Annals of Internal Medicine: Gastrointestinal Cancer Topic Collection

Screening Colonoscopy and Colorectal Cancer Risk

Tue, 05 Mar 2013 00:00:00 GMT

An Automated Intervention With Stepped Increases in Support to Increase Uptake of Colorectal Cancer Screening A Randomized Trial

Green BB, Wang C, Anderson ML, et al. — Tue, 05 Mar 2013 00:00:00 GMT

Chinese translation

Background:

Screening decreases colorectal cancer (CRC) incidence and mortality, yet almost half of age-eligible patients are not screened at recommended intervals.

Objective:

To determine whether interventions using electronic health records (EHRs), automated mailings, and stepped increases in support improve CRC screening adherence over 2 years.

Design:

4-group, parallel-design, randomized, controlled comparative effectiveness trial with concealed allocation and blinded outcome assessments. (ClinicalTrials.gov: NCT00697047)

Setting:

21 primary care medical centers.

Patients:

4675 adults aged 50 to 73 years not current for CRC screening.

Intervention:

Usual care, EHR-linked mailings (“automated”), automated plus telephone assistance (“assisted”), or automated and assisted plus nurse navigation to testing completion or refusal (“navigated”). Interventions were repeated in year 2.

Measurements:

The proportion of participants current for screening in both years, defined as colonoscopy or sigmoidoscopy (year 1) or fecal occult blood testing (FOBT) in year 1 and FOBT, colonoscopy, or sigmoidoscopy (year 2).

Results:

Compared with those in the usual care group, participants in the intervention groups were more likely to be current for CRC screening for both years with significant increases by intensity (usual care, 26.3% [95% CI, 23.4% to 29.2%]; automated, 50.8% [CI, 47.3% to 54.4%]; assisted, 57.5% [CI, 54.5% to 60.6%]; and navigated, 64.7% [CI, 62.5% to 67.0%]; P < 0.001 for all pair-wise comparisons). Increases in screening were primarily due to increased uptake of FOBT being completed in both years (usual care, 3.9% [CI, 2.8% to 5.1%]; automated, 27.5% [CI, 24.9% to 30.0%]; assisted, 30.5% [CI, 27.9% to 33.2%]; and navigated, 35.8% [CI, 33.1% to 38.6%]).

Limitation:

Participants were required to provide verbal consent and were more likely to be white and to participate in other types of cancer screening, limiting generalizability.

Conclusion:

Compared with usual care, a centralized, EHR-linked, mailed CRC screening program led to twice as many persons being current for screening over 2 years. Assisted and navigated interventions led to smaller but significant stepped increases compared with the automated intervention only. The rapid growth of EHRs provides opportunities for spreading this model broadly.

Primary Funding Source:

National Cancer Institute, National Institutes of Health.

Screening Colonoscopy and Risk for Incident Late-Stage Colorectal Cancer Diagnosis in Average-Risk Adults A Nested Case–Control Study

Doubeni CA, Weinmann S, Adams K, et al. — Tue, 05 Mar 2013 00:00:00 GMT

Chinese translation

Background:

The effectiveness of screening colonoscopy in average-risk adults is uncertain, particularly for right colon cancer.

Objective:

To examine the association between screening colonoscopy and risk for incident late-stage colorectal cancer (CRC).

Design:

Nested case–control study.

Setting:

Four U.S. health plans.

Patients:

1039 average-risk adults enrolled for at least 5 years in one of the health plans. Case patients were aged 55 to 85 years on their diagnosis date (reference date) of stage IIB or higher (late-stage) CRC during 2006 to 2008. One or 2 control patients were selected for each case patient, matched on birth year, sex, health plan, and prior enrollment duration.

Measurements:

Receipt of CRC screening 3 months to 10 years before the reference date, ascertained through medical record audits. Case patients and control patients were compared on receipt of screening colonoscopy or sigmoidoscopy by using conditional logistic regression that accounted for health history, socioeconomic status, and other screening exposures.

Results:

In analyses restricted to 471 eligible case patients and their 509 matched control patients, 13 case patients (2.8%) and 46 control patients (9.0%) had undergone screening colonoscopy, which corresponded to an adjusted odds ratio (AOR) of 0.29 (95% CI, 0.15 to 0.58) for any late-stage CRC, 0.36 (CI, 0.16 to 0.80) for right colon cancer, and 0.26 (CI, 0.06 to 1.11; P = 0.069) for left colon/rectum cancer. Ninety-two case patients (19.5%) and 173 control patients (34.0%) had screening sigmoidoscopy, corresponding to an AOR of 0.50 (CI, 0.36 to 0.70) overall, 0.79 (CI, 0.51 to 1.23) for right colon late-stage cancer, and 0.26 (CI, 0.14 to 0.48) for left colon cancer.

Limitation:

The small number of screening colonoscopies affected the precision of the estimates.

Conclusion:

Screening with colonoscopy in average-risk persons was associated with reduced risk for diagnosis of incident late-stage CRC, including right-sided colon cancer. For sigmoidoscopy, this association was seen for left CRC, but the association for right colon late-stage cancer was not statistically significant.

Primary Funding Source:

National Cancer Institute of the National Institutes of Health.

Eradication of Hepatitis C Virus Infection and the Development of Hepatocellular Carcinoma A Meta-analysis of Observational Studies

Morgan RL, Baack B, Smith BD, et al. — Tue, 05 Mar 2013 00:00:00 GMT

Background:

Hepatitis C virus (HCV) is a leading cause of hepatocellular carcinoma (HCC). In the United States, this form of cancer occurs in approximately 15 000 persons annually. A systematic review of the evidence is needed to assess the benefits of treatment of HCV-infected persons on development of HCC.

Purpose:

To systematically review observational studies to determine the association between response to HCV therapy and development of HCC among persons at any stage of fibrosis and those with advanced liver disease.

Data Sources:

MEDLINE, EMBASE, CINAHL, the Cochrane Library, Web of Science, and the Database of Abstracts of Reviews and Effectiveness from inception through February 2012.

Study Selection:

English-language observational studies that compared therapy-derived sustained virologic response (SVR) with no response to therapy among HCV-infected persons, targeted an adult population, and had an average follow-up of at least 2 years.

Data Extraction:

Two investigators independently extracted data into uniform relative risk measures. The Grading of Recommendations Assessment, Development and Evaluation framework was used to determine the quality of the evidence.

Data Synthesis:

Thirty studies fulfilled the inclusion criteria, and 18 provided adjusted effect estimates that were used to calculate pooled relative risks. Among HCV-infected persons, SVR was associated with reduced risk for HCC (relative risk for all persons, 0.24 [95% CI, 0.18 to 0.31], moderate-quality evidence; advanced liver disease hazard ratio, 0.23 [CI, 0.16 to 0.35], moderate-quality evidence).

Limitation:

In the meta-analyses, some variables could not be controlled for because of the observational design of the included studies.

Conclusion:

Sustained virologic response after treatment among HCV-infected persons at any stage of fibrosis is associated with reduced HCC. The evidence was determined to be of moderate quality.

Primary Funding Source:

Centers for Disease Control and Prevention.