Screening Colonoscopy Can Benefit Healthier Elders

This Month in Gastroenterology

Colon Cancer Screening Models: Lessons and Challenges

This study examined the use of breast, cervical, colorectal, and prostate cancer-screening services by persons with serious mental illness enrolled in the Sacramento County Mental Health clinics. Of 387 outpatients approached from January 2005 to May 2007, 229 were interviewed. Whereas 97% of the women had received cervical cancer screening at least once in their lifetime, more than 50% of eligible persons over age 50 had never received colorectal cancer screening. Recent use of screening services was highest for cervical cancer (69% had had a Pap test in the past three years) and lowest for colorectal cancer (12% had had a fecal occult blood stool test in the past year or a flexible sigmoidoscopy or colonoscopy in the past five years). Among persons with serious mental illness, lifetime screening of cervical cancer was higher than for breast, prostate, and colorectal cancers. Receipt of routine, timely cancer screening was low, especially for colorectal cancer.

1539 Background: Clinical practice guidelines (CPGs) for cervical, breast, colorectal and prostate cancer screening are well- established. The purpose of this study was to determine how adherence to CPGs has changed over the past five years. Methods: The National Health Interview Survey is a population-based survey, designed to be representative of the entire civilian non-institutionalized population in the US. To determine trends in adherence to CPGs, data from the 2000 and 2005 surveys were analyzed using SAS and SAS-callable SUDAAN software. Results: There was a significant decline in women over the age of 21 reporting having had a PAP smear within the preceding three years and women over the age of 40 reporting having had a mammogram within the preceding two years over the period of 2000 to 2005. However, the rate of men over the age of 50 reporting having had a PSA did not significantly change over this period. The rate of colorectal cancer (CRC) screening with either proctoscopy, sigmoidoscopy or colonoscopy increased between 2000 and 2005. While an increase in CRC screening between 2000 and 2005 was observed in both women (32.3% to 39.9%, p<0.0001) and men (37.2% to 42.7%, p<0.0001), men were significantly more likely to report having had endoscopic screening than women, independent of survey year (p<0.0001). On multivariate analysis, controlling for insurance status, educational level and family income, the trends in colorectal, cervical and breast cancer between 2000 and 2005 remained significant. Conclusions: There has been a significant decline in adherence to breast and cervical cancer screening CPGs over the past five years, while CRC screening has improved over the same time period. Although rates of PAP smears and mammography are high compared with lower GI endoscopy and PSA testing, the decline in breast and cervical cancer screening is concerning. Number of people (%) P value 2000 2005 Univariate Multivariate PAP smear within past 3 yrs 13,538 (78.7) 12,215 (74.1) P<0.0001 P<0.0001 Mammogram within past 2 yrs 7,289 (68.5) 7,061 (65.5) P=0.0005 P=0.0003 Endoscopy within past 10 yrs 4,260 (34.5) 5,337 (41.2) P<0.0001 P<0.0001 PSA within the past yr 2,104 (46.0) 2,350 (54.0) P=0.7649 P=0.8681 No significant financial relationships to disclose.

PD17-07 PSA TESTING AND COLORECTAL CANCER SCREENING TRENDS FROM 2012 TO 2020: ANALYSIS OF THE CDC BEHAVIORAL RISK FACTOR SURVEILLANCE SYSTEM (BRFSS)

Background: Colorectal cancer (CRC) mortality is 47% higher in African American men and 34% higher in African American women compared to non-Hispanic white men and women. Methods: Nine African American churches in Los Angeles (LA) participated in a one-group pre/post-test pilot study to promote cancer screening (2015-2018). Each church identified 5 Community Health Advisors (CHAs) who received training to recruit study participants ages 50 to 75; assess participants’ adherence to cancer screening guidelines of the U.S. Preventive Services Task Force; and provide one-on-one counseling for participants who were not adherent. Participants completed telephone surveys 3 months after the intervention. The goal of this analysis was to understand CRC screening outcomes among 163 African American participants who were baseline non-adherent to CRC screening guidelines. We fit bivariate and multivariate mixed effects logistic regression models to assess correlates of (1) discussion of CRC screening with provider and (2) receipt of CRC screening during follow-up. Results: 49% of respondents reported that they discussed CRC screening with a provider during the follow-up period and 28% of respondents reported receipt of CRC screening. Respondents who reported that they were counseled by a CHA were more than twice as likely to discuss CRC screening with their provider as those who reported that they did not receive the intervention (54% versus 24%, p&amp;lt;0.005). Those who had a regular doctor, who had more than 3 health care visits in the past 3 months and who had a routine check-up in the past 12 months were also significantly more likely to discuss CRC screening with a provider (all p&amp;lt;.001). Females were almost twice as likely as males to receive CRC screening during the follow-up period than males (35% versus 18%, p&amp;lt;.02) and South LA residents were significantly less likely to receive CRC screening than participants outside of South LA (22% versus 38%, p&amp;lt;.02). Those who had a routine check-up in the past 12 months were also significantly more likely to report receipt of CRC testing during the follow-up period (all p&amp;lt;0.01). Those who had discussed CRC screening with a provider were significantly more likely to obtain CRC screening (p&amp;lt;.001). Knowledge of CRC screening guidelines was low overall but significantly higher among those who received CRC screening than among their counterparts who did not receive screening (p&amp;lt;.02). In multivariable analyses, receipt of CHA counseling (OR 3.77) was significantly associated with discussing CRC screening with a provider during follow-up but not with CRC screening. Residence in South LA (OR 0.38) was significantly associated with lack of CRC screening. Conclusions: Findings confirm the important role of health care providers and suggest that residence in South LA constitutes an additional barrier to CRC screening. Further research and additional resources are needed to address disparities in the uptake of CRC screening among African Americans, especially in South LA. Citation Format: Annette E. Maxwell, Aziza Lucas-Wright, Cindy Chang, Rhonda Santifer, Catherine M. Crespi. Factors associated with colorectal cancer screening in a peer-counseling intervention study in partnership with African American churches [abstract]. In: Proceedings of the AACR Virtual Conference: Thirteenth AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2020 Oct 2-4. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2020;29(12 Suppl):Abstract nr PO-035.

Challenges With Colorectal Cancer Family History Assessment—Motivation to Translate Polygenic Risk Scores Into Practice

Polygenic Risk Scores for Follow Up After Colonoscopy and Polypectomy: Another Tool for Risk Stratification and Planning Surveillance?

Introduction: Colorectal cancer (CRC) is the 2nd leading cause of cancer-related deaths in the U.S. The American College of Gastroenterology recently updated their CRC screening guidelines in March 2021 to screen ages 45-75. The U.S. Preventive Services Task Force also added Grade B recommendations to screen individuals aged 45-49 as of May 2021. With these updates in mind, a quality improvement project was initiated to increase CRC screening in patients aged 45-49 years. Methods: Our primary objective was to improve rates of CRC screening in ages 45-49. Only average risk patients aged 45-49 with no prior CRC screening were included. Patients with a personal or family history of CRC, adenomatous polyps, Lynch syndrome, familial adenomatous polyposis, & recent gastrointestinal bleed were excluded. In June 2021, our institution’s healthcare gaps were modified to include CRC screening for ages 45-49. Patients 3 months pre-intervention were compared to those 3 months post-intervention. Baseline demographics were also assessed. The type of screening, adenoma detection rates, colonic lesion rates, & malignant neoplasm rates were evaluated as secondary outcomes. (Figure) Results: Overall demographics were similar between the two groups. Both had similar age, BMI, sex, race, & ethnicity. The amount of open healthcare gaps, use of alcohol, & tobacco use were also very similar. We found a statistically significant improvement in CRC screening rates after the intervention. A total of 59 patients (0.0445%) completed CRC screening pre-intervention. While 131 patients (0.0989%) received CRC screening post-intervention. Our primary objective was met with a P < 0.0001. A comprehensive increase of 71 patients received CRC screening post-intervention. Secondary outcomes however revealed no significant difference between the pre & post-intervention groups. (Table) Conclusion: Our implementation did not assess other CRC screening modalities other than colonoscopy & FIT MTS-DNA stool testing as our institution predominantly uses these two methods for screening. Despite this limitation, our project successfully achieved its goal. A total of 71 additional patients completed CRC screening. This translates to an improvement of CRC screening by over 200%. Though there was no significant difference in detecting malignant adenomatous neoplasms, this increase still theoretically translates to detection of 2 additional patients diagnosed with CRC per epidemiological studies. Overall further work needs to be done to improve our CRC screening rates.Figure 1.: Number of Patients Who Received Colorectal Cancer Screening by Month Table 1. - Demographics & Outcomes Pre-Intervention Post-Intervention P-value Median Age 48 47 Median BMI 30.5 29.6 Male Sex Percentage 54.2% 46.9% P = 0.53 [95% CI: -0.147 to 0.285] Median Care Gap Score¶ 3 3 Max Care Gap Score♠ 7 7 Average Alcohol Use Per Week 3 / week 4 / week Smoking Percentage♥ 8% 20% P = 0.073 [95% CI: -0.238 to 0.010] Caucasian Race 86.4% 91.3% P = 0.736 [95% CI: -0.343 to 0.240] African American Race 4.7% 4.31% Hispanic Ethnicity 0.53% 0.63% Asian Americans and Pacific Islanders Race 0.79% 0.80% Total Patients Eligible for CRC♣ Screening 132452 132432 Total CRC Screened Number of Patients 59 131 Total CRC Screened Percentage 0.0445% 0.0989% P < 0.0001 [95% CI: -0.000748 to -0.000340] CRC Screened through Colonoscopy 59 80 CRC Screened through FIT MTS-DNA 0 51 Adenoma Detection Rate on Colonoscopyº 44.1% 38.8% P = 0.63 [95% CI: -0.162 to 0.269] Colonic Lesion Detection Rate on Colonoscopya 42.4% 40% P = 0.83 [95% CI: -0.192 to 0.240] Malignant Adenomatous Neoplasms Detection Rate on Colonoscopy 0% 0% ¶Median number of healthcare gaps that were unresolved in patients after CRC screening took place♠. Maximum number of healthcare gaps that were unresolved in patients after CRC screening took place♥. Percentage of patients with any prior history of smoking as documented by Social History.♣. Colorectal Cancer.ºPercentage of patients who were found to have 1 or more precancerous polyps detected on colonoscopy.a. Percentage of patient who were found to have colonic lesions of any kind aside for polyps on colonoscopy.

Purpose: We partnered with a local Federally Qualified Health Center (FQHC) to test implementation of evidence-based interventions (EBI) promoting Fecal Immunochemical Test (FIT) CRC screening in an environment in which colonoscopy has been the prevailing screening strategy. We report on implementation adaptations and preliminary results. Background: Sociocultural and medical concerns are barriers to colonoscopy uptake in some populations. An additional barrier to CRC screening is system level capacity for colonoscopy that results in a back log of cases and long wait times. With Covid-19, the additional backlog in overdue CRC screening has underscored the need to expand FIT testing capacity to address screening needs and to pre-empt further racial/ethnic and SES disparities in CRC outcomes. This trial tests the unique and additive value of multiple EBIs for increasing CRC screening (primarily through FIT testing, but also colonoscopy when indicated) while evaluating the success of implementing these approaches. EBIs include the use of medical reminders, addressing the structural barriers (social determinants of health [SDOH]), and assistance from community health workers. Methods: Participants (3500), ages 45-75, were identified from a large FQHC in New Haven, CT and determined to be overdue for CRC screening. Participants were randomly assigned to one of the four arms of the study: 1) Provider reminder (overdue for CRC screening) only; 2) Provider Reminder + SDOH short message and one-size-fits all link to resources; 3) Provider Reminder + SDOH short message and offer for individualized navigation (trained navigators from local community) to address SDOH and other barriers; 4) Provider Reminder + offer to participate in a CRC educational program as phase 2 of the NCI's Screen to Save program (not an EBI). Preliminary data on uptake of CRC screening will be presented. Results: With input from stakeholders, we have: 1) lowered age eligibility from 50 to 45 to align with new guidelines; 2) expanded the target population to 2 additional satellite clinics, more than doubling the proposed study enrollment; 3) incorporated design changes in the patient reminders. The collaboration between research team and clinician stakeholders has been critical in minimizing disruptions to clinical workflow while assuring fidelity to the evidence-based interventions. Preliminary outcomes (within one month of intervention) on uptake of intervention across the 4 arms of the study, i.e., referral for CRC screening and test completion will be presented. Conclusion: The unique challenges of this urban community of primarily African American/Black, Hispanic/Latinx and/or low socioeconomic status individuals stem from the disproportionate burden of SDOH barriers. Findings will inform primary care setting implementation of EBIs to address the anticipated increase in disparities in CRC screening, exacerbated by COVID-19 changes in health care access and utilization, as well as the increased demand associated with the change in guidelines. Citation Format: Beth A. Jones, Sakinah C. Suttiratana, Sally A. DeGiovanni, Levita Y. Robinson, Michael J. Couturie, Denise Stevens, Monique K. Stefanou, Jose DeJesus, Eduardo Reyes, Jonathan Colon, Maryanne Cosgrove, Steven J. Parra. Implementing evidence-based interventions (EBI) to increase uptake of fecal immunochemical test (FIT) colorectal cancer (CRC) screening in Vulnerable Populations [abstract]. In: Proceedings of the AACR Virtual Conference: 14th AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2021 Oct 6-8. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2022;31(1 Suppl):Abstract nr PO-025.

Background: Though colorectal cancer (CRC) screening rates have increased significantly over the past two decades, screening disparities persist among Latinos. To increase CRC screening rates among Latinos, a promotor-led intervention was implemented to provide educational workshops and link community members to screenings through a partnered Federally Qualified Health Center (FQHC). Aims: To assess screening completion at 6-months follow-up. To identify barriers influencing adherence to CRC screening among participants who participated in a promotor-led intervention. Methods: The Juntos Contra el Cáncer/Together Against Cancer (JUNTOS) program was a promotor-led cancer prevention study that provided CRC prevention workshops to adults ages 50 to 75 in a primarily Latino community in San Diego, CA. Based on the Social Ecological Framework, the intervention targeted knowledge of CRC, screening attitudes, social support, screening barriers, and linked participants to community resources. Promotors assisted participants in scheduling appointments, which is the first step in CRC screening at the partnering FQHC. From December 2016 to July 2018, a total of 66 participants who were not up to date with CRC screening attended a 2.5-hour workshop, received follow-up calls from promotors, and completed a 6-month assessment. Demographics, health conditions, CRC knowledge, and attitudes changes towards screening were compared between participants who completed a CRC screening (adherent) and those who did not at 6 months (nonadherent). Chi-squared and t-tests were conducted to assess significant differences among adherent and nonadherent participants. For nonadherent participants, barriers to scheduling an appointment were evaluated. Results: The sample included 66 Latinos ages 50 to 75 (women=70%). Results from the 6-month follow-up show that 59% participants reported completing CRC screening. Findings show a statistically significant decrease in negative attitudes towards CRC screening from baseline to follow-up (M1=2.88 [SD=.81], M2=2.53 [SD=.85], p&amp;lt;.001). Differences in demographics, health conditions, attitudes towards screening, CRC knowledge, and health behaviors were not statistically significant at baseline between adherent and nonadherent participants at follow-up. The most frequently reported barriers for nonadherent participants to schedule an appointment with their medical provider were being too busy (48%) and not having health insurance (41%). Conclusions: Preliminary findings suggest that the delivery of the promotor-led intervention improved attitudes of CRC screening and led to increases in self-reported screening rates among nonadherent adults. For uninsured participants, waiving the appointment or providing additional support to navigate the health system may help them complete CRC screening. Overall, these findings build the evidence on the preliminary efficacy of group-based CRC education and linkages to care for nonadherent adults. Citation Format: Carolina López de la Torre, Jill N. JoaDumbauld, Jessica Haughton, Anthony Barrios, Dalia Rojas, Mirna Díaz, José López, Maria Milla, Samir Gupta, Jesse Nodora, Christian Ramers, Felipe Garcia-Bigley, Jessica Marquez, Balambal Baharti, Elva M. Arredondo. Colorectal cancer screening completion rates and barriers to colorectal cancer screening 6 months following participation in CRC screening intervention [abstract]. In: Proceedings of the Eleventh AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2018 Nov 2-5; New Orleans, LA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2020;29(6 Suppl):Abstract nr B113.

Marked health disparities exist in colorectal cancer (CRC) screening, incidence, and mortality among medically-underserved communities. Literature suggests certain health beliefs (e.g., perceived risk) may be related to screening behavior. This study examined changes in CRC health beliefs following receipt of one of two educational interventions aimed at promoting CRC screening uptake among a medically-underserved population. We compared changes in CRC health beliefs at baseline and 12 months later both within and between the two intervention groups. Enrolled participants were aged 50-75, at average CRC risk, not up-to-date with CRC screening guidelines, enrolled in a randomized controlled trial to increase CRC screening that was conducted at community clinics in the Tampa Bay area, and completed both the baseline and 12 month follow-up assessments. Participants were randomized to receive either a culturally-targeted photonovella and DVD plus fecal immunochemical test (FIT) intervention (titled Colorectal Cancer Awareness, Research, Education and Screening, or CARES, intervention group condition) or a Centers for Disease Control and Prevention (CDC) standard educational brochure plus FIT intervention (comparison group condition). At both time points, participants completed a questionnaire that included multiple health-related beliefs including Preventive Health Model (PHM) constructs (i.e., perceived susceptibility, perceived salience, self-efficacy, response efficacy, cancer worry, social influence, and religious beliefs), CRC awareness, decisional conflict regarding CRC screening, cancer fatalism, trust in the healthcare system, and perceived discrimination. Changes in health belief scores and group differences in change were examined using Student's t-tests. The majority of participants (n=270) were: female (58%); white (67%) or black (26%); insured (59%) including county health insurance; had a household income &amp;lt;$10,000 (65%); and had a high school education (35%) or more than high school education (41%). In both intervention conditions, there was an increase in CRC awareness, PHM social influence, and trust in the healthcare system (all p's&amp;lt;.0001). In the CARES intervention group, there also was an increase in PHM salience (p&amp;lt;.05). Among individuals in the comparison group, there was an increase in PHM response efficacy (p&amp;lt;.01) and PHM self-efficacy (p&amp;lt;.0001). There were no significant between-group differences on any of the health belief change scores. Both CRC screening interventions promoted positive changes in multiple health beliefs from baseline to 12 months which suggests clear benefits of educational interventions. The interventions had common positive effects (i.e., CRC awareness, PHM social influence, and trust in the healthcare system), but also unique effects on PHM salience (CARES condition) and PHM self-efficacy and PHM response efficacy (comparison condition). However, between-group intervention comparisons were not significant suggesting that both educational interventions are beneficial. Given that individuals in both intervention groups were provided with access to CRC screening via FIT kit, future analyses will examine whether changes in health beliefs were associated with higher CRC screening uptake. Citation Format: Shannon M. Christy, Steven K. Sutton, Enmanuel Chavarria, Stacy N. Davis, Rania Abdulla, Gwendolyn P. Quinn, Susan T. Vadaparampil, Chitra Ravindra, Ida Schultz, Richard Roetzheim, David Shibata, Cathy D. Meade, Clement K. Gwede. Changes in health beliefs among medically-underserved patients enrolled in a community-based randomized controlled trial to promote colorectal cancer screening. [abstract]. In: Proceedings of the Ninth AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2016 Sep 25-28; Fort Lauderdale, FL. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2017;26(2 Suppl):Abstract nr A63.

How Good Is Your Dentist? How Good Is Your Endoscopist? The Quality Imperative

Background:Colorectal cancer (CRC) screening is cost-effective in many Western countries, and many have successfully implemented CRC screening programs. For countries with a lower CRC incidence, like Saudi Arabia, the value of CRC screening is less evident and requires careful weighing of harms, benefits, and costs.Methods:We used the MISCAN-Colon microsimulation model to simulate a male and female cohort with life expectancy and CRC risk as observed in Saudi Arabia. For both cohorts, we evaluated strategies without screening, with annual or biennial faecal immunochemical testing (FIT), and with 10-yearly or once-only colonoscopy. We also considered different start and end ages of screening. For both cohorts, we estimated lifetime costs and effects of each strategy. We then identified a set of potentially cost-effective strategies using incremental cost-effectiveness ratios (ICERs) defined as the additional cost per additional quality-adjusted life year (QALY).Results:Without CRC screening, an estimated 14 per 1,000 males would develop CRC during their lifetime and 9 would die from CRC. Several strategies proved potentially cost-effective including biennial FIT at ages 55-65 (ICER of $7,400), once-only colonoscopy at age 55 (ICER of $7,700), and 10-yearly colonoscopy at ages 50–65, 45–65, and 45–75 (ICERs of $34,000, 71,000, and 375,000, respectively). For females, risk of CRC was lower and CRC screening was therefore less cost-effective, but efficient strategies were largely similar.Conclusions:Despite low CRC incidence in Saudi Arabia, some FIT or colonoscopy screening strategies may meet reasonable thresholds of cost-effectiveness. The optimal strategy will depend on multiple factors including the willingness to pay per QALY, the colonoscopy capacity, and the accepted budget impact.

In 2021, the US Preventive Services Task Force (USPSTF) issued a final recommendation to lower the initial age for colorectal cancer (CRC) screening to 451. At many institutions, trainees play a critical role in the implementation of CRC screening guidelines. The aim of the current study is to assess trainee awareness of recent changes to CRC screening guidelines. Trainees in surgical and non-surgical residency and fellowship programs at a single academic medical center were surveyed, in February of 2023, regarding awareness of recent changes to CRC screening guidelines. Additional information regarding trainee recommendations for various types of screening modalities and their perceptions of patient awareness was obtained. A total of 116 trainees responded to the survey, reflecting a 39% response rate. Of trainees recommending CRC screening, 75% recommended screening to be initiated at age 45, 13% at age 50, 6% at age 40, and 2% at age greater than 50. Trainee knowledge of screening guidelines came from medical school learning (70.7%) and USPSTF guidelines (82%). The most recommended screening modalities were colonoscopy (87%), fecal immunochemical testing (FIT) (31%), and fecal occult blood testing (FOBT) (15%). In comparing trainees who perform colonoscopies versus trainees from primary care specialties, there was no statistical difference between groups regarding knowledge on current screening guideline recommendations. Most trainees recommended CRC screening during their training. Unfortunately, many trainees were unaware of recent changes to CRC screening guidelines. These results revealed an important knowledge gap to be addressed among surgical and non-surgical trainees.