Comparing a fecal immunochemical test and circulating tumor DNA blood test for colorectal cancer screening adherence.

BACKGROUND AND AIM: Colorectal cancer (CRC) screening programs are most effective at reducing disease incidence and mortality through sustained screening participation. A novel blood test modality is being explored for CRC screening, but it is unclear whether it will provide sustained screening participation. This study aimed to investigate whether a circulating tumor DNA (ctDNA) blood test improved CRC screening re-participation when compared with a fecal immunochemical test (FIT) and to define the predictors of sustained CRC screening in an Australian population. METHODS: South Australians who initially participated in CRC screening using a ctDNA blood test (n = 36) or FIT (n = 547) were offered the same CRC screening test approximately 2 years later through an extended phase of a randomized controlled trial. Surveys collected demographic, psychosocial, and clinical information. Predictors of CRC screening re-participation were explored using chi-square, Wilcoxon tests, and logistic regression. RESULTS: Participants offered a second ctDNA blood test were equally likely to re-participate in CRC screening as those who completed a FIT in the first round and who were offered the same test (61% vs 66% re-participation respectively, P = 0.6). CRC fatalism, health activation, and self-efficacy were associated with repeated screening participation. Test awareness was predictive of repeated FIT-based CRC screening. CONCLUSIONS: Targeted interventions to improve CRC screening awareness and increase patient health activation may improve CRC screening adherence. A ctDNA blood test may be a suitable CRC screening option to maintain CRC screening adherence in people who do not participate in screening with FIT.

Patient attitudes towards changes in colorectal cancer surveillance: An application of the Health Belief Model.

OBJECTIVE: This is to determine whether health beliefs regarding colorectal cancer (CRC) screening could predict discomfort with a change to CRC surveillance proposing regular faecal immunochemical tests (FIT) instead of colonoscopy. METHODS: Eight hundred individuals enrolled in a South Australian colonoscopy surveillance programme were invited to complete a survey on surveillance preferences. Responses were analysed using binary logistic regression predicting discomfort with a hypothetical FIT-based surveillance change. Predictor variables included constructs based on the Health Belief Model: perceived threat of CRC, perceived confidence to complete FIT and colonoscopy (self-efficacy), perceived benefits from current surveillance and perceived barriers to FIT and colonoscopy. RESULTS: A total of 408 participants (51%) returned the survey (complete data n = 303; mean age 62 years, 52% male). Most participants (72%) were uncomfortable with FIT-based surveillance reducing colonoscopy frequency. This attitude was predicted by a higher perceived threat of CRC (OR = 1.03 [95% CI 1.01-1.04]), higher colonoscopy self-efficacy (OR = 1.34 [95% CI 1.13-1.59]) and lower perceived barriers to colonoscopy (OR = 0.92 [95% CI 0.86-0.99]). CONCLUSIONS: Health beliefs regarding colonoscopy and perceived threat of CRC may be important to consider when changing CRC surveillance protocols. If guideline changes were introduced, these factors should be addressed to provide patients reassurance concerning the efficacy of the alternative protocol.

Mapping Information Needs over the Diagnosis, Treatment, and Survivorship Trajectory for Esophago-gastric Cancer Patients and Their Main Supporters: a Retrospective Survey.

This study reports preliminary data about the information needs of esophago-gastric cancer survivors and their supporters across diagnosis and treatment by identifying time-specific needs and whether the information provided aligned with the needs at each time point. Survivors (n = 26) and supporters (n = 15) were recruited from a public teaching hospital in South Australia. Both groups provided recall data describing personal information domain challenges at 6 clinically significant time points ranging from diagnosis to > 2 years post diagnosis. Responses were analyzed using descriptive statistics for non-normally distributed data. Needs relating to communication, tests, disease, and the physical effects information domains were consistently high across time and in groups. Supporters' overall needs were greater than those of survivors, particularly at times of high need. At times of low need, both groups reported information overload. Our results confirm that survivors and supporters require information throughout the cancer trajectory, up to 2 years after diagnosis, and supporters' needs are likely to be even greater. Results highlight the importance of timely and relevant information provision and provide a basis for the development of resources to empower survivors and supporters to identify and articulate their personal information needs. Patient navigators may provide an avenue to facilitate this approach.

Thinking Style as a Predictor of Men's Participation in Cancer Screening.

Men's participation in cancer screening may be influenced by their thinking style. Men's need for cognition (NFC) and faith in intuition were measured to explore whether they varied by demographic variables or predicted screening behavior. Australian males ( n = 585, aged 50-74 years) completed surveys about past screening and were subsequently offered mailed fecal occult blood tests (FOBTs). Demographic predictors included age, socioeconomic status, educational attainment, and language spoken at home. The screening behaviors were self-reported prostate cancer screening (prostate-specific antigen testing and digital rectal examinations [DREs]), and colorectal cancer screening (self-reported FOBT participation and recorded uptake of the FOBT offer). Analysis comprised principal component analysis and structural equation modelling. NFC was positively related to demographic variables education, socioeconomic status, and speaking English at home. Faith in intuition was negatively related to educational attainment. NFC predicted variance in self-reported DRE participation ( r = .11, p = .016). No other relationships with thinking style were statistically significant. The relationship of NFC to DRE participation may reflect the way certain attributes of this screening method are processed, or alternatively, it may reflect willingness to report participation. The relationship of thinking style to a range of healthy behaviors should be further explored.

Exploring the validity of the continuum of resistance model for discriminating early from late and non-uptake of colorectal cancer screening: implications for the design of invitation and reminder letters.

BACKGROUND: The continuum of resistance model contends that respondents lie at one end of a continuum and non-respondents at the other with respect to factors demonstrated to impact on screening participation. PURPOSE: The aim of this study was to explore the validity of this model for the prediction of participation in colorectal cancer screening. METHOD: People aged 50 to 74 years were asked to complete a survey (n = 1,250). Eligible respondents (n = 376, 30 %) were invited to complete a faecal occult blood test (FOBT). The cutoff period for the determination of participation rates was 12 weeks, with a reminder sent at 6 weeks. RESULTS: FOBTs were returned by n = 196 people (132 within 6 weeks, 64 following a reminder). Participation was generally influenced by the same variables in both the first 6 weeks and the second 6 weeks, consistent with the continuum of resistance model. These variables were having known someone with bowel cancer and the social cognitive factor, perceptions of barriers to screening. There is a suggestion, however, that other factors may be differentially associated with early, late and non-participants. CONCLUSION: Participation in screening appears somewhat consistent with the continuum of resistance model in that early and late participants respond to some of the same factors. This suggests that the same messages are relevant to early, late and non-screeners, but further consideration of what other factors may be influencing discrete stages of readiness to participate is necessary.

Internet usage and openness to internet-delivered health information among Australian adults aged over 50 years.

BACKGROUND: The cost of healthcare in Australia's ageing population is ever increasing. In an attempt to reduce these rising costs, the internet has been suggested as a possible means of disseminating health-related information and promoting preventive health behaviours. OBJECTIVE: Our objective was to determine the proportion of Australians aged 50-74 years who have internet access, and the characteristics of internet usage, current online health information seeking behaviour, and the willingness to receive unsolicited health information via the Internet. METHOD: A random sample of N=25,511 urban older Australians aged 50 to 74 years received a questionnaire via mail and were asked to complete questions concerning variables related to internet usage. N=8,762 returned a competed questionnaire. RESULTS: Eighty-two per cent of respondents reported having internet access, mainly at home (94%), and the majority actively use this technology (93%). Younger people and those of higher socio-economic status and higher education were more likely to have access (p<.001). Approximately 61% reported actively seeking health-related information online but only 32% expressed a willingness to receive unsolicited health information via the internet. Females were more likely to currently search for health-related information than males but were less likely to be open to receiving unsolicited health information (both p<.001). CONCLUSION: According to the data it appears the majority of urban Australians aged over 50 have access to the internet at some location and 60% of them use the internet for health-related purposes. The data also suggests, however, that delivering health information via the internet alone would disadvantage those who are older, less educated, and less financially well-off.

The impact of computer self-efficacy, computer anxiety, and perceived usability and acceptability on the efficacy of a decision support tool for colorectal cancer screening.

OBJECTIVE: This study investigated the efficacy of an internet-based personalized decision support (PDS) tool designed to aid in the decision to screen for colorectal cancer (CRC) using a fecal occult blood test. We tested whether the efficacy of the tool in influencing attitudes to screening was mediated by perceived usability and acceptability, and considered the role of computer self-efficacy and computer anxiety in these relationships. METHODS: Eighty-one participants aged 50-76 years worked through the on-line PDS tool and completed questionnaires on computer self-efficacy, computer anxiety, attitudes to and beliefs about CRC screening before and after exposure to the PDS, and perceived usability and acceptability of the tool. RESULTS: Repeated measures ANOVA found that PDS exposure led to a significant increase in knowledge about CRC and screening, and more positive attitudes to CRC screening as measured by factors from the Preventive Health Model. Perceived usability and acceptability of the PDS mediated changes in attitudes toward CRC screening (but not CRC knowledge), and computer self-efficacy and computer anxiety were significant predictors of individuals' perceptions of the tool. CONCLUSION: Interventions designed to decrease computer anxiety, such as computer courses and internet training, may improve the acceptability of new health information technologies including internet-based decision support tools, increasing their impact on behavior change.

Decision Support and the Effectiveness of Web-based Delivery and Information Tailoring for Bowel Cancer Screening: An Exploratory Study.

BACKGROUND: Colorectal cancer (CRC) is the third most commonly diagnosed cancer in males and the second in females throughout the developed world. Population screening using fecal occult blood tests (FOBTs) facilitates early detection and greater chance of survival, but participation rates are low. We developed a Web-based decision tool to provide information tailored to an individual's decision stage for CRC screening and attitude toward screening utilizing the Preventive Health Model (PHM) and Precaution Adoption Process Model (PAPM) as theoretical frameworks for screening behavior. We describe the practical steps employed in the tool's design and the subsequent conduct of an exploratory study. OBJECTIVE: To design a decision tool for CRC screening and conduct an exploratory study among average-risk men and women to (1) test the impact of message type (tailored vs non-tailored) and message delivery modality (Web-based vs paper-based) on attitudes toward screening and screening uptake, and (2) investigate the acceptability of the decision tool and relevance of materials. METHODS: Participants (n = 100), recruited from a population sample of men and women aged 50-76 residing in urban Adelaide, Australia, were randomly assigned to a control group or one of 4 interventions: (1) Web-based and tailored information, (2) paper-based and tailored information, (3) Web-based and non-tailored (generic) information, or (4) paper-based and non-tailored information. Participation was augmented by snowball recruitment (n = 19). Questionnaires based on PHM variables were administered pre- and post-intervention. Participants were given the opportunity to request an FOBT. Following the intervention, participants discussed the acceptability of the tool. RESULTS: Full data were available for 87.4% (104/119) of participants. Post-intervention, perceived susceptibility scores for individuals receiving tailored information increased from mean 10.6 (SD 2.1) to mean 11.8 (SD 2.2). Scores on self-efficacy increased in the tailored group from mean 11.7 (SD 2.0) to mean 12.6 (SD 1.8). There were significant time x modality x message effects for social influence and salience and coherence, reflecting an increase in these scores for tailored Web-based participants only; social influence scores increased from mean 11.7 (SD 2.6) to mean 14.9 (SD 2.3), and salience and coherence scores increased from mean 16.0 (SD 2.2) to mean 17.7 (SD 2.1). There was no greater influence of modality or message type on movement toward a decision to screen or screening uptake, indicating that neither tailored messages nor a Web modality had superior effect. Overall, participants regarded tailored messages positively, but thought that the Web tool lacked "media richness." CONCLUSIONS: This exploratory study confirms that tailoring on PHM predictors of CRC screening has the potential to positively address attitudes toward screening. However, tailoring on these variables did not result in significantly increased screening uptake. Future research should consider other possible psychosocial influences. Mode of delivery did not affect outcomes, but as a delivery medium, the Web has economic and logistical advantages over paper.

Cross-cultural validation of the preventive health model for colorectal cancer screening: an Australian study.

We investigated whether the five-factor structure of the Preventive Health Model for colorectal cancer screening, developed in the United States, has validity in Australia. We also tested extending the model with the addition of the factor Self-Efficacy to Screen using Fecal Occult Blood Test (SESFOBT). Randomly selected men and women aged between 50 and 76 years (n = 414) responded to a survey. Confirmatory factor analyses indicated that the U.S. model provided adequate fit for the group as a whole and for men and women separately, thereby demonstrating cross-cultural validity for measuring factors influencing the decision to screen. The inclusion of SESFOBT in the model resulted in a comparable, but less parsimonious, fit. However, self-efficacy is a demonstrated mediator of intention and action, and it is argued that the addition of SESFOBT as a sixth factor may have utility for the design of strategies to increase actual uptake of FOBT.

Protocol for population testing of an Internet-based Personalised Decision Support system for colorectal cancer screening.

BACKGROUND: Australia has a comparatively high incidence of colorectal (bowel) cancer; however, population screening uptake using faecal occult blood test (FOBT) remains low. This study will determine the impact on screening participation of a novel, Internet-based Personalised Decision Support (PDS) package. The PDS is designed to measure attitudes and cognitive concerns and provide people with individually tailored information, in real time, that will assist them with making a decision to screen. The hypothesis is that exposure to (tailored) PDS will result in greater participation in screening than participation following exposure to non-tailored PDS or resulting from the current non-tailored, paper-based approach. METHODS/DESIGN: A randomised parallel trial comprising three arms will be conducted. Men and women aged 50-74 years (N = 3240) will be recruited. They must have access to the Internet; have not had an FOBT within the previous 12 months, or sigmoidoscopy or colonoscopy within the previous 5 years; have had no clinical diagnosis of bowel cancer. Groups 1 and 2 (PDS arms) will access a website and complete a baseline survey measuring decision-to-screen stage, attitudes and cognitive concerns and will receive immediate feedback; Group 1 will receive information 'tailored' to their responses in the baseline survey and group 2 will received 'non-tailored' bowel cancer information. Respondents in both groups will subsequently receive an FOBT kit. Group 3 (usual practice arm) will complete a paper-based version of the baseline survey and respondents will subsequently receive 'non-tailored' paper-based bowel cancer information with accompanying FOBT kit. Following despatch of FOBTs, all respondents will be requested to complete an endpoint survey. Main outcome measures are (1) completion of FOBT and (2) change in decision-to-screen stage. Secondary outcomes include satisfaction with decision and change in attitudinal scores from baseline to endpoint. Analyses will be performed using Chi-square tests, analysis of variance and log binomial generalized linear models as appropriate. DISCUSSION: It is necessary to restrict participants to Internet users to provide an appropriately controlled evaluation of PDS. Once efficacy of the approach has been established, it will be important to evaluate effectiveness in the wider at-risk population, and to identify barriers to its implementation in those settings. TRIAL REGISTRATION: Australian New Zealand Clinical Trials Registry ACTRN12610000095066.

Metformin in polycystic ovary syndrome: systematic review and meta-analysis.

OBJECTIVE: To assess the effectiveness of metformin in improving clinical and biochemical features of polycystic ovary syndrome. DESIGN: Systematic review and meta-analysis. DATA SOURCES: Randomised controlled trials that investigated the effect of metformin compared with either placebo or no treatment, or compared with an ovulation induction agent. SELECTION OF STUDIES: 13 trials were included for analysis, including 543 women with polycystic ovary syndrome that was defined by using biochemical or ultrasound evidence. MAIN OUTCOME MEASURE: Pregnancy and ovulation rates. Secondary outcomes of clinical and biochemical features of polycystic ovary syndrome. RESULTS: Meta-analysis showed that metformin is effective in achieving ovulation in women with polycystic ovary syndrome, with odds ratios of 3.88 (95% confidence interval 2.25 to 6.69) for metformin compared with placebo and 4.41 (2.37 to 8.22) for metformin and clomifene compared with clomifene alone. An analysis of pregnancy rates shows a significant treatment effect for metformin and clomifene (odds ratio 4.40, 1.96 to 9.85). Metformin has an effect in reducing fasting insulin concentrations, blood pressure, and low density lipoprotein cholesterol. We found no evidence of any effect on body mass index or waist:hip ratio. Metformin was associated with a higher incidence of nausea, vomiting, and other gastrointestinal disturbance. CONCLUSIONS: Metformin is an effective treatment for anovulation in women with polycystic ovary syndrome. Its choice as a first line agent seems justified, and there is some evidence of benefit on variables of the metabolic syndrome. No data are available regarding the safety of metformin in long term use in young women and only limited data on its safety in early pregnancy. It should be used as an adjuvant to general lifestyle improvements and not as a replacement for increased exercise and improved diet.