Impact of COVID-19 pandemic on fecal immunochemical test screening uptake and compliance to diagnostic colonoscopy.

BACKGROUND AND AIM: During this COVID-19 pandemic, Taiwan is one of the few countries where fecal immunochemical test and endoscopic activity for colorectal cancer screening keeps ongoing. We aimed to investigate how screening uptake and colonoscopy rate were affected in one of the biggest screening hubs in Northern Taiwan. METHODS: We conducted a prospective observational study tracing and analyzing the screening uptake and the trend of compliance to diagnostic colonoscopy in fecal immunochemical test-positive subjects in the National Taiwan University Hospital screening hub since the outbreak of COVID-19 and compared it with that of the corresponding periods in the past 3 years. Cancellation and rescheduling rates of colonoscopy and related reasons were also explored. RESULTS: Screening uptake during December 2019 to April 2020 was 88.8%, which was significantly lower than that in the corresponding period of the past 3 years (91.2-92.7%, P for trend < 0.0001). Colonoscopy rate in this period was 66.1%, which was also significantly lower than that in the past 3 years (70.2-77.5%, P for trend = 0.017). Rescheduling or cancellation rate was up to 10.9%, which was significantly higher than that in the past 3 years (P for trend = 0.023), and half of them was due to the fear of being infected. CONCLUSION: Fecal immunochemical test screening was significantly affected by COVID-19 pandemic. In order to resume the practice in COVID-19 era, screening organizers should consider various approaches to secure timely diagnosis of colorectal cancer.

Physical fitness cognition, assessment, and promotion: A cross-sectional study in Taiwan.

INTRODUCTION: Many health organizations have promoted the importance of the health-related benefits of physical fitness and physical activity. Studies have evaluated effective public health practice aiming to understand the cognition of physical activity among youths and adolescents. However, studies investigating the level of cognition and knowledge of physical fitness among Asian adults are lacking. PURPOSE: This study aimed to investigate the self-awareness level of physical fitness and exercise prescription and the demand for physical fitness assessment among Taiwanese adults. METHODS: In January-July 2019, a cross-sectional anonymous survey was conducted using Research Electronic Data Capture to gather data on demographic data, cognition investigation of physical fitness and exercise prescription, cognitive test of physical fitness and exercise prescription, and demand for physical fitness assessment. RESULTS: The questionnaire was answered by 200 respondents. The rating for cognition investigation of physical fitness was 2.63-3.13 (unclear to mostly clear) and for exercise prescription was 2.05-2.76 (unclear) (rated on a 5-point Likert scale). Results show that lack of awareness was highest for health-related physical fitness, exercise prescription, and exercise progress planning. 98% of subjects did not know the latest recommended guidelines for physical activity, despite most agreeing that physical fitness and exercise are good for health. Most subjects (72%) indicated a willingness to accept self-pay service for physical fitness assessments. CONCLUSIONS: This is the first study to report on the demand for cognition, assessment, and promotion of physical fitness among Taiwanese adults. The study shows that the subjects widely lack knowledge in the cognition of physical fitness and exercise prescription. Furthermore, a self-pay service for the physical fitness assessment and individualized exercise prescription were acceptable to most subjects, especially those undergoing regular health examinations. The findings are encouraging and will aid support for health organizations and professionals in the development and management of promotion strategies on health-related physical fitness in preventive medicine and health promotion.

The Rise of Colorectal Cancer in Asia: Epidemiology, Screening, and Management.

PURPOSE OF REVIEW: Colorectal cancer (CRC) remains the third most commonly diagnosed cancer globally, and its incidence and mortality rates have been on the rise in Asia. In this paper, we summarize the recent trends and screening challenges of CRC in this region. RECENT FINDINGS: In 2018, Asia had the highest proportions of both incident (51.8%) and mortality (52.4%) CRC cases (all genders and ages) per 100,000 population in the world. In addition, there has been a rising trend of this disease across Asia with some regional geographic variations. This rise in CRC can be attributed to westernized dietary lifestyle, increasing population aging, smoking, physical inactivity, and other risk factors. In curbing the rising trend, Japan, South Korea, Singapore, and Taiwan have launched nationwide population-based screening programs. CRC screening across this region has been found to be effective and cost-effective compared with no screening at all. The emergence of new therapies has caused a reduction in case fatality; however, these new options have had a limited impact on cure rates and long-term survival due to the great disparity in treatment capacity/resources and screening infrastructures among Asian countries with different degrees of economic development. CRC is still rising in Asia, and implementation of screening is necessary for moderate- to high-incidence countries and construction of treatment capacity is the priority task in low-incidence and low-income countries. Unless countries in Asia implement CRC screening, the incidence and mortality rates of this disease will continue to rise especially with the rapidly rising population growth, economic development, westernized lifestyle, and increasing aging.

Colorectal Cancer Screening in Asia.

PURPOSE OF REVIEW: Colorectal cancer (CRC) is increasing in Asia, especially in regions with higher levels of economic development. Several Asian countries have launched population CRC screening programs to combat this devastating disease because previous studies have demonstrated that either fecal occult blood test or lower gastrointestinal endoscopy can effectively reduce CRC mortality. RECENT FINDINGS: Screening includes engaging the population, testing, administering a confirmation examination, and treating screening-detected neoplasms; thus, monitoring the whole process using measurable indicators over time is of utmost importance. Only when the quality of every step is secured can the effectiveness of CRC screening be maximized. Screening and verification examination rates remain low in Asian countries, and important infrastructure, including cancer or death registry systems, colonoscopy capacity, and reasonable subsidization for screening, is lacking or insufficient. Future research should identify potential local barriers to screening. Good communication and dialog among screening organizers, clinicians, professional societies, and public health workers are indispensible for successful screening programs.

Knowledge of, attitudes toward, and barriers to participation of colorectal cancer screening tests in the Asia-Pacific region: a multicenter study.

BACKGROUND: The rapid increase in the incidence of colorectal cancer (CRC) in the Asia-Pacific region in the past decade has resulted in recommendations to implement mass CRC screening programs. However, the knowledge of screening and population screening behaviors between countries is largely lacking. OBJECTIVE: This multicenter, international study investigated the association of screening test participation with knowledge of, attitudes toward, and barriers to CRC and screening tests in different cultural and sociopolitical contexts. METHODS: Person-to-person interviews by using a standardized survey instrument were conducted with subjects from 14 Asia-Pacific countries/regions to assess the prevailing screening participation rates, knowledge of and attitudes toward and barriers to CRC and screening tests, intent to participate, and cues to action. Independent predictors of the primary endpoint, screening participation was determined from subanalyses performed for high-, medium-, and low-participation countries. RESULTS: A total of 7915 subjects (49% male, 37.8% aged 50 years and older) were recruited. Of the respondents aged 50 years and older, 809 (27%) had undergone previous CRC testing; the Philippines (69%), Australia (48%), and Japan (38%) had the highest participation rates, whereas India (1.5%), Malaysia (3%), Indonesia (3%), Pakistan (7.5%), and Brunei (13.7%) had the lowest rates. Physician recommendation and knowledge of screening tests were significant predictors of CRC test uptake. In countries with low-test participation, lower perceived access barriers and higher perceived severity were independent predictors of participation. Respondents from low-participation countries had the least knowledge of symptoms, risk factors, and tests and reported the lowest physician recommendation rates. "Intent to undergo screening" and "perceived need for screening" was positively correlated in most countries; however, this was offset by financial and access barriers. LIMITATIONS: Ethnic heterogeneity may exist in each country that was not addressed. In addition, the participation tests and physician recommendation recalls were self-reported. CONCLUSIONS: In the Asia-Pacific region, considerable differences were evident in the participation of CRC tests, physician recommendations, and knowledge of, attitudes toward, and barriers to CRC screening. Physician recommendation was the uniform predictor of screening behavior in all countries. Before implementing mass screening programs, improving awareness of CRC and promoting the physicians' role are necessary to increase the screening participation rates.

Revisit of field cancerization in squamous cell carcinoma of upper aerodigestive tract: better risk assessment with epigenetic markers.

We quantified field cancerization of squamous cell carcinoma in the upper aerodigestive tract with epigenetic markers and evaluated their performance for risk assessment. Methylation levels were analyzed by quantitative methylation-specific PCR of biopsied specimens from a training set of 255 patients and a validation set of 224 patients. We also measured traditional risk factors based on demographics, lifestyle, serology, genetic polymorphisms, and endoscopy. The methylation levels of four markers increased stepwise, with the lowest levels in normal esophageal mucosae from healthy subjects without carcinogen exposure, then normal mucosae from healthy subjects with carcinogen exposure, then normal mucosae from cancer patients, and the highest levels were in cancerous mucosae (P < 0.05). Cumulative exposure to alcohol increased methylation of homeobox A9 in normal mucosae (P < 0.01). Drinkers had higher methylation of ubiquitin carboxyl-terminal esterase L1 and metallothionein 1M (P < 0.05), and users of betel quid had higher methylation of homeobox A9 (P = 0.01). Smokers had increased methylation of all four markers (P < 0.05). Traditional risk factors allowed us to discriminate between patients with and without cancers with 74% sensitivity (95% CI: 67%-81%), 74% specificity (66%-82%), and 80% area under the curve (67%-91%); epigenetic markers in normal esophageal mucosa had values of 74% (69%-79%), 75% (67%-83%), and 83% (79%-87%); and both together had values of 82% (76%-88%), 81% (74%-88%), and 91% (88%-94%). Epigenetic markers done well in the validation set with 80% area under the curve (73%-85%). We concluded that epigenetics could improve the accuracies of risk assessment.

Gastric plasma biomarkers and Operative Link for Gastritis Assessment gastritis stage.

INTRODUCTION: The Operative Link for Gastritis Assessment (OLGA) staging system has been proposed as a histopathological reporting system of gastric atrophy. Noninvasive methods for indirect evaluation of gastric mucosal atrophy by biomarkers are also being introduced. OBJECTIVES: To analyze gastric mucosal atrophy by biomarkers, pepsinogen I (PgI), pepsinogen II (PgII), PgI/PgII ratio, fasting gastrin-17 (G-17), stimulated gastrin-17 (sG-17), in relation to OLGA gastritis stage. PATIENTS AND METHODS: Gastric biopsies were taken from 269 prospective patients referred for upper endoscopy because of dyspeptic problems and evaluated by two expert pathologists (D.J. and P.S.). Atrophy was assessed according to the OLGA staging system. Pg I, PgII, Pg I/II, G-17, sG-17 were determined in a plasma sample. RESULTS: The mean levels of PgI and PgI/PgII decreased significantly from 90.8 µg/l and 7.6 in stage 0 gastritis to 64.3 µg/l and 4.3 in high-stage gastritis. The mean values of G-17 and sG-17 were significantly higher among patients with stage II gastritis compared with stage 0 and high-stage gastritis.The proportion of patients with normal mucosa and nonatrophic gastritis according to biomarkers decreased from 78% in stage 0 to 22% in high-stage (III-IV) gastritis. Among the latter no case with normal mucosa, according to biomarkers, was observed. CONCLUSIONS: A significant inverse correlation between the mean levels of PgI, PgI/II ratio and the OLGA stage was observed. Percentage of dyspeptic patients with normal mucosa, by blood biomarkers, decreased with increasing OLGA gastritis stages. OLGA staging system provides a good frame for scientific analysis of gastric mucosal atrophy.

A prospective evaluation of the feasibility of primary screening with unsedated colonoscopy.

BACKGROUND: Colonoscopy is the most effective screening tool for colorectal cancer. In Taiwan, colonoscopy is used much less than sigmoidoscopy for screening because sedation significantly increases the cost and is not readily available, and unsedated colonoscopy is considered to be poorly tolerated. However, unsedated colonoscopy has been shown to be well accepted and may improve the cost-effectiveness and access to colonoscopic screening. OBJECTIVES: To compare the feasibility of unsedated colonoscopy and sigmoidoscopy for primary screening and to analyze factors associated with acceptance of the procedures and need for sedation. DESIGN: Single center, prospective. SETTING: National Taiwan University Medical Center. POPULATION AND INTERVENTIONS: A consecutive series of 261 subjects without history of colonoscopy or sigmoidoscopy who underwent unsedated colonoscopy (n = 176) or sigmoidoscopy (n = 85) for primary screening. MAIN OUTCOME MEASUREMENTS: Pain scores, acceptance, and need for sedation. RESULTS: No significant differences in pain, acceptance, and need for sedation were found between the colonoscopy and sigmoidoscopy groups. Only 9.6% in the colonoscopy group and 10.1% in the sigmoidoscopy group considered sedation necessary. Multivariate analyses revealed that the examinee's sex and the endoscopist, but not the type of endoscopic examination, were associated with the severity of pain and need for sedation. LIMITATIONS: Nonrandomized study design. CONCLUSIONS: Unsedated colonoscopy for primary screening is well accepted in nine tenths of examinees who accept this option and is similar to sigmoidoscopy in pain, acceptance, and need for sedation. Primary screening with unsedated colonoscopy is feasible, as with sigmoidoscopy.

Cost-effectiveness analysis between primary and secondary preventive strategies for gastric cancer.

OBJECTIVE: The present study is done to assess the relative cost-effectiveness, optimal initial age, and interscreening interval between primary and secondary prevention strategies for gastric cancer. METHODS: Base-case estimates, including variables of natural history, efficacy of intervention, and relevant cost, were derived from two preventive programs targeting a high-risk population. Cost-effectiveness was compared between chemoprevention with (13)C urea breath testing followed by Helicobacter pylori (H. pylori) eradication and high-risk surveillance based on serum pepsinogen measurement and confirmed by endoscopy. The main outcome measure was cost per life-year gained with a 3% annual discount rate. RESULTS: The incremental cost-effectiveness ratio (ICER) for once-only chemoprevention at age 30 years versus no screening was U.S. $17,044 per life-year gained. Eradication of H. pylori at later age or with a periodic scheme yielded a less favorable result. Annual high-risk screening at age of 50 years versus no screening resulted in an ICER of U.S. $29,741 per life-year gained. The ICERs of surveillance did not substantially vary with different initial ages or interscreening intervals. Chemoprevention could be dominated by high-risk surveillance when the initial age was older than 44 years. Otherwise, chemoprevention was more cost-effective than high-risk surveillance, either at ceiling ratios of U.S. $15,762 or up to U.S. $50,000. The relative cost-effectiveness was most sensitive to the infection rate of H. pylori and proportion of early gastric cancer in all detectable cases. CONCLUSIONS: Early H. pylori eradication once in lifetime seems more cost-effective than surveillance strategy. However, the choice is still subject to the risk of infection, detectability of early gastric cancer, and timing of intervention.

A community-based study of Helicobacter pylori therapy using the strategy of test, treat, retest, and re-treat initial treatment failures.

BACKGROUND: Although eradication of Helicobacter pylori infection can decrease the risk of gastric cancer, the optimal regimen for treating the general population remains unclear. We report the eradication rate (intention-to-treat and per protocol) of a community-based H. pylori therapy using the strategy of test, treat, retest, and re-treat initial treatment failures. MATERIALS AND METHODS: In 2004, a total of 2658 residents were recruited for 13C-urea breath testing. Participants with positive results for infection received a standard 7-day triple therapy (esomeprazole 40 mg once daily, amoxicillin 1 g twice daily, and clarithromycin 500 mg twice daily), and a 10-day re-treatment (esomeprazole 40 mg once daily, amoxicillin 1 g twice daily, and levofloxacin 500 mg once daily) if the follow-up tests remained positive. Both H. pylori status and side-effects were assessed 6 weeks after treatment. RESULTS: Among 886 valid reporters, eradication rates with initial therapy were 86.9% (95% confidence interval [CI]: 84.7-89.1%) and 88.7% (95%CI: 86.5-90.9%) by intention-to-treat and per protocol analysis, respectively. Re-treatment eradicated infection in 91.4% (95%CI: 86-96.8%) of 105 nonresponders. Adequate compliance was achieved in 798 (90.1%) of 886 subjects receiving the initial treatment and in all 105 re-treated subjects. Mild side-effects occurred in 24% of subjects. Overall intention-to-treat and per protocol eradication rates were 97.7% (95%CI: 96.7-98.7%) and 98.8% (95%CI: 98.5-99.3%), respectively, which were only affected by poor compliance (odds ratio, 3.3; 95%CI, 1.99-5.48; p < .0001). CONCLUSIONS: A comprehensive plan using drugs in which the resistance rate is low in a population combined with the strategy of test, treat, retest, and re-treat of needed can result in virtual eradication of H. pylori from a population. This provides a model for planning country- or region-wide eradication programs.