Areas of improvement for colorectal cancer screening: Results of a screening initiative for 10,000 health care employees in Austria

Abstract

Background and study aims Participation in and quality of colorectal cancer (CRC) screening varies greatly and it is unclear how much of CRC screening guideline quality metrics reach patients. The aims of this prospective observational study were to provide data from everyday practice in Austria.

Patients and methods All employees aged ≥ 50 years were invited and received a stool-based-test (FIT (cut-off 25 mcg Hb/g) and M2PK), which could be dropped off at the workplace. All individuals with positive tests were called and offered a colonoscopy near their workplace/home in ≤ 3 weeks performed by unselected endoscopists. Non-attendees received email and telephone reminders.

Results Of 10,239 eligible employees (2706 males, 7533 females), 2390 (23%) (plus 673 < 50 years) median age 53 (interquartile range 50;56) participated in the stool-based screening (18% males, 25% females). Of 3063 tests, 747 (24%) were positive. The follow-up rate for 616 individuals who accepted or eventually underwent colonoscopy was 84% (n = 517). The adenoma detection rate (ADR) was 20.5% (31% in men, 17% in women) and varied substantially, ranging from 15% in hospitals (excluding the study center) to 18.5% among office-based endoscopists, and up to 36% in the study center. Most European Society of Gastrointestinal Endoscopy-recommended performance indicators were unmet, including the polyp detection rate (PDR), ADR, reporting of polyp characteristics, and bowel preparation adequacy.

Conclusions There is a serious gap between recommended standards and real-world CRC screening colonoscopy quality. Implementation of CRC screening should not only be accompanied by strategies to increase participation rates but focus on implementation of rigorous, mandatory colonoscopy quality assurance programs.

Keywords

Endoscopy Lower GI Tract - Polyps/adenomas/... - CRC screening - Quality and logistical aspects - Quality management - Performance and complications

Publication History

Received: 26 August 2024

Accepted after revision: 12 October 2024

Article published online:
28 November 2024

• References

• 1 Brenner H, Heisser T, Cardoso R. et al. Reduction in colorectal cancer incidence by screening endoscopy. Nat Rev Gastroenterol Hepatol 2023; 21: 125-133
• 2 Franklyn J, Lomax J, Labib P. et al. Colorectal cancer outcomes determined by mode of presentation: analysis of population data in England between 2010 and 2014. Tech Coloproctol 2022; 26: 363-372
• 3 Colorectal Cancer Screening Across Europe. 2018 UEG (United European Gastroenterology). https://ueg.eu/files/779/67d96d458abdef21792e6d8e590244e7.pdf
• 4 Bretthauer M, Loberg M, Wieszczy P. et al. Effect of colonoscopy screening on risks of colorectal cancer and related death. N Engl J Med 2022; 387: 1547-1556
• 5 Moss S, Ancelle-Park R, Brenner H. et al. European guidelines for quality assurance in colorectal cancer screening and diagnosis. First Edition--Evaluation and interpretation of screening outcomes. Endoscopy 2012; 44: SE49-SE64
• 6 Kaminski MF, Robertson DJ, Senore C. et al. Optimizing the quality of colorectal cancer screening worldwide. Gastroenterology 2020; 158: 404-417
• 7 Cardoso R, Guo F, Heisser T. et al. Utilisation of colorectal cancer screening tests in European countries by type of screening offer: Results from the European Health Interview Survey. Cancers (Basel) 2020; 12: 1409
• 8 Singal AG, Gupta S, Skinner CS. et al. Effect of colonoscopy outreach vs fecal immunochemical test outreach on colorectal cancer screening completion: A randomized clinical trial. JAMA 2017; 318: 806-815
• 9 Kaminski MF, Thomas-Gibson S, Bugajski M. et al. Performance measures for lower gastrointestinal endoscopy: a European Society of Gastrointestinal Endoscopy (ESGE) Quality Improvement Initiative. Endoscopy 2017; 49: 378-397
• 10 Bronzwaer MES, Depla A, van Lelyveld N. et al. Quality assurance of colonoscopy within the Dutch national colorectal cancer screening program. Gastrointest Endosc 2019; 89: 1-13
• 11 Frösch B, Antony K, Ivansits S. Übersicht nationaler Kolonkrebs-Screening-Programme. 2016. Gesundheit Österreich; Vienna:
• 12 Caviglia GP, Cabianca L, Fagoonee S. et al. Colorectal cancer detection in an asymptomatic population: fecal immunochemical test for hemoglobin vs. fecal M2-type pyruvate kinase. Biochem Med (Zagreb) 2016; 26: 114-120
• 13 Leen R, Seng-Lee C, Holleran G. et al. Comparison of faecal M2-PK and FIT in a population-based bowel cancer screening cohort. Eur J Gastroenterol Hepatol 2014; 26: 514-518
• 14 Lieberman DA, Rex DK, Winawer SJ. et al. Guidelines for colonoscopy surveillance after screening and polypectomy: A consensus update by the US Multi-Society Task Force on Colorectal Cancer. Gastroenterology 2012; 143: 844-857
• 15 Kaminski MF, Regula J, Kraszewska E. et al. Quality indicators for colonoscopy and the risk of interval cancer. N Engl J Med 2010; 362: 1795-1803
• 16 Kligman E, Li W, Eckert GJ. et al. Adenoma detection rate in asymptomatic patients with positive fecal immunochemical tests. Dig Dis Sci 2018; 63: 1167-1172
• 17 Zorzi M, Antonelli G, Barbiellini Amidei C. et al. Adenoma detection rate and colorectal cancer risk in fecal immunochemical test screening programs: an observational cohort study. Ann Intern Med 2023; 176: 303-310
• 18 Corley DA, Jensen CD, Chubak J. et al. Evaluating different approaches for calculating adenoma detection rate: Is screening colonoscopy the gold standard?. Gastroenterology 2023; 165: 784-787 e4
• 19 Mohan BP, Khan SR, Daugherty E. et al. Pooled rates of adenoma detection by colonoscopy in asymptomatic average-risk individuals with positive fecal immunochemical test: a systematic review and meta-analysis. Gastrointest Endosc 2022; 96: 208-222 e14
• 20 Navarro M, Nicolas A, Ferrandez A. et al. Colorectal cancer population screening programs worldwide in 2016: An update. World J Gastroenterol 2017; 23: 3632-3642
• 21 Vanaclocha-Espi M, Ibanez J, Molina-Barcelo A. et al. Optimal cut-off value for detecting colorectal cancer with fecal immunochemical tests according to age and sex. PLoS One 2021; 16: e0254021
• 22 Penz D, Waldmann E, Hackl M. et al. Colorectal cancer and precursor lesion prevalence in adults younger than 50 years without symptoms. JAMA Netw Open 2023; 6: e2334757
• 23 van den Berg DMN, Nascimento de Lima P, Knudsen AB. et al. NordICC Trial results in line with expected colorectal cancer mortality reduction after colonoscopy: A modeling study. Gastroenterology 2023; 165: 1077-1079 e2
• 24 Cardoso R, Guo F, Heisser T. et al. Colorectal cancer incidence, mortality, and stage distribution in European countries in the colorectal cancer screening era: an international population-based study. Lancet Oncol 2021; 22: 1002-1013
• 25 Wilhelmsen M, Njor SH, Roikjaer O. et al. Impact of screening on short-term mortality and morbidity following treatment for colorectal cancer. Scand J Surg 2021; 110: 465-471
• 26 Troelsen FS, Sorensen HT, Pedersen L. et al. Root-cause analysis of 762 Danish post-colonoscopy colorectal cancer patients. Clin Gastroenterol Hepatol 2023; 21: 3160-3169.e5
• 27 Zessner-Spitzenberg J, Waldmann E, Jiricka L. et al. Comparison of adenoma detection rate and proximal serrated polyp detection rate and their effect on post-colonoscopy colorectal cancer mortality in screening patients. Endoscopy 2023; 55: 434-441
• 28 Rutter MD, Senore C, Bisschops R. et al. The European Society of Gastrointestinal Endoscopy Quality Improvement Initiative: developing performance measures. Endoscopy 2016; 48: 81-89
• 29 Lee TJ, Siau K, Esmaily S. et al. Development of a national automated endoscopy database: The United Kingdom National Endoscopy Database (NED). United European Gastroenterol J 2019; 7: 798-806
• 30 Mon HM, Robb KA, Demou E. Effectiveness of workplace cancer screening interventions: a systematic review. BMC Cancer 2024; 24: 999
• 31 Gautom P, Rosales AG, Petrik AF. et al. Evaluating the reach of a patient navigation program for follow-up colonoscopy in a large federally qualified health center. Cancer Prev Res 2024; 17: 325-333
• 32 Basu P, Ponti A, Anttila A. et al. Status of implementation and organization of cancer screening in The European Union Member States-Summary results from the second European screening report. Int J Cancer 2018; 142: 44-56
• 33 Litwin O, Sontrop JM, McArthur E. et al. Uptake of colorectal cancer screening by physicians is associated with greater uptake by their patients. Gastroenterology 2020; 158: 905-914
• 34 Hannon PA, Vu T Ogdon S. et al. Implementation and process evaluation of a workplace colorectal cancer screening program in eastern Washington. Health Promot Pract 2013; 14: 220-227
• 35 Walsh JM, Potter MB, Arora M. et al. A workplace colorectal cancer screening program in firefighters: lessons learned. Occup Med (Lond) 2014; 64: 255-258