M. Deutekom

Uptake of faecal occult blood test colorectal cancer screening by different ethnic groups in the Netherlands

We investigated the participation rates in CRC screening with a FOBT among various ethnic groups in the Netherlands. Individuals (n = 10 054) were invited by mail and grouped by country of birth. Overall participation rate was 49%. Participation among ethnic minority groups was significantly lower than among ethnic Dutch [adjusted OR for participation: Middle- or Central-East 0.25 (0.18-0.34), African 0.48 (0.34-0.67), Surinamese and Antillean 0.51 (0.43-0.61), South- or South-East Asian 0.56 (0.46-0.69) and other Western 0.78 (0.63-0.96)]. Further studies are needed to explore whether ethnic minority groups are not reached or that low uptake is determined by other causes.

Relationship between external anal sphincter atrophy at endoanal magnetic resonance imaging and clinical, functional, and anatomic characteristics in patients with fecal incontinence

PurposeExternal anal sphincter atrophy at endoanal magnetic resonance imaging has been associated with poor outcome of anal sphincter repair. We studied the relationship between external anal sphincter atrophy on endoanal magnetic resonance imaging and clinical, functional, and anatomic characteristics in patients with fecal incontinence.MethodsIn 200 patients (mean Vaizey score, 18 (±2.9 standard deviation)) magnetic resonance images were evaluated for external anal sphincter atrophy (none, mild, or severe) by radiologists blinded to anorectal functional test results and details from medical history. Subgroups of patients with and without atrophy were compared for medical history, anal manometry, pudendal nerve latency testing, anal sensitivity testing, external anal sphincter thickness, and external anal sphincter defects. Whenever significant differences were detected, we tested for differences between patients with mild and severe atrophy.ResultsExternal anal sphincter atrophy was demonstrated in 123 patients (62 percent): graded as mild in 79 (40 percent), and severe in 44 patients (22 percent). Patients with atrophy were more often female (P < 0.001) and older (P = 0.003). They had a lower maximal squeeze (P = 0.01) and squeeze increment pressure (P < 0.001). Patients with severe atrophy had a lower maximal squeeze (P = 0.003) and squeeze increment pressure (P < 0.001) than patients with mild atrophy. These effects were not attenuated by potential confounding variables. Patients with atrophy could not be identified a priori by other characteristics.ConclusionsExternal anal sphincter atrophy at endoanal magnetic resonance imaging was depicted in 62 percent of patients, varying from mild to severe. Because increasing levels of atrophy were associated with impaired squeeze function, further studies are needed to evaluate whether grading atrophy is clinically valuable in selecting patients for anal sphincter repair.

Pelvic floor muscle lesions at endoanal MR imaging in female patients with faecal incontinence

To evaluate the frequency and spectrum of lesions of different pelvic floor muscles at endoanal MRI in women with severe faecal incontinence and to study their relation with incontinence severity and manometric findings. In 105 women MRI examinations were evaluated for internal anal sphincter (IAS), external anal sphincter (EAS), puborectal muscle (PM) and levator ani (LA) lesions. The relative contribution of lesions to differences in incontinence severity and manometric findings was studied. IAS (nu2009=u200959) and EAS (nu2009=u200961) defects were more common than PM (nu2009=u200923) and LA (nu2009=u200926) defects. PM and LA defects presented mainly with IAS and/or EAS defects (isolated nu2009=u20092 and nu2009=u20093). EAS atrophy (nu2009=u200973) was more common than IAS (nu2009=u200919), PM (nu2009=u200916) and LA (nu2009=u20099) atrophy and presented mainly isolated. PM and LA atrophy presented primarily with EAS atrophy (isolated nu2009=u20093 and nu2009=u20091). Patients with IAS and EAS lesions had a lower resting and squeeze pressure, respectively; no other associations were found. PM and LA lesions are relatively common in patients with severe faecal incontinence, but the majority of lesions are found in women who also have IAS and/or EAS lesions. Only an association between anal sphincter lesions and manometry was observed.

Low priority main reason not to participate in a colorectal cancer screening program with a faecal occult blood test.

BACKGROUNDnCompared with screening programs for breast and cervical cancer, reported participation rates for colorectal cancer (CRC) screening are low. The effectiveness of a screening program is strongly influenced by the participation rate. The aim of this study was to investigate the main reasons not to participate in a population-based, invitational CRC screening program.nnnMETHODSnIn the Dutch study program for CRC screening, a random selection of 20 623 persons were invited received a faecal occult blood test. Of the non-participants, 500 were randomly selected and contacted for a standardized telephone interview from November 2006 to May 2007 to document the main reason not to participate.nnnRESULTSnIn total, 312 (62%) non-participants could be included for analysis. Most frequently, reported reasons for non-participation were time-related or priority-related (36%), including did not notice test in mailbox (13%) and forgot (8%). Other reasons were health-related issues, such as severe illness (9%), or emotional reasons, such as family circumstances (7%).nnnCONCLUSIONSnThe majority of the reported reasons not to participate reflect low priority for screening. Adding extra instructions and information, and addressing specific concerns through additional interventions should be considered to improve individual decision-making about participation in future CRC population-based screening programs.

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

Background 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. Aims 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). Methods 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. Results 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. Conclusion Patient groups, defined by indication for colonoscopy, experience the colonoscopy procedure differently.

FIT false-positives in colorectal cancer screening experience psychological distress up to 6 weeks after colonoscopy.

PurposeScreening programs for colorectal cancer aim at reducing cancer mortality. We assessed psychological effects of being invited to an immunochemical fecal test (FIT)-based screening program.MethodsAsymptomatic persons aged 50–74xa0years were invited to a Dutch screening pilot. The Psychological Consequences Questionnaire (PCQ) was used to measure the psychological effects of screening. Screen positives had two additional measurements: before undergoing the colonoscopy and 4xa0weeks after receiving the colonoscopy findings.ResultsA number of 3,828 invitees (46xa0% male, mean age 60xa0years) completed the first PCQ. FIT positives had a higher mean total PCQ score (8.32, SD 8.84; score range 0–36) than those who declined participation (3.72, SD 6.30); participants still waiting for their FIT result had a mean score of 2.74 (SD 5.11), and those with a negative FIT result had the lowest score (2.06, SD 4.43) (pu2009<u20090.001). In the 373 FIT positives who underwent colonoscopy, 195 completed the pre-colonoscopy questionnaire and 253, the post-colonoscopy questionnaire. Mean total, physical, and social PCQ scores had decreased significantly between the first questionnaire and the pre-colonoscopy one, but scores on the emotional subscale did not. In false-positives, mean total, physical, and emotional PCQ scores decreased significantly, while in true-positives, a significant decrease in mean emotional PCQ score was observed.ConclusionPsychological consequences for invitees to a Dutch FIT-based colorectal cancer screening pilot differ, depending on timing and FIT result. FIT positives are more distressed than FIT negatives. FIT positives still experience psychological distress 6xa0weeks after a normal colonoscopy.

Comparison of guaiac and immunological fecal occult blood tests in colorectal cancer screening: the patient perspective.

Abstract Objective. Colorectal cancer (CRC) screening programs can decide upon the type of fecal occult blood test (FOBT): the guaiac FOBT (g-FOBT) or the immunological FOBT (i-FOBT). The effectiveness of any screening program depends not only on the diagnostic performance of the screening test but also on the compliance and general acceptance of the test by the public. Any decision on the type of FOBT for CRC screening should also take acceptation and perception into account. The aim of the present study was to study differences in patient perception between i-FOBT and g-FOBT and differences in perception and participation rates among relevant subgroups in a population based study. Material and methods. Differences in patient perception of i-FOBT and g-FOBT and differences in perception and participation rates among relevant subgroups were investigated (n = 20,623) by sending a short questionnaire to all invited to the first Dutch CRC screening trial. Results. i-FOBT was perceived significantly more favorable than g-FOBT. About 1275 (32%) participants reported the g-FOBT not easy to use, not easy to perform, disgusting or shameful compared to 742 (16%) for the i-FOBT (p < 0.001). The participation rate was significantly higher in those who received i-FOBT compared to the g-FOBT group: 6159 of 10,322 (60%) versus 4839 of 10,301 (47%) (p < 0.001). Conclusions. These findings support the selection of i-FOBT as the more appropriate test for population screening programs.

Patient burden of colonoscopy after positive fecal immunochemical testing for colorectal cancer screening

BACKGROUNDnIrrespective of the primary test used in colorectal cancer (CRC) screening, colonoscopy needs to be performed in positive screenees. This procedure is generally perceived as burdensome.We aimed to explore the burden of the colonoscopy in fecal immunochemical test (FIT)-positive screenees.nnnTRIAL REGISTRATION NUMBERnNTR1327.nnnMETHODSnTwo weeks after their colonoscopy, a random sample of screenees in the Dutch CRC screening pilot who underwent colonoscopy after a positive FIT were asked to rate their experience on a five-point scale (1=not at all, 5=very) for embarrassment, pain, and burden. Aspects that would add to satisfaction and the level of disturbance of daily activity and sleep were also assessed.nnnRESULTSnOf 373 invited individuals, 273 (73 %)completed the questionnaire; 53% were men,mean age was 63 years (standard deviation [SD]7). The bowel preparation received the highest burden score (mean score 2.87, SD 1.28) and was chosen as the most burdensome aspect by 56%.The highest levels of pain were assigned to postcolonoscopy abdominal complaints (2.55, SD1.03). The procedure was rated as only slightly embarrassing (1.49, SD 0.68). Adequate explanation of the procedure, immediate discussion of preliminary colonoscopy results, and a short waiting time between FIT result and colonoscopy were selected most often as potential contributors to satisfaction.nnnCONCLUSIONnBowel preparation and postcolonoscopy abdominal complaints are experienced as the most burdensome elements by persons undergoing colonoscopy in a FIT screening program. A more easily tolerable bowel preparation, carbondioxide insufflation, and adequate and timely communication are seen as measures to alleviate the burden and increase satisfaction with the procedure.

Getting adequate information across to colorectal cancer screening subjects can be difficult.

Objectives Participation in screening should be the outcome of an informed decision. We evaluated whether invitees in the first Dutch colorectal cancer (CRC) screening programme were adequately informed after having received a detailed information leaflet. Methods A total of 20,623 subjects aged 50–75 years were invited to the fecal occult blood test (FOBT) screening programme. All received a detailed information leaflet by mail between May 2006 and January 2007. After two weeks, a reminder letter was sent to all invitees, accompanied by a survey on CRC and screening. Results The survey was completed by 9594 invitees (47%). Almost all responders (99%) found the leaflet clear and readable. Almost all indicated that CRC can be treated better if found early (99%). Only 20% of the responders answered all knowledge-related answers correctly. Almost half of the responders (47%) believed that a negative FOBT excludes the presence of CRC. Older age and having a positive family member for CRC were correctly identified as risk factors by 80%. Conclusion This study demonstrates that although an information leaflet was reported as being clear and readable, the information provided in it was not always understood well. This suggests that other educational options should be investigated in order to improve general knowledge of CRC in screening invitees.

Involvement of previous non-participants cannot fully compensate for lower participation in a second round of FIT-screening

INTRODUCTIONnThe effectiveness of colorectal cancer (CRC) screening programs depends on repeated participation. Little is known on later rounds in programs that use the fecal immunochemical test (FIT), in particular whether previous participants are likely to participate again, and if non-participants persist in declining. We compared overall participation in a second round to that in a first round, and evaluated differences in participation rates based on previous response.nnnMETHODSnAsymptomatic persons aged 50-74 years were invited to a second round of a FIT-based CRC screening pilot. We assessed the participation rate overall and within second round subgroups of previous participants, previous non-participants, and first time invitees. We also assessed whether participation rates were similar for males and females and for age groups.nnnRESULTSnIn the first screening round, 2871 of 5309 invitees returned the FIT (participation rate of 57%). This was higher than in the second in which 3187 of 5925 participated (54%; p = 0.0008). Second round participation rate was 85% (2034/2385) among previous participants, 18% (325/1826) among previous non-participants and 48% (828/1714) among first time invitees (p < .0001). Overall, males and persons aged under 55 were less likely to participate.nnnCONCLUSIONSnParticipation in a second round of FIT-screening was significantly lower than in the first round, largely due to a drop in participation in first round participants, and a relatively low response among first time invitees. This loss of uptake was partially compensated by a willingness to be screened in previous non-participants.