Effect of Behavioral Interventions on the Uptake of Colonoscopy for Colorectal Cancer Screening: A Systematic Review and Meta-Analysis
INTRODUCTION/BACKGROUND:Screening decreases colorectal cancer incidence and mortality, but uptake in the United States remains suboptimal. Prior studies have investigated the effect of various interventions on overall colorectal cancer screening and stool-based testing, but the effect on colonoscopy-the predominant screening test in the United States-has not been fully examined. We performed a systematic review and meta-analysis to assess the effect of behavioral interventions on screening colonoscopy uptake. METHODS:We searched PubMed, Embase, and Cochrane databases through January 2022 for controlled trials that assessed the effect of behavioral interventions on screening colonoscopy uptake. All titles, abstracts, and articles were screened by at least 2 independent reviewers. Odds ratios were extracted from the original article or calculated from the raw data. The primary outcome was the relative increase in screening colonoscopy completion with any behavioral intervention. We performed random-effects meta-analysis, with subgroup analysis by type of intervention. RESULTS:A total of 25 studies with 30 behavioral interventions were analyzed. The most common interventions were patient navigation (n = 11) and multicomponent interventions (n = 6). Overall, behavioral interventions increased colonoscopy completion by 54% compared with controls (odds ratio [OR] 1.54, 95% confidence interval [CI] 1.26-1.88). Patient navigation (OR 1.78, 95% CI 1.35-2.34) and multicomponent interventions (OR 1.84, 95% CI 1.17-2.89) had the strongest effect on colonoscopy completion among interventions examined in multiple studies. Significant heterogeneity was observed both overall and by intervention type. There was no evidence of publication bias. DISCUSSION/CONCLUSIONS:Behavioral interventions increase screening colonoscopy completion and should be adopted in clinical practice. In particular, patient navigation and multicomponent interventions are the best-studied and most effective interventions.
Blood Test Increases Colorectal Cancer Screening in Persons Who Declined Colonoscopy and Fecal Immunochemical Test: A Randomized Controlled Trial
BACKGROUND & AIMS/OBJECTIVE:The septin 9 blood test is indicated for colorectal cancer screening in individuals who decline first-line tests, but participation in this context is unclear. We conducted a randomized controlled trial to compare reoffering colonoscopy and fecal immunochemical test (FIT) alone versus also offering the blood test among individuals who declined colonoscopy and FIT. METHODS:Screen-eligible Veterans aged 50-75 years who declined colonoscopy and FIT within the previous 6 months were randomized to letter and telephone outreach to reoffer screening with colonoscopy/FIT only (control), or additionally offering the blood test as a second-line option (intervention). The primary outcome was completion of any screening test within 6 months. The secondary outcome was completion of a full screening strategy within 6 months, including colonoscopy for those with a positive noninvasive test. RESULTS:Of 359 participants who completed follow-up, 9.6% in the control group and 17.1% in the intervention group completed any screening (7.5% difference; P = .035). Uptake of colonoscopy and FIT was similar in the 2 groups. The full screening strategy was completed in 9.0% and 14.9% in the control and intervention groups, respectively (5.9% difference; P = .084). CONCLUSIONS:Among individuals who previously declined colonoscopy and FIT, offering a blood test as a secondary option increased screening by 7.5% without decreasing uptake of first-line screening options. However, completion of a full screening strategy did not increase. These findings indicate that a blood test is a promising method to improve colorectal cancer screening, but obtaining a timely colonoscopy after a positive noninvasive test remains a challenge (ClincialTrials.gov number, NCT03598166).
The Importance of Professional Societies as Academic Homes
Gastric Cancer Risk Factors in a Veteran Population
INTRODUCTION/BACKGROUND:Risk factors for gastric cancer in the United States are not well understood, especially in populations with a low proportion of immigrants. We conducted a matched case-control study in a Veteran Affairs Medical Center to identify risk factors for gastric cancer. MATERIALS AND METHODS/METHODS:Gastric cancer patients and age- and sex-matched controls were identified in a 1:4 ratio from January 1, 1997 to October 31, 2018. Demographic, medical, endoscopic, and histologic data were extracted. We performed conditional logistic regression to estimate odds ratios and 95% CIs for associations between potential risk factors and gastric cancer. RESULTS:Most gastric cancer cases were diagnosed on initial endoscopy (71.4%). Of these, the most common presenting stage was stage IV (40.8%). Risk factors for gastric cancer included Black and Asian race and never or current (compared to former) drinkers, although Helicobacter pylori eradication and pernicious anemia were associated with decreased risk. CONCLUSIONS:The high proportion of late-stage gastric cancer diagnoses highlights the need for improved risk stratification as well as screening and surveillance protocols in the U.S. population. Racial disparities among veterans in an equal-access system necessitate further investigation into the etiology of these disparities.
Disaggregating Racial and Ethnic Data: A Step Toward Diversity, Equity, and Inclusion
Disaggregating Racial and Ethnic Data: A Step Toward Diversity, Equity, and Inclusion [Editorial]
Up-to-Date Colonoscopy Use in Asian and Hispanic Subgroups in New York City, 2003-2016
BACKGROUND:Colorectal cancer screening uptake in the United States overall has increased, but racial/ethnic disparities persist and data on colonoscopy uptake by racial/ethnic subgroups are lacking. We sought to better characterize these trends and to identify predictors of colonoscopy uptake, particularly among Asian and Hispanic subgroups. STUDY/METHODS:We used data from the New York City Community Health Survey to generate estimates of up-to-date colonoscopy use in Asian and Hispanic subgroups across 6 time periods spanning 2003-2016. For each subgroup, we calculated the percent change in colonoscopy uptake over the study period and the difference in uptake compared to non-Hispanic Whites in 2015-2016. We also used multivariable logistic regression to identify predictors of colonoscopy uptake. RESULTS:All racial and ethnic subgroups with reliable estimates saw a net increase in colonoscopy uptake between 2003 and 2016. In 2015-2016, compared with non-Hispanic Whites, Puerto Ricans, Dominicans, and Central/South Americans had higher colonoscopy uptake, whereas Chinese, Asian Indians, and Mexicans had lower uptake. On multivariable analysis, age, marital status, insurance status, primary care provider, receipt of flu vaccine, frequency of exercise, and smoking status were the most consistent predictors of colonoscopy uptake (≥4 time periods). CONCLUSIONS:We found significant variation in colonoscopy uptake among Asian and Hispanic subgroups. We also identified numerous demographic, socioeconomic, and health-related predictors of colonoscopy uptake. These findings highlight the importance of examining health disparities through the lens of disaggregated racial/ethnic subgroups and have the potential to inform future public health interventions.
Racial and Ethnic Disparities in Early-Onset Colorectal Cancer Survival
BACKGROUND:Young adults diagnosed with colorectal cancer (CRC) comprise a growing, yet understudied, patient population. We estimated 5-year relative survival of early-onset CRC and examined disparities in survival by race-ethnicity in a population-based sample. METHODS:We used the National Cancer Institute's Surveillance, Epidemiology, and End Results program of cancer registries to identify patients diagnosed with early-onset CRC (20-49 years of age) between January 1, 1992, and December 31, 2013. For each racial-ethnic group, we estimated 5-year relative survival, overall and by sex, tumor site, and stage at diagnosis. To illustrate temporal trends, we compared 5-year relative survival in 1992-2002 vs 2003-2013. We also used Cox proportional hazards regression models to examine the association of race-ethnicity and all-cause mortality, adjusting for age at diagnosis, sex, county type (urban vs rural), county-level median household income, tumor site, and stage at diagnosis. RESULTS:We identified 33,777 patients diagnosed with early-onset CRC (58.5% White, 14.0% Black, 13.0% Asian, 14.5% Hispanic). Five-year relative survival ranged from 57.6% (Black patients) to 69.1% (White patients). Relative survival improved from 1992-2002 to 2003-2013 for White patients only; there was no improvement for Black, Asian, or Hispanic patients. This pattern was similar by sex, tumor site, and stage at diagnosis. In adjusted analysis, Black (adjusted hazard ratio [aHR], 1.42; 95% confidence interval [CI], 1.36-1.49), Asian (aHR, 1.06; 95% CI, 1.01-1.12), and Hispanic (aHR, 1.16; 95% CI, 1.10-1.21) race-ethnicity were associated with all-cause mortality. CONCLUSION/CONCLUSIONS:Our study adds to the well-documented disparities in CRC in older adults by demonstrating persistent racial-ethnic disparities in relative survival and all-cause mortality in patients with early-onset CRC.
Diversity, equity, and inclusion in gastroenterology training: a call to action
Age-Specific Trends in Colorectal Cancer Mortality Rates Over a 27-Year Period [Meeting Abstract]
Introduction: Incidence rates of colorectal cancer (CRC) are increasing among younger adults (age , 50 years) in the U.S., and more recently, rates have increased in persons age 50-54 years. To better understand the corresponding changes in mortality, we examined trends in CRC mortality rates by age over a 27-year time period.
Method(s): We used population-based data from the National Cancer Institute's Surveillance, Epidemiology, and End Results program of cancer registries to estimate age-specific (30-84 years, by 5-year age group) mortality rates per 100,000 persons during the period 1992-2019. We used joinpoint regression analysis to quantify changes in the direction and magnitude of mortality rates; the slope of the best-fit line between joinpoints corresponds to the annual percent change (APC) in mortality, with p< 0.05 indicating a statistically significant difference from a slope of zero.
Result(s): Between 1992 and 2019, CRC mortality rates steadily increased by about 1% per year for ages 30-34 and 35-39 years. For ages 40-44 and 45-49 years, rates decreased by , 1% per year from 1992 until the mid 2000s and subsequently increased from 2004 to 2019 (APC 1.1, p< 0.05) and 2006 to 2019 (APC 1.3, p< 0.05), respectively (Table). For age groups 50-54 to 60-64 years, mortality rates decreased by about 2% per year from 1992 until the mid 2000s; however, after 2006, rates increased for age 50-54 years (APC 0.5, p< 0.05) and decreased more slowly for ages 55-59 (APC -0.4, p< 0.05) and 60-64 (APC -1.5, p< 0.05) years. Mortality rates also decreased at a lower rate for age 65-69 years, beginning in 2011 (APC for 2011-2019: -1.7, p< 0.05 vs. APC for 2001-2010: -3.9, p< 0.05). For age groups 70-74 to 80-84 years, mortality rates steadily decreased by about 3% per year from 2000 to 2019.
Conclusion(s): Age-specific CRC mortality rates mirror the well-described trends in CRC incidence rates, with increasing rates in every age group up to 50-54 years and slowing rates at age 55-59 years. Our findings suggest that CRC diagnoses and deaths are increasingly common in middle-aged adults, despite the availability of screening and improved treatment options. Future efforts should identify factors contributing to increasing CRC mortality rates, as well as implement strategies to improve screening participation in these age groups