BACKGROUND:Microsimulation models use empirical evidence about cancer epidemiology and screening test performance to predict the long-term effectiveness of screening regimens and are essential for developing cancer screening guidelines. Colorectal cancer (CRC) provides a clear example. CRC arises through 2 pathways, the adenoma-carcinoma pathway and the serrated pathway. Sessile serrated lesions (SSLs) are the primary serrated precursor lesion. SSLs are more difficult to detect and remove than adenomas. METHODS:We describe version 3.0 of the Colorectal Cancer Simulated Population model for Incidence and Natural history, which adds new information about the serrated pathway and CRC risk in adults younger than 50 years, then estimate the effectiveness of decennial colonoscopy from 45 to 75 years old. The model was calibrated using a Bayesian approach to estimate 95% credible intervals (CIs) that reflect uncertainty in predictions. RESULTS:The model validated well to studies of the effect of 1-time screening and outcomes from surveillance colonoscopy. In the absence of screening, SSLs accounted for 10.6% (95% CI = 3.3 - 21.6) of CRC, increasing to 23.5% (95% CI = 7.7% - 46.0%) with screening because of selective removal of adenomas. Screening was predicted to prevent 93.9% (95% CI = 92.0% - 94.3%) of CRC and 95.3% (95% CI = 93.8% - 96.5%) of CRC mortality. CONCLUSIONS:Although SSLs are less common than adenomas, they likely make up a large fraction of CRC that arises in people who participate in screening. This points to the importance of improving the ability to detect SSLs, especially large SSLs, at colonoscopy.

BACKGROUND:Public health emergencies can substantially affect routine health care. Large cancer screening declines during the early months of the COVID-19 pandemic are well documented; however, COVID-19's impact on follow-up of abnormal screening exams and cancer diagnoses is less reported. We examined the impacts of COVID-19 on the cervical, colorectal, and lung cancer screening processes, within 10 health systems in the Population-based Research to Optimize the Screening Process (PROSPR) consortium. METHODS:PROSPR data were used to calculate: (i) monthly rates of cancer testing and, for pre-COVID and COVID time periods, (ii) proportions of individuals receiving recommended follow-up within 6 months of an abnormal test, and (iii) cancer incidence. Surveys were used to assess the healthcare systems' local context. RESULTS:During the first 2 months of the pandemic, cancer testing decreased across all health systems and cancer types (range, 18%-96%). Overall, decreases in monthly rates were followed by rapid recovery to prepandemic rates. The rates of 6-month follow-up of abnormal screening results trended down in the COVID versus pre-COVID periods, as did the diagnosis of new cancers. CONCLUSIONS:Declines in cancer testing in the early months of the COVID-19 pandemic were short term, with at least short-term impacts on diagnostic follow-up and cancer diagnosis. The systems with the smallest decreases were those that both utilized remote screening outreach (e.g., mailed fecal immunochemical test kits) and did not pause that outreach at the start of the pandemic. IMPACT:Strategies and policies implemented by healthcare systems during public health emergencies can help minimize disruptions in care. See related In the Spotlight, p. 1481.

Introduction:Studies have shown that patient portals facilitate cancer screening, but less is known about how. Causal pathway diagrams, which include influencing factors such as mechanisms and moderators, can be used to understand how portals improve screening. The authors conducted a scoping review of influencing factors to inform early causal pathway diagrams of the portal as a strategy to increase cancer screening. Methods:The authors searched PubMed for U.S. studies published from 2014 to 2024, including average-risk patients; portal interventions/evaluations; and primary outcomes of breast, cervical, colorectal, or lung cancer screening. Two authors completed manuscript screening and data extraction and synthesized findings to create causal pathway diagrams. Results:Thirty-two studies met inclusion criteria. Studies were often set in large academic health systems (n=13) or utilized survey data from nationally representative cohorts (n=11); 6 were RCTs. Most studies focused on breast (n=10) or colorectal (n=9) cancer screening. Of 21 studies comparing portal use with no use, 18 found that portals were associated with increased screening. Most proposed influencing factors were hypothetical, citing findings from prior literature rather than observed directly. Of the 10 studies that performed statistical analysis, significant moderators included provider recommendation for self-scheduling; significant mechanisms included cancer worry and patient activation for general portal use, cancer fatalism and patient activation for secure messaging with providers, and choice architecture for interventions delivered through secure messaging. Discussion:Few studies directly tested influencing factors, suggesting a significant research gap. More research is needed to further evaluate proposed mechanisms to understand how portals facilitate cancer screening and optimize implementation. Registration:The protocol for this scoping review was registered through Open Science Framework.

Supplemental Table 1 shows the multivariate analysis of factors associated with colorectal cancer test completion in 2024

Supplemental Table 2 shows the multivariate analysis of factors associated with colorectal cancer test completion in 45 to 49 year olds in 2021 compared to 2024

Background: In 2021, the US Preventive Services Task Force (USPSTF) lowered the recommended age for colorectal cancer screening from 50 to 45 years. This study examined colorectal cancer test completion and test modalities used among adults 45 to 49 years of age compared with those 50 years and older.Methods: We conducted a retrospective cohort study using electronic health records from an integrated academic-community health system that implemented organized screening. Adults 45 to 75 years of age eligible for colorectal cancer screening between 2021 and 2024 were included. Outcomes were colorectal cancer test completion and test modality: colonoscopy, fecal immunochemical test (FIT), FIT-DNA, CT colonography, or flexible sigmoidoscopy.Results: Approximately 80,000 adults were eligible for screening annually. Colorectal cancer test completion increased from 61.8% (2021) to 70.8% (2024), with the largest increase in the 45- to 49-year age group (25.6% to 51.7%). Colonoscopy and FIT were the most used modalities; among 45 to 49 year olds, FIT increased by 12.2% and colonoscopy by 14.2%. FIT-DNA use increased slightly, whereas flexible sigmoidoscopy use declined. Racial and ethnic disparities in colorectal cancer test completion decreased across groups.Conclusions: Following the 2021 USPSTF recommendation, colorectal cancer test completion improved across all age groups, especially in adults 45 to 49 years of age. Colonoscopy and FIT use predominated. Ongoing efforts are needed to improve screening among younger adults to reach the 80% national screening goal.Impact: This study demonstrated that expanding colorectal cancer testing to 45 to 49 year olds led to increased uptake of colonoscopy and FIT. It highlights how organized outreach and providing options in screening modalities can improve colorectal cancer test completion across several patient populations.

Patient navigation is a promising intervention that could improve follow-up of abnormal fecal immunochemical test (FIT) results in colorectal cancer (CRC) screening. We describe changes in navigation activities in an organized screening program aimed to improve follow-up colonoscopy completion. Between 2022 and 2023, we decreased the time between an abnormal FIT result and contact from the program's patient navigator from 3 months to 1 month and provided the patient navigator with direct access to schedule colonoscopies at two endoscopy sites. We conducted a pre-post analysis that examined the proportion of patients with abnormal FIT results who completed a colonoscopy, were referred for a colonoscopy, time to referral, time to colonoscopy, and colonoscopy outcomes including CRC diagnoses. Our analysis included 368 patients with abnormal FIT results: 175 in 2022 and 193 in 2023. After changes to navigation activities, colonoscopy completion within 1 year increased by 22.9% points (42.9% to 65.8%; p < 0.001). In 2022, the median time (interquartile range; IQR) to colonoscopy was 103.5 (IQR 60.2-161.5) days. In 2023, the median time to colonoscopy was 99.0 (IQR 52.0-150.0) days. Differences in the proportion of patients referred to colonoscopy, time to referral, and time to colonoscopy were not statistically significant. Patient navigation beginning within 1 month of an abnormal FIT result and granting a patient navigator direct access to the endoscopy scheduling template increased 1-year colonoscopy completion. Understanding navigation activities in CRC screening programs could inform broader adoption of practices that are associated with increased follow-up colonoscopy completion.

Supplemental Table 3 shows the multivariate analysis of factors associated with colorectal cancer test completion in 65 to 75 year olds in 2021 compared to 2024

Stool tests are an essential component of colorectal cancer (CRC) screening. Patients with positive test results are at increased risk of CRC, and a timely follow-up with colonoscopy is recommended. Follow-up colonoscopy rates remain suboptimal. The current article reviews the barriers to timely colonoscopy, highlights evidence-based interventions, and provides actionable recommendations for endoscopists, health systems, and policymakers. By implementing coordinated strategies, including patient navigation, digital tools, and open access colonoscopy, health care organizations can close critical gaps in the CRC screening continuum and decrease CRC incidence and mortality.

Importance:In colorectal cancer (CRC) screening, too many patients fail to receive follow-up colonoscopy after an abnormal fecal immunochemical test (FIT), and transportation is a frequently reported barrier. Objective:To determine the outcomes and cost-effectiveness of providing a rideshare intervention to patients with abnormal FIT results. Design, Setting, and Participants:The CRC-Simulated Population Model for Incidence and Natural History microsimulation model was used to simulate the outcomes and cost-effectiveness of a rideshare intervention to improve colonoscopy completion in a population-based CRC screening program. Cohorts were adherent to annual FIT-based screening; baseline analyses assumed that 35% would complete a follow-up colonoscopy. Data were analyzed from November 14, 2023, to July 8, 2025. Intervention:A $40 or $100 rideshare to increase completion of follow-up colonoscopy. Main Outcomes and Measures:Lifetime outcomes included the number of CRC cases, deaths, and life-years gained (LYG) per 1000 people screened and costs associated with improved completion of a colonoscopy after an abnormal FIT result. Results:Four single-age cohorts (ages 45, 55, 65, and 70 years on January 1, 2024) of 10 million people each were simulated. In cohorts with similar sex distribution as the US population (aged 45 years, 50.0% male; aged 55 years, 49.4% male); aged 65 years, 48.0% male; and aged 70 years, 46.9% male), compared with no intervention, using a rideshare intervention starting at age 45 years that costs $100 per ride to increase colonoscopy completion from 35% to 70% was associated with a reduction in CRC cases per 1000 by 26.3% (30.7 vs 41.6 cases per 1000), CRC deaths per 1000 by 32.5% (9.8 vs 14.6 cases per 1000), 24.9 LYG per 1000, and at $100 per ride cost $43 308 per 1000 people screened and saved $330 587 per 1000 people screened. Conclusions and Relevance:In a microsimulation model, increasing colonoscopy completion in a population with abnormal FIT results via a rideshare intervention was cost saving up to $100 per ride due to the combined outcome of cancer prevention and early detection.

BACKGROUND & AIMS:Although the adenoma detection rate (ADR) is associated with postcolonoscopy colorectal cancer risk, it is unknown to what extent this reflects missed colorectal cancer (CRC) vs missed precancerous lesions. The association between physician ADR and prevalent CRC detection during colonoscopy were evaluated. METHODS:The study used the cross-sectional 2019-2022 GI Quality Improvement Consortium data for more than 1.73 million colonoscopies performed by 3567 endoscopists for screening or abnormal fecal test follow-up from 683 US endoscopy units. Endoscopist ADR and sessile serrated lesion detection rate (SSLDR) were determined based on screening examinations. RESULTS:CRC was detected in 0.3% of screening and 1.5% of follow-up colonoscopies. From lowest to highest endoscopist ADR quintile, CRC detection increased from 26.6 (95% CI, 24.4-27.9) to 33.1 (95% CI, 29.7-33.7), and from 107.8 (95% CI, 96.2-129.4) to 164.7 (95% CI, 140.8-188.6) per 10,000 screening and abnormal fecal test follow-up colonoscopies, respectively. In multivariable models with lowest ADR quintile as reference, the odds ratios of CRC detection in the highest ADR quintile were 1.27 (95% CI, 1.14-1.41) for screening and 1.50 (95% CI, 1.16-1.93) for abnormal fecal test follow-up colonoscopies. Compared with high-ADR/high-SSLDR endoscopists, the ORs of CRC detection were lower for low-ADR endoscopists irrespective of SSLDR (high-SSLDR, 0.87; 95% CI, 0.80-0.96; low-SSLDR 0.92; 95% CI, 0.85-0.98), but similar for high-ADR/low-SSLDR endoscopists. CONCLUSIONS:ADR reflects prevalent CRC detection as well as detection and removal of CRC precursors. Our findings suggest that postcolonoscopy CRC is not uncommonly due to missed CRC, especially among endoscopists with low ADR.

BACKGROUND:Patients treated for stage I to III colorectal cancer are at high risk for developing new and recurrent colon cancers. Therefore, professional organizations recommend a surveillance colonoscopy approximately 1-year postsurgical resection to ensure early detection. Despite these guidelines, surveillance colonoscopy completion rates remain suboptimal. OBJECTIVE:This multimethods study aimed to explore patient-identified barriers and facilitators affecting the completion of 1-year surveillance colonoscopies among stage I to III colorectal cancer survivors. DESIGN:Multimethods study. SETTINGS:The study was conducted within the Hutchinson Institute for Cancer Outcomes Research Value in Cancer Care Network, which comprises 46 clinics across 13 counties in Washington State. PATIENTS:We enrolled stage I to III colorectal cancer survivors who had not completed surveillance colonoscopy within 18 months of surgery. Participants completed questionnaires and semistructured interviews between December 2023 and June 2024. MAIN OUTCOME MEASURES:Questionnaire data and interview transcripts were independently coded and analyzed by 2 coders to identify key themes and subthemes related to barriers and facilitators of surveillance colonoscopy completion. RESULTS:The study included 19 patients. The median (interquartile range) participant age was 73 (17.8) years, 9 (47.4%) were men, and 8 (42.1%) had stage I cancer. All participants reported cognitive and environmental factors as both barriers and facilitators to surveillance colonoscopy completion. The most reported barriers were fear of the colonoscopy results and cancer recurrence (cognitive) and challenges with the bowel preparation (environmental). The most frequently reported facilitators were patient's motivation to receive reassurance (cognitive) and clinic assistance in scheduling appointments (environmental). LIMITATIONS:Results may not be generalizable due to population and selection bias of participants. CONCLUSIONS:This study identified barriers and facilitators to completing a 1-year surveillance colonoscopy, which will guide future interventions. Addressing both psychological concerns and improving communication between patients and clinics could be key strategies to enhance adherence rates and improve long-term outcomes for colorectal cancer survivors. See Video Abstract . PERSPECTIVAS DE LOS PACIENTES SOBRE LAS BARRERAS Y LOS FACILITADORES PARA COMPLETAR LA COLONOSCOPIA DE SEGUIMIENTO AL AO EN SUPERVIVIENTES DE CNCER COLORRECTAL UN ANLISIS MULTIMTODO:ANTECEDENTES:Los pacientes tratados por cáncer colorrectal en estadio I-III corren un alto riesgo de desarrollar nuevos cánceres de colon y de que estos reaparezcan. Por lo tanto, las organizaciones profesionales recomiendan una colonoscopia de vigilancia aproximadamente un año después de la resección quirúrgica para garantizar la detección precoz. A pesar de estas directrices, las tasas de realización de colonoscopias de vigilancia siguen siendo insuficientes.OBJETIVO:Este estudio multimétodo tenía como objetivo explorar las barreras y los facilitadores identificados por los pacientes que afectan a la realización de colonoscopias de vigilancia al año entre los supervivientes de cáncer colorrectal en estadio I-III.DISEÑO:Estudio multimétodo.ENTORNO:El estudio se llevó a cabo en el Hutchinson Institute for Cancer Outcomes Research Value in Cancer Care Network, que comprende 46 clínicas en 13 condados del estado de Washington.PACIENTES:Se inscribieron supervivientes de cáncer colorrectal en estadio I-III que no habían completado la colonoscopia de vigilancia en los 18 meses posteriores a la cirugía. Los participantes completaron cuestionarios y entrevistas semiestructuradas entre diciembre de 2023 y junio de 2024.PRINCIPALES MEDIDAS DE RESULTADOS:Los datos de los cuestionarios y las transcripciones de las entrevistas fueron codificados y analizados de forma independiente por dos codificadores para identificar los temas y subtemas clave relacionados con las barreras y los facilitadores de la realización de la colonoscopia de vigilancia.RESULTADOS:El estudio incluyó a diecinueve pacientes. La mediana (rango intercuartílico) de la edad de los participantes fue de 73 (17,8) años, 9 (47,4 %) eran hombres y 8 (42,1 %) tenían cáncer en estadio I. Todos los participantes informaron de factores cognitivos y ambientales como barreras o facilitadores para completar la colonoscopia de vigilancia. Las barreras más mencionadas fueron el miedo a los resultados de la colonoscopia y a la recurrencia del cáncer (cognitivo) y las dificultades con la preparación intestinal (ambiental). Los facilitadores más frecuentes fueron la motivación del paciente para recibir tranquilidad (cognitivo) y la ayuda de la clínica para programar las citas (ambiental).LIMITACIONES:Los resultados pueden no ser generalizables debido al sesgo de selección de la población y de los participantes.CONCLUSIONES:Este estudio identificó barreras y facilitadores para completar una colonoscopia de vigilancia anual con el fin de orientar futuras intervenciones. Abordar las preocupaciones psicológicas y mejorar la comunicación entre los pacientes y las clínicas podrían ser estrategias clave para mejorar las tasas de adherencia y los resultados a largo plazo de los supervivientes de cáncer colorrectal. ( AI-generated translation ).

Colonoscopy completion after abnormal fecal immunochemical test (FIT) results is inadequate, and patient fear is a commonly reported barrier. We developed and piloted a video decision aid that addresses fear of colonoscopy among patients with abnormal FIT results. We developed a video decision aid and, in a pilot study, randomized patients in a safety-net healthcare system with abnormal FIT results and no follow-up colonoscopy to the intervention or usual care. Both groups completed a baseline survey that measured fear of colonoscopy, knowledge about colorectal cancer (CRC), self-efficacy, and intent to complete a colonoscopy, and the intervention group repeated the survey after watching the video. Sixty patients were enrolled in the study. Participants that watched the video reported a 17.7% decrease in fear of colonoscopy ( p < 0.01) across six domains, including fear of the bowel prep ( p < 0.01), the actual colonoscopy procedure ( p < 0.01), and possible complications from the procedure ( p = 0.04). Participant CRC knowledge also increased across several measures, including a 43.5% decrease in the belief that it is difficult to know which CRC prevention recommendations to follow. Overall, 78.3% of participants found the video to be helpful, and 90.6% would recommend the video to other patients with abnormal FIT results. In a safety-net population with abnormal FIT results, a video decision aid decreased fear of colonoscopy and increased knowledge about CRC. The video decision aid was acceptable to participants and can be considered an additional tool to improve follow-up of abnormal FIT results.

Introduction: Patient portals may facilitate breast cancer screening and could be an important factor to address inequities; however, this association is not well characterized. The authors sought to examine this association in a large academic health system to inform interventions to address breast cancer screening inequities. Methods: The authors conducted a cross-sectional study among Black patients in a large academic health system using logistic regression to examine the association between breast cancer screening and portal use, adjusting for multilevel covariates and interactions. The authors estimated average marginal effects to examine the additive probability of breast cancer screening completion given portal use in the prior 12 months. Results: In the unadjusted model, portal use was associated with an estimated mean 24.8 percentage points (95% CI=20.7, 29.0) increased likelihood of completing breast cancer screening. In the adjusted model, portal use was associated with an estimated mean 16.2 percentage points (95% CI=11.2, 21.3) increased likelihood for completing breast cancer screening. Conclusions: Improving portal access and use among racialized groups who face both portal and breast cancer screening inequities could be one strategy to address inequities. These pilot data will inform subsequent community-engaged research to better understand this association and develop and test a portal intervention to facilitate breast cancer screening access among Black patients eligible for screening.

INTRODUCTION:Low-literacy, pictorial instructions improve fecal immunochemical test (FIT) completion and might enhance colorectal cancer (CRC) screening. The aim of this study was to compare FIT completion among English-speaking and Spanish-speaking patients in an organized CRC screening program based on the type of instructions received (quick response [QR] code linked to video vs pictorial instructions).METHODS:In this randomized controlled quality improvement study, English-speaking and Spanish-speaking patients eligible for mailed outreach through an organized CRC screening program were randomized 1:1 to receive a FIT kit with either a QR code-linked video or pictorial instructions in their preferred language. Patient demographics (sex, age, race, ethnicity, and insurance type) and clinical outcomes (FIT completion and time to completion) were abstracted from electronic health records.RESULTS:Thirteen thousand four hundred seventy-one English-speaking patients and 508 Spanish-speaking patients were included. Overall, 31.9% of patients who received mailed outreach completed CRC screening by FIT. However, FIT completion was higher among patients who received QR code instructions vs pictorial instructions (33.5% vs 30.4%, absolute difference 3.1%, 95% confidence interval 1.5%-4.6%). These findings were similar among English-speaking and Spanish-speaking patients. The median time to FIT completion was 2 days longer (24 days, 95% confidence interval 23-25) for patients who received QR code instructions versus pictorial instructions; however there was no difference in time to FIT completion by the language group.DISCUSSION:Providing QR code-based education offers a promising format for delivering low literacy instructions, which might be a practical strategy to improve FIT completion for CRC screening.