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BACKGROUND: At-home colorectal cancer (CRC) screening is an effective way to reduce CRC mortality, but screening rates in medically underserved groups are low. To plan the implementation of a pragmatic randomized trial comparing two population-based outreach approaches, we conducted qualitative research on current processes and barriers to at-home CRC screening in 10 community health centers (CHCs) that serve medically underserved groups, four each in Massachusetts and California, and two tribal facilities in South Dakota.
METHODS: We conducted 53 semi-structured interviews with clinical and administrative staff at the participating CHCs. Participants were asked about CRC screening processes, categorized into eight domains: patient identification, outreach, risk assessment, fecal immunochemical test (FIT) workflows, FIT-DNA (i.e., Cologuard) workflows, referral for a follow-up colonoscopy, patient navigation, and educational materials. Transcripts were analyzed using a Rapid Qualitative Analysis approach. A matrix was used to organize and summarize the data into four sub-themes: current process, barriers, facilitators, and solutions to adapt materials for the intervention.
RESULTS: Each site\'s process for stool-based CRC screening varied slightly. Interviewees identified the importance of offering educational materials in English and Spanish, using text messages to remind patients to return kits, adapting materials to address health literacy needs so patients can access instructions in writing, pictures, or video, creating mailed workflows integrated with a tracking system, and offering patient navigation to colonoscopy for patients with an abnormal result.
CONCLUSIONS: Proposed solutions across the three regions will inform a multilevel intervention in a pragmatic trial to increase CRC screening uptake in CHCs.

BACKGROUND: Faecal immunochemical test (FIT)-based screening is effective in reducing colorectal cancer (CRC) incidence, but its sensitivity for proximal lesions remains low.
OBJECTIVE: We compared age-adjusted CRC surgical resection rates across anatomic sites (proximal colon, distal colon, rectum), age groups and sex over 20 years in a large Italian population. We particularly focused on changes in trends following FIT-screening implementation in the target population (50-69 years).
METHODS: This retrospective study analysed data from the Veneto Region\'s administrative Hospital Discharge Dataset, involving over 54 000 patients aged 40-89 (43.4% female) who underwent CRC surgery between 2002 and 2021.
RESULTS: Overall, surgery rates increased until 2007 (annual percentage changes: 2.5% in males, 2.9% in females) and then declined (-4.2% in males, -3.4% in females). This decline was steeper for distal and rectal cancers compared with proximal cancer, suggesting a shift towards more right-sided CRC surgery.In males, the prescreening increase in proximal surgery was reversed after screening implementation (slope change: -6%) while the prescreening decline accelerated for distal (-4%) and rectal (-3%) surgeries. In females, stable prescreening trends shifted downward for all sites (-5% for proximal, -8% for distal and -7% for rectal surgery). However, the change in trends between prescreening and postscreening periods was not different across anatomic sites for either sex (all slope change differences in pairwise comparisons were not statistically significant).
CONCLUSIONS: The shift towards proximal surgery may not be entirely due to the FIT\'s low sensitivity but may reflect an underlying upward trend in proximal cancers independent of screening.

BACKGROUND: People with low income have worse outcomes throughout the cancer care continuum; however, little is known about income and the diagnostic interval. We described diagnostic pathways by neighborhood income and investigated the association between income and the diagnostic interval.
METHODS: This was a retrospective cohort study of colon cancer patients diagnosed 2007-2019 in Ontario using routinely collected data. The diagnostic interval was defined as the number of days from the first colon cancer encounter to diagnosis. Asymptomatic pathways were defined as first encounter with a colonoscopy or guaiac fecal occult blood test not occurring in the emergency department and were examined separately from symptomatic pathways. Quantile regression was used to determine the association between neighborhood income quintile and the conditional 50th and 90th percentile diagnostic interval controlling for age, sex, rural residence, and year of diagnosis.
RESULTS: A total of 64,303 colon cancer patients were included. Patients residing in the lowest income neighborhoods were more likely to be diagnosed through symptomatic pathways and in the emergency department. Living in low-income neighborhoods was associated with longer 50th and 90th-percentile symptomatic diagnostic intervals compared to patients living in the highest income neighborhoods. For example, the 90th percentile diagnostic interval was 15 days (95% CI 6-23) longer in patients living in the lowest income neighborhoods compared to the highest.
CONCLUSIONS: These findings reveal income inequities during the diagnostic phase of colon cancer. Future work should determine pathways to reducing inequalities along the diagnostic interval and evaluate screening and diagnostic assessment programs from an equity perspective.

In this editorial, we discuss the article by Agatsuma et al. We concentrate specifically on the current routinely used screening tests recommended by society guidelines and delve into the significance of early diagnosis of colorectal cancer (CRC) and its substantial impact on both incidence and mortality rates. Screening is highly recommended, and an early diagnosis stands out as the most crucial predictor of survival for CRC patients. Therefore, it is essential to identify and address the barriers hindering adherence to screening measures, as these barriers can vary among different populations. Furthermore, we focus on screening strategy optimization by selecting high-risk groups. Patients with comorbidities who regularly visit hospitals have been diagnosed at an early stage, showing no significant difference compared to patients undergoing regular screening. This finding highlights the importance of extending screening measures to include patients with comorbidities who do not routinely visit the hospital.

OBJECTIVE: This study aims to identify the factors influencing colorectal cancer (CRC) screening practices, along with the barriers and facilitators from the perspective of primary care physicians (PCPs) in Ukraine. Considering health care system challenges, including those posed by the ongoing war, this research seeks to inform improvements in CRC screening and outcomes in Ukraine and other low- and middle-income countries (LMICs).
METHODS: A survey was designed and distributed electronically to Ukrainian PCPs, focusing on CRC screening practices, beliefs, and barriers. The survey incorporated questions adapted from established cancer screening surveys and frameworks. Complete responses were collected from 740 PCPs. Sample statistics were computed, and population-level perceptions and associations with CRC screening practices were estimated by standardizing responses to national PCP demographics.
RESULTS: The majority of respondents were women (91%) and specialized in family medicine (84%). Respondents believed in the effectiveness of colonoscopy for reducing CRC mortality (80%), with 75% of PCPs referring patients for this screening modality. Major barriers identified include inadequate training of PCPs in screening and lack of resources. Respondents reported high utilization of fecal occult blood test and colonoscopy for screening when these tests were said to be available in their practices. Self-reported familiarity with CRC screening guidelines and participation in educational workshops were positively associated with screening referrals.
CONCLUSIONS: The study highlights the role of access to CRC screening tests and awareness of screening guidelines in enhancing CRC screening practices among Ukrainian PCPs. Addressing training and resource barriers, alongside public health interventions targeting patient-related barriers, is essential. These findings offer valuable insights for LMICs facing similar challenges, emphasizing the need for tailored strategies to improve cancer screening in these health care settings.

BACKGROUND: Mobile phone-based SMS text message reminders have the potential to improve colorectal cancer screening participation rates.
OBJECTIVE: This study assessed the effectiveness and acceptability of adding targeted SMS text message reminders to the standard procedure for those who picked up but did not return their screening kit at the pharmacy within 14 days in a colorectal cancer screening program in Catalonia, Spain.
METHODS: We performed a randomized control trial among individuals who picked up a fecal immunochemical test (FIT) kit for colorectal cancer screening at the pharmacy but did not return it within 14 days. The intervention group (n=4563) received an SMS text message reminder on the 14th day of kit pick up and the control group (n=4806) received no reminder. A 30-day reminder letter was sent to both groups if necessary. The main primary outcome was the FIT completion rate within 30, 60, and 126 days from FIT kit pick up (intention-to-treat analysis). A telephone survey assessed the acceptability and appropriateness of the intervention. The cost-effectiveness of adding an SMS text message reminder to FIT completion was also performed.
RESULTS: The intervention group had higher FIT completion rates than the control group at 30 (64.2% vs 53.7%; P<.001), 60 (78.6% vs 72.0%; P<.001), and 126 (82.6% vs 77.7%; P<.001) days. Participation rates were higher in the intervention arm independent of sex, age, socioeconomic level, and previous screening behavior. A total of 339 (89.2%) interviewees considered it important and useful to receive SMS text message reminders for FIT completion and 355 (93.4%) preferred SMS text messages to postal letters. We observed a reduction of US $2.4 per participant gained in the intervention arm for invitation costs compared to the control arm.
CONCLUSIONS: Adding an SMS text message reminder to the standard procedure significantly increased FIT kit return rates and was a cost-effective strategy. SMS text messages also proved to be an acceptable and appropriate communication channel for cancer screening programs.
BACKGROUND: ClinicalTrials.gov NCT04343950; https://www.clinicaltrials.gov/study/NCT04343950.
UNASSIGNED: RR2-10.1371/journal.pone.0245806.

OBJECTIVE: We examined the extent to which funded satellite clinics could sustain the California Colon Cancer Control Program (C4P) strategies implemented in health systems to increase uptake of the fecal immunochemical test (FIT) or immunochemical fecal occult blood test (iFOBT) for colorectal cancer (CRC) screening in the absence of future C4P funds.
BACKGROUND: Seven health systems consisting of 38 satellite clinics participated in C4P to examine the sustainability of the program in the absence future Centers for Disease Control and Prevention (CDC) funding.
METHODS: Quantitative and qualitative methods with a close and open-ended survey approach, and a prospective cohort design were used to examine the sustainability of the C4P in health systems.
RESULTS: A total of 61% of satellite clinics could not sustain funding stability. Only 26% could sustain funding stability. About, 71%, 26%, and 21% of the satellite clinics could sustain the small media platform, patient navigation services, and community health workers (CHWs), respectively. All the satellite clinics sustained the provider reminder system and professional development. Roughly, 71% and 42% of funded satellite clinics could not sustain the patient navigators and CHWs, respectively. The satellite clinics that could sustain funding stability, sustained patient navigation services and CHWs. Health systems that could not sustain funding stability, could not sustain patient navigation services and CHWs. Qualitatively, the need to support uninsured priority populations, health educators, patient navigators, care coordination activities, outreach services, and provision of enhanced services emerged. The need to support enhanced quality measures, expansion of funding, Medi-Cal Public Hospital Redesign and Incentive coverage, health plan, community linkages, resource sharing, and best practices specifically on CRC screening emerged. Themes such as automated reminder, limited personalized care delivery and capacity, transportation barriers, staff salary, expansion of care through patient navigation, and culturally appropriate media campaign also emerged.
CONCLUSIONS: Overall, to address sustainability barriers, funding stability should be maintained in the health systems.

UNASSIGNED: Residents of Appalachian regions in Kentucky experience increased colorectal cancer (CRC) incidence and mortality. While population-based screening methods, such as fecal immunochemical tests (FITs), can reduce many screening barriers, written instructions to complete FIT can be challenging for some individuals. We developed a novel audiovisual tool (\"talking card\") to educate and motivate accurate FIT completion and assessed its feasibility, acceptability, and efficacy.
UNASSIGNED: We collected data on the talking card via: (1) cross-sectional surveys exploring perceptions of images, messaging, and perceived utility; (2) follow-up focus groups centered on feasibility and acceptability; and (3) efficacy testing in community-based FIT distribution events, where we assessed FIT completion rate, number of positive vs. negative screens, demographic characteristics of participants, and primary drivers of FIT completion.
UNASSIGNED: Across the three study phases, 692 individuals participated. Survey respondents positively identified with the card\'s sounds and images, found it highly acceptable, and reported high-to-very high self-efficacy and response efficacy for completing FIT, with nearly half noting greater likelihood to complete screening after using the tool. Focus group participants confirmed the acceptability of the individuals featured on the card. Nearly 75% of participants provided a FIT accurately completed it, with most indicating the talking card, either alone or combined with another strategy, helped with completion.
UNASSIGNED: To reduce CRC screening disparities among Appalachian Kentuckians, population-based screening using contextually relevant implementation strategies must be used alongside clinic-based education. The talking card represents a novel and promising strategy to promote screening uptake in both clinical and community settings.

UNASSIGNED: Insufficient adherence to colorectal cancer (CRC) screening impedes individual and population health benefits, with about one-third of individuals non-adherent to available screening options. The impact of poor adherence is inadequately considered in most health economics models, limiting the evaluation of real-world population-level screening outcomes. This study introduces the CAN-SCREEN (Colorectal cANcer SCReening Economics and adherENce) model, utilizing real-world adherence scenarios to assess the effectiveness of a blood-based test (BBT) compared to existing strategies.
UNASSIGNED: The CAN-SCREEN model evaluates various CRC screening strategies per 1,000 screened individuals for ages 45-75. Adherence is modeled in two ways: (1) full adherence and (2) longitudinally declining adherence. BBT performance is based on recent pivotal trial data while existing strategies are informed using literature. The full adherence model is calibrated using previously published Cancer Intervention and Surveillance Modeling Network (CISNET) models. Outcomes, including life-years gained (LYG), CRC cases averted, CRC deaths averted, and colonoscopies, are compared to no screening.
UNASSIGNED: Longitudinal adherence modeling reveals differences in the relative ordering of health outcomes and resource utilization, as measured by the number of colonoscopies performed per 1,000, between screening modalities. BBT outperforms the fecal immunochemical test (FIT) and the multitarget stool DNA (mtsDNA) test with more CRC deaths averted (13) compared to FIT and mtsDNA (7, 11), more CRC cases averted (27 vs. 16, 22) and higher LYG (214 vs. 157, 199). BBT yields fewer CRC deaths averted compared to colonoscopy (13, 15) but requires fewer colonoscopies (1,053 vs. 1,928).
UNASSIGNED: Due to limited data, the CAN-SCREEN model with longitudinal adherence leverages evidence-informed assumptions for the natural history and real-world longitudinal adherence to screening.
UNASSIGNED: The CAN-SCREEN model demonstrates that amongst non-invasive CRC screening strategies, those with higher adherence yield more favorable health outcomes as measured by CRC deaths averted, CRC cases averted, and LYG.
This study explored the impact of poor adherence to colorectal cancer (CRC) screening, where about one-third of people face barriers to screening. Common models don’t consider real-world adherence, so we introduced the CAN-SCREEN model. It uses real-world data to determine how well a blood-based test (BBT) could work compared to existing tests. We studied people starting CRC screening at age 45. The model looked at two adherence scenarios: assuming everyone follows guidelines, and using real-world data about how people follow screening guidelines over time. The BBT\'s performance was based on a recent study, and we compared it to existing methods using data from the literature. Results per 1,000 simulated patients showed that the BBT outperforms two guideline-recommended stool-based tests, fecal immunochemical test (FIT) and the multitarget stool DNA (mtsDNA) test, with more CRC deaths averted (13) compared to FIT and mtsDNA (7, 11), more CRC cases averted (27 vs. 16, 22) and higher LYG (214 vs. 157, 199). BBT prevents less CRC deaths than colonoscopy (13 vs. 15), but it leads to fewer colonoscopies (1,053 compared to 1,928). Despite some limitations due to limited data, our model relies on informed assumptions for the natural history of CRC and real-world adherence. In conclusion, our CAN-SCREEN model shows that CRC screening strategies combining good test performance with high adherence give better health outcomes. Adding a blood test, which could be easier for people to use, could save lives and reduce the number of colonoscopies needed.