Diagnostic accuracy of one or two faecal haemoglobin and calprotectin measurements in patients with suspected colorectal cancer

Background: The role of faecal biomarkers in patients at ‘high risk’ of colorectal cancer (CRC) is not yet defined. Pre-analytical factors, such as heterogeneity of biomarker distribution within faeces, may influence their optimisation in clinical practice. We undertook to determine whether repeat or combined biomarker testing improves diagnostic accuracy for CRC or clinically significant disease.

Methods: Patients referred with suspected CRC provided two separate faecal samples each for faecal immunochemical testing (FIT) and faecal calprotectin (FC) prior to investigation. Diagnostic accuracy of FIT and FC were evaluated based on final diagnoses.

Results: Five hundred fifteen patients completed a full colorectal evaluation. The optimal cut-off for CRC using a single FIT was ≥12 µgHb/g faeces (84.6% sensitivity, 88.5% specificity). For two FIT, the cut-off was ≥43 µgHb/g faeces if either and ≥2 µgHb/g faeces if both were positive. There was no advantage in their diagnostic accuracy compared with a single FIT. FC had a lower diagnostic accuracy for CRC than FIT, which was not improved by repeat FC. No benefit was identified with FIT-FC combined.

For CRC, significant adenomatous polyps and organic enteric disease combined, FIT and FC performed similarly to each other but were poorer predictors (AUC 0.677 and 0.660). There was no uplift in diagnostic accuracy when the tests were repeated or combined.

Conclusion: This study supports using a single FIT at a cut-off close to that recommended by NICE DG30 to improve diagnostic accuracy for ‘two-week wait’ patients referred with suspected CRC.     

Diagnostic accuracy of a quantitative faecal immunochemical test vs. symptoms suspected for colorectal cancer in patients referred for colonoscopy

Abstract

Objective: Determine diagnostic accuracy of a quantitative faecal immunochemical haemoglobin test (QuikRead go^® FIT, Orion Diagnostica Oy) in symptomatic patients referred for colonoscopy, at various cut-offs and for one or two tests.

Methods: Patients referred to four endoscopy units in mid-Sweden between 2013 and 2017 provided information on lower abdominal symptoms and faecal samples from two separate days prior to colonoscopy.

Results: In all, 5.4% (13/242) patients had colorectal cancer (CRC). For one FIT at cut-off 10?µg Hb/g faeces, sensitivity for CRC was 92% (95% CI 78–100%) and specificity 77% (95% CI 72–83%); equal to 74%; 95% CI 68–80 (178/242) colonoscopies potentially avoidable and one CRC missed. Based on the maximal outcome of two FITs, sensitivity was 100%, specificity 71% (66–77%) and 68%; 95% CI 62–74 (160/237) colonoscopies potentially avoidable. Among 17% (42/242) patients with one FIT of >200?µg Hb/g faeces, 85% (11/13) had CRC. Positive predictive values of FIT varied 16.9–26.2% depending on cut-off and one or two FITs, whereas NPVs were 99% and above in all scenarios.

In 60 patients reporting rectal bleeding, one FIT at cut-off 10?µg Hb/g discriminated well between CRC and other conditions (p?=?.001). In regression models, FIT was more important than age, sex and all symptoms.

Conclusion: One or two FITs in symptomatic patients referred for colonoscopy imply powerful risk stratification abilities for CRC, even among patients reporting rectal bleeding. Larger studies in various settings will clarify how to make the best use of this opportunity.

Trial registration: Clinicaltrails.gov NCT 02491593     

Fecal immunochemical test in cancer screening – colonoscopy outcome in FIT positives and negatives

Objectives: Fecal immunochemical test (FIT) is used in colorectal cancer (CRC) screening, but evaluations of multiple sample strategies in colonoscopy screening cohorts are rare. The aim of this study was to assess accuracy of FIT for advanced neoplasia (AN) with two fecal samples in a colonoscopy screening cohort.

Materials and methods: The study comprised 1155 participants of the colonoscopy arm in SCREESCO (Screening of Swedish Colons, NCT02078804), a randomized controlled study on CRC screening of 60-year-olds from the Swedish average-risk population. Participants provided two FIT samples prior to colonoscopy. First sample, mean of two, and any of the two samples above cut off level were assessed. Colonoscopy findings (CRC, advanced adenoma (AA), AN (CRC?+?AA) and adenoma characteristics) were evaluated in uni- and multivariable analysis in relation to FIT positivity (at ≥10?µg hemoglobin (Hb)/g).

Results: Of 1155 invited, 806 (416 women, 390 men) participated. CRC, AA and non-AA were found in one (0.1%), 80 (9.9%) and 145 (18%), respectively. Sensitivity and specificity for AN were 20%/93%, 25%/92% and 26%/89% for first, mean of two and any of the two samples respectively at cut off level 10?µg/g, corresponding to 60 (74%)–65 (80%) participants with missed AN. The difference in sensitivity between screening strategies was non-significant. The specificity for first sample was significantly higher than for any of the two samples at cut off 10?µg/g (p?=?.02) and 20?µg/g (p?=?.04). FIT positivity in participants with adenoma was associated with pedunculated shape (p?=?.007) and high-risk dysplasia (p?=?.009).

Conclusions: In an average-risk colonoscopy screening cohort of 60-year-olds, sensitivity for AN was modest and did not increase when using two samples instead of one. FIT predominantly detected adenomas with pedunculated shape and high-risk dysplasia, and participants with flat or broad based adenomas may thus be missed in screening.     

Quantitative FIT stratification is superior to NICE referral criteria NG12 in a high-risk colorectal cancer population

Background

Guidelines for urgent investigation of colorectal cancer (CRC) are based on age and symptom-based criteria. This study aims to compare the diagnostic value of clinical features and faecal immunochemical test (FIT) results to identify those at a higher risk of CRC, thereby facilitating effective triage of patients.

Methods

We undertook a review of all patients referred for investigation of CRC at our centre between September 2016 and June 2018. Patients were identified using a prospectively recorded local database. We performed a logistic regression analysis of factors associated with a diagnosis of CRC.

Results

One-thousand-and-seven-hundred-eighty-four patients with FIT results were included in the study. Change in bowel habit (CIBH) was the most common referring clinical feature (38.3%). Patients diagnosed with CRC were significantly older than those without malignancy (74.0 years vs 68.9 years, p?=?0.0007). Male patients were more likely to be diagnosed with CRC than females (6.5% vs 2.5%, Chi-squared 16.93, p?<?0.0001). CRC was diagnosed in 3.5% (24/684) with CIBH compared to 8.1% (6/74) with both CIBH and iron deficiency anaemia. No individual or combination of referring clinical features was associated with an increased diagnosis of CRC (Chi-squared, 8.03, p?=?0.155). Three patients with negative FIT results (<?4 µg Hb/g faeces) were diagnosed with CRC (3/1027, 0.3%). The highest proportion of cancers detected was in the?≥?100 µg Hb/g faeces group (55/181, 30.4%).

Conclusion

In a multivariate model, FIT outperforms age, sex and all symptoms prompting referral. FIT has greater stratification value than any referral symptoms. FIT does have value in patients with iron deficiency anaemia.

     

Diagnosing colorectal cancer and inflammatory bowel disease in primary care: The usefulness of tests for faecal haemoglobin,faecal calprotectin,anaemia and iron deficiency. A prospective study

Objective: Abdominal complaints are common reasons to consult primary care but they are seldom caused by colorectal cancer (CRC), high-risk adenomas (HRAs), or inflammatory bowel disease (IBD). Reliable diagnostic aids would be helpful in deciding which patients to refer for bowel imaging. Our aim was to assess the value of a faecal immunochemical test (FIT) and a faecal calprotectin (FC) test in detecting CRC, HRAs and IBD in primary care, and the value of combining these tests with anaemia and iron-deficiency tests.

Materials and methods: This prospective study included 373 consecutive patients that received a FIT or a FC test ordered by a primary care physician. We collected samples for FITs, FC tests, full blood counts and iron-deficiency tests. Physicians were instructed to refer patients with a positive FIT or FC test (cut-off ≥100μg/g) for bowel imaging. The patients’ presenting symptoms were recorded. Patients were followed for 2 years.

Results: The best test for detecting CRC and IBD was the combination of the FIT and haemoglobin concentration. This test had a sensitivity, specificity, positive predictive value and negative predictive value of 100%, 61.7%, 11.7% and 100%, respectively. The FIT detected a significantly larger proportion of CRC, HRAs and IBD than the FC test (0.92 versus 0.46, 95% confidence interval 0.22–0.67).

Conclusion: A negative FIT combined with a normal haemoglobin concentration could rule out CRC and IBD with a high degree of safety. This could be useful in prioritising referrals for bowel imaging from primary care.     

Fecal immunochemical test accuracy in average-risk colorectal cancer screening

AIM:To assess the fecal immunochemical test(FIT)accuracy for colorectal cancer(CRC)and advanced neoplasia(AN)detection in CRC screening.METHODS:We performed a multicentric,prospective,double blind study of diagnostic tests on asymptomatic average-risk individuals submitted to screening colonoscopy.Two stool samples were collected and the fecal hemoglobin concentration was determined in the first sample(FIT1)and the highest level of both samples(FITmax)using the OC-sensor.Areas under the curve(AUC)for CRC and AN were calculated.The best FIT1and FITmax cut-off values for CRC were determined.At this threshold,number needed to scope(NNS)to detect a CRC and an AN and the cost per lesion detected were calculated.RESULTS:About 779 individuals were included.An AN was found in 97(12.5%)individuals:a CRC in 5(0.6%)and an advanced adenoma(≥10 mm,villous histology or high grade dysplasia)in 92(11.9%)subjects.For CRC diagnosis,FIT1 AUC was 0.96(95%CI:0.95-0.98)and FITmax AUC was 0.95(95%CI:0.93-0.97).For AN,FIT1 and FITmax AUC were similar(0.72,95%CI:0.66-0.78 vs 0.73,95%CI:0.68-0.79,respectively,P=0.34).Depending on the number of determinations and the positivity threshold cut-off used sensitivity for AN detection ranged between 28%and 42%and specificity between 91%and 97%.At the best cut-off point for CRC detection(115 ng/mL),the NNS to detect a CRC were 10.2 and 15.8;and the cost per CRC was 1814€and 2985€on FIT1 and FITmax strategies respectively.At this threshold the sensitivity,NNS and cost per AN detected were 30%,1.76,and 306€,in FIT1 strategy,and 36%,2.26€and 426€,in FITmax strategy,respectively.CONCLUSION:Performing two tests does not improve diagnostic accuracy,but increases cost and NNS to detect a lesion.     

Disparities in Colorectal Cancer Screening Practices in a Midwest Urban Safety-Net Healthcare System

Aims

Although colorectal cancer screening (CRC) using stool-based test is well-studied, evidence on fecal immunochemical test (FIT) patterns in a safety-net healthcare system utilizing opportunistic screening is limited. We studied the FIT completion rates and adenoma detection rate (ADR) of positive FIT-colonoscopy (FIT-C) in an urban safety-net system.

Methods

We performed a retrospective cross-sectional chart review on individuals?≥?50 years who underwent CRC screening using FIT or screening colonoscopy, 09/01/2017–08/30/2018. Demographic differences in FIT completion were studied; ADR of FIT-C was compared to that of screening colonoscopy.

Results

Among 13,427 individuals with FIT ordered, 7248 (54%) completed the stool test and 230 (48%) followed up a positive FIT with colonoscopy. Increasing age (OR 1.01, CI 1.01–1.02), non-Hispanic Blacks (OR 0.87, CI 0.80–0.95, p?=?0.002), current smokers (OR 0.84, CI 0.77–0.92, p?<?0.0001), those with Medicaid (OR 0.86, CI 0.77–0.96, p?=?0.006), commercial insurance (OR 0.85, CI 0.78–0.94, p?=?0.002), CCI score?≥?3 (OR 0.82, CI 0.74–0.91, p?<?0.0001), orders by family medicine providers (OR 0.87, CI 0.81–0.94, p?<?0.0001) were associated with lower completion of stool test. Individuals from low median household income cities had lower follow-up of positive FIT, OR 0.43, CI 0.21–0.86, p?=?0.017. ADR of FIT-C was higher than that of screening colonoscopy.

Conclusion

Adherence to CRC screening is low in safety-net systems employing opportunistic screening. Understanding demographic differences may allow providers to formulate targeted strategies in high-risk vulnerable groups.

     

Positive predictive value of fecal immunochemical test for high-risk colonic adenomas and carcinoma: A health maintenance organization cohort screening study in Lebanon

Background and Study AimsFecal Immunochemical Test (FIT) is one of the leading modalities for colorectal cancer screening. Studies show that FIT is highly sensitive for the detection of colorectal cancer (CRC) but not similarly accurate for detection of pre-cancerous advanced adenomas (AA). We studied the performance metrics of FIT for the detection of CRC and AA in a health maintenance organization (HMO) cohort screening program.Patients and MethodsRetrospective cohort study of asymptomatic persons of screening age belonging to a HMO. Endoscopy and pathology reports of those who tested positive were used to calculate the positive predictive value (PPV) of FIT, and characterize endoscopic findings on colonoscopy.ResultsBetween 1995 and 2017, 3000 persons had screening fecal occult testing as part of their Employee Health Care plan. Of those, 150 had a positive qualitative FIT (cutoff 10 Âµg hemoglobin/g feces). All underwent colonoscopy, and median time to colonoscopy was 27 days. 4 (2.6%) had carcinoma (2 stage IIIA and 2 stage IIIB), 106 (70.6%) had adenomas of which 40 (26.6% of the total cohort) had advanced adenomas (≥1 cm, villous features, or high-grade dysplasia) giving a PPV for AA and carcinoma of 29% and 3% respectively. When stratified by age, the PPV of AA; carcinoma was [50–59 (21.7%; 0.0%)], [60–69 (14.6%; 4.2%)], [70–79 (42.6%; 2.1%)], [80–89 (33.3%; 11.1%)].ConclusionThe performance characteristics of FIT testing are acceptable for population screening in resource-limited settings. The results of this study are helpful when discussing expectations prior to colonoscopy in people with positive FIT.     

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.     

Proportional incidence of interval colorectal cancer in a large population-based faecal immunochemical test screening programme

BackgroundThe European guidelines for quality assurance in colorectal cancer (CRC) screening recommend that interval cancer rate be expressed as a proportion of background incidence rate.AimTo determine the crude and adjusted proportional incidence of interval CRC in an Italian regional two-yearly faecal immunochemical test (FIT) screening programme.MethodsThe programme (year of implementation, 2005) is targeted at over 1,000,000 people aged 50–69 years. The test is a one-sample OC-Sensor (Eiken Chemical Co., Tokyo, Japan). The study covered one-third of the regional area. Excerpts of 434,295 eligible negative FIT records dated 2005–2012 from 193,193 subjects were retrieved from the regional CRC screening data warehouse. By 31 December 2013, the cohort accumulated 198,302 man-years and 235,370 woman-years. Interval CRCs were identified by record-linkage with the local population-based cancer registry. Their number was divided by the expected number, estimated with age-period-cohort models, to obtain the proportional incidence.ResultsThe proportional incidence of interval CRC for men and women was, respectively, 0.06 (95% confidence interval (CI), 0.04–0.09) and 0.17 (95% CI, 0.13–0.23) in the first interval year, and 0.21 (95% CI, 0.16–0.26) and 0.28 (95% CI, 0.22–0.36) in the second year.ConclusionsThe results were acceptable and in line with previous studies.     

The fecal immunochemical test has high accuracy for detecting advanced colorectal neoplasia before age 50

BackgroundIn contrast to the decreasing incidence of colorectal cancer (CRC) in adults ≥50 years, the CRC incidence in young adults <50 years is increasing. The fecal immunochemical test (FIT) may be useful for advanced colorectal neoplasia (ACRN) screening in a young population.AimsTo evaluate the diagnostic accuracy of FIT in a young population.MethodsThe diagnostic performance of FIT for detecting ACRN was compared among the following age groups who underwent FIT and colonoscopy as part of a comprehensive health screening program: 30–39, 40–49, and ≥50 years.ResultsOf 26,316 participants, 464 (1.8%) had ACRN and 805 (3.1%) showed positive FIT results. No significant differences in the sensitivity (22.1%, 17.2%, and 22.0%; p = 0.435) and specificity (97.2%, 97.4%, and 96.9%; p = 0.344) of FIT for detecting ACRN were observed among the groups. However, 30–39 age group had a significantly higher accuracy of FIT for ACRN (96.7%) than 40–49 and ≥50 age groups (95.9% and 93.8%; p < 0.001). The areas under the receiver operating characteristic curves of FIT for ACRN of three age groups were not significantly different (67.2, 66.2, and 61.7; p = 0.952).ConclusionsThe diagnostic performance of FIT for ACRN in a young population (<50 years) was not inferior to that in the current screening-age population (≥50 years). The FIT may be a good choice for detecting ACRN in a young population.     

Similar fecal immunochemical test results in screening and referral colorectal cancer

AIM: To improve the interpretation of fecal immunochemical test (FIT) results in colorectal cancer (CRC) cases from screening and referral cohorts. METHODS: In this comparative observational study, two prospective cohorts of CRC cases were compared. The first cohort was obtained from 10 322 average risk subjects invited for CRC screening with FIT, of which, only subjects with a positive FIT were referred for colonoscopy. The second cohort was obtained from 3637 subjects scheduled for elective colonoscopy with a positive FIT result. The same FIT and positivity threshold (OC sensor; ≥ 50 ng/mL) was used in both cohorts. Colonoscopy was performed in all referral subjects and in FIT positive screening subjects. All CRC cases were selected from both cohorts. Outcome measurements were mean FIT results and FIT scores per tissue tumor stage (T stage). RESULTS: One hundred and eighteen patients with CRC were included in the present study: 28 cases obtained from the screening cohort (64% male; mean age 65 years, SD 6.5) and 90 cases obtained from the referral cohort (58% male; mean age 69 years, SD 9.8). The mean FIT results found were higher in the referral cohort (829 ± 302 ng/mLvs 613 ± 368 ng/mL,P = 0.02). Tissue tumor stage (T stage) distribution was dif-ferent between both populations [screening population: 13 (46%) T1, eight (29%) T2, six (21%) T3, one (4%) T4 carcinoma; referral population: 12 (13%) T1, 22 (24%) T2, 52 (58%) T3, four (4%) T4 carcinoma], and higher T stage was significantly associated with higher FIT results (P 0.001). Per tumor stage, no significant difference in mean FIT results was observed (screening vs referral: T1 498 ± 382 ng/mL vs 725 ± 374 ng/mL, P = 0.22; T2 787 ± 303 ng/mL vs 794 ± 341 ng/mL, P = 0.79; T3 563 ± 368 ng/mLvs 870 ± 258 ng/mL,P = 0.13; T4 not available). After correction for T stage in logistic regression analysis, no significant differences in mean FIT results were observed between both types of cohorts (P = 0.10). CONCLUSION: Differences in T stage distribution largely explain differences in FIT results between screening and referral cohorts. Therefore, FIT results should be reported according to T stage.     

Impact of colorectal cancer screening participation in remote northern Canada: A retrospective cohort study

BACKGROUNDScreening provides earlier colorectal cancer (CRC) detection and improves outcomes. It remains poorly understood if these benefits are realized with screening guidelines in remote northern populations of Canada where CRC rates are nearly twice the national average and access to colonoscopy is limited.AIMTo evaluate the participation and impact of CRC screening guidelines in a remote northern population.METHODSThis retrospective cohort study included residents of the Northwest Territories, a northern region of Canada, age 50-74 who underwent CRC screening by a fecal immunohistochemical test (FIT) between January 1, 2014 to March 30, 2019. To assess impact, individuals with a screen-detected CRC were compared to clinically-detected CRC cases for stage and location of CRC between 2014-2016. To assess participation, we conducted subgroup analyses of FIT positive individuals exploring the relationships between signs and symptoms of CRC at the time of screening, wait-times for colonoscopy, and screening outcomes. Two sample Welch t-test was used for normally distributed continuous variables, Mann-Whitney-Wilcoxon Tests for data without normal distribution, and Chi-square goodness of fit test for categorical variables. A P value of < 0.05 was considered to be statistically significant.RESULTS6817 fecal tests were completed, meaning an annual average screening rate of 25.04%, 843 (12.37%) were positive, 629 individuals underwent a follow-up colonoscopy, of which, 24.48% had advanced neoplasia (AN), 5.41% had CRC. There were no significant differences in stage, pathology, or location between screen-detected cancers and clinically-detected cancers. In assessing participation and screening outcomes, we observed 49.51% of individuals referred for colonoscopy after FIT were ineligible for CRC screening, most often due to signs and symptoms of CRC. Individuals were more likely to have AN if they had signs and symptoms of cancer at the time of screening, waited over 180 d for colonoscopy, or were indigenous [respectively, estimated RR 1.18 95%CI of RR (0.89-1.59)]; RR 1.523 (CI: 1.035, 2.240); RR 1.722 (CI: 1.165, 2.547)].CONCLUSIONScreening did not facilitate early cancer detection but facilitated higher than anticipated AN detection. Signs and symptoms of CRC at screening, and long colonoscopy wait-times appear contributory.     

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     

Original research: Characteristics and attitudes of first round invitees in the Irish National Colorectal Cancer Screening Programme

Background/objectiveColorectal cancer (CRC) screening is proven to reduce CRC-related mortality. Faecal immunochemical testing (FIT)-positive clients in the Irish National CRC Screening Programme underwent colonoscopy. Round 1 uptake was 40.2%. We sought to identify barriers to participation by assessing knowledge of CRC screening and examining attitudes towards FIT test and colonoscopy.MethodsQuestionnaires based on a modified Champion’s Health Belief Model were mailed to 3500 invitees: 1000 FIT-positive, 1000 FIT-negative and 1500 non-participants. 44% responded: 550 (46%) FIT-positive, 577 (48%) FIT-negative and 69 (6%) non-responders (NR).Results25% of respondents (n=286) did not perceive a personal risk of cancer, did not perceive CRC to be a serious disease and did not perceive benefits to screening. These opinions were more likely to be expressed by men (p=0.035). One-fifth (n=251) found screening stressful. Fear of cancer diagnosis and test results were associated with stress. FIT-positive clients, women and those with social medical insurance were more likely to experience stress.ConclusionsThe CRC screening process causes stress to one-fifth of participants. Greater use of media and involvement of healthcare professionals in disseminating information on the benefits of screening may lead to higher uptake in round 2.     

Association Between Primary Care Visits and Colorectal Cancer Screening Outcomes in the Era of Population Health Outreach

Background

Population outreach strategies are increasingly used to improve colorectal cancer (CRC) screening. The influence of primary care on cancer screening in this context is unknown.

Objective

To assess associations between primary care provider (PCP) visits and receipt of CRC screening and colonoscopy after a positive fecal immunochemical (FIT) or fecal occult blood test (FOBT).

Design

Population-based cohort study.

Participants

A total of 968,072 patients ages 50–74 years who were not up to date with CRC screening in 2011 in four integrated healthcare systems (three with screening outreach programs using FIT kits) in the Population-Based Research Optimizing Screening through Personalized Regimens (PROSPR) consortium.

Measures

Demographic, clinical, PCP visit, and CRC screening data were obtained from electronic health records and administrative databases. We examined associations between PCP visits in 2011 and receipt of FIT/FOBT, screening colonoscopy, or flexible sigmoidoscopy (CRC screening) in 2012 and follow-up colonoscopy within 3 months of a positive FIT/FOBT in 2012. We used multivariable logistic regression and propensity score models to adjust for confounding.

Results

Fifty-eight percent of eligible patients completed a CRC screening test in 2012, most by FIT. Those with a greater number of PCP visits had higher rates of CRC screening at all sites. Patients with ≥1 PCP visit had nearly twice the adjusted-odds of CRC screening (OR?=?1.88, 95 % CI: 1.86–1.89). Overall, 79.6 % of patients with a positive FIT/FOBT completed colonoscopy within 3 months. Patients with ≥1 PCP visit had 30 % higher adjusted odds of completing colonoscopy after positive FIT/FOBT (OR?=?1.30; 95 % CI: 1.22–1.40).

Conclusions

Patients with a greater number of PCP visits had higher rates of both incident CRC screening and colonoscopy after positive FIT/FOBT, even in health systems with active population health outreach programs. In this era of virtual care and population outreach, primary care visits remain an important mechanism for engaging patients in cancer screening.

     

Multiple colorectal cancers in the elderly: a retrospective study of both surgical and autopsy cases

Background. Multiple primary cancers are not rare events in the large intestine, and account for approximately 5–7% of patients with colorectal cancer (CRC). There are few reports demonstrating clinicopathologic features of multiple CRCs in the elderly. Methods. We clinicopathologically investigated 947 surgical patients and 362 autopsy samples from patients aged 65 years or more with CRC, including 81 surgical and 34 autopsy cases of multiple CRCs. We compared the data in the very old group (age ≥ 85 years) with those of the younger age groups, i.e., a young-old group (65–74 years) and a middle-old group (75–84 years). Results. The proportion of multiple CRCs was 8.6% (81/947) in the surgical patients and 9.4% (34/362) in the autopsy cases, with no significant difference among the three age groups. Similar site distributions and sex ratios, indicating proximal shift and female predominance with advancing age, were found in multiple and single CRCs, except for autopsy cases with multiple CRCs. Multiple CRCs in nonadjacent segments of the large intestine accounted for 11% (9/81) in surgical cases and 35% (12/34) in autopsy cases. In autopsy cases, the incidence of extracolorectal malignancies in patients with a single CRC was 22% (17/76) in the young-old group, 27% (39/147) in the middle-old group, and 35% (37/105) in the very old group, whereas the incidences in patients with multiple CRCs were 25% (1/4), 11% (2/18), and 50% (6/12), respectively. Regarding the organs with extracolorectal malignancies, the stomach (29%) was most frequent, followed by lung (14%), hematopoietic system (12%), and pancreatobiliary system (10%). Conclusions. These results indicate that the incidence of multiple CRCs in elderly patients with CRC is approximately 8%–10%, with no age-related difference, while extracolorectal malignancies increase with advancing age. Received: November 2, 2000 / Accepted: April 27, 2001