Report in English with a Dutch summary (KCE reports 45A)

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102 Screening for Colorectal Cancer KCE reports vol.45 patients' homes before a physical examination 475; reminder-feedback and educational outreach intervention in primary care practices 476; organizational level interventions, such as a team approach to colorectal cancer screening 477; using an educational multimedia computer program in a university-affiliated, community-based Internal Medicine outpatient practice 478; provider recommendation to FDRs of CRC patients 479, but a single optimal strategy cannot be determined from the currently available data 194. Attempts to promote CRC screening have used both a public health model that targets entire communities, e.g., mass media campaigns, and a medical model that targets individuals, e.g., general practice patients. Most of these efforts, however, did not include systematic evaluation of strategies to increase adherence 403. The data on FOBT adherence show that the median adherence rate to programmatic offers of FOBT can reach between 40% and 50%, depending on the type of population offered the test, e.g., patients or employees in employer-sponsored programs. Approximately 50% of those initially offered testing in unselected populations will respond to minimal prompts or interventions 403. A salient issue for FOBT, however, is whether or not the behavior can be sustained over time. Fewer studies examined adherence to sigmoidoscopy. Here, adherence was highest in relatives of CRC cases and in employer-sponsored programs offered to workers at increased risk of CRC. At present, we know very little about the determinants of CRC screening behaviors, particularly as they relate to rescreening 403. In the 1997 Vernon review 403 the most intensive strategies delivered to welldefined populations of eligible persons rarely increased adherence above 50%. In studies that delivered minimal or relatively impersonal interventions, adherence ranged from approximately 10% to 30% 454, 480, 467, 456, 468. In general, adherence was lowest when persons were asked to pick up a test kit or to mail in a reply card in order to receive a kit 454, 481, 482. Various strategies ranging from the use of a letter signed by one s own physician and including FOBT kits in the mailing 480, 483 to intensive follow-up with instructional telephone calls 467, 468 were effective at increasing adherence, compared with a control group, to approximately 50%. Nichols et al. 482 evaluated the inclusion of an educational booklet in conjunction with five different contact strategies and found no effect of the booklet. A second mailed follow-up reminder increased adherence in all studies reporting its use 481, 456, 459. Thompson et al. found that a simple reminder postcard was as effective as more complex interventions, some of which were based on the Health Belief Model 473. Zapka et al. 475 tested, in a primary care RCT setting, the effect of an educational video about CRC, the importance of early detection, and screening options, mailed to patients' homes before a physical examination, on performance of colorectal cancer screening, particularly sigmoidoscopy. Overall screening rates were the same in the intervention and control groups (55%). In regression modelling, intervention participants were nonsignificantly more likely to complete sigmoidoscopy alone or in combination with another test (odds ratio 1,22; 95% CI: 0,88 to 1,70). Intervention dose (viewing at least half of the video) was significantly related to receiving sigmoidoscopy with or without another test (odds ratio 2,81; CI: 1,85 to 4,26). However, recruitment records showed that at least 23% of people coming for periodic health assessments were currently screened by a lower-endoscopy procedure and therefore were not eligible. Furthermore, the primary care sample studied consisted primarily of middle-class white persons who had high screening rates at baseline and the trial was conducted during a period of increased health insurance coverage for lower-endoscopy procedures and public media attention to colon cancer
KCE reports vol.45 Screening for Colorectal Cancer 103 screening. As a result, the results may not be generalizable to other populations. Under these limitations, a mailed video showed no effect on the overall rate of colorectal cancer screening and only modestly improved sigmoidoscopy screening rates among patients in primary care practices. 5.7.5 Conclusions In choosing which screening test to adhere to, an important element to consider is patient s preferences484, 485. In order to have a high level of uptake any CRC screening program requires proper education and information of the public on the risk factors for CRC and the alternative screening tools 55, 56, 185, 486, 58. This implies a substantial amount of initial planning and resource allocation, including defining roles of the different health professionals and including training of the community of general practitioners185 and even gastroenterologists398, 487. Key messages All studies investigating the effectiveness of CRC screening in average risk populations have been conducted in males and females starting from age 45 or 50 and up to age 75. There is high quality evidence from RCTs that screening with guaiac FOBT reduces CRC mortality. The estimated CRC mortality reduction due to screening with gFOBT is around 15%. There is, however, no evidence for overall mortality reduction. There is no direct evidence from RCTs that screening with iFOBT reduces CRC mortality. In theory, iFOBT should have improved performance characteristics compared to gFOBT. However, there is conflicting evidence regarding the comparative performance of iFOBT and gFOBT, partly due to important differences and detection limits between tests. There is currently no evidence from large RCTs that screening with FS reduces CRC mortality. However, 3 large trials are currently running but results are not anticipated before 2008. There is no direct evidence to support combined screening using FOBT and FS. Although colonoscopy is a highly sensitive diagnostic technique, there is no direct evidence that screening an average risk population using colonoscopy reduces CRC mortality. Although virtual colonoscopy is a rapidly evolving and reliable diagnostic technique, there is no direct evidence that screening an average risk population using virtual colonoscopy reduces CRC mortality. Patient participation is of crucial importance in population based CRC screening and while planning screening programs consideration should be given to methods to optimize adherence and minimise harms. This involves careful selection of screening strategy in combination with information and education of the public and involved clinicians on potential benefits and harms, but leaving the ultimately choice on whether or not to be screened to the individual.
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KCE reports 1. Effectiviteit en kos
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