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.

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.

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.