Towards risk-stratified colorectal cancer screening. Adding risk factors to the fecal immunochemical test: Evidence, evolution and expectations.

With increasing incidence and mortality, colorectal cancer (CRC) is a growing health problem worldwide. An effective way to address CRC is by screening for fecal (occult) blood by the fecal immunochemical test (FIT). However, there is room for improvement since precursor lesions and CRC bleed intermittent and can therefore be missed by the FIT (false negatives) or, the detected blood did not result from precursor lesions or CRC (false positives). This review provides the latest evidence on risk prediction models using FIT combined with additional risk factors before colonoscopy, which risk factors to include and if these models will better discriminate between normal findings and CRC compared to the FIT-only. Many prediction models are known for CRC, but compared to the FIT, these are less effective in detecting CRC. The literature search resulted in 645 titles where 11 papers matched the inclusion criteria and were analyzed. Comparing the FIT-only with the risk prediction models for detecting CRC resulted in a significantly increased discrimination for the models. In addition, 2 different risk-stratification categories before colonoscopy were distinguished, namely the 1-model approach which combined risk factors with FIT results in a prediction model while the 2 step approach used risk factors apart from the FIT. Finally, combining FIT with CRC risk factors by means of a model before colonoscopy seems effective regarding discriminative power, however, more research is needed for validation combined with transparent and standardized reporting to improve quality assessment, for which suggestions are reported in this study.

Inclusive Crisis Communication in a Pandemic Context: A Rapid Review.

Background: Crisis communication might not reach non-native speakers or persons with low literacy levels, a low socio-economic status, and/or an auditory or visual impairments as easily as it would reach other citizens. The aim of this rapid review was to synthesize the evidence on strategies used to improve inclusive pandemic-related crisis communication in terms of form, channel, and outreach. Methods: After a comprehensive search and a rigorous screening and quality assessment exercise, twelve comparative studies were selected for inclusion in this review. Data were analyzed and represented by means of a structured reporting of available effects using narrative tables. Results: The findings indicate that a higher message frequency (on any channel) may lead to a lower recall rate, audio-visual productions and tailored messages prove to be valuable under certain conditions, and primary healthcare practitioners appear to be the most trusted source of information for most groups of citizens. Trust levels were higher for citizens who were notified in advance of potential exceptions to the rule in the effect of preventive and curative measures promoted. Conclusions: This review contributes to combatting information inequality by providing evidence on how to remove the sensorial, linguistic, cultural, and textual barriers experienced by minorities and other underserved target audiences in COVID-19-related governmental crisis communication in response to the societal, health-related costs of ineffective communication outreach.

Mixed-Method Systematic Review and Meta-Analysis of Shared Decision-Making Tools for Cancer Screening.

This review aimed to synthesize evidence on the effectiveness of shared decision-making (SDM) tools for cancer screening and explored the preferences of vulnerable people and clinicians regarding the specific characteristics of the SDM tools. A mixed-method convergent segregated approach was employed, which involved an independent synthesis of quantitative and qualitative data. Articles were systematically selected and screened, resulting in the inclusion and critical appraisal of 55 studies. Results from the meta-analysis revealed that SDM tools were more effective for improving knowledge, reducing decisional conflict, and increasing screening intentions among vulnerable populations compared to non-vulnerable populations. Subgroup analyses showed minimal heterogeneity for decisional conflict outcomes measured over a six-month period. Insights from the qualitative findings revealed the complexities of clinicians' and vulnerable populations' preferences for an SDM tool in cancer screening. Vulnerable populations highly preferred SDM tools with relevant information, culturally tailored content, and appropriate communication strategies. Clinicians, on the other hand, highly preferred tools that can be easily integrated into their medical systems for efficient use and can effectively guide their practice for cancer screening while considering patients' values. Considering the complexities of patients' and clinicians' preferences in SDM tool characteristics, fostering collaboration between patients and clinicians during the creation of an SDM tool for cancer screening is essential. This collaboration may ensure effective communication about the specific tool characteristics that best support the needs and preferences of both parties.

Virtual Reality for Distraction and Relaxation in a Pediatric Hospital Setting: An Interventional Study With a Mixed-Methods Design.

Accumulating evidence supports the use of virtual reality (VR) as an effective pain and anxiety management tool for pediatric patients during specific medical procedures in dedicated patient groups. However, VR is still not widely adopted in everyday clinical practice. Feasibility and acceptability measures of clinicians' experiences are often missing in studies, thereby omitting an important stakeholder in VR use in a clinical setting. Therefore, the aim of this mixed-methods study was to investigate the feasibility, acceptability, tolerability (primary outcomes), and preliminary effectiveness (secondary outcome) of Relaxation-VR in both pediatric patients aged 4-16 years and clinicians. Relaxation-VR is a VR application prototype aimed to provide distraction and relaxation for a variety of patient populations and procedures and is used to reduce anxiety, stress (tension) and pain for children in hospital. Multiple measures of acceptability, feasibility and tolerability, and pre-to-post changes in measures of pain, anxiety, stress and happiness were assessed in pediatric patients. At the end of the study, acceptability and feasibility of VR use was assessed in clinicians. Results indicate that VR use (in particular, the Relaxation-VR prototype) for both distraction and relaxation is acceptable, feasible and tolerable for a variety of pediatric patients aged 4-16 years, as assessed in both patients and clinicians, and can reduce anxiety, pain and tension (stress), and increase happiness in a hospital setting.

Occurrence and characteristics of faecal immunochemical screen-detected cancers vs non-screen-detected cancers: Results from a Flemish colorectal cancer screening programme.

BACKGROUND: Colorectal cancer (CRC) and its precursor lesions are detected at an early stage by CRC screening programmes, which reduce CRC-related mortality. An important quality indicator for CRC screening is the occurrence of interval CRC (IC) between screening rounds. Currently there is no guideline regarding acceptable levels of ICs in CRC screening programmes, and ICs reported in prior work vary considerably. METHODS: This study describes the occurrence of screen-detected (SD) CRC and non-screen-detected CRC within the population-based CRC screening programme of Flanders, stratified by multiple variables such as sex, age, tumour location and tumour stage between October 2013 and July 2017. In addition, faecal immunochemical test (FIT) IC proportions over the sum of SD-CRCs and FIT-ICs are calculated, together with FIT sensitivity and programme sensitivity to display the effectiveness of detecting CRC by the screening programme. RESULTS: Of 1,212,354 FIT participants, 4094 were diagnosed with SD-CRC, whereas 772 participants were diagnosed with CRC between FIT-screening rounds. Significant associations were shown between people not being SD for CRC and women, older individuals, right-sided tumour location and more advanced tumour stage. Furthermore, a clear distinction was shown between the right-sided and the left-sided colorectum concerning all above-mentioned variables and distributions of tumour stages. CONCLUSION: The Flemish FIT-interval CRC proportion of 15.9% was within the limits of previously published results. In addition, calculations show that the effectiveness of the screening programme is dependent on tumour location, suggesting that future research should report results stratified by location.

Should Flanders consider lowering its target age for colorectal cancer screening to 45-49?

INTRODUCTION: Colorectal cancer (CRC) screening generally starts screening by the age of 50 based on guidelines. Lately however, a U.S. guideline recommended to start CRC screening from age 45 and, very recently, two studies were published that addressed young-onset in Europe (in part) (Vuik et al., 2019; Araghi et al., 2019). MATERIALS AND METHODS: Flemish CRC incidence and mortality data contextualise trend results for age groups under 50 and what the implications could be for practice. RESULTS: CRC incidence rates showed considerable variability over a 12-year period without a clear increase in disease burden for the age group 45-49 in Flanders. In several age groups under 39 an increasing incidence trend was visible for both genders. Data was analysed in a period where no CRC screening was present in Flanders. DISCUSSION: Decreasing the target age for the Flemish CRC screening does not seem to be straightforward and primary prevention should be considered more prominently.

Risk stratification for colorectal neoplasia detection in the Flemish colorectal cancer screening programme.

BACKGROUND: The quantitative faecal immunochemical test (FIT) detects pre-cancerous lesions and colorectal cancer (CRC). Current CRC screening programmes are based upon a binary FIT result. This study evaluates the possibility of personalised risk prediction, based on FIT, age and gender to gain more insight into improving discrimination between normal outcomes, pre-cancerous lesions, carcinoma in situ and CRC working towards a more tailored screening approach. METHODS: In this retrospective study, from October 2013 until July 2016, data from 57,421 participants who underwent a colonoscopy after a positive FIT in the Flemish CRC screening programme were analysed using a multinomial multivariable logistic regression model. RESULTS: A significant difference in risk of detecting neoplasia was found between the established risk profiles based on the combination of the quantitative FIT, age and gender. The odds for detecting CRC in men aged 74, with a FIT result of ≥1000 ng/ml, was higher by a factor of 58.43 than that for women aged 56, with a FIT result of 75 ng/ml. CONCLUSION: A large difference in risk with regard to the detection of colorectal neoplasia was found, based on demographics of the population. For some participants, the chance of finding no anomalies was more than 60%. Including additional variables in a prediction model could further increase discrimination between outcomes and practicality.