, 4189 underwent 3 days FOBT, and the rest were our control group. The method of successive visits to each community by the medical team and educational meeting was chosen. For allocation and gathering of tests, teams of volunteers have been organised. In case of positive FOBT (176 subjects), total colonoscopy was performed. Seventeen (17) polypoids (in 15 patients) and 20 cases of diverticulosis were detected. The compliance of FOBT group was 49% (from 4189). Colonoscopy accepted 89% from 176 patients with positive test. We concluded that our study shows poor compliance of screening population. There is a need for co-operation of medical services, local authorities, media and volunteers support organising.