Randomized study of biennial screening with a faecal occult blood test: results after nine screening rounds

Background: Two large true population studies in Europe have shown a significant reduction in mortality from colorectal cancer (CRC) by screening with a faecal occult blood test. In one trial conducted in Funen County, 61,933 individuals (aged 45–75 years) were randomly allocated either to a control group or to receive a biennial Hemoccult‐II test. Methods: These individuals were followed from 1985 to 2002 and 9 screening rounds were performed. Results: First screening was accepted by 67% (20,672). Positivity rates varied between 0.8% and 3.8%, and the cumulative proportion of the test group having colonoscopy was 5.3%. Screen‐detected CRC was early (Dukes' A) in 36% compared to 11% among controls. Incidence of CRC was unchanged, but mortality was reduced by 11%. This figure increased to 43% in persons participating in all 9 rounds. No more than 8,558 were screened at the 9th round. Patients with CRC detected between screenings had better survival than controls. Death rates from causes other than CRC among participants never became higher than among controls. Conclusion: The lesser reduction in mortality from CRC of 11% compared to 18% after 5 screening rounds may be explained by the decrease in the number screened. Efficacy in those screened supports the introduction of countrywide screening in Denmark, but it must be ascertained that acceptability, proportion of early CRC and logistics all reach the same standard as in the randomized trial.     

Aspects of colorectal cancer screening,methods, age and gender

Colorectal cancer (CRC) is, besides breast, prostate, lung and skin cancers, the most common cancer worldwide and is suitable for screening. The incidence of CRC varies considerably in different parts of the world: in well-developed countries, the incidence is between 30 and 70 per 100 000 inhabitants, whereas in less-developed countries such as sub-Saharan Africa, it is 10–20/100 000 inhabitants. Women have a lower incidence of CRC, which is usually one-third of total incidence. Several studies have shown that it is possible to decrease mortality from CRC with about 20%, which is evidenced through the data from countries with screening programmes. Though the method of choice to identify blood samples in faecal matter is under debate, the most feasible way is to perform colonoscopy. Other methods include more advanced faecal analyses, testing for mutations from CRC, sigmoidoscopy, CT colonoscopy or optical colonoscopy. Colonoscopy is in most countries not available in sufficient amount and has to be carried out with great accuracy; otherwise, lesions will be missed to identify, thus leading to complications. Gender is an issue in CRC screening, as women have about 20% fewer colorectal adenomas and CRCs, but they also have more right-sided lesions, which are more difficult to detect with tests for faecal blood since they create less blood in faeces. Thus, other strategies may have to be developed for women in order for screening to have the same effect. It is essential to introduce colorectal cancer screening in all countries together with other clinical pieces of advice such as information on smoking, obesity and exercise in order to reduce one of the most dangerous cancers.     

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).     

Colorectal cancer screening

Colorectal cancer (CRC) is the third most common cause of cancer death worldwide and a major health problem. In this review, the different approaches for CRC screening will be outlined with emphasis on evidence-based medicine. Evidence from randomized trials on the effectiveness of CRC screening is summarized. Several screening tools for CRC are available. They can be categorized according to their mode of action: early detection tools such as the faecal occult blood test (FOBT) and cancer prevention tools such as flexible sigmoidoscopy and colonoscopy. Meta-analyses of randomized trials show that FOBT screening reduces CRC mortality by 16% (risk ratio 0.84; 95% confidence interval (CI) 0.78-0.9) compared with 30% (risk ratio 0.7; 95% CI 0.6-0.81) for flexible sigmoidoscopy screening. FOBT screening is cheap and noninvasive, but results in large numbers of false-positive tests and needs to be repeated frequently. Flexible sigmoidoscopy is more invasive, but is effective for once-only screening. Although colonoscopy screening is used in some countries, no randomized trials have been conducted to estimate its benefit, and therefore, it should not be recommended at the present time. Faecal occult blood test and flexible sigmoidoscopy are the two CRC screening tools that can be recommended as they have been proven to reduce CRC mortality. Colonoscopy has the potential to be superior to FOBT and flexible sigmoidoscopy, but needs to be evaluated in randomized trials before any recommendation can be provided.     

Race and colorectal cancer screening compliance among persons with a family history of cancer

AIM: To determine compliance to colorectal cancer (CRC) screening guidelines among persons with a family history of any type of cancer and investigate racial differences in screening compliance.METHODS: We used the 2007 Health Information National Trends Survey and identified 1094 (27.4%) respondents (weighted population size = 21959672) without a family history of cancer and 3138 (72.6%) respondents (weighted population size = 58201479) with a family history of cancer who were 50 years and older. We defined compliance with CRC screening as the use of fecal occult blood testing within 1 year, sigmoidoscopy within 5 years, or colonoscopy within 10 years. We compared compliance with CRC screening among those with and without a family member with a history of cancer.RESULTS: Overall, those with a family member with cancer were more likely to be compliant with CRC screening (64.9% vs 55.1%; OR = 1.45; 95%CI: 1.20-1.74). The absolute increase in screening rates associated with family history of cancer was 8.2% among whites. Hispanics had lowest screening rates among those without family history of cancer 41.9% but had highest absolute increase (14.7%) in CRC screening rate when they have a family member with cancer. Blacks had the lowest absolute increase in CRC screening (5.3%) when a family member has a known history of cancer. However, the noted increase in screening rates among blacks and Hispanics when they have a family member with cancer were not higher than whites without a family history of cancer: (54.5% vs 58.7%; OR = 1.16; 95%CI: 0.72-1.88) for blacks and (56.7% vs 58.7%; OR = 1.25; 95%CI: 0.72-2.18) for Hispanics.CONCLUSION: While adults with a family history of any cancer were more likely to be compliant with CRC screening guidelines irrespective of race/ethnicity, blacks and Hispanics with a family history of cancer were less likely to be compliant than whites without a family history. Increased burden from CRC among blacks may be related to poor uptake of screening among high-risk groups.     

Switching from guaiac to immunochemical faecal occult blood test increases participation and diagnostic yield of colorectal cancer screening

BackgroundCompared with the guaiac-faecal occult blood test (gFOBT), faecal immunological tests (FIT) are considered to be more effective for colorectal cancer (CRC) screening. However, only scarce research has examined the outcomes of switching to FIT within a mature gFOBT-based CRC screening programme.MethodsWe reported a 15-year experience of biennial FOBT screening in a well-defined population of approximately one million inhabitants, including six gFOBT-based screening rounds and one round with FIT at the 30 μg Hb/g cut-off. The main outcome measures were screening participation, FOBT positivity and advanced neoplasia detection in each round.ResultsIn this study, 647 676 screenings were performed in 228 716 different individuals, leading to 17 819 positives and 16 580 follow-up colonoscopies. Compared with the last gFOBT round, switching to FIT led to an increased participation of nearly 20% points, and a fivefold increased detection of CRC and advanced adenoma among invitees (3-fold among attendees). The numbers needed to screen and scope to detect one advanced neoplasia declined from 221 to 66 and from 4.7 to 2.6, respectively.ConclusionsThe present population-based study demonstrated a dramatical increase in the diagnostic yield of advanced neoplasia by switching to FIT within a mature gFOBT-based CRC screening programme.     

Acceptance on colorectal cancer screening upper age limit in South Korea

BACKGROUND The Korea National Cancer Screening Program currently provides screening for colorectal cancer(CRC) for adults older than 50 years with no upper age limit. In general, people are likely to only pay attention to the benefits of cancer screening and to neglect its risks. Most consider the benefits of cancer screening as being far greater than the risks and are unaware that any potential benefits and harms can vary with age.AIM To report acceptance of an upper age limit for CRC screening and factors associated therewith among cancer-free individuals in Korea.METHODS The present study analyzed data from the Korea National Cancer Screening Survey 2017, a nationally representative random sample of 4500 Korean individuals targeted for screening for the five most common types of cancer. A total of 1922 participants were included in the final analysis. The baseline characteristics of the study population are presented as unweighted numbers and weighted proportions. Both univariate and multivariate logistic regression models were developed to examine factors related with acceptance of an upper age limit for CRC screening; subgroup analysis was also applied.RESULTS About 80%(1554/1922) of the respondents agreed that CRC screening should not be offered for individuals older than 80 years. Specifically, those who had never been screened for CRC had the highest acceptance rate(91%). Overall, screening history for CRC [screened by both fecal occult blood test and colonoscopy, adjusted odds ratio(aOR) = 0.33, 95%CI: 0.22-0.50] and other cancers(aOR = 0.55, 95%CI: 0.34-0.87), as well as a family history of cancer(aOR = 0.66, 95%CI: 0.50-0.87), were negatively associated with acceptance of an upper age limit for CRC screening. In contrast, metropolitan residents(aOR = 1.86, 95%CI: 1.29-2.68) and people who exercised regularly(aOR = 1.42, 95%CI: 1.07-1.89) were more likely to accept an upper age limit. After subgrouping, we found gender, marital status, and lifetime smoking history among never-screened individuals and residential region, family history of cancer, and physical activity among never-screened individuals to be associated with acceptance of an upper age limit.CONCLUSION This study describes acceptance of an upper age limit for CRC screening and factors associated with it, and provides perspectives that should be considered, in addition to scientific evidence, when developing population-based cancer screening policies and programs.     

Colorectal cancer screening:20 years of development and recent progress

Colorectal cancer(CRC)is the second most common cancer in Europe and its incidence is steadily increasing.This trend could be reversed through timely secondary prevention(screening).In the last twenty years,CRC screening programs across Europe have experienced considerable improvements(fecal occult blood testing;transition from opportunistic to population based program settings).The Czech Republic is a typical example of a country with a long history of nationwide CRC screening programs in the face of very high CRC incidence and mortality rates.Each year,approximately 8000 people are diagnosed with CRC and some 4000 die from this malignancy.Twenty years ago,the first pilot studies on CRC screening led to the introduction of the opportunistic Czech National Colorectal Cancer Screening Program in 2000.Originally,this program was based on the guaiac fecal occult blood test(FOBT)offered by general practitioners,followed by colonoscopy in cases of FOBT positivity.The program has continuously evolved,namely with the implementation of immunochemical FOBTs and screening colonoscopy,as well as the involvement of gynecologists.Since the establishment of the Czech CRC Screening Registry in 2006,2405850 FOBTs have been performed and 104565 preventive colonoscopies recorded within the screening program.The overall program expanded to cover 25.0%of the target population by 2011.However,stagnation in the annual number of performed FOBTs lately has led to switching to the option of a population-based program with personal invitation,which is currently being prepared.     

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.     

The intelligent,painless, “germ-free” colonoscopy: A Columbus’ egg for increasing population adherence to colorectal cancer screening?

Colorectal cancer (CRC) represents a major cause of morbidity and mortality. Although it is widely accepted that CRC screening in average risk populations lowers CRC incidence and mortality, a disappointedly low adherence rate to both faecal occult blood testing and colonoscopy-based screening programs has been observed in Italy and in other European countries. Main reasons for the low acceptance of colonoscopy-based CRC screening has been ascribed to lack of recommendations given by general practitioners, fear of discomfort or complications, embarrassment, and avoidance of unpleasant preparation.     

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.     

Cost-effectiveness of colorectal cancer screening

Colorectal cancer (CRC) screening in France is based on a faecal occult blood test every two years in average risk subjects 50-74 years of age while other endoscopic or non-endoscopic screening methods are used in Europe and in the USA. Beside the reduced incidence of and mortality from CRC found in available studies, cost-effectiveness data need to be taken into account. Because of the delay between randomized controlled trials and clinical results, transitional probabilistic models of screening programs are useful for public health policy makers. The aim of the present review was to promote the implementation of cost-effectiveness studies, to provide a guide to analyze cost-effectiveness studies on CRC screening and, to propose a French cost effectiveness study comparing CRC screening strategies. Most of these trials were performed by US or UK authors and demonstrate that the incremental cost-effectiveness ratio varies between 5 000 and 15 000 US dollars/one year life gained, with wide variations: these results were highly dependent on the unit costs of the different devices as well as the predictive values of the screening tests. Although CRC screening programs have been implemented in several administrative districts of France since 2002, and the results of these randomized controlled trials using fecal occult blood have been updated, cost-effectiveness criteria need to be integrated; especially since the results of screening campaigns based on other tools such as flexible sigmoidoscopy should be available in 2007.     

A questionnaire-based survey on screening for gastric and colorectal cancer by physicians in East asian countries in 2010

Background: The incidence of gastric cancer (GC) is high, and colorectal cancer (CRC) has significantly increased in Asian countries. Aim: To examine the current screening for GC and CRC within East Asia by means of a questionnaire survey. Methods: Representative members of the Committee of the International Gastrointestinal Consensus Symposium provided a questionnaire to physicians in six East Asian countries. Results: A total of 449 physicians participated in this survey. In all countries, more than 70% of physicians started GC screening between 40 and 59 years. The most popular method to screen for GC was endoscopy (92.7%), but combination methods such as Helicobacter pylori (HP) antibody, barium X-ray, and tumor marker with endoscopy differed by country. For HP-positive individuals, most physicians screened every year by endoscopy, and for individuals post-HP eradication, about half of physicians (56.3%) thought there was a need to follow-up with GC screening. Among all physicians, the most common age to start CRC screening was in the 40s (39.8%) and 50s (40.9%). Based on the American Cancer Society Recommendations, a fecal occult blood test every year was the most popular method for CRC screening overall. However, among each country, this test was most popular in only Japan (76.9%) and Indonesia. In other countries, sigmoidoscopy every 5 years and total colonoscopy every 10 years were the most popular methods. Conclusion: There are similarities and differences in the screening of GC and CRC among East Asian countries.     

Options for screening for colorectal cancer

Unlike other types of cancer, there are several options for screening for colorectal cancer (CRC). The most extensively examined method, faecal occult blood testing (FOBT), has been shown, in three large randomized trials, to reduce mortality from CRC by up to 20% if offered biennally and possibly more if offered every year. Recently published data from the US trial suggest that CRC incidence rates are also reduced by up to 20%, but only after 18 years. In this study, the number of positive slides was associated with the positive predictive value both for CRC and adenomas larger than 1 cm, suggesting that the reduction in CRC incidence was caused by the identification and removal of large adenomas. In this respect, this study supports the concept that removing adenomas prevents CRC. More efficient methods of detecting adenomas include the use of colonoscopy or flexible sigmoidoscopy (FS). Considerable evidence exists from case-control and uncontrolled cohort studies to suggest that endoscopic screening by sigmoidoscopy reduces incidence of distal colorectal cancer. However, in the absence of evidence from a randomized trial, several countries have been reluctant to introduce endoscopic screening. Three trialsare currently in progress (in the UK, Italy and the US) to address this issue. Two of these trials are examining the hypothesis that a single FS screen at around age 55-64 might be a cost-effective and acceptable method for reducing CRC incidence rates. Recruitment and screening are now complete in both studies and the first analysis of results on incidence rates is expected in 2004. Colonoscopy screening at 10-year intervals has recently been endorsed in the US on the basis that the reductions in incidence observed with distal CRC screening can be extrapolated to the proximal colon. However, data are lacking and a pilot study for a trial of the acceptability and efficacy of colonoscopy screening is in progress in the US. It has also been suggested that FOBT testing should be used to detect proximal CRC missed by sigmoidoscopy screening, but the small amount of published data suggest that supplementing FS with FOBT offers very little advantage over FS alone. Other forms of CRC screening are under investigation and represent exciting options for the future. Extraction of DNA from stool is now feasible and a number of research groups have shown high sensitivity for CRC using a panel of DNA markers including mutations in k-ras, APC, p53 and BAT26. Data so far indicate that, with the exception of k-ras, these markers are highly specific and therefore represent a significant improvement over FOBT. Whether these tests will replace or supplement existing methods of screening has yet to be determined. It has been suggested that BAT26, which is a marker of microsatellite instability, a feature of proximal sporadic CRC, might be a useful adjunct to sigmoidoscopy screening. Others have suggested that a test for occult blood should be included with the DNA markers to further increase sensitivity. It is not yet known how sensitive these markers are for adenomas--it is only by detecting adenomas that CRC incidence rates can be reduced. A final exciting new option for screening is virtual colonoscopy (VC), which by screening out people without neoplasia allows colonoscopy to be reserved for patients requiring a therapeutic intervention. The sensitivity of VC for large adenomas and CRC appears to be high, although results vary by centre and there is a steep learning curve. Sensitivity for small adenomas is low, but perhaps it is less essential to find such lesions. Some groups have suggested that virtual colonoscopy might be a useful option for investigating patients who test positive with stool-based screening tests. Whichever CRC screening method is finally chosen (and there is no reason why several methods should not ultimately be available), high quality endoscopy resources will always be required to investigate and treat neoplastic lesions detected.     

Colorectal cancer screening: An updated review of the available options

Colorectal cancer(CRC) is a significant cause of morbidity and mortality worldwide. However,colon cancer incidence and mortality is declining over the past decade owing to adoption of effective screening programs. Nevertheless,in some parts of the world,CRC incidence and mortality remain on the rise,likely due to factors including "westernized" diet,lifestyle,and lack of health-care infrastructure and resources. Participation and adherence to different national screening programs remain obstacles limiting the achievement of screening goals. Different modalities are available ranging from stool based tests to radiology and endoscopy with varying sensitivity and specificity. However,the availability of these tests is limited to areas with high economic resources. Recently,FDA approved a blood-based test(Epi procolon?) for CRC screening. This blood based test may serve to increase the participation and adherence rates. Hence,leading to increase in colon cancer detection and prevention. This article will discuss various CRC screening tests with a particular focus on the data regarding the new approved blood test. Finally,we will propose an algorithm for a simple cost-effective CRC screening program.     

Lung cancer screening – are we there yet?

BackgroundLung cancer is the most lethal cancer and most cases are the result of cigarette smoking. Although a high risk target population for screening can be defined, and although early stage lung cancer has a much better prognosis than advanced disease, there is still no clear evidence that lung cancer screening decreases mortality. Accordingly, current guidelines suggest that there is no evidence to support routine screening. Although randomized studies in the 1970^′s which used chest x-ray and sputum for screening were clearly negative in the last 20 years more sensitive screening tools such as chest computed tomography have revolutionized the field. However, randomized controlled trials of computed tomography have only recently been launched.Aims of this reviewOur objectives are to provide the reader with the rationale for screening for lung cancer, to review the older screening studies and their limitations, and to summarize the current knowledge and ongoing trials of lung cancer screening.Literature searchA literature search using Medline was conducted from 1966 onwards searching for articles with relevant key words such as lung cancer screening chest X – ray low dose computerized tomography cancer screening guideline. When appropriate additional references were found from the bibliographies of identified papers of interest.ConclusionsRecent uncontrolled multicenter studies of chest computed tomography scans show encouraging results. However, until data from, large properly designed and appropriately analyzed randomized controlled trials which may overcome research biases is available, the benefit of lung cancer screening, if any is still unknown.     

Population-based screening for colorectal cancer: Australian research and implementation

Australia is one of the first countries in the world to implement an organized whole-of-population screening program for colorectal cancer (CRC). Australians have made broad contributions to CRC in general ranging from primary prevention through genetics, secondary prevention and treatment, to palliation. This overview focuses on some of the contributions of direct relevance to population-based screening, stretching from technology development to population-based controlled studies and health services research. In terms of simple screening tests in a two-step screening strategy, the evidence is overwhelming that fecal immunochemical tests for hemoglobin (FITs) improve detection and are more acceptable. FIT-based screening is clearly acceptable to Australians and it has been demonstrated that a national organized screening program is feasible. In terms of benefit for Australians, with full roll out and high uptake by the population we could see the number of cases dying from CRC halved by this strategy. To this will be added the extra-screening benefits of improved diagnosis, improved treatment and improved public awareness, all benefits of other screening programs. CRC screening has progressed from a matter of irrelevance and distaste, to commonwealth government policy in the context of an organized program for all Australians.     

Potential for prevention: a cohort study of colonoscopies and removal of adenomas in a FIT-based colorectal cancer screening programme

Introduction: Evidence suggests that colorectal cancer (CRC) screening using guaiac faecal occult blood tests (gFOBT) reduces the CRC burden by facilitating timely removal of adenomas. Yet, the faecal immunochemical test (FIT) is being implemented in many countries. The aim of this study was to analyse the risk of having adenomas detected when invited for FIT-based screening as compared to those not yet invited.

Material and Methods: The study was designed as a register-based retrospective cohort study. The potential for prevention was estimated as number of individuals who had no adenomas, non-advanced adenomas, and advanced adenomas detected per 1000 invited/not yet invited individuals and the relative risk (RR) of each of the three outcomes.

Results: A total of 1,359,340 individuals were included, 29.6% of whom had been invited and 70.4% had not yet been invited to participate in CRC screening. Compared with the not yet invited population, the invited group had a RR of no adenomas of 2.28 (2.22–2.34) and a RR of advanced adenomas of 7.41 (6.93–7.91). The RR of colonoscopy was 2.93 (2.87–2.99) for the invited population compared with the not yet invited population.

Conclusion: The RR of having a colonoscopy was three times higher among those invited compared to those not yet invited for CRC screening and twice as often those who had been invited compared to those not yet invited had no adenomas detected. Still, the risk of advanced adenomas was more than seven times higher among the invited population, indicating that the screening programme holds great potential for reducing the CRC burden.

Abbreviations: CI: Confidence interval; CRC: Colorectal cancer; FIT: Faecal immunochemical test; ICD: International Classification of Disease; RR: Relative risk     

Design,organization and management of a controlled population screening study for detection of colorectal neoplasia: attendance rates in the NORCCAP study (Norwegian Colorectal Cancer Prevention)

BACKGROUND: In the past three decades, the incidence of colorectal cancer (CRC) in Norway has doubled, surpassing all other Nordic countries for both men and women to become the most frequently diagnosed cancer. A small-scale, randomized study on flexible sigmoidoscopy (FS) screening in Telemark, Norway, has shown a reduction in accumulated CRC incidence after 13 years. The aim of our study was to evaluate the effect on CRC mortality and morbidity by screen detection of CRC and removal of precursor lesions (polypectomy), and to test out the management and organization mimicking a countrywide screening service. A total of 13,823 men and women (1:1), age 55-64 years, were drawn randomly from the population registries in Oslo (urban) and the county of Telemark (mixed urban and rural) and invited to have a screening examination. The rest of the relevant age cohorts constituted the control groups. In the screening group, 535 individuals were excluded according to exclusion criteria, rendering 13,288 individuals eligible for screening examination. METHODS: A once only screening model was used. In the screening group, individuals were randomized to have a once only FS or a combination of FS and faecal occult blood test (FOBT). RESULTS: The overall attendance rate was 8,849 out of 13,288 (67%); 73% in Telemark and 60% in Oslo. Attendance for FS only was 68% and 65% for combined FS&FOBT. CONCLUSIONS: The present FSIFS&FOBT screening study obtained a high acceptance rate for both screening modalities. The attendance rate was stable throughout the trial, suggesting an acceptable model for management of future countrywide screening.     

Favorable colorectal cancer mortality-to-incidence ratios in countries with high expenditures on health and development index: A study based on GLOBOCAN database

Background:Global variation in the incidence and outcomes of colorectal cancer (CRC) is associated with many factors, among which screening policies and early treatment play substantial roles. However, screening programs and intense treatment are expensive and require good health care systems. For CRC, no clear association has yet been established between clinical outcomes and health care disparities.Method:We used the mortality-to-incidence ratio (MIR) of CRC as a measure of clinical outcomes for comparison with the Human Development Index (HDI), current health expenditure (CHE), and current health expenditure as a percentage of gross domestic product (CHE/GDP) using linear regression analyses. We included 171 countries based on data from the GLOBOCAN 2018 database.Results:We found that the regions with the lowest MIRs for CRC are Oceania and North America. A significant correlation was observed between incidence, mortality and HDI, CHE, and CHE/GDP among the countries enrolled. Furthermore, lower MIRs of CRC significantly correlated with higher HDI, CHE, and CHE/GDP (P < 0.001, P < 0.001, and P < 0.001, respectively).Conclusion: CRC MIRs tend to be most favorable in countries with high health care expenditures and a high HDI.