Introduction

The societal benefits of population-based bowel cancer screening are well documented in both an Australian and global context. Australia’s National Bowel Cancer Screening Program (NBCSP) has helped reduce rates of bowel cancer morbidity and mortality since its inception in 2006. (1) Despite the reported successes of the NBCSP, there are limitations in participation data for sub-populations, making it difficult to demonstrate equitable program impacts across the diverse Australian population. One of these groups is people with disability. While available data is limited, that which is available shows that people with severe or profound activity limitations participating in the NBCSP show higher screening positivity rates (13% vs 7%), a lower diagnostics assessment follow-up rate (43% vs 64%) and experience a longer median time between positive screen and diagnostic assessment (63 days vs 49 days), demonstrating further disparities and accessibility issues. (2)

Aims & Methods

This study aimed to create knowledge gains on barriers and enablers to accessing the NBCSP for people with disability. To our knowledge this is the first Australian study to collect data on support needs for people with disability (and their carers) when accessing the NBCSP. Multiple qualitative data collection methods were adopted, including arts-based methods such as visual experience, storytelling and photo-elicitation to provide rich and empathic insight into the experience of completing an iFOBT for people with disability. This process was facilitated throughout online in-depth interviews. Participants were recruited through Queenslanders with a Disability Network.

Results

15 participants with diverse communication, mobility and self-care abilities participated in the online in-depth interviews. Preliminary analysis of data findings indicates several key system level barriers preventing equal access to participating in the NBCSP. Kit packaging, instruction format and complexity level, size of collection tubes for faecal sample and the need for additional carer support to complete the kit was listed as key barriers across the participant cohort. While barriers differed significantly between disability sub-populations, several synergies remained around the need for simplification of instructions, improved kit packaging and design and the need for prompts or helpline information to facilitate engagement with a carer to support ease of iFOBT completion. Photos submitted by participants about their experience accessing the kit highlighted that although everyone in Australia receives the kit the same way (in the mail) not everyone completes the kit in the same way, with many people needing supports and assistance to navigate kit completion successfully.

Conclusion

This study provided novel, critically needed information and empathetic insights into the lived experience for people with a disability. Results highlighted the need for priority population consideration and consumer consultation to improve the design of the iFOBT, with particular focus on the packaging/kit instructions, with a call for easy read formats, inclusive video guides and references to support carer engagement. Many additional barriers exist that impact the ability for diverse population groups to participate in the program and without reasonable adjustments and navigation inclusions in Program design, disparities between and across population groups will continue to exist. Findings will be shared and used to shape policy and practice impacting system level barriers to equal program access for diverse populations across Australia.

References

1. Analysis of bowel cancer outcomes for the National Bowel Cancer Screening Program 2018. Australian Institute of Health and Welfare; 2018.
2. Health AIo, Welfare. National Bowel Cancer Screening Program monitoring report 2022. Canberra: AIHW; 2022.

Introduction

After pilot studies, New Zealand implemented a national colorectal cancer (CRC) screening program in 2017 with a graduate roll out by district health board. The program invites individuals aged 60 to 74 years to perform a fecal immunochemical test (FIT), using a positivity cut-off of 40 microgram Hemoglobin per gram feces. While health disparities exist between Māori and non-Māori populations across various health domains, there has been no systematic assessment of these inequities in the context of CRC screening.

Aims & Methods

This study aimed to assess the differences on key performance indicators of the National Bowel Screening Program between Māori and non-Māori populations in New Zealand and inform policy to improve equity. In this population-based study, we used data from the national population register of invitees for CRC screening between 2017 and 2023, which contained outcomes of up to four screening rounds of the National Bowel Cancer Screening Program in New Zealand. Key performance indicators were the FIT and follow-up colonoscopy participation rate, FIT positivity rate, positive predictive value (PPV) and detection rate of advanced neoplasia (AN; CRC and advanced adenomas). Multivariate logistic regression analyses were used to assess the association between ethnicity and key performance indicators, adjusted for confounding factors such as age, sex and invitation round.

Results

A total of 1,171,205 individuals were invited for CRC screening between 2017 and 2023 for up to four screening rounds. Of these, 675,274 (57.7%) individuals participated (Table 1). Compared to European descent, the Māori, Pacific and Asian populations were less likely to participate in FIT screening, with odds ratios (OR) of 0.60, 0.37 and 0.51 respectively, while the Māori ((OR: 1.52) and Pacific (OR: 1.27) were more likely to have a positive FIT result compared to the European descent population. Participation to follow-up colonoscopy was not significantly different by ethnicity. Asian, Māori and Pacific people had a significantly lower PPV for AN compared to European descent (OR 0.67, 0.67, 0.54 respectively). The detection rate for AN was significantly higher for Māori individuals compared to the European descent population (OR 1.13), while being significantly lower for Pacific and Asian (0.78 and 0.73, respectively).

Conclusion

CRC screening outcomes in New Zealand differ significantly by ethnicity, in particular for the Māori and Pacific people, with Māori exhibiting the highest yield of CRC screening. These findings highlight the importance of increasing participation in this population subgroup. Given the disparities in screening yield, risk-based screening strategies tailored to ethnicity could also be considered.

References

1. Hill S, Sarfati D, Blakely T, Robson B, Purdie G, Chen J, et al. Survival disparities in Indigenous and non-Indigenous New Zealanders with colon cancer: the role of patient comorbidity, treatment and health service factors. Journal of Epidemiology & Community Health. 2010;64(2):117-23.

Introduction

Adequate bowel preparation is paramount for a high-quality screening colonoscopy. Despite the importance of adequate bowel preparation, there is a lack of large studies that associated the degree of bowel preparation with long-term colorectal cancer outcomes in screening patients.

Aims & Methods

In a large population-based screening program database in Austria, quality of bowel preparation was estimated according to the Aronchick scale by the endoscopist (excellent, good, fair, poor and inadequate bowel preparation). We used logistic regression to assess the influence of bowel preparation on the detection of different polyp types and the inter-physician variation in bowel preparation scoring. Time to event analyses were performed to investigate the association of bowel preparation with post-colonoscopy colorectal cancer (PCCRC) death.

Results

335466 colonoscopies between 01/2012 and follow-up until 12/2022 were eligible for the analyses. As compared to excellent bowel preparation, adenoma detection was not significantly lower for good bowel preparation (OR 1.01, 95% CI 0.9971 - 1.0329, p = 0.1023), however, adenoma detection was significantly lower in fair bowel preparation (OR 0.97, 95% CI 0.9408 - 0.9939, p = 0.0166). Individuals who had fair or lower bowel preparation at screening colonoscopy had significantly higher hazards for PCCRC death (HR for fair bowel preparation 2.56, 95% CI 1.67 - 3.94, p <0.001).

Conclusion

Fair bowel preparation on the Aronchick scale was not only associated with a lower adenoma detection probability, but also with increased risk for PCCRC death. Efforts should be made to increase bowel cleansing above fair scores.

Disclosure

MT had advised for Abbvie, Albireo, BiomX, Boehringer Ingelheim, Falk, Gilead, Genfit, Hightide, Intercept, Jannsen, MSD, Novartis, Phenex, Pliant, Regulus, Siemens, Shire, has received grants / research support from Albireo, Alnylam, Cymabay, Falk Pharma, Gilead, Intercept, MSD, Takeda, UltraGenyx, had received speakersfees form BMS, Falk Foundation, Gilead, Intercept, Madrigal, MSD, Roche, has received travel grants from AbbVie, Falk Foundation, Gilead, Intercept, Janssen, Roche, the Medical Universities of Graz and Vienna have filed patents on medical use of norUDCA and is listed as co-inventor.
All other authors have no conflict of interest to declare.

Introduction

Colorectal cancer (CRC) and other bowel diseases is a significant health concern globally. In several countries, the fecal immunochemical test (FIT) is a cornerstone in CRC screening for early detection of cancer in asymptomatic individuals. Moreover, the utility of FIT extends beyond this, as it is increasingly recommended for evaluating symptomatic patients as part of the clinical pathway to render possible or rule out serious bowel pathology. Therefore, we aimed to quantify the findings of serious bowel conditions following a non-screening FIT test in the Danish population.

Aims & Methods

This study investigated use of FIT beyond the national CRC screening program in Denmark. We aimed (1) to assess utilization patterns of FIT in contexts other than screening and (2) to examine ensuing diagnoses. Our goal was to quantify the findings of CRC and other bowel diseases in symptomatic patients, thereby assessing its broader potential.
This cohort study was conducted within the Danish universal public healthcare system, delivered by five administrative regions. National CRC screening using FIT was initiated in 2014, but utilization of FIT for symptomatic patients varies between regions. The cut-off for a positive test is ≥10 µg haemoglobin/g faeces for symptomatic populations.
The study used data from the Danish Civil Registration System, the Danish National Patient Registry covering all Danish hospitals, and the Clinical Laboratory Information Register. The cohort included all patients who underwent FIT between 2014 and 2021 outside the Danish CRC screening program.
We employed descriptive statistics to examine FIT administration and demographic distributions across the Danish regions, as well as fecal haemoglobin levels among tested individuals. In addition, we estimated the cumulative incidence of CRC and inflammatory bowel disease (IBD) diagnoses following FIT, considering death as a competing risk and evaluated the proportion of diagnoses for CRC and IBD during the year following FIT.

Results

We identified 19,787 individuals who underwent FIT outside the national CRC screening program in 2014 to 2021. Of these, 4,283 (22%) individuals had a positive FIT result. Among tested individuals, 10,807 (55%) were female. Median age at testing was 64 years. Use of FIT varied across the regions, with 36% of the study cohort being from the Central Denmark Region, and 1.6% being from the Region of Southern Denmark.
Positive FIT cases had a shorter median time to CRC diagnosis (28 days) and any diagnosis (36 days) compared to negative FIT cases (711 and 58 days, respectively). Within one year of the FIT, 370 (1.9%) individuals were diagnosed with CRC, with higher occurrence for FIT positive individuals (7.9%) than for FIT negative individuals (0.2%) (risk difference: 7.7 percentage points [95% CI: -3.2, 11.1]).
Among individuals with a positive FIT result, 83 (1.9%) were diagnosed with IBD within one year, compared to 51 (0.3%) individuals with a negative FIT (risk difference: 1.6 percentage points [95% CI: -5.8, 7.3]).

Conclusion

We found that FIT used outside the national CRC screening program had over 20% positivity. A positive test indicated higher risk of CRC and IBD. Differences in diagnoses are expected due to varied follow-up procedures after positive and negative FIT results. A negative test, while not definitive, suggests a potential to rule out disease and could reduce unnecessary investigations when assessing symptomatic patients.