Attitude to Secondary Prevention and Concerns about Colonoscopy Are Independent Predictors of Acceptance of Screening Colonoscopy

Background: Colonoscopy in combination with endoscopic polypectomy has been shown to be an efficient measure for reducing colorectal cancer incidence. In Germany, a colorectal cancer screening program based on colonoscopy for individuals aged 55 and above was introduced in 2002. However, for largely unknown reasons, participation rates remain low. The purpose of this study was to identify factors influencing compliance with colorectal cancer screening. Methods: A structured survey of 239 individuals aged 55-79 years ;was performed. Statistical analysis included chi(2) test, t test, principal component analysis, and logistic regression. Results: 56% of previously screened, but only 26% of non-screened individuals had received a recommendation to undergo screening colonoscopy. 50% of the non-screened believed a screening colonoscopy should only be performed in case of complaints. Univariate analysis identified participation in any secondary prevention measures (p < 0.001), concerns about colonoscopy (p < 0.012), and knowledge about colorectal cancer (p < 0.001) as critical issues distinguishing between groups. Multivariate analysis revealed that secondary prevention (p < 0.001) and concerns about colonoscopy (p = 0.026) were independent predictors of compliance with screening recommendations. Conclusion: Our survey has identified critical factors deterring compliance with colorectal cancer screening recommendations. This will help to direct future campaigns in order to increase participation in colorectal cancer screening. Copyright (C) 2010 S. Karger AG, Base

Patient Understanding of Benefits, Risks, and Alternatives to Screening Colonoscopy

While several tests and strategies are recommended for colorectal cancer (CRC) screening, studies suggest that primary care providers often recommend colonoscopy without providing information about its risks or alternatives. These observations raise concerns about the quality of informed consent for screening colonoscopy

Neoplasia at 10-year follow-up screening colonoscopy in a private U.S. practice: comparison of yield to first-time examinations

Background and Aims Prior studies assessing the yield of a second screening colonoscopy performed 10 years after an initial negative screening colonoscopy did not include a control group of persons undergoing their first screening colonoscopy during the same time interval. Our aim was to describe the incidence of neoplasia at a second screening colonoscopy (performed at least 8 years after the first colonoscopy) in average risk individuals and compare it with the yield of first screening examinations performed during the same time interval. Methods Review of a database of outpatient screening colonoscopies performed between January 2010 and December 2015 in an Atlanta private practice. Results A total of 2105 average risk individuals underwent screening colonoscopy, including 470 individuals (53.6% female; mean age 64.0 ± 3.9 years) who underwent a second screening examination. In those undergoing second screening, the mean interval between examinations was 10.4 years (±1.1; range 8-15 years). At second screening, the polyp detection rate (PDR), adenoma detection rate (ADR) and advanced neoplasm rate (ANR) were 44.7%, 26.6%, and 7.4%, respectively. Of 40 advanced neoplasms in 35 individuals, 33 (82.5%) were proximal to the sigmoid colon, and there were no cancers. During the same interval, 1635 individuals (49.4% female; mean age 52.6 ± 3.4 years) underwent their first screening colonoscopy. The PDR, ADR and ANR were 53.5%, 32.2%, and 11.7%, respectively. Of 243 advanced neoplasms in 192 individuals, 152 (62.6%) were proximal to the sigmoid colon, and there were no cancers. After adjustment for age, gender, body mass index, and endoscopist, PDR, ADR, and ANR were all lower at the second screening colonoscopies than at first-time colonoscopies (all p<0.001). Conclusions Despite being 10 years older, persons with a negative screening colonoscopy 10 years earlier had numerically lower rates of adenomas and advanced neoplasms at their second screening examination compared with patients in the same practice undergoing their first screening colonoscopy, and they had no cancers. The fraction of advanced neoplasms that were proximal to the sigmoid was high in both first and second screenings. These results support the safety of the recommended 10-year interval between colonoscopies in average risk persons with an initial negative examination

Yield of a second screening colonoscopy 10 years after an initial negative examination in average-risk individuals

Background and Aims Current guidelines recommend screening colonoscopy at 10-year intervals in average-risk individuals who had baseline screening colonoscopy (no polyps or only hyperplastic polyps ≤5 mm in the recto-sigmoid colon), but the yield of repeat screening at 10 years is unknown. Our aim was to describe the yield of second screening colonoscopy in average-risk individuals performed at least 8 years after a first screening colonoscopy had shown no polyps or only distal hyperplastic polyps ≤5 mm in size. Methods This was a review of a database for colonoscopies performed at Indiana University Hospital between January 1999 and November 2015. Results A total of 4463 individuals underwent screening colonoscopy between January 1999 and July 2007, of which 1566 individuals had no polyps, and 334 individuals had only distal hyperplastic polyps ≤5 mm; 378 individuals (58.4% female) had follow-up screening at least 8 years after the baseline screening examination, with a mean (± standard deviation [SD]) interval of 9.74 years (± 1.2 years; range 8-15 years). Mean (± SD) age at baseline screening examination was 56.7 years (± 5.5 years) and at follow-up screening examination was 66.4 years (± 5.6 years). At the second screening, there were 224 patients (59.3%) with at least 1 polyp, including 144 (38.1%) with at least 1 conventional adenoma. The adenoma detection rate at the second screening examination was 36.1% and 56.8% in the groups with no polyp at baseline and with only distal hyperplastic polyps, respectively. There were 15 advanced neoplasms in 13 individuals (3.4%), of which 12 lesions were proximal to the sigmoid colon. There were no cancers at follow-up. Conclusions Among individuals aged ≥50 years, with normal baseline screening colonoscopy results, the incidence of advanced lesions at a second screening colonoscopy at least 8 years later was comparable to that in baseline screening studies. Our findings support current recommendations for screening at 10-year intervals in average-risk individuals

Risk of advanced colorectal neoplasia according to age and gender.

Colorectal cancer (CRC) is one of the leading causes of cancer related morbidity and death. Despite the fact that the mean age at diagnosis of CRC is lower in men, screening by colonoscopy or fecal occult blood test (FOBT) is initiated at same age in both genders. The prevalence of the common CRC precursor lesion, advanced adenoma, is well documented only in the screening population. The purpose of this study was to assess the risk of advanced adenoma at ages below screening age. We analyzed data from a census of 625,918 outpatient colonoscopies performed in adults in Bavaria between 2006 and 2008. A logistic regression model to determine gender- and age-specific risk of advanced neoplasia was developed. Advanced neoplasia was found in 16,740 women (4.6%) and 22,684 men (8.6%). Male sex was associated with an overall increased risk of advanced neoplasia (odds ratio 1.95; 95% confidence interval, CI, 1.91 to 2.00). At any age and in any indication group, more colonoscopies were needed in women than in men to detect advanced adenoma or cancer. At age 75 14.8 (95% CI, 14.4-15.2) screening, 18.2 (95% CI, 17.7-18.7) diagnostic, and 7.9 (95% CI, 7.6-8.2) colonoscopies to follow up on a positive FOBT (FOBT colonoscopies) were needed to find advanced adenoma in women. At age 50 39.0 (95% CI, 38.0-40.0) diagnostic, and 16.3 (95% CI, 15.7-16.9) FOBT colonoscopies were needed. Comparable numbers were reached 20 and 10 years earlier in men than in women, respectively. At any age and independent of the indication for colonoscopy, men are at higher risk of having advanced neoplasia diagnosed upon colonoscopy than women. This suggests that starting screening earlier in life in men than in women might result in a relevant increase in the detection of asymptomatic preneoplastic and neoplastic colonic lesions

Bowel preparation quality scales for colonoscopy.

Colorectal cancer (CRC) is the third most common cancer and second leading cause of cancer-related death in the United States. Colonoscopy is widely preferred for CRC screening and is the most commonly used method in the United States. Adequate bowel preparation is essential for successful colonoscopy CRC screening. However, up to one-quarter of colonoscopies are associated with inadequate bowel preparation, which may result in reduced polyp and adenoma detection rates, unsuccessful screens, and an increased likelihood of repeat procedure. In addition, standardized criteria and assessment scales for bowel preparation quality are lacking. While several bowel preparation quality scales are referred to in the literature, these differ greatly in grading methodology and categorization criteria. Published reliability and validity data are available for five bowel preparation quality assessment scales, which vary in several key attributes. However, clinicians and researchers continue to use a variety of bowel preparation quality measures, including nonvalidated scales, leading to potential confusion and difficulty when comparing quality results among clinicians and across clinical trials. Optimal clinical criteria for bowel preparation quality remain controversial. The use of validated bowel preparation quality scales with stringent but simple scoring criteria would help clarify clinical trial data as well as the performance of colonoscopy in clinical practice related to quality measurements

Colorectal Cancer Brochure Development for African Americans

Introduction: African Americans are more likely to die from colorectal cancer (CRC) than any other racial/ethnic group in the United States. Unfortunately, African Americans are also less likely to undergo screening for CRC than their White counterparts. Focus groups methodology was used to refine educational brochures designed to increase CRC screening among African Americans. Methods: Two series of focus groups were completed, with a total of seven groups and 39 participants. Six different brochures (stage-matched and culturally sensitive) designed to promote CRC screening among African Americans were evaluated. Results: All participants thought that the brochures motivated them to talk with their health care providers about screening. Cost, pain, medical mistrust and fear were identified as major barriers and the brochures were modified to address these concerns. Conclusions: Focus groups methodology with African Americans can be used to inform brochures designed to increase African Americans CRC screening that addresses their major concerns

The effect of non-medical factors on variations in the performance of colonoscopy among different health care settings

Background: Previous studies in the literature have shown significant variations in colonoscopy performance, even when medical factors are taken into account. This study aimed to examine the role of non-medical factors (i.e. embodied in health care system design) as possible contributors to variations in colonoscopy performance. Methods: We used patient data from a multicenter observational study conducted between 2000 and 2002 in 21 centers across 11 western countries. Variability was captured through two performance outcomes (diagnostic yield and colonoscopy withdrawal time), jointly studied as dependent variables using a multilevel two-equation system. Results: Results showed that open-access systems and high-volume colonoscopy centers were independently associated with a higher likelihood of detecting significant lesions and higher withdrawal durations. Fee for service (FFS) payment was associated with shorter withdrawal durations, and had an indirect negative impact on the diagnostic yield. Teaching centers exhibited lower detection rates and higher withdrawal times. Conclusions: Our results suggest that gate-keeping colonoscopy is likely to miss patients with significant lesions and that developing specialized colonoscopy units is important to improve performance. Results also suggest that FFS may result in a lower quality of care in colonoscopy practice and highlight that longer withdrawal times do not necessarily mean higher quality in teaching-centers.Medical Practice Variation (MPV), performance, non-medical factors, panel two-equation linear-probit model, colonoscopy

A Multi-Level Fit-Based Quality Improvement Initiative to Improve Colorectal Cancer Screening in a Managed Care Population.

IntroductionColorectal cancer (CRC) is a common but largely preventable disease with suboptimal screening rates despite national guidelines to screen individuals age 50-75. Single-component interventions aimed to improve screening uptake only modestly improve rates; data suggest that multi-modal approaches may be more effective.MethodsWe designed, implemented, and evaluated the impact of a multi-modal intervention on CRC screening uptake among unscreened patients in a large managed care population. Patient-level components included a mailed letter with education about screening options and pre-colonoscopy telephone counseling. For providers, we facilitated communication of screening test results and work-flow for abnormal results. System-level modifications included establishment of a patient navigator, expedited work-up for abnormal results, and stream-lined colonoscopy scheduling. We measured the rate of screening uptake overall, screening uptake by modality, change in the proportion of the population screened, and positive fecal immunochemical test (FIT) follow-up rates in the 1-year study period.ResultsThere were 5093 patients in the intervention cohort. Of these, 33.2% participated in FIT or colonoscopy screening within 1 year of the mailing. A total of 1078 (21.2%) participants completed a FIT and 611 (12.0%) completed a screening colonoscopy. The screening rate in the managed care population increased from 65.1 to 76.6%. Fifty-nine patients (5.5%) had a positive FIT, of which 30 (50.8%) completed a diagnostic colonoscopy.ConclusionMulti-modal interventions can result in substantial improvement in CRC screening uptake in large and diverse managed care populations.Translational impactHealth systems should shift their focus from single-level to multi-level interventions when addressing barriers to CRC screening

Quality of colonoscopy in an organised colorectal cancer screening programme with immunochemical faecal occult blood test. The EQuIPE study (Evaluating Quality Indicators of the Performance of Endoscopy)

OBJECTIVES: To assess variation in the main colonoscopy quality indicators in organised colorectal cancer (CRC) screening programmes based on faecal immunochemical test (FIT). DESIGN: Data from a case-series of colonoscopies of FIT-positive subjects were provided by 44 Italian CRC screening programmes. Data on screening history, endoscopic procedure and histology results, and additional information on the endoscopy centre and the endoscopists were collected. The adenoma detection rate (ADR) and caecal intubation rate (CIR) were assessed for the whole population and the individual endoscopists. To explore variation in the quality indicators, multilevel analyses were performed according to patient/centre/endoscopist characteristics. RESULTS: We analysed 75 569 (mean age: 61.3 years; men: 57%) colonoscopies for positive FIT performed by 479 endoscopists in 79 centres. ADR ranged from 13.5% to 75% among endoscopists (mean: 44.8%). ADR was associated with gastroenterology specialty (OR: 0.87 for others, 95% CI 0.76 to 0.96) and, at the endoscopy centre level, with the routine use of sedation (OR: 0.80 if occasional (600 colonoscopies; 95% CI 1.11 to 2.04) and, at the endoscopy centre level, screening-dedicated sessions (OR: 2.18; 95% CI 1.24 to 3.83) and higher rates of sedation (OR: 0.47 if occasional; 95% CI 0.24 to 0.92). CONCLUSIONS: The quality of colonoscopy was affected by patient-related, endoscopist-related and centre-related characteristics. Policies addressing organisational issues should improve the quality of colonoscopy in our programme and similar programmes. Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://group.bmj.com/group/rights-licensing/permissions