Cost-effectiveness analysis of two strategies for mass screening for colorectal cancer in France

The implementation of colorectal cancer mass screening is a high public health priority in France, as in most other industrialised countries. Despite evidences that screening using guaiac fecal occult blood test may reduce colorectal cancer mortality, no European country has organised widespread mass screening with this test. The low sensitivity of this test constitutes its main limitation. Immunological tests, which provide higher sensitivity than the guaiac test, may constitute a satisfactory alternative. This study was carried out to compare the costs and the effectiveness of 20 years of biennial colorectal cancer (CRC) screening with an automated reading immunological test (Magstream) with those obtained with a guaiac stool test (Haemoccult). The model used to estimate the costs and effectiveness of successive biennial CRC screening campaigns was a transitional probabilistic model. The parameters used in this model concerning costs and CRC epidemiological data were calculated from results obtained in the screening program run in Calvados or from published results of foreign studies because of the lack of French studies. The use of Magstream for 20 years of biennial screening costs 59 euros more than Haemoccult per target individual, and should lead to a mean increase in individual life expectancy of 0.0198 years (i.e. about one week), which corresponds to an incremental cost-effectiveness ratio of 2980 euros per years of life saved. Our results suggest that using an immunological test could increase the effectiveness of CRC screening at a reasonable cost for society.     

New screening method for occult gastrointestinal bleeding: immunologic and guaiac slide tests

A valid mass screening method for occult, bleeding gastrointestinal pathology including colorectal cancer should be monospecific for human hemoglobin, sensitive for approximately 3 mg of human blood per 1 g of stool, capable of differentiating upper and lower gastrointestinal bleeding, cost effective, uncomplicated, and acceptable to patients. Hemoccult II, a guaiac peroxidase detection test, is nonspecific for human blood and cannot differentiate between upper and lower gastrointestinal bleeding. A radial immunodiffusion slide test for detecting human hemoglobin was compared with a guaiac test over a four-year period in 211 patients. in gastrointestinal problems diagnosed by endoscopy, roentgenographic rays, and other procedures, the Hemoccult II was positive in 9 of 41 cases of upper gastrointestinal tract origin (21 percent detection rate), whereas the radial immunodiffusion method, expected to be negative as a result of action of gastrointestinal proteases, was positive in only 3 and negative in 38 of the 41 samples (92 percent accuracy). The two tests were equally effective in detecting lower gastrointestinal bleeding (14 of 37 samples, 37 percent accuracy). The findings of this study indicate that the immunologic test may remedy the deficiencies of the guaiac test. The concomitant use of the immunologic and appropriately sensitive guaiac test appears to fulfill screening test requisites.     

Cancer screening services for the elderly

The reported practices and recommendations of primary care physicians with regard to cancer screening of elderly patients (65 years and older) were studied in a 1987 survey of 400 Maryland physicians. More than 90 percent of physicians in four specialties studied reported providing digital rectal examinations, physical breast examinations, and mammography to the elderly. However, only 54 percent of obstetrician-gynecologists and 68 percent of general practitioners provided sigmoidoscopy, 70 percent of obstetrician-gynecologists provided stool guaiac slide tests, 74 percent of general practitioners provided breast self-exam instruction, and 79 percent of internists provided Pap tests. Physicians were asked what screening intervals they recommended for each test for asymptomatic elderly patients. These reports were compared with current American Cancer Society (ACS) recommendations. Large proportions of physicians in four specialties recommended sigmoidoscopy and mammography less often than the ACS recommended. More than 20 percent of physicians in the four specialties believed the elderly do not need routine sigmoidoscopy. Most physicians (90 percent or more) recommended Papanicolaou tests more often than the ACS recommended. Specialty and young physician age were the best predictors of physicians' overall adherence to ACS recommendations for cancer screening schedules.     

Peer Reviewed: Exploring Perceptions of Colorectal Cancer and Fecal Immunochemical Testing Among African Americans in a North Carolina Community

Introduction

African Americans have a lower colorectal cancer screening rate than whites and higher disease incidence and mortality. Despite wide acceptance of colonoscopy for accurate screening, increasing promotion of high-sensitivity stool test screening, such as the fecal immunochemical test (FIT), may narrow racial, ethnic, and socioeconomic disparities in screening. This study provides formative research data to develop an intervention to increase colorectal cancer screening among underinsured and uninsured African Americans in central North Carolina.

Methods

We held 4 focus groups to explore knowledge, beliefs, and attitudes about colorectal cancer screening, particularly FIT. Participants (n = 28) were African American adults recruited from neighborhoods with high levels of poverty and unemployment. Constructs from the diffusion of innovation theory were used to develop the discussion guide.

Results

In all groups, participants noted that lack of knowledge about colorectal cancer contributes to low screening use. Attitudes about FIT sorted into 4 categories of "innovation characteristics": relative advantage of FIT compared with no screening and with other screening tests; compatibility with personal beliefs and values; test complexity; and test trialability. A perceived barrier to FIT and other stool tests was risk of incurring costs for diagnostic follow-up.

Conclusion

Community-based FIT screening interventions should include provider recommendation, patient education to correctly perform FIT, modified FIT design to address negative attitudes about stool tests, and assurance of affordable follow-up for positive FIT results.     

Variation in Recommendations for Cancer Screening among Primary Care Physicians in New Mexico

The acceptance of age-appropriate cancer screening as an integral part of primary care has grown among physicians over the past decade. We conducted a mailed survey of all primary care physicians in New Mexico in order to better understand their current cancer screening practices. We found a high rate of self-reported screening, particularly for prostate and colorectal cancer. The screening rates were influenced only slightly by the introduction of evidence-based guidelines, with younger physicians and those with university affiliations more likely to follow recommendations. Female physicians and obstetrician-gynecologists endorsed breast and cervical cancer screening among all age groups and were less likely to follow recommendations for less frequent screening in women as they age. Since a physician's practice beliefs influence his/her attitude toward testing, tailoring education by physician specialty may be more effective than using generic messages in encouraging compliance with the most recent evidence-based guidelines.     

Colorectal cancer screening: practices and opinions of primary care physicians

BACKGROUND: The Canadian Task Force on Preventive Health Care (CTFPHC), in 2001, concluded that there is good evidence to include annual or biennial fecal occult blood testing (FOBT) and fair evidence to include flexible sigmoidoscopy in the periodic health examination of asymptomatic adults more than 50 years of age. METHODS: Mailed survey of Alberta primary care physicians to determine current colorectal cancer (CRC) screening practices, familiarity with the new guideline, and opinions about, and barriers to, screening average-risk patients. RESULTS: Response rate was 58.0% (n = 965). Less than half (41.9%) were familiar with the new Canadian guideline. The majority (74.7%) recommended that asymptomatic patients undergo screening; however, only 35.6% offered screening to at least 75% of average-risk patients. Few (9.4%) rated fecal occult blood as an "excellent or very good" screening test. Most (64.1%) physicians would choose colonoscopy if they themselves were to undergo screening. Concerns were raised about cost-effectiveness, inconsistencies of current recommendations, and resources. CONCLUSION: Although supportive of colorectal cancer screening of average-risk patients, few physicians recommend screening for the majority of their patients. Clarification of inconsistencies between guidelines, resource issues, and the availability of efficacious screening tests is required for wider acceptance of the new Canadian guideline.     

Aktueller Stand der Evidenz und Entwicklung der Darmkrebsfrüherkennung in Deutschland

Colon cancer is currently the third leading cause of cancer death in men and women in Germany, with a total of about 25,000 deaths per year. Established methods for early detection of colorectal cancer include lower gastrointestinal endoscopy and fecal occult blood testing. For both procedures, there is evidence of a reduction in colorectal cancer-specific mortality and for endoscopy a reduction of colorectal cancer incidence has been shown.In Germany, the guaiac test for fecal occult blood has been offered since 1977. Additionally, screening colonoscopy has been offered since 2002 and in 2016, the guaiac test was replaced by the immunological fecal occult blood test, which has an improved diagnostic performance. Overall, participation rates have been low over the past decades and differed between men, women, and age groups.Personal invitations are expected to be sent out starting in 2019 as part of the introduction of an organized colorectal cancer screening program in Germany. The program also provides for measures to systematically monitor and improve the quality of colorectal cancer screening. It remains to be seen which effects these changes will have and whether the trend towards declining colon cancer incidence and mortality that has been observed in Germany will continue in the coming years.     

Comparing participation rates between immunochemical and guaiac faecal occult blood tests: a systematic review and meta-analysis

Background

Biennial screening with faecal occult blood tests (FOBts) has been found to reduce colorectal cancer mortality. Faecal immunochemical tests (FITs) are superior to guaiac faecal occult blood tests (G-FOBts) due to their improved sensitivity and specificity. However the effectiveness of a screening programme depends highly on participation rates. The aim of this study was to review studies comparing guaiac faecal occult blood tests and faecal immunochemical tests, in terms of participation rates.

Methods

We searched PubMed and the Cochrane Library (2000-September 2011) to identify randomised control trials comparing guaiac faecal occult blood test with faecal immunochemical test participation rates. One author screened the titles and abstracts, and performed data extraction which was then checked by the other authors. Risk of bias in the included studies was also assessed.

Results

Seven studies met the eligibility criteria and were entered into a meta-analysis. Participation rates were significantly higher for individuals offered faecal immunochemical tests compared to those offered a guaiac faecal occult blood test (RR 1.21; 95% CI 1.09-1.33). Potential factors that could have influenced participation were discussed.

Conclusions

Colorectal cancer screening programmes currently using guaiac faecal occult blood tests could improve participation rates by converting to faecal immunochemical tests. More research examining the acceptability of faecal immunochemical tests, from a patient perspective, is warranted.     

Family physicians' beliefs about breast cancer screening by mammography

A survey of 509 family physicians in New York State was conducted to assess opinions about mammography and use of mammography in screening asymptomatic women of different ages. Findings indicate that most family physicians believe that mammography is an effective procedure for detecting breast cancer in its early stages, but many do not utilize mammography as a screening procedure in their own practices. The major deterrents to the use of mammography in screening asymptomatic women relate to concerns about the safety and reliability of the procedure, the low probability of detecting breast cancer through screening, the patient's willingness to accept a recommendation to have a mammogram, and cost. The results from this study point out the need to better educate primary care physicians about the use of mammography in screening for breast cancer, especially in regard to its safety and reliability.     

大肠癌序贯筛检方案在人群中应用的前瞻性评估

目的 建立并验证大肠癌序贯筛检方案在我国人群中应用的效果。方法 以大肠癌高发区嘉善县１９８９年３０岁及以上者作为目标人群,采用随机分组空白对照研究设计,以免疫法粪便潜血试验结合个体危险度隶属度函数（ＡＤ值）为初筛手段,纤维肠为复筛的序贯筛检方案。结果 经筛检后筛检人群与对照人群的大肠癌８年累积发病率分别为３．９５‰（９５％ＣＩ为３．８１～４．１０）和４．０１‰（９５％ＣＩ为３．８６～４．１６）,两     

The contribution of a negative colorectal screening test result to symptom appraisal and help‐seeking behaviour among patients subsequently diagnosed with an interval colorectal cancer

Background

Colorectal cancer (CRC) screening programmes using a guaiac faecal occult blood test (gFOBt) reduce CRC mortality. Interval cancers are diagnosed between screening rounds: reassurance from a negative gFOBt has the potential to influence the pathway to diagnosis of an interval colorectal cancer.

Methods

Twenty‐six semi‐structured face‐to‐face interviews were carried out in Scotland and England, with individuals diagnosed with an interval colorectal cancer following a negative gFOBt result.

Results

Participants reported they were reassured by a negative gFOBt, interpreting their result as an “all clear”. Therefore, most did not suspect cancer as a possible cause of symptoms and many did not recall their screening result during symptom appraisal. Among those who did consider cancer, and did think about their screening test result, reassurance from a negative gFOBt led some to “downplay” the seriousness of their symptoms with some interviewees explicitly stating that their negative test result contributed to a delayed decision to seek help.

Conclusion

Screening participants need to be informed of the limitations of screening and the ongoing risk of developing colorectal cancer even when in receipt of a negative result: the importance of minimizing delay in seeking medical advice for colorectal symptoms should be emphasized.     

Sex and race are risk factors for colorectal cancer within reach of the sigmoidoscope

There is controversy about the efficacy and feasibility of flexible fiberoptic sigmoidoscopy (FFS) as a screening test for colorectal cancer in asymptomatic adults aged 50 years and over. Some authorities recommend periodic FFS screening for all such adults, whereas other authorities do not recommend screening FFS at all. There is evidence that some physicians have adopted a policy of "selective screening" by emphasizing screening FFS for adults with ancillary risk factors such as a personal history of colon polyps or previous colorectal cancer, or a family history of colon, female genital, or breast cancer. Results of this study of the subsite distribution of colorectal cancer show that both male sex and Oriental race are risk factors for colorectal cancer within reach of FFS, and that the risk of being male and Oriental (relative risk [RR] = 1.9) is of the same magnitude as that for other ancillary risk factors known for the general population (excluding specific rare disorders). Knowledge that sex and race are risk factors for colorectal cancer detectable by screening FFS may be important to those physicians who choose the selective screening approach. Further research is necessary to determine whether selective screening for colorectal cancer is efficacious, or whether the race and sex differences noted in this study are important in the etiology of colorectal cancer.     

Cancer education among primary care physicians in an underserved community

INTRODUCTION: Urban minority groups, such as those living in north Manhattan, are generally underserved with regard to cancer prevention and screening practices. Primary care physicians are in a critical position to counsel their patients on these subjects and to order screening tests for their patients. METHODS: Eighty-four primary care physicians in two intervention communities who received educational visits about cancer screening and prevention were compared with 38 physicians in a nearby community who received no intervention. With pre- and post-test interviews over an 18-month period, the physicians were asked about their attitudes toward, knowledge of (relative to American Cancer Society guidelines), and likelihood of counseling and screening for breast, cervical, colorectal, and prostate cancers. RESULTS: Comparison of the two surveys of physicians indicated no statistically significant differences in knowledge of cancer prevention or screening. At post-test, however, intervention group physicians identified significantly fewer barriers to practice than control physicians (p<0.05). While overall, the educational visits to inner-city primary care physicians did not appear to significantly alter cancer prevention practices, there was a positive dose-response relationship among the subgroup of participants who received three or more project contacts. CONCLUSIONS: We uncovered significant changes in attitude due to academic detailing among urban primary care physicians practicing in north Manhattan. A significant pre-test sensitization effect and small numbers may have masked overall changes in cancer prevention and screening behaviors among physicians due to the intervention.     

Colorectal cancer and its prevention: prevalence of beliefs,attitudes, intentions and behaviour

Abstract: There is so far only limited evidence from randomised controlled trials that screening for colorectal cancer using the faecal occult blood test produces significant mortality reductions in screened groups, but there is considerable activity and interest in the use of such screening in Australia. Beliefs, attitudes, intentions and behaviour in relation to colorectal cancer and screening were examined among participants 40 years and older (n = 1776) who took part in a representative population survey. While there were high levels of awareness of faecal occult blood test screening, most respondents had not had a test, nor did they intend to take a test in the future. Important determinants of participation in screening were a family history of colorectal cancer, a belief that bowel cancer can be cured if detected at an early stage, a perception of personal susceptibility to bowel cancer and an acceptance of the technique. Factors such as these are likely to influence the success of any future screening program in Australia.     

The importance of health insurance as a determinant of cancer screening: evidence from the Women's Health Initiative

BACKGROUND: Amid current changes in health care access across the United States, the importance of health insurance status and insurance type relative to demographic, actual, and perceived health variables as determinants of screening for breast, colorectal, and cervical cancer is uncertain. This analysis evaluates the hypothesis that health insurance independently predicts cancer screening in the Women's Health Initia tive Observational Study cohort. METHODS: Questionnaire data from 55,278 women en rolled in the Women's Health Initiative Observational Study between September 1994 and February 1997 were analyzed by multiple logistic regression to identify predictors of self-reported mammography within 2 years, Pap smear within 3 years, and stool guaiac or flexible sigmoidoscopy within 5 years. RESULTS: Positive determinants of reporting cancer screening were age, ethnic origin, household income, educational level, family history of cancer, having a usual care provider, time since last provider visit, and insurance status and type. Smoking, diabetes, and, among older women, prior cardiovascular events were negative determinants of cancer screening. Among women younger than 65, lacking health insurance or having fee-for-service insurance was strongly associated with failure to report cancer screening, independently of having or using a usual care provider and of demographics, self-perceived health, and health characteristics. Among women 65 and older, those with Medicare alone were less likely, whereas those with Medicare + prepaid insurance were more likely, to report cancer screening. CONCLUSIONS: In the Women's Health Initiative Obser vational Study, a large, diverse group of older women, health insurance type and status were among the most important determinants of cancer screening indepen dent of demographics, chronic health conditions, and self-perceived health characteristics.     

Colorectal cancer screening among the medically underserved

Prevalence of physician recommendation and patient completion of colorectal cancer screening was investigated among Federally Qualified Health Centers (FQHC) serving low-income neighborhoods in Chicago. Medical records of 3,416 patients receiving primary care services at 1 of 31 FQHCs were randomly chosen for review. In all, 642 patients were identified by age and family history as eligible for colorectal cancer screening and included in this study. Patient demographic information and colorectal cancer screening history were collected. The physician screening recommendation rate was 9.2% (n=59); 7.0% (n=45) of patients were determined to have been appropriately screened for colorectal cancer, primarily by Fecal Occult Blood Test (94.1%, n=43). Among patients who received a recommendation from their physician, 76.2% had completed a screening test. Older patients were more likely than their younger counterparts to have received a recommendation from their physician (p<.05) and to have been screened (p<.01). Organizational interventions are needed to support physicians in medically underserved areas and to promote recommended screening practices.     

The Effect of Presenting Information about Invasive Follow-Up Testing on Individuals’ Noninvasive Colorectal Cancer Screening Participation Decision: Results from a Discrete Choice Experiment

ObjectivesMany national colorectal cancer screening campaigns have a similar structure. First, individuals are invited to take a noninvasive screening test, and, second, in the case of a positive screening test result, they are advised to undergo a more invasive follow-up test. The objective of this study was to investigate how much individuals’ participation decision in noninvasive screening is affected by the presence or absence of detailed information about invasive follow-up testing and how this effect varies over screening tests.MethodsWe used a labeled discrete choice experiment of three noninvasive colorectal cancer screening types with two versions that did or did not present respondents with detailed information about the possible invasive follow-up test (i.e., colonoscopy) and its procedure. We used data from 631 Dutch respondents aged 55 to 75 years. Each respondent received only one of the two versions (N = 310 for the invasive follow-up test information specification version, and N = 321 for the no-information specification version).ResultsMixed logit model results show that detailed information about the invasive follow-up test negatively affects screening participation decisions. This effect can be explained mainly by a decrease in choice shares for the most preferred screening test (a combined stool and blood sample test). Choice share simulations based on the discrete choice experiment indicated that presenting invasive follow-up test information decreases screening participation by 4.79%.ConclusionsDetailed information about the invasive follow-up test has a negative effect on individuals’ screening participation decisions in noninvasive colorectal cancer screening campaigns. This result poses new challenges for policymakers who aim not only to increase uptake but also to provide full disclosure to potential screening participants.     

Cancer Screening and Haitian Immigrants: The Primary Care Provider Factor

Background: Haitian immigrants, among the fastest growing immigrant communities in the United States, have low cancer screening rates. Several patient barriers have been identified and associated with low screening rates but little is known on provider barriers for cancer screening. To address this gap, we assessed the cancer screening practices, attitudes, and beliefs of primary care providers serving the Haitian community. Methods: We surveyed a random sample of physicians serving first generation Haitian immigrants in New York City, identified through their zip codes of practice. Participants completed a questionnaire to assess their beliefs, attitudes and practices surrounding cancer screening, and their perceptions of patient barriers to screening. Results: 50 of 87 physicians (58%) consented to participate in the study. Cancer site-specific and overall cancer screening scores were created for breast, cervical, and colorectal cancer screening. 75% of providers followed breast cancer screening guidelines, 16% for cervical cancer, and 30% for colorectal cancer. None of the providers in the sample were following guidelines for all three cancer sites. Additionally, 97% reported recommending digital rectal exam and PSA annually to patients 50 years or older with no family history, and 100% to patients over 50 years old with family history. Conclusions: The reported practices of providers serving the Haitian immigrant community in New York City are not fully consistent with practice guidelines. Efforts should be made to reinforce screening guideline knowledge in physicians serving the Haitian immigrant community, to increase the utilization of systems that increase cancer screening, and to implement strategies to overcome patient barriers.     

Colorectal cancer incidence in pattern and model makers: Evidence from a screening program

This study is designed to evaluate the efficacy of colorectal cancer screening in a high risk population of pattern and model makers. The cohort of 1,641 white male automotive pattern and model makers was identified in 1981, and offered colorectal cancer screening. The program involved periodic 60 cm flexible sigmoid examination, stool occult blood testing, and digital rectal examination. Screening was offered in 1981, 1982, 1985, 1988, and 1991. Approximately 60% of those eligible participated in at least one screening examination. Nonparticipants showed a relative risk for incident colorectal cancer of over 10, compared to those who participated at least once in the screening. Cohort tracking has accumulated 10 years; results suggest a benefit to colorectal cancer screening in this population.     

Incremental net benefit and acceptability of alternative health policies: a case study of mass screening for colorectal cancer

The incremental net benefit (INB) and the related acceptability curves for public health programs provide valuable tools for decision making. We proposed to apply them to the assessment of mass screening of colorectal cancer. The now standard guaiac fecal occult blood test (FOBT) is already implemented in several countries. We considered the innovative immunological FOBT and computed tomography colonography (CTC) as competing screening technologies. Using biennial guaiac FOBT as the reference strategy, we estimated the cost-effectiveness of the following alternatives: biennial immunological FOBT, CTC every 5 years (strategy CTC5), and CTC every 10 years (strategy CTC10). Over a 30-year horizon and from the perspective of a third-party payer, we developed a Markov model on a hypothetical cohort of 100,000 subjects at average risk of colorectal cancer. Close expected net benefits between immunological FOBT and CTC5 induced uncertainty in the choice of the optimal strategy. Probabilistic sensibility analysis then suggested that below a willingness to pay (WTP) per life-years gained (LYG) of 8,587 €/LYG, CTC10 was optimal, while CTC5 would be preferred beyond a WTP of 8,587 €/LYG.