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First results of a pilot population-based faecal occult blood colorectal cancer screening program

Bernard DENIS, Philippe PERRIN, Patrick STRENTZ, Francis GUTH, Jean Marc BOYAVAL, Sylvie Bénédicte JUNG

Results according to ageDespite strong evidence that screening reduces both colorectal cancer (CRC) mortality and incidence, CRC screening remain underutilized. Aim : to report the first results of a population-based pilot faecal occult blood (FOBT) CRC screening program.Methods : this program took place in the French area of Haut-Rhin (710 000 inhabitants). All 627 general practitioners (GP) were invited to attend paid educational meetings on CRC screening. The screening test used for average risk persons was a biennial non rehydrated FOBT (Hemoccult II) without dietary restriction. Residents aged 50-74 years were invited twice by mail to visit their GP for a CRC screening. The recall letter included a reply coupon which could be used to specify reasons for non participation. FOBT were provided free of charge by the GPs.Results : after 19 months, 608 GPs (97%) followed a CRC screening training, 78 % of them attended dedicated meetings. 185 863 persons (99.2%) received the first invitation letter and 103 660 (55.3%) the recall letter. 15 642 (8.3%) persons were excluded for medical reasons (high risk of CRC, concurrent severe disease). 618 (98.6 %) GPs provided tests, 84.3 % of them being completed. Each GP had a mean number of 100 persons having completed a FOBT (range 1 - 589). 68 777 persons (36.7%) completed a FOBT. Participation was higher in women (38.3%) than in men (35%)(p<0.001) and ranged from 26.3% to 51.8% according to districts. The impact of the first letter lasted a mean of 6 months and led to 59% of the global participation, that of the recall letter lasted 6 months and led to 30% of the overall participation and 55% of all exclusions. FOBT positivity rate was 3.6%. It was higher in men (4.3%) than in women (3.1%)(p<0.001). The positive predictive value calculated on the 1705 first colonoscopic procedures was 9.8% for CRC (7.2% in women, 12% in men), 19.9% for advanced adenomas (13.7% in women, 25.1% in men) and 11.7% for non advanced adenomas. 26.3% of CRC were in situ. One perforation was recorded.Conclusion : GP's awareness of CRC screening can be increased to a high level. CRC screening rates can be enhanced through a population-based screening program when GPs are motivated and involved. Efforts should be directed at men in the 2nd half of our program, since their participation is lower than women despite a higher CRC risk. Our first results indicate that a participation rate of 60 % should be launched at the end of the program.

Despite strong evidence that screening reduces both colorectal cancer (CRC) mortality and incidence, CRC screening remain underutilized 

Aimto report the first results of a population-based pilot faecal occult blood (FOBT) CRC screening program.

- This program took place in the French area of Haut-Rhin (0.71 million inhabitants). - All 627 general practitioners (GP) were invited to attend paid educational meetings on CRC screening. - The screening test used for average risk persons was a biennial non rehydrated FOBT (Hemoccult II) without dietary restriction. - Residents aged 50-74 years were invited twice by mail to visit their GP for a CRC screening. The recall letter included a reply coupon which could be used to specify reasons for non participation. 12 to 15 months after the 1st invitation, FOBT were mailed to persons who didn’t complete the test and a last recall letter was sent if necessary 6 weeks later. - FOBT analysis was centralized in the Centre d’Examens de Santé of the CPAM in Mulhouse- FOBT were provided free of charge. Financing was ensured through the French Social Security and the Haut-Rhin Administration (Conseil Général du Haut-Rhin).- Start of the program was spread out according to districts over a year from September 2003 to September 2004. Results below are those assessed in April 2005, 19 months after the mailing of the first invitations.

Conclusions

- GP's awareness of CRC screening can be increased to a high level.

- when GPs are involved and motivated, CRC screening rates can be

enhanced a lot through a population-based screening program.

- Our first results indicate that an adjusted screening rate of 60 %

should be launched at the end of the program.

- Efforts should be directed at men, since their compliance is lower

than women despite a higher CRC risk.

Digestive Disease Week, Chicago, 15 May 2005

Results : invitation / exclusion / participationinvited population

population aged 50-74 years 187,360

1st invitation letter 185,863 (99.2 %)

recall letter 103,660 (55.3 %)

FOB test mailing 37,571 (20.1 %)

exclusions

recent CRC screening 10,103 (5.4%)

high risk of CRC 4,885 (2.6%)

concurrent severe disease 654 (0.3%)

total population excluded 15,642 (8.3 %)

participation

crude participation 68,777 (36.7 %)

adjusted participation 68,777 (39.7 %)

Association pour le Dépistage du Cancer colorectal dans le Haut-Rhin (ADECA 68), 39 avenue de la Liberté, Colmar, FRANCE

Abstract

Background

Results : FOBT / colonoscopy

CRC screening training608 GPs (97 %) followed a CRC screening training

- 75.6 % attended dedicated meetings- 21.4 % had an individual training

FOBT distribution618 GPs (98.6 %) provided FOBT

- mean number of persons having completed a FOBT = 100 / GP (range 1 – 589)

- 84.3 % of the FOBT provided by GPs were completed

men women p

total exclusions 7,417 (8.1%) 8,225 (8.5%) < 0.01

recent CRC screening 4,467 (4.9%) 5,636 (5.9%) < 0.01

high risk of CRC 2,616 (2.9%) 2,269 (2.4%) < 0.01

concurrent severe disease 334 (0.4%) 320 (0.3%) NS

crude participation 35% 38.3% < 0.01

adjusted participation 37.8% 41.6% < 0.01

FOBT positivity rate 4.3% 3.1% < 0.01

PPV for neoplasia 464 (50.3%) 241 (30.8%) < 0.01

PPV for cancer 111 (12%) 56 (7.2%) < 0.01

PPV for advanced adenoma 232 (25.1%) 107 (13.7%) < 0.01

detection rate for neoplasia 14.55 ‰ 6.53 ‰ < 0.01

detection rate for cancer 3.48 ‰ 1.52 ‰ < 0.01

detection rate for advanced adenoma 7.27 ‰ 2.90 ‰ < 0.01

CRC stages n (%)

in situ 44 (26.3%)

invasive 123 (73.7%)

stage 1 37 (51.4%)

stage 2 16 (22.2%)

stage 3 14 (19.4%)

stage 4 5 (6.9%)

stage unknown 51

FOBT: 70,397 tests completed - 2,559 (3.6 %) positive- 2,127 (3.0 %) uninterpretable, 1,409 (72 %) were completed again- 84.3 % of positive FOBT were followed by a colonoscopy (March 2004)

FOBT positivity rate 3.6 %

PPV for neoplasia 41.4 %

PPV for cancer 9.8 %

PPV for advanced adenoma 19.9 %

detection rate for neoplasia 10.25 ‰ screened

detection rate for cancer 2.43 ‰ screened

detection rate for advanced adenoma 4.93 ‰ screened

Results : diagnostic yield

Results according to gender

Methods

Results : GP’s involvement

50-54 55-59 60-64 65-69 70-74

total exclusions % 4.6 7.8 9.4 11.1 12.8

crude participation % 27.3 35.9 40 41.4 44

adjusted participation % 28.7 39 44.1 46.5 50.4

FOBT positivity rate % 2.8 3.4 3.8 4.2 4.7

PPV for neoplasia % 41.3 37.8 45.1 50.3 45.7

PPV for cancer % 6.3 8.6 12 11 13.2

PPV for advanced adenoma % 20.9 18.2 20.9 26.1 21.8

detection rate neoplasia ‰ 7.3 8.6 11.2 14.5 14.8

detection rate cancer ‰ 1.1 2 3 3.2 4.2

detection rate advanced adenoma ‰ 3.7 4.1 5.2 7.5 7.1

Colonoscopy: 1,705 recorded- 95.3 % complete- 5 complications recorded :

- 1 perforation- 2 bleeding- 2 abdominal pain

Impact of invitations

participation

exclusions