Implementation of population screening for colorectal cancer by repeated fecal occult blood test in the Netherlands

<p>Abstract</p> <p>Background</p> <p>Colorectal cancer (CRC) is the third most prevalent type of cancer in the world. Its prognosis is closely related to the disease stage at the time of diagnosis. Early detection of symptomless CRC or precursor lesions through population screening could reduce CRC mortality. However, screening programs are only effective if enough people are willing to participate. This study aims to asses the uptake of a second round of fecal occult blood test (FOBt) based screening and to explore factors that could potentially increase this uptake.</p> <p>Methods and design</p> <p>Two years after the first screening round, 10.000 average risk persons, aged 50 to 75, will again receive an invitation to participate in immunohistochemical FOBt (iFOBt) based screening. Eligible persons will be recruited through a city population database. Invitees will be randomized to receive either an iFOBt with a faeces collection paper or an iFOBt without a collection paper. The iFOBts will be analyzed in a specialized laboratory at the Academic Medical Centre. Positive iFOBts will be followed by a consultation at our outpatient clinic and, in the absence of contra-indications and after informed consent, by a colonoscopy. The primary outcome measure is the participation rate. Secondary outcome measures are the effect of the addition of a collection paper on the participation rate, reasons for participation and non-participation, measures of informed choice and psychological consequences of screening and measures of psychological and physical burden associated with the iFOBt and the colonoscopy. Another secondary outcome measure is the diagnostic yield of the program.</p> <p>Discussion</p> <p>In order to implement population screening for colorectal cancer in the Netherlands, information is needed on the uptake of repeated rounds of FOBt-based screening and on factors that could potentially increase this uptake in the future since effectiveness of such a program depends on the willingness of persons to participate. This study will provide information on the actual uptake and perception of a second round of iFOBt-based screening. The results of this study will contribute to the future implementation of a national colorectal screening program in the Netherlands.</p> <p>Trial registration</p> <p>Dutch Trial register: NTR1327</p

Most participate in faecal immunochemical test-based colorectal cancer screening out of curiosity about their chances of developing cancer

Several clinical trials have shown that colorectal cancer (CRC) screening can reduce cancer deaths. Its effectiveness is affected by the participation level. To develop targeted invitations, we need to understand why individual persons decide to participate. To evaluate reasons for participation among persons invited for faecal immunochemical test-based CRC screening, a total of 10 265 asymptomatic persons aged 50-75 years were invited to a Dutch CRC screening pilot (2008-2009). Reasons for participation were elicited by a questionnaire. A total of 3554 (66%) participants returned the questionnaire. Obtaining more certainty about the chances of developing cancer (ticked by 88%) and the occurrence of cancer in the family or the circle of acquaintances (18%) were the most frequently selected reasons for participation. We also explored reasons for nonparticipation among nonparticipants. In this subgroup, comorbidity and the absence of symptoms were the most frequently reported reasons for declining to participate, but the response rate was low. The vast majority of the participants decided to take up the screening because they wanted to know more about their chances of developing cancer. Copyright (C) 2015 Wolters Kluwer Health, Inc. All rights reserve

A feces collection paper does not enhance participation in a fecal immunochemical test-based colorectal cancer screening program: randomized clinical trial

Discomfort with the collection of a stool sample is a frequently cited barrier for participation in fecal test-based colorectal cancer screening. The objective was to evaluate whether a feces collection paper enhances participation in a fecal immunochemical test (FIT)-based colorectal cancer screening program. Randomized clinical trial. Second round of a biannual Dutch FIT-based colorectal cancer screening program pilot. A random sample of 10 265 individuals from the general population, men and women aged 50-75 years at an average risk for colorectal cancer, was eligible for participation. Invitees were randomized to an FIT-only group (n=5136) or an FIT in combination with a feces collection paper group (n=5129). The main outcome measure was participation in screening. Overall, 5367 tests of 10 265 were returned (52%). In the FIT-only group, 2694 tests were returned [52%; 95% confidence interval (CI): 51-54%] versus 2673 tests in the collection paper group (52%; 95% CI: 51-54%). This difference in the participation rate was not significant (relative risk: 0.99; 95% CI: 0.97-1.04). A feces collection paper does not increase participation rates in FIT-based colorectal cancer screening. Future studies should explore other ways of facilitating participation in colorectal cancer screening program

Patient satisfaction with the colonoscopy procedure: endoscopists overestimate the importance of adverse physical symptoms

BACKGROUND: Colonoscopy is a frequently performed procedure associated with a substantial burden for the patient. Most of what is known about patient satisfaction stems from surveys that target issues doctors believe to be important. It has been noticed that patients often focus on different aspects. AIM: To have patients and endoscopists rate the extent to which each of a list of patient-generated issues-of-concern contributes to patient satisfaction with the colonoscopy procedure. SUBJECTS: A sample of consecutive patients undergoing colonoscopy in a Dutch tertiary teaching hospital and a convenience sample of endoscopists. METHODS: Colonoscopy patients and endoscopists were asked to rate on a five-point Likert scale the importance of 55 items concerning the colonoscopy procedure for patient satisfaction. Items were derived from focus group sessions with colonoscopy patients. Endoscopists were invited to rate the importance of the same set of items from a patient perspective. An analysis was carried out of whether patients and endoscopists rated the importance of items differently. RESULTS: 69 patients and 34 endoscopists completed the questionnaire. The ratings of the endoscopists were significantly different from those of patients (p<0.0001). Endoscopists underestimated the importance of involving patients in decisions, discussing risks and complications, providing the opportunity for substantive questions and offering a comfortable temperature in the examination room. Endoscopists overestimated the importance of adverse physical symptoms, such as pain and abdominal cramps, and the role of the treating doctor. CONCLUSIONS: Endoscopists do not have a good perception of the items that contribute most to patient satisfaction with the colonoscopy procedure. Overcoming this gap may be an essential step towards improving patient satisfaction by targeting those concerns most relevant to patients

Lower Risk of Advanced Neoplasia Among Patients With a Previous Negative Result From a Fecal Test for Colorectal Cancer

BACKGROUND & AIMS: Consecutive rounds of fecal occult blood tests (FOBTs) are used to screen for colorectal cancer (CRC); they detect precursor lesions and early-stage disease. We assessed whether the positivity rate and the positive predictive values (PPVs) for advanced neoplasia and CRC decrease with repeated testing by using fecal immunochemical tests (FITs). METHODS: Data were collected from 2 rounds of screening. In the first round, average-risk persons (50 to 74 years old) were randomly assigned to groups that received the guaiac FOBT or FIT. In the second round, the subjects received only FIT (1594 received FIT after guaiac FOBT and 2022 received FIT after FIT). The positivity rate and PPV for advanced neoplasia and CRC were compared between second-round participants with a previous negative test result (FIT after guaiac FOBT or FIT after FIT) and first-round participants (guaiac FOBT or FIT). RESULTS: The rate of positive results from FIT was 7.4% in the FIT-after-FIT group, compared with 8.1% in the first-round FIT group (P = .34). A significant decrease was observed in the PPV for advanced neoplasia between the first and second round from 55% (132/239) to 44% (112/252; P = .017). The PPV for CRC was 8% (20/239) in the first round versus 4% (9/252) in the second round (P = .024). Ten interval cancers were diagnosed. There were no significant differences in stages of cancers detected in the first and second round or the interval cancers. CONCLUSIONS: The rate of positive results from FIT does not decrease after repeated CRC screening, but the PPVs of FIT for advanced neoplasia and for CRC are significantly lower among second-round participants who tested negative in the first roun

Assessing knowledge and attitudes towards screening among users of Faecal Immunochemical Test (FIT)

Background Informed decision making is recognized as important in screening. Invitees should be provided with relevant information, enabling them to make an informed decision. This may be more difficult in ethnic minority and low socio-economic status groups. We aimed to assess the proportion of informed decisions to participate in a faecal immunochemical test (FIT)-based colorectal cancer (CRC) screening pilot and to explore differences in knowledge and attitude across various subgroups. Methods Asymptomatic persons aged 50-74 were invited to a second round of a Dutch FIT-based pilot screening programme for CRC. An information leaflet containing all information relevant to enable informed decision making accompanied the invitation. Informed choice was assessed by a mailed questionnaire. Knowledge was elicited through 18 items and attitude towards screening through four items. Main outcome measure was the proportion of informed decision makers among participants. Differences between subgroups were evaluated using logistic regression. Results Of 5367 screening participants, 2774 (52%) completed the questionnaire. Knowledge was adequate in 2554 (92%); 2736 (99%) showed a positive attitude towards screening. A total of 2525 persons had made an informed choice (91%); male gender, low education level, non-Dutch ethnicity and not speaking Dutch at home were negatively associated with having adequate knowledge in multivariable analysis. Conclusion In FIT-based screening for CRC, the majority of responders made an informed decision to participate. However, we did not succeed in equally providing all population subgroups with sufficient information. Future initiatives should be aimed at reaching these groups to further enable informed decision makin

Low-Fiber Diet in Limited Bowel Preparation for CT Colonography: Influence on Image Quality and Patient Acceptance

OBJECTIVE. The purpose of this study was to determine whether a low-fiber diet is necessary for optimal tagging-only bowel preparation for CT colonography. SUBJECTS AND METHODS. Fifty consecutively enrolled patients received an iodine bowel preparation: 25 patients used a low-fiber diet and 25 used no special diet. One observer determined the tagging quality per segment on a 5-point scale (1, inhomogeneous tagging; 5, excellent preparation) and the largest size of untagged feces. Semiautomatic measurements of density and homogeneity of residual feces were performed. Patient acceptance was assessed with questionnaires. Per polyp sensitivity for polyps 6 mm in diameter and larger was calculated for two experienced observers. RESULTS. Tagging quality was scored less than grade 5 in 15 segments (10%) in the low-fiber diet group and in 25 segments (17%) in the unrestricted diet group (p = 0.098). One piece of untagged feces 10 mm in diameter or larger was found in the low-fiber diet group, and 12 were found in the unrestricted diet group (p <0.001). Automatic measurement of attenuation resulted in a mean value of 594 HU in the low-fiber diet group and 630 HU in the unrestricted diet group (p = 0.297). In the low-fiber diet group, 22% of patients indicated that the bowel preparation was extremely or severely burdensome; 8% of patients in the unrestricted diet group had this response (p = 0.19). Thirty-two polyps 6 mm in diameter or larger were found in the low-fiber diet group and 30 in the unrestricted diet group. Observer 1 had 84% and 77% sensitivity in detecting polyps 6 mm in diameter or larger in the low-fiber diet and unrestricted diet groups, respectively (p = 0.443), and observer 2 had 97% and 83% sensitivity (p = 0.099). CONCLUSION. Use of a low-fiber diet in bowel preparation for CT colonography results in significantly less untagged feces and shows a trend toward better residue homogeneit

Patients' perception of colonoscopy: patients with inflammatory bowel disease and irritable bowel syndrome experience the largest burden

Colonoscopy is a frequently performed procedure worldwide with a negative perception, leading to reluctance to undergo the procedure. Perceptions could differ depending on the specific indication for the colonoscopy. To compare patient satisfaction with the colonoscopy procedure between five different patient groups: inflammatory bowel disease (IBD), familial predisposition for cancer, adenoma/carcinoma surveillance, symptoms suggestive of cancer, and irritable bowel syndrome (IBS). A prospective questionnaire study was carried out in two regional hospitals and two tertiary teaching hospitals in the Netherlands. A total of 797 consecutive patients scheduled for colonoscopy between October 2009 and June 2010, 146 (18%) IBD, 153 (19%) adenoma or carcinoma surveillance, 104 (13%) familial predisposition, 280 (35%) symptoms suggestive of cancer, and 114 (14%) IBS-like symptoms, were included. Two questionnaires were administered: one on the day of the procedure and another 6 weeks after the procedure. The main outcome measurements were embarrassment, pain, burden, most burdensome aspect, and overall level of satisfaction. Patients with IBD and IBS reported significantly more embarrassment and burden from the bowel preparation phase (P=0.040 and 0.018, respectively) and more pain during the colonoscopy procedure (P=0.018). This difference in pain was also observed when adjusting for volume of sedation administered, familiarity with the endoscopist, duration of the colonoscopy, or whether or not an intervention was performed. All patient groups were less satisfied with the procedure at 6 weeks than directly after the colonoscopy; they recalled more embarrassment and burden, but less pain. Patient groups, defined by indication for colonoscopy, experience the colonoscopy procedure differentl

Incidence and prevalence of primary biliary cholangitis in the Netherlands – A nationwide cohort study

Background &amp; Aims: Although primary biliary cholangitis (PBC) is considered a rare disorder, accurate determination of its incidence and prevalence remains challenging due to limited comprehensive population-based registries. We aimed to assess the incidence and prevalence of PBC in the Netherlands over time through the nationwide Dutch PBC Cohort Study (DPCS). Methods: DPCS retrospectively included every identifiable patient with PBC in the Netherlands from 1990 onwards in all 71 Dutch hospitals. Incidence and prevalence were assessed between 2008-2018 by Poisson regression between sex and age groups over time. Results: On the 1st of January 2008, there were 1,458 patients with PBC in the Netherlands. Between 2008-2018, 2,187 individuals were newly diagnosed, 46 were transplanted and 468 died. The yearly incidence of PBC in 2008 was 1.38, increasing to 1.74 per 100,000 persons in 2018. When compared to those aged <45 years, females aged 45-64 years (adjusted incidence rate ratio 4.21, 95% CI 3.76-4.71, p <0.001) and males ≥65 years (adjusted incidence rate ratio 14.41, 95% CI 9.62-21.60, p <0.001) were at the highest risk of being diagnosed with PBC. The male-to-female ratio of patients newly diagnosed with PBC during the study period was 1:14 in those <45 years, 1:10 in patients aged 45-64 years, and 1:4 in those ≥65 years. Point prevalence increased from 11.9 in 2008 to 21.5 per 100,000 persons in 2018. Average annual percent change in this time period was 5.94% (95% CI 5.77-6.15, p <0.05), and was the highest among the population aged ≥65 years (5.69%, 95% CI 5.32-6.36, p <0.001). Conclusions: In this nationwide cohort study, we observed an increase in both the incidence and prevalence of PBC in the Netherlands over the past decade, with marked age and sex differences. Impact and implications:: This nationwide Dutch primary biliary cholangitis (PBC) Cohort Study, including all hospitals in the Netherlands, showed that the incidence and prevalence of PBC have increased over the last decade. The age-dependent PBC incidence rate differed for males (highest risk ≥65 years) and females (highest risk between 45 and 65 years), which may be related to a difference in the timing of exposure to environmental triggers of PBC. The largest increase in PBC prevalence over time was observed in the population aged ≥65 years, which may have implications for the use of second-line therapies. These results therefore indicate that further studies are needed to elaborate on the advantages and disadvantages of add-on therapies in the elderly population