Contextual factors associated with cancer screening uptake: A systematic review of observational studies.

We conducted a systematic review of a wide range of contextual factors related to cancer screening uptake that have been studied so far. Studies were identified through PubMed and Web of Science databases. An operational definition of context was proposed, considering as contextual factors: social relations directly aimed at cancer screening, health care provider and facility characteristics, geographical/accessibility measures and aggregated measures at supra-individual level. We included 70 publications on breast, cervical and/or colorectal cancer screening from 42 countries, covering a data period of 24 years. A wide diversity of factors has been investigated in the literature so far. While several of them, as well as many interactions, were robustly associated with screening uptake (family, friends or provider recommendation, provider sex and experience, area-based socio-economic status…), others showed less consistency (ethnicity, urbanicity, travel time, healthcare density …). Screening inequities were not fully explained through adjustment for individual and contextual factors. Context, in its diversity, influences individual screening uptake and lots of contextual inequities in screening are commonly shared worldwide. However, there is a lack of frameworks, standards and definitions that are needed to better understand what context is, how it could modify individual behaviour and the ways of measuring and modifying it.

Recherche interventionnelle pour la réduction des inégalités sociales et territoriales de dépistage des cancers.

Social inequalities constitute a major obstacle to the social and economic cohesion of a country, particularly those affecting the health field. In the field of cancer screening, the current situation is that of a social gradient of participation and strong territorial inequalities. This paper reports on the results of two interventional investigations to add incentives to the existing device to provide screening tests for specific populations. A prospective trial with a collective randomization unit was set up from April 2011 to April 2013 in the 3 areas of Northern France (Aisne, Oise and Somme), to assess social workers' help with screening of colorectal cancer (Prado trial). A retrospective study was conducted on the experience of mammobile driving in the area of Orne for several years. The analysis of the results shows that each of these devices is capable of reducing or even erasing social and territorial inequalities at a reasonable cost to society. It also shows that in terms of screening, inequalities can only be reduced if additional devices dedicated to particular populations are added to the national system according to a principle of proportionate universalism.

Cost-Effectiveness Analysis of a Mobile Mammography Unit for Breast Cancer Screening to Reduce Geographic and Social Health Inequalities.

BACKGROUND: Breast cancer is the leading cancer in terms of incidence and mortality among women in France. Effective organized screening does exist, however, the participation rate is low, and negatively associated with a low socioeconomic status and remoteness. OBJECTIVES: To determine the cost-effectiveness of a mobile mammography (MM) program to increase participation in breast cancer screening and reduce geographic and social inequalities. METHODS: A cost-effectiveness analysis from retrospective data was conducted from the payer perspective, comparing an invitation to a mobile mammography unit (MMU) or to a radiologist's office (MM or RO group) with an invitation to a radiologist's office only (RO group) (n = 37 461). Medical and nonmedical direct costs were estimated. Outcome was screening participation. The mean incremental cost and effect, the incremental cost-effectiveness ratio, and the cost-effectiveness acceptability curve were estimated. RESULTS: The mean incremental cost for invitation to MM or RO was estimated to be €23.21 (95% CI, 22.64-23.78) compared with RO only, and with a point of participation gain of 3.8% (95% CI, 2.8-4.8), resulting in an incremental cost per additional screen of €610.69 (95% CI, 492.11-821.01). The gain of participation was more important in women living in deprived areas and for distances exceeding 15 km from an RO. CONCLUSION: Screening involving a MMU can increase participation in breast cancer screening and reduce geographic and social inequalities while being more cost-effective in remote areas and in deprived areas. Because of the retrospective design, further research is needed to provide more evidence of the effectiveness and cost-effectiveness of using a MMU for organized breast cancer screening and to determine the optimal conditions for implementing it.

[Intervention research for the reduction of social and local inequalities in matters relating to cancer screening] / Recherche interventionnelle pour la réduction des inégalités sociales et territoriales de dépistage des cancers.

Social inequalities constitute a major obstacle to the social and economic cohesion of a country, particularly those affecting the health field. In the field of cancer screening, the current situation is that of a social gradient of participation and strong territorial inequalities. This paper reports on the results of two interventional investigations to add incentives to the existing device to provide screening tests for specific populations. A prospective trial with a collective randomization unit was set up from April 2011 to April 2013 in the 3 areas of Northern France (Aisne, Oise and Somme), to assess social workers' help with screening of colorectal cancer (Prado trial). A retrospective study was conducted on the experience of mammobile driving in the area of Orne for several years. The analysis of the results shows that each of these devices is capable of reducing or even erasing social and territorial inequalities at a reasonable cost to society. It also shows that in terms of screening, inequalities can only be reduced if additional devices dedicated to particular populations are added to the national system according to a principle of proportionate universalism.

Longterm Risk of Solid Organ De Novo Malignancies After Liver Transplantation: A French National Study on 11,226 Patients.

De novo malignancies are one of the major late complications and causes of death after liver transplantation (LT). Using extensive data from the French national Agence de la Biomédecine database, the present study aimed to quantify the risk of solid organ de novo malignancies (excluding nonmelanoma skin cancers) after LT. The incidence of de novo malignancies among all LT patients between 1993 and 2012 was compared with that of the French population, standardized on age, sex, and calendar period (standardized incidence ratio; SIR). Among the 11,226 LT patients included in the study, 1200 de novo malignancies were diagnosed (10.7%). The risk of death was approximately 2 times higher in patients with de novo malignancy (48.8% versus 24.3%). The SIR for all de novo solid organ malignancies was 2.20 (95% confidence interval [CI], 2.08-2.33). The risk was higher in men (SIR = 2.23; 95% CI, 2.09-2.38) and in patients transplanted for alcoholic liver disease (ALD; SIR = 2.89; 95% CI, 2.68-3.11). The cancers with the highest excess risk were laryngeal (SIR = 7.57; 95% CI, 5.97-9.48), esophageal (SIR = 4.76; 95% CI, 3.56-6.24), lung (SIR = 2.56; 95% CI, 2.21-2.95), and lip-mouth-pharynx (SIR = 2.20; 95% CI, 1.72-2.77). In conclusion, LT recipients have an increased risk of de novo solid organ malignancies, and this is strongly related to ALD as a primary indication for LT.

Cost-Effectiveness Analysis of a Navigation Program for Colorectal Cancer Screening to Reduce Social Health Inequalities: A French Cluster Randomized Controlled Trial.

BACKGROUND: Patient navigation programs to increase colorectal cancer (CRC) screening adherence have become widespread in recent years, especially among deprived populations. OBJECTIVES: To evaluate the cost-effectiveness of the first patient navigation program in France. METHODS: A total of 16,250 participants were randomized to either the usual screening group (n = 8145) or the navigation group (n = 8105). Navigation consisted of personalized support provided by social workers. A cost-effectiveness analysis of navigation versus usual screening was conducted from the payer perspective in the Picardy region of northern France. We considered nonmedical direct costs in the analysis. RESULTS: Navigation was associated with a significant increase of 3.3% (24.4% vs. 21.1%; P = 0.003) in participation. The increase in participation was higher among affluent participants (+4.1%; P = 0.01) than among deprived ones (+2.6%; P = 0.07). The cost per additional individual screened by navigation compared with usual screening (incremental cost-effectiveness ratio) was €1212 globally and €1527 among deprived participants. Results were sensitive to navigator wages and to the intervention effectiveness whose variations had the greatest impact on the incremental cost-effectiveness ratio. CONCLUSIONS: Patient navigation aiming at increasing CRC screening participation is more efficient among affluent individuals. Nevertheless, when the intervention is implemented for the entire population, social inequalities in CRC screening adherence increase. To reduce social inequalities, patient navigation should therefore be restricted to deprived populations, despite not being the most cost-effective strategy, and accepted to bear a higher extra cost per additional individual screened.

Survival of patients with cancer starting chronic dialysis: Data from kidney and cancer registries in lower Normandy.

AIM: Cancer and chronic kidney disease are known to be associated. The way in which a history of cancer can influence outcome in dialysis is not well described. This work aimed to evaluate survival of cancer patients starting chronic dialysis after their diagnosis of cancer. METHODS: We merged data from cancer registries and a dialysis registry, and explored patients' charts. RESULTS: Between January 2001 and December 2008, 74 patients with incident cancer in the two-counties-study-area (Calvados and Manche) started chronic dialysis after their diagnosis of cancer. Survival of these incident dialysis patients with a previous diagnosis of cancer was respectively 80.9% (confidence interval 69.9; 88.2) and 68.3% (confidence interval 56.3%; 77.7%) at 1 and 2 years. Only 29 of the 74 patients (39.2%) were still alive at the end of the observation period; median participation time was 2.8 years (1st and 3rd quartiles: 1.3-4.4). Survival of patients with cancer was not different to that of non-cancer dialysis patients matched for age and sex, except in patients with haematological malignancies who had a poorer outcome. In a multivariate stratified Cox model, the history of cancer before dialysis start was not associated with death, after adjustment on diabetes. CONCLUSION: In our study, survival in dialysis was not different among patients with a history of cancer compared to matched patients without malignancy. We can hypothesize that only some selected patients with cancer have access to dialysis. Studies in ESRD patients with cancer should be performed to evaluate access to dialysis in that population.

Could mobile mammography reduce social and geographic inequalities in breast cancer screening participation?

Evaluation of mobile mammography for reducing social and geographic inequalities in breast cancer screening participation. We examined the responses to first invitations to undergo breast cancer screening from 2003 to 2012 in Orne, a French department. Half of the participants could choose between screening in a radiologist's office or a mobile mammography (MM) unit. We calculated the participation rate and individual participation model according to age group, deprivation quintile and distance. Among participants receiving an MM invitation, the preference was for MM. This was especially the case in the age group >70years and increased with deprivation quintile and remoteness. There were no significant participation trends with regard to deprivation or remoteness. In the general population, the influence of deprivation and remoteness was markedly diminished. After adjustment, MM invitation was associated with a significant increase in individual participation (odds ratio=2.9). MM can target underserved and remote communities, allowing greater participation and decreasing social and geographic inequalities in the general population. Proportionate universalism is an effective principle for public health policy in reducing health inequalities.

Patient navigation to reduce social inequalities in colorectal cancer screening participation: A cluster randomized controlled trial.

Despite free colorectal cancer screening in France, participation remains low and low socioeconomic status is associated with a low participation. Our aim was to assess the effect of a screening navigation program on participation and the reduction in social inequalities in a national-level organized mass screening program for colorectal cancer by fecal-occult blood test (FOBT). A multicenter (3 French departments) cluster randomized controlled trial was conducted over two years. The cluster was a small geographical unit stratified according to a deprivation index and the place of residence. A total of 14,556 subjects (72 clusters) were included in the control arm where the FOBT program involved the usual postal reminders, and 14,373 subjects (66 clusters) were included in the intervention arm. Intervention concerned only non-attended subjects with a phone number available defined as the navigable population. A screening navigator was added to the usual screening organization to identify and eliminate barriers to CRC screening with personalized contact. The participation rate by strata increased in the intervention arm. The increase was greater in affluent strata than in deprived ones. Multivariate analyses demonstrated that the intervention mainly with phone navigation increased individual participation (OR=1.19 [1.10, 1.29]) in the navigable population. For such interventions to reduce social inequalities in a country with a national level organized mass screening program, they should first be administered to deprived populations, in accordance with the principle of proportionate universalism. ClinicalTrials.gov Identifier: NCT01555450.

National organization of uterine cervical cancer screening and social inequality in France.

Some of the inequality in uterine cervical cancer (UCC) screening uptake are due to the socioeconomic deprivation of women. A national organized screening programme has proven to be effective in increasing the uptake, but may increase socioeconomic inequality. Therefore, we compared inequality in uptake of UCC screening between two French departments, one of which is experimenting an organized screening programme. We used reimbursement data from the main French health insurance scheme to compare screening rates in the municipalities of the two departments over a three-year period. The experimental department had higher screening rates, but the increase in deprivation in municipalities had a greater effect on the decrease in participation in this department. Moreover, while screening rates were higher in urban areas, the negative effect of deprivation on participation was greater in rural areas. Although these departments were compared at the same time under different conditions, socioeconomic inequality between them may have been greater before the experimentation started. However, screening may have led to an increase in socioeconomic inequality between women screened. Special attention must be paid to changes in socioeconomic and geographic inequality in the uptake of UCC screening when the programme is rolled out nationally.

No effect of comorbidities on the association between social deprivation and geographical access to the reference care center in the management of colon cancer.

BACKGOUND: Patients with colon cancer in France exhibit one of the steepest socioeconomic survival gradients in Europe. Among the putative causes for this situation, comorbidities are frequently incriminated but evidence of this is lacking. AIMS: Measure the influence of social deprivation and geographical access to the reference care center for the management of colon cancer, and the putative role of associated comorbidities. MATERIALS AND METHODS: The study population comprised all 1383 resected colon cancer cases diagnosed between 2005 and 2010 in the area covered by the "Calvados Registry of Digestive Tumors". Social environment was assessed by using the European Deprivation Index and travel time to the reference care center and comorbidities by using Charlson's comorbidity index. RESULTS: Our results confirm the existence of socioeconomic or geographical inequalities at each step of colon cancer management, but without any role of associated comorbidities. The effect of deprivation is mainly explained by age at diagnosis, while travel time to the reference care center is an independent predictor of cancer management. CONCLUSION: We found no effect of comorbidities on the association between socioeconomic factors and the management of colon cancer in this French department.

Incidence and characteristics of chronic renal replacement therapy in patients with cancer: data from kidney and cancer registries in Basse-Normandie.

Aims To estimate the incidence of chronic dialysis in patients with a history of cancer and assess how renal replacement therapy is initiated in this population. Methods We merged data from cancer registries and hospital databases in one French region to identify patients with an incident cancer between 2001 and 2008 who started chronic dialysis. Results Mean participation time was 3.4 ± 2.7 years. Males comprised 58.5 % of participants. During the study period, 74 chronic dialysis treatments were initiated. Chronic interstitial nephritis was the leading cause of end-stage renal disease (21.6 %), and 46.6 % of dialysis initiation cases were unplanned. The incidence rate of chronic dialysis initiation in the population of incident cancer patients was 370 per million population/year (74 events/199,809 person-years). After age-adjustment, the standardized incidence ratio was 1.26, 95 % confidence interval 0.98-1.57, p = 0.55. Conclusion Cancer patients are known to be at risk of chronic kidney disease. However, the standardized incidence ratio of chronic dialysis initiation did not differ significantly between cancer patients and the general population. Further studies should be performed to identify the barriers to starting renal replacement therapy in cancer patients.

Totally implanted venous access-associated adverse events in oncology: Results from a prospective 1-year surveillance programme.

INTRODUCTION: During the last decade, most studies on totally implanted venous access-associated adverse events (TIVA-AE) were conducted retrospectively and/or were based on a limited sample size. The aim of our survey was two-fold: to estimate the incidence of TIVA-AE and to identify risk factors in patients with cancer. METHODS: Data from our routine surveillance of TIVA-AE were collected prospectively between October 2009 and January 2011 in two oncology referral centers in Northern France. The open cohort under surveillance during the same time period was reconstituted retrospectively using data from the hospital information systems. Incidences of first TIVA-AE per 1000 TIVA-days were calculated. Risk factors were identified using multivariate logistic regressions. RESULTS: We included 2286 cancer patients, corresponding to 582,347 TIVA-days. Among the 133 first TIVA-AE observed (incidence 0.23 per 1000 TIVA-days [0.19-0.27]), there were 50 infectious AE (incidence 0.09 [0.06-0.11]) and 83 non-infectious AE (incidence 0.14 [0.11-0.17]). Compared to non-metastatic solid cancers, metastatic cancers (aOR=2.3 [0.9-6.0]), and hematologic malignancies (aOR=3.2 [1.1-8.8]) tended to be associated with a higher risk of infectious TIVA-AE (P=0.087). Solid cancer type was associated with non-infectious TIVA-AE (P=0.030), especially digestive cancers. DISCUSSION: We report accurate estimations of TIVA-AE incidences in one of the largest populations among previously published studies. As in previous studies, metastatic cancers and hematologic malignancies tended to be associated with a higher risk of infectious TIVA-AE. Further studies are warranted to confirm the effect of digestive cancers.

Fractionated elution of 99Mo/99mTc generators using calibrated vials.

Fractionated elution consists in collecting the fractions of an eluate with the highest radioactive concentration. It may be useful to meet the requirements of a subset of clinical radiopharmacy procedures. This study aims to describe and evaluate straightforward procedures allowing to readily perform fractionated elution on dry and wet columns Mo/Tc generators by using calibrated vials. The main objectives of this study consisted in determining the relationship between eluate volume and elution yield using different vials calibration and assessing repeatability of the procedure. Elution vials were calibrated to obtain different eluate volumes by addition of air for wet column generator (WCG) and subtraction of saline for dry column generator (DCG) (n≥5 for each calibration). The relationship between the eluate volume and the elution yield was determined by a regression model for both DCG and WCG. Then repeatability evaluation was performed using 3-ml vial calibration. Relationships between the eluate volume (V) and the elution yield (Y) for DCG and WCG were Y=57.551 ln(V)+10.526 and Y=50.256 ln(V)+17.597, respectively. For repeatability assessment (n=30 for DCG and n=31 for WCG), the median volume and the interquartile range for DCG and WCG were 2.98 ml (2.92-3.01) and 3.28 ml (2.71-3.40), respectively, and median (interquartile range) eluate yields were 84.73% (81.30-86.33) and 81.78% (78.91-85.20), respectively. The volume was significantly higher for WCG than DCG (P=0.036) and also significantly more variable (P<0.001). The elution yield was significantly lower for WCG than DCG (P=0.025), but no difference in variability between the two generators was found (P=0.874). Easy-to-handle fractionated elution methods are compatible with both DCG and WCG. Fractionation using calibrated vials exhibits a better reproducibility with DCG than WCG generators and represents the only proposed method so far to master fractionated elution with DCG.

Fractionated elution using the TEKCIS technetium-99m generator.

The TEKCIS technetium-99m (Tc) generator was designed to allow dry column shipment and automatized conception. A high Tc radioactive concentration is required in a subset of radiopharmacy procedures. Fractionated elution can be a useful tool to meet this requirement, especially when current elution is close to the generator expiration date. The aim of our study was to assess TEKCIS generator elution kinetics and to determine the optimal fractionated elution time to fit with procedures requiring the highest Tc radioactive concentration in clinical use. After duplicate elution at several predetermined elution times, the volume and activity of each eluate were measured. Two optimal time points were selected to perform fractionated elution and repeatability (n=34 and 33) assessed on TEKCIS generators calibrated at 6 or 8 GBq. The complete eluate volume (5 ml) was collected after 60 s of elution. A logarithmic equation was established between eluate volume (v, ml) from elapsed elution time (t, s): v=1.8335ln(t)-2.5965. Using the reciprocal equation, elution times required to obtain some commonly eluted volumes were calculated. Fractionated elutions during 15 and 20 s were selected and an average elution volume from 2.74 to 3.27 ml was collected, with an average elution yield of approximately 90 and 100%, respectively. Our work provides a simple and reliable methodology for the use of fractionated elution with the new TEKCIS generator.