Is there endoscopic capacity to provide colorectal cancer screening to the unscreened population in the United States?

doi:10.1053/j.gastro.2004.09.052

Gastroenterology

Volume 127, Issue 6, December 2004, Pages 1661-1669

https://doi.org/10.1053/j.gastro.2004.09.052 Get rights and content

Background & Aims: Screening rates for colorectal cancer remain low compared with screening rates for other cancers. The size of the unscreened population and the capacity to provide widespread screening are unknown. We estimated the number of average-risk persons aged 50 years or older not screened for colorectal cancer, the number of procedures required for this population, and the endoscopic capacity to satisfy this unmet need. Methods: Using data from the US Census Bureau and the Centers for Disease Control and Prevention’s National Health Interview Survey, we designed a forecasting model to estimate the number of persons in the United States currently not screened for colorectal cancer and the number of examinations needed to screen these persons. Test need was compared with available capacity, based on results from the national Survey of Endoscopic Capacity, assuming different proportions of available capacity were used for colorectal cancer screening. Results: Approximately 41.8 million average-risk people aged 50 years or older have not been screened for colorectal cancer according to national guidelines. Sufficient capacity exists to screen the unscreened population within 1 year using fecal occult blood testing followed by diagnostic colonoscopy for positive tests. Depending on the proportion of available capacity used for colorectal cancer screening, it could take up to 10 years to screen the unscreened population using flexible sigmoidoscopy or colonoscopy. Conclusions: The capacity exists for widespread screening with fecal occult blood testing. The capacity for screening with flexible sigmoidoscopy or colonoscopy depends on the proportion of available capacity used for colorectal cancer screening.

Section snippets

Materials and methods

We designed a forecasting model to (1) estimate the number of average-risk people aged 50 years or older who have not been screened for colorectal cancer, (2) describe the sociodemographic characteristics of this population, and (3) estimate the annual number of procedures required to provide screening and follow-up examinations for this population.

Results

Of the 70.1 million persons in the United States aged 50 years or older at average risk for colorectal cancer, 28.3 million people (40.4%) have been screened within recommended intervals: approximately 15.7 million with endoscopy (flexible sigmoidoscopy or colonoscopy) only, 6.7 million with FOBT only, and 5.9 million with both FOBT and endoscopy. The remaining 41.8 million people have not been screened for colorectal cancer (Figure 1). Of those, approximately 23.2 million are women (55%), 38.5

Discussion

We present the first national estimate of the size of the unscreened population and new results on the capacity to screen the entire eligible US population for colorectal cancer. Our results show that 41.8 million US adults have not been screened for colorectal cancer according to national guidelines. If all of the currently available endoscopic capacity were used for screening, tests would be immediately available for an FOBT screening program, where the only necessary endoscopy would be

References (28)

J.D. Hardcastle et al.
Randomised controlled trial of faecal-occult-blood screening for colorectal cancer
Lancet
(1996)
O. Kronborg et al.
Randomised study of screening for colorectal cancer with faecal-occult-blood test
Lancet
(1996)
L.C. Seeff et al.
How many endoscopies are performed for colorectal cancer screening? Results from CDC’s Survey of Endoscopic Capacity
Gastroenterology
(2004)
S. Winawer et al.
Gastrointestinal Consortium Panel. Colorectal cancer screening and surveillance: clinical guidelines and rationale—updated based on new evidence
Gastroenterology
(2003)
Cancer facts and figures, 2004. Publication 02-250M-no. 5008.04
(2004)
J.S. Mandel et al.
The effect of fecal occult-blood screening on the incidence of colorectal cancer
N Engl J Med
(2000)
J.S. Mandel et al.
Reducing mortality from colorectal cancer by screening for fecal occult blood. Minnesota Colon Cancer Control Study
N Engl J Med
(1993)
J.V. Selby et al.
A case-control study of screening sigmoidoscopy and mortality from colorectal cancer
N Engl J Med
(1992)
P.A. Newcomb et al.
Screening sigmoidoscopy and colorectal cancer mortality
J Natl Cancer Inst
(1992)
J.S. Mandel et al.
Colorectal cancer mortalityeffectiveness of biennial screening for fecal occult blood
J Natl Cancer Inst
(1999)

L.C. Seeff et al.

Patterns and predictors of colorectal cancer test use in the adult US population

Cancer

(2004)

Colorectal cancer test use among persons aged ≥50 years—United States, 2001

MMWR

(2003)

Census, 2000, Public Use Microdata Sample, United States, prepared by the US Census Bureau,...

US Department of Commerce, Census Bureau. Current population survey: annual demographic file, 2001 (computer...

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One in three adults above 50 years old have not been screened for colorectal cancer as of 2013.¹ Rural areas have even lower screening and have more general surgeons compared to gastroenterologists,² offering surgeons as a reservoir for necessary services.
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Cancelled and missed colonoscopy appointments waste resources, increase colonoscopy delays, and can adversely affect patient outcomes. We examined individual and organizational factors associated with missed and cancelled colonoscopy appointments in Veteran Health Administration facilities.
From 69 facilities meeting inclusion criteria, we identified 27,994 patients with colonoscopy appointments scheduled for follow-up, on the basis of positive fecal occult blood test results, between August 16, 2009 and September 30, 2011. We identified factors associated with colonoscopy appointment status (completed, cancelled, or missed) by using hierarchical multinomial regression. Individual factors examined included age, race, sex, marital status, residence, drive time to nearest specialty care facility, limited life expectancy, comorbidities, colonoscopy in the past decade, referring facility type, referral month, and appointment lead time. Organizational factors included facility region, complexity, appointment reminders, scheduling, and prep education practices.
Missed appointments were associated with limited life expectancy (odds ratio [OR], 2.74; P = .0004), no personal history of polyps (OR, 2.74; P < .0001), high facility complexity (OR, 2.69; P = .007), dual diagnosis of psychiatric disorders and substance abuse (OR, 1.82; P < .0001), and opt-out scheduling (OR, 1.57; P = .02). Cancelled appointments were associated with age (OR, 1.61; P = .0005 for 85 years or older and OR, 1.44; P < .0001 for 65–84 years old), no history of polyps (OR, 1.51; P < .0001), and opt-out scheduling (OR, 1.26; P = .04). Additional predictors of both outcomes included race, marital status, and lead time.
Several factors within Veterans Health Administration clinic control can be targeted to reduce missed and cancelled colonoscopy appointments. Specifically, developing systems to minimize referrals for patients with limited life expectancy could reduce missed appointments, and use of opt-in scheduling and reductions in appointment lead time could improve both outcomes.
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¹: S.K.C.’s current affiliation is: Epidemiology Program Office, Centers for Disease Control and Prevention, Atlanta, Georgia.

²: N.-A.M.M.’s current affiliation is: National Immunization Program, Centers for Disease Control and Prevention, Atlanta, Georgia.

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Rapid communicationsIs there endoscopic capacity to provide colorectal cancer screening to the unscreened population in the United States?

Section snippets

Materials and methods

Results

Discussion

Lancet

Lancet

Gastroenterology

Gastroenterology

Cancer facts and figures, 2004. Publication 02-250M-no. 5008.04

The effect of fecal occult-blood screening on the incidence of colorectal cancer

N Engl J Med

Reducing mortality from colorectal cancer by screening for fecal occult blood. Minnesota Colon Cancer Control Study

N Engl J Med

A case-control study of screening sigmoidoscopy and mortality from colorectal cancer

N Engl J Med

Screening sigmoidoscopy and colorectal cancer mortality

J Natl Cancer Inst

Colorectal cancer mortalityeffectiveness of biennial screening for fecal occult blood

J Natl Cancer Inst

Patterns and predictors of colorectal cancer test use in the adult US population

Cancer

Colorectal cancer test use among persons aged ≥50 years—United States, 2001

MMWR

Rapid communications
Is there endoscopic capacity to provide colorectal cancer screening to the unscreened population in the United States?