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

Background: Irrespective 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. Trial Registration Number: NTR1327.

Methods: Two 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.

Results: Of 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, SD 1.03). 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.

Conclusion: Bowel 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, carbon dioxide insufflation, and adequate and timely communication are seen as measures to alleviate the burden and increase satisfaction with the procedure.

• References

• 1 Segnan N, Senore C, Andreoni B et al. Comparing attendance and detection rate of colonoscopy with sigmoidoscopy and FIT for colorectal cancer screening. Gastroenterology 2007; 132: 2304-2312
• 2 Hol L, van Leerdam ME, van Ballegooijen M et al. Screening for colorectal cancer: randomised trial comparing guaiac-based and immunochemical faecal occult blood testing and flexible sigmoidoscopy. Gut 2010; 59: 62-68
• 3 Bleiker EM, Menko FH, Taal BG et al. Screening behavior of individuals at high risk for colorectal cancer. Gastroenterology 2005; 128: 280-287
• 4 Harewood GC, Wiersema MJ, Melton LJ III. A prospective, controlled assessment of factors influencing acceptance of screening colonoscopy. Am J Gastroenterol 2002; 97: 3186-3194
• 5 Denters MJ, Deutekom M, Fockens P et al. Implementation of population screening for colorectal cancer by repeated fecal occult blood test in the Netherlands. BMC Gastroenterol 2009; 9: 28
• 6 Nagengast F, Kaandorp C. Revised CBO guideline: Follow-up after polypectomy [in Dutch]. Ned Tijdschr Geneeskd 2001; 145: 2022-2025
• 7 Essink-Bot ML, de Koning HJ, Nijs HG et al. Short-term effects of population-based screening for prostate cancer on health-related quality of life. J Natl Cancer Inst 1998; 90: 925-931
• 8 Essink-Bot ML, Rijnsburger AJ, van Dooren S et al. Women’s acceptance of MRI in breast cancer surveillance because of a familial or genetic predisposition. Breast 2006; 15: 673-676
• 9 Essink-Bot ML, Kruijshaar ME, Bac DJ et al. Different perceptions of the burden of upper GI endoscopy: an empirical study in three patient groups. Qual Life Res 2007; 16: 1309-1318
• 10 Kruijshaar ME, Kerkhof M, Siersema PD et al. The burden of upper gastrointestinal endoscopy in patients with Barrett’s esophagus. Endoscopy 2006; 38: 873-878
• 11 Liedenbaum MH, Denters MJ, de Vries AH et al. Low-fiber diet in limited bowel preparation for CT colonography: influence on image quality and patient acceptance. AJR Am J Roentgenol 2010; 195: W31-W37
• 12 Liedenbaum MH, Denters MJ, Zijta FM et al. Reducing the oral contrast dose in CT colonography: evaluation of faecal tagging quality and patient acceptance. Clin Radiol 2011; 66: 30-37
• 13 Denters MJ, Deutekom M, Bossuyt PM et al. Patient satisfaction with the colonoscopy procedure: endoscopists overestimate the importance of adverse physical symptoms. Frontline Gastroenterology 2012; 3: 130-136
• 14 Sint NJ, de Jonge V, Korfage IJ et al. Benchmarking patient experiences in colonoscopy using the Global Rating Scale. Endoscopy 2012; 44: 462-72
• 15 Belsey J, Epstein O, Heresbach D. Systematic review: oral bowel preparation for colonoscopy. Aliment Pharmacol Ther 2007; 25: 373-384
• 16 Khan MA, Piotrowski Z, Brown MD. Patient acceptance, convenience, and efficacy of single-dose versus split-dose colonoscopy bowel preparation. J Clin Gastroenterol 2010; 44: 310-311
• 17 Rex DK, Johnson DA, Anderson JC et al. American College of Gastroenterology guidelines for colorectal cancer screening 2009 [corrected]. Am J Gastroenterol 2009; 104: 739-750
• 18 Bretthauer M, Hoff G, Thiis-Evensen E et al. Carbon dioxide insufflation reduces discomfort due to flexible sigmoidoscopy in colorectal cancer screening. Scand J Gastroenterol 2002; 37: 1103-1107
• 19 Bretthauer M, Lynge AB, Thiis-Evensen E et al. Carbon dioxide insufflation in colonoscopy: safe and effective in sedated patients. Endoscopy 2005; 37: 706-709
• 20 Stevenson GW, Wilson JA, Wilkinson J et al. Pain following colonoscopy: elimination with carbon dioxide. Gastrointest Endosc 1992; 38: 564-567
• 21 Sumanac K, Zealley I, Fox BM et al. Minimizing postcolonoscopy abdominal pain by using CO(2) insufflation: a prospective, randomized, double blind, controlled trial evaluating a new commercially available CO(2) delivery system. Gastrointest Endosc 2002; 56: 190-194
• 22 Yamano HO, Yoshikawa K, Kimura T et al. Carbon dioxide insufflation for colonoscopy: evaluation of gas volume, abdominal pain, examination time and transcutaneous partial CO2 pressure. J Gastroenterol 2010; 45: 1235-1240
• 23 Janz NK, Wren PA, Schottenfeld D et al. Colorectal cancer screening attitudes and behavior: a population-based study. Prev Med 2003; 37 (06) 627-634
• 24 Rawl SM, Menon U, Champion VL et al. Do benefits and barriers differ by stage of adoption for colorectal cancer screening?. Health Educ Res 2005; 20: 137-148
• 25 Wardle J, Williamson S, McCaffery K et al. Increasing attendance at colorectal cancer screening: testing the efficacy of a mailed, psychoeducational intervention in a community sample of older adults. Health Psychol 2003; 22: 99-105
• 26 Mitchell KA, Rawl SM, Champion VL et al. Development and psychometric testing of the colonoscopy embarrassment scale. West J Nurs Res 2012; 34: 548-564
• 27 van Rijn AF, van Rossum LG, Deutekom M et al. Low priority main reason not to participate in a colorectal cancer screening program with a faecal occult blood test. J Public Health (Oxf) 2008; 30: 461-465
• 28 Yacavone RF, Locke GR III, Gostout CJ et al. Factors influencing patient satisfaction with GI endoscopy. Gastrointest Endosc 2001; 53: 703-710
• 29 Davies AR, Ware JE Jr. GHAA’s consumer satisfaction survey and user’s manual. Washington, DC: Group Health Association of America; 1991
• 30 American Society for Gastrointestinal Endoscopy. Quality and outcomes assessment in gastrointestinal endoscopy. Gastrointest Endosc 2000; 52: 827-830
• 31 de Wijkerslooth TR, de Haan MC, Stoop EM et al. Burden of colonoscopy compared to non-cathartic CT-colonography in a colorectal cancer screening programme: randomised controlled trial. Gut 2012; 61: 1552-1559