Impact of a health literacy intervention combining general practitioner training and a consumer facing intervention to improve colorectal cancer screening in underserved areas: protocol for a multicentric cluster randomized controlled trial.

BACKGROUND: Colorectal cancer (CRC) is a leading cause of cancer burden worldwide. In France, it is the second most common cause of cancer death after lung cancer. Systematic uptake of CRC screening can improve survival rates. However, people with limited health literacy (HL) and lower socioeconomic position rarely participate. Our aim is to assess the impact of an intervention combining HL and CRC screening training for general practitioners (GPs) with a pictorial brochure and video targeting eligible patients, to increase CRC screening and other secondary outcomes, after 1 year, in several underserved geographic areas in France. METHODS: We will use a two-arm multicentric randomized controlled cluster trial with 32 GPs primarily serving underserved populations across four regions in France with 1024 patients recruited. GPs practicing in underserved areas (identified using the European Deprivation Index) will be block-randomized to: 1) a combined intervention (HL and CRC training + brochure and video for eligible patients), or 2) usual care. Patients will be included if they are between 50 and 74 years old, eligible for CRC screening, and present to recruited GPs. The primary outcome is CRC screening uptake after 1 year. Secondary outcomes include increasing knowledge and patient activation. After trial recruitment, we will conduct semi-structured interviews with up to 24 GPs (up to 8 in each region) and up to 48 patients (6 to 12 per region) based on data saturation. We will explore strategies that promote the intervention's sustained use and rapid implementation using Normalization Process Theory. We will follow a community-based participatory research approach throughout the trial. For the analyses, we will adopt a regression framework for all quantitative data. We will also use exploratory mediation analyses. We will analyze all qualitative data using a framework analysis guided by Normalization Process Theory. DISCUSSION: Limited HL and its impact on the general population is a growing public health and policy challenge worldwide. It has received limited attention in France. A combined HL intervention could reduce disparities in CRC screening, increase screening rates among the most vulnerable populations, and increase knowledge and activation (beneficial in the context of repeated screening). TRIAL REGISTRATION: Registry: ClinicalTrials.gov. TRIAL REGISTRATION NUMBER: 2020-A01687-32 . Date of registration: 17th November 2020.

Addressing Cancer Screening Inequities by Promoting Cancer Prevention Knowledge, Awareness, Self-Efficacy, and Screening Uptake Among Low-Income and Illiterate Immigrant Women in France.

Objective: Cancer screening rates are suboptimal for disadvantaged populations in France, yet little evidence exists on their cancer-related knowledge and screening barriers. The main objective of this study was to examine cancer-related knowledge, awareness, self-efficacy, and perceptions of screening barriers among low-income, illiterate immigrant women in France following an 8-weeks cancer educational intervention. Methods: Semi-structured qualitative interviews were conducted with 164 female participants in the Ain department of France between January 2019 and March 2020. Adopting the Health Belief Model as an intervention and analytic framework, salient themes were identified using qualitative thematic analysis. Results: Increased levels of perceived susceptibility to and perceived severity of cancer contributed to higher motivation to get screened. Barriers to screening included low French proficiency, shame surrounding illiteracy, and constant worries due to precarious living conditions. Perceived benefits (e.g., valuing one's health and health-promoting behaviors), cues to action from a trusted source, and greater self-efficacy (e.g., more autonomous in healthcare-seeking) outweighed perceived barriers, including cultural barriers. Conclusions: Implications include developing audience-responsive targeted cancer screening communication strategies and educational materials to increase screening rates and reduce cancer and cancer screening inequities.

Prediction of the severity of colorectal lesion by fecal hemoglobin concentration observed during previous test in the French screening program.

BACKGROUND: The rate of positive tests using fecal immunochemical test (FIT) does not decrease with subsequent campaigns, but the positive predictive value of advanced neoplasia significantly decreases in subsequent campaign after a first negative test. A relationship between the fecal hemoglobin concentration (Fhb) and the opportunity to detect a colorectal cancer in subsequent campaign has been shown. AIM: To predict the severity of colorectal lesions based on Fhb measured during previous colorectal cancer screening campaign. METHODS: This etiological study included 293750 patients aged 50-74, living in Auvergne-Rhône-Alpes (France). These patients completed at least two FIT [test(-1) and test(0)] between June 2015 and December 2019. Delay between test(-1) and test(0) was > 1 year and test(-1) result was negative (< 150 ngHb/mL). The severity of colorectal lesions diagnosed at test(0) was described according to Fhb measured at test(-1) [Fhb(-1)]. The relationship between the severity classified in seven ordinal categories and the predictive factors was analyzed in an ordered multivariate polytomous regression model. RESULTS: The test(0) positive rate was 4.0%, and the colonoscopy completion rate was 97.1% in 11594 patients who showed a positive test(0). The colonoscopy detection rate was 77.7% in those 11254 patients who underwent a colonoscopy. A total of 8748 colorectal lesions were detected (including 2182 low-risk-polyps, 2400 high-risk-polyp, and 502 colorectal cancer). The colonoscopy detection rate varied significantly with Fhb(-1) [0 ngHb/mL: 75.6%, (0-50 ngHb/mL): 77.3%, (50-100 ngHb/mL): 88.7%, (100-150 ngHb/mL): 90.3%; P = 0.001]. People with a Fhb(-1) within (100-150 ngHb/mL) (P = 0.001) were 2.6 (2.2; 3.0) times more likely to have a high severity level compared to those having a Fhb(-1) value of zero. This risk was reduced by 20% in patients aged 55-59 compared to those aged < 55 [adjusted odds ratio: 0.8 (0.6; 1.0)]. CONCLUSION: The study showed that higher Fhb(-1) is correlated to an increased risk of severity of colorectal lesions. This risk of severity increased among first-time participants (age < 55) and the elderly (≥ 70). To avoid the loss of chance in these age groups, the FIT positivity threshold should be reduced to 100 ngHb/mL. The other alternative would be to reduce the time between the two tests in these age groups from the current 2 years to 1 year.

Colorectal cancer fecal screening test completion after age 74, sources and outcomes in French program.

BACKGROUND: Elderly patients aged at least 75 years old (Elderly_75), represent 45% of colorectal cancer (CRC) incidence. As others, the French Colorectal Cancer Screening Program (CRCSP) does not include Elderly_75. To date, there is little evidence to justify stopping screening at 74 years of age. AIM: To describe CRC fecal screening test completion after age 74, source (CRCSP/Provider ordered) and outcomes of these tests. METHODS: The study concerned 18704 Elderly_75 residing in eleven French districts (Ain, Doubs, Essonne, Haute-Saone, Hauts-de-Seine, Jura, Seine-Saint-Denis, Territoire-de-Belfort, Val-de-Marne, Val-d'Oise, Yonne), having performed a CRC screening test between January 2008 and December 2017. The tests performed in a circumstance of delayed response to a solicitation (DRS) from the local cancer screening managing center (Managing-Center) were distinguished from the tests non-solicited by the Managing-Center, performed after a recommendation by a General Practitioner (GP) or other provider ordered (RGP). DRS was any test realized by an Elderly_75 following an initial invitation from the Managing-Center with a maximum 24 mo after this invitation. Any Non-DRS test was considered RGP. The outcomes of these tests were described according to the circumstances of test completion. RESULTS: Of 18995 screening-tests were performed at ages: 75 (83.5%), 76-80 (13.4%) and > 80 (3.1%) years old. Elderly_75 performed the screening test in a circumstance of DRS (71.9%) or RGP (28.1%). The proportion of the tests that could not be analyzed and not restarted was 13.2%. For these unanalyzed tests, the reason was age-related in 78.0% of cases, related to the laboratory's refusal to analyze the test of people aged ≥ 77. Reported colonoscopy completion rate was 81.3%. For those 575 people with reported colonoscopy, no complication was listed. 18.0% of the 366 Elderly_75 with lesions had no anteriority in the CRCSP. The neoplasia (124 Low-risk-polyps, 159 High-risk-polyps, 13 Unspecified-polyps and 70 CRCs) detection rate was 19.3/1000 Elderly_75 screened and the CRC detection rate was 3.7/1000 Elderly_75 screened. CONCLUSION: The high rate of colonoscopy completion after a positive test and the high proportion of screened lesions observed suggest that the lengthening of the screening period could allow significant detection of CRC and polyps that occur in Elderly_75 excluded from CRCSP.