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Screening for colorectal cancer in France: How to improve adhesion and participation?
Accepted Manuscript Title: Screening for colorectal cancer in France: how to improve adhesion and participation? Author: Jean-Christophe Saurin PII: DOI: Reference:
S1590-8658(16)30818-0 http://dx.doi.org/doi:10.1016/j.dld.2016.11.014 YDLD 3302
To appear in:
Digestive and Liver Disease
Please cite this article as: Saurin Jean-Christophe.Screening for colorectal cancer in France: how to improve adhesion and participation?.Digestive and Liver Disease http://dx.doi.org/10.1016/j.dld.2016.11.014 This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
Screening for colorectal cancer in France: how to improve adhesion and participation? Jean-Christophe Saurin* Gastroenterology unit, Pavillon L 2° et., Hôpital E. Herriot, 5 Pl d’Arsonval, 69437 Lyon Cedex 03 *Corresponding author: Tel: +33 4 72 11 03 69; Fax: +33 6 72 27 04 64 Keywords: Screening; Fecal immunological test; Colorectal cancer
Colorectal cancer (CRC) in France accounts for about 42 000 new cases and about 18 000 death each year. The major public health issues regarding this important disease in France like in other European countries are thus i) to reduce the mortality related to advanced colorectal cancer and ii) in a second step, to reduce the incidence by removing pre-cancerous colorectal lesions. Until major progresses are made in the treatment of advanced colorectal cancer, which probably can be expected in the next 20 years, the main tool for lowering colorectal cancer-related number of deaths is screening. According to a relatively recent analysis, the major survival gain observed during the last 20 years in colorectal cancer patients in the United States relies firstly on improved screening, secondly on risk factors prevention, and very little on advanced colorectal cancer treatment.[1] What is the situation of CRC screening in France? There are 16 million people at average risk for colorectal cancer, aged 50-74 years (4 % cumulative risk, 1 person in 25), which represent the target population for mass screening. This screening has been extended to the whole country in 2009 taking advantage of regional structures dedicated to colorectal and breast cancer screening present in every French department and centralizing the results of CRC screening. The 2 cornerstones of this generalized CRC screening are i) the use of the same test for the whole target population, and ii) the central role of the general practitioner in distributing this test based on the demonstration of a 80 %-90 % fulfillment of the test when proposed by the GP as compared to 30 % when directly sent to the target person by mail.[2] The target population are invited every 2year to perform a fecal occult blood test. Recently, after a strong collective action of the French gastroenterology, endoscopy, and cancerology scientific societies, the French government accepted the switch from the guaiac-based to immunological haemoglobin testing as the accepted test for the whole target population. Interestingly, based on several published studies, the French Health Authority (HAS) had recommended this switch since 2008. Finally, the switch was initiated in 2015 and is now completely effective in 2016, with the first results expected early in 2017. The main limitation of a mass screening campaign is the low participation of invited people. Using the “ Hemoccult° test, the final mean participation in the target population was 30 %, far from the European recommended objective of 45 % participation which would allow a 15 % (at least) reduction in CRC mortality. The Fecal
Immunochemical Test (FIT) is expected to improve greatly these results for two reasons. First, the test is more acceptable as much simpler (one stool sample instead of 6), and acceptability studies all showed an improvement of 10 to 30 % over guaiac-based tests.[2, 3] Secondly a higher adhesion to an improved test is expected by GPs and gastroenterologists: much better sensitivity (from 40 % to 80 % for CRC, identification of 4 times more advanced adenomas), and better reliability because of an automatized lecture. One can expect that FIT will allow not only a reduction of CRC-related mortality, but even a reduction of incidence of CRC by the detection of early lesions and their endoscopic treatment, i.e. prevention of CRC.[4] For all these reasons, there is a real hope of an improved participation/compliance of the target population and of the practitioners in charge of providing the screening tests.
The strengths of CRC screening in France are the generalized screening on the whole territory, the relatively long history and culture of screening, and probably the excellent survey of CRC screening provided by the regional organizations responsible for screening (management structures). Only GPs provide the test to patients : this strength may also become a weakness. Indeed, two important decisions have been made by the National Health Service (Caisse National Assurance Maladie des travailleurs salaries CNAM): first, no test is directly sent to the target population. Secondly, the test is distributed almost only by GPs, despite the fact that management structures are able to provide some tests to patients or doctors. In this setting, there is a risk that a significant proportion of the target population, those people that do not go to the GP, never hear about the CRC screening test, and on the other hand not all GPs are adherent to the screening process, which may also limit the population access to screening.
What does the paper by Jean Faivre and al. [4] add to the present knowledge on CRC screening? The paper deals with the importance of a postal invitation including the screening test. What is this about? The accepted process for FIT screening in France is based on the opportunity for the GP to explain and give the test to all target patients seen in consultation. But some patients are not informed by the GP (group 1) and some others never meet the GP (20 % from the 50-74 aged population in France: group 2). Both of them never get the test, and despite regular information from their regional screening structure by mail, they do not perform the test. Group 1 may represent a significant proportion of the target population as about 30 % (2016 data) of the GP never order FIT tests and probably never recommend FIT to their patients. Moreover, during the 20092014 screening campaigns, a non- responder had been routinely invited by a second incentive letter including a test. Earlier studies demonstrated this improvement in guaiac test based screening campaign.[5] In this issue of Digestive and Liver Diseases, J Faivre and al. showed that applying this process with the FIT, the expected improvement of screening participation represents an increase from 30 % (only GP-based campaign) to 54 % (GP based + second invitation) of participation.
What are the fear and hopes of colorectal cancer screening in France? The fear would be to limit the participation to those 30 % of people in the 16 million target population that were already adherent to the guaiac based screening test. Despite the inherent qualities of FIT over guaiac tests,[6, 7] limiting the screening to 30 % of persons would be an important failure at a population level. This would lead to loss of motivation of management structures, of GPs, of gastroenterologists on the long term and could even lead the government to stop or limit the screening program, which would represent a major failure of the preventive sanitary process, as in any modern European country. The hopes are the evident qualities of the FIT, already reported by a high number of GPs and gastroenterologists impressed by the significant results of colonoscopy, after a positive FIT. This could, on the opposite, improve motivation and adherence of the GPs which is a cornerstone of a large diffusion of the screening test. Some early results from the French sanitary survey in September 2016 reported that 4 million tests have been read (for a target number of 8 million people in one campaign) which is rather reassuring. However a huge work is necessary to comfort and confirm these results, and the INCA committee for the surveillance of screening will remain vigilant that any procedure that can improve screening will be adopted. And the new postal invitation proposed by Faivre and al., although not being the unique solution for a well accepted test, is one important help in this process (to a limited cost estimated at 2 % of the total campaign) and will be supported by all French scientific societies in the near future. However, a lot remains to be done to diffuse screening to the part of the population that is never concerned by any screening campaign, mostly (but not only) characterized by low levels of education and literacy barriers.[8] Innovative solutions are to be developed in this setting. Conflict of Interest The author declares no conflicts of interest.
References 1. Edwards BK, Ward E, Kohler BA, et al Annual report to the nation on the status of cancer, 1975-2006, featuring colorectal cancer trends and impact of interventions (risk factors, screening, and treatment) to reduce future rates. Cancer 116: 544-573. 2. Tazi MA, Faivre J, Dassonville F, et al. Participation in faecal occult blood screening for colorectal cancer in a well defined French population: results of five screening rounds from 1988 to 1996. J Med Screen 1997; 4: 147-151. 3. Faivre J, Dancourt V, Denis B, et al. Comparison between a guaiac and three immunochemical faecal occult blood tests in screening for colorectal cancer. Eur J Cancer 48: 2969-2976. 4. Christine Piette, Gérard Durand, J-F. Bretagne, Jean Faivre. Additional mailing phase for FIT after a medical offer phase: the best way to improve compliance with colorectal cancer screening in France. Dig Liver Dis, in press (2017). 10.1016/j.dld.2016.09.015 5. Faivre J, Dancourt V, Manfredi S, et al. Positivity rates and performances of immunochemical faecal occult blood tests at different cut-off levels within a colorectal cancer screening programme. Dig Liver Dis 44: 700-704. 6. Faivre J, Dancourt V, Lejeune C. Screening for colorectal cancer with immunochemical faecal occult blood tests. Dig Liver Dis 44: 967-973. 7. Lepage C, Hamza S. Faecal immunochemical tests: a valuable tool for colorectal cancer screening. Dig Liver Dis 44: 629-630. 8. Solmi F, Von Wagner C, Kobayashi LC, et al. Decomposing socio-economic inequality in colorectal cancer screening uptake in England. Soc Sci Med 134: 76-86.
S1590-8658(16)30818-0 http://dx.doi.org/doi:10.1016/j.dld.2016.11.014 YDLD 3302
To appear in:
Digestive and Liver Disease
Please cite this article as: Saurin Jean-Christophe.Screening for colorectal cancer in France: how to improve adhesion and participation?.Digestive and Liver Disease http://dx.doi.org/10.1016/j.dld.2016.11.014 This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
Screening for colorectal cancer in France: how to improve adhesion and participation? Jean-Christophe Saurin* Gastroenterology unit, Pavillon L 2° et., Hôpital E. Herriot, 5 Pl d’Arsonval, 69437 Lyon Cedex 03 *Corresponding author: Tel: +33 4 72 11 03 69; Fax: +33 6 72 27 04 64 Keywords: Screening; Fecal immunological test; Colorectal cancer
Colorectal cancer (CRC) in France accounts for about 42 000 new cases and about 18 000 death each year. The major public health issues regarding this important disease in France like in other European countries are thus i) to reduce the mortality related to advanced colorectal cancer and ii) in a second step, to reduce the incidence by removing pre-cancerous colorectal lesions. Until major progresses are made in the treatment of advanced colorectal cancer, which probably can be expected in the next 20 years, the main tool for lowering colorectal cancer-related number of deaths is screening. According to a relatively recent analysis, the major survival gain observed during the last 20 years in colorectal cancer patients in the United States relies firstly on improved screening, secondly on risk factors prevention, and very little on advanced colorectal cancer treatment.[1] What is the situation of CRC screening in France? There are 16 million people at average risk for colorectal cancer, aged 50-74 years (4 % cumulative risk, 1 person in 25), which represent the target population for mass screening. This screening has been extended to the whole country in 2009 taking advantage of regional structures dedicated to colorectal and breast cancer screening present in every French department and centralizing the results of CRC screening. The 2 cornerstones of this generalized CRC screening are i) the use of the same test for the whole target population, and ii) the central role of the general practitioner in distributing this test based on the demonstration of a 80 %-90 % fulfillment of the test when proposed by the GP as compared to 30 % when directly sent to the target person by mail.[2] The target population are invited every 2year to perform a fecal occult blood test. Recently, after a strong collective action of the French gastroenterology, endoscopy, and cancerology scientific societies, the French government accepted the switch from the guaiac-based to immunological haemoglobin testing as the accepted test for the whole target population. Interestingly, based on several published studies, the French Health Authority (HAS) had recommended this switch since 2008. Finally, the switch was initiated in 2015 and is now completely effective in 2016, with the first results expected early in 2017. The main limitation of a mass screening campaign is the low participation of invited people. Using the “ Hemoccult° test, the final mean participation in the target population was 30 %, far from the European recommended objective of 45 % participation which would allow a 15 % (at least) reduction in CRC mortality. The Fecal
Immunochemical Test (FIT) is expected to improve greatly these results for two reasons. First, the test is more acceptable as much simpler (one stool sample instead of 6), and acceptability studies all showed an improvement of 10 to 30 % over guaiac-based tests.[2, 3] Secondly a higher adhesion to an improved test is expected by GPs and gastroenterologists: much better sensitivity (from 40 % to 80 % for CRC, identification of 4 times more advanced adenomas), and better reliability because of an automatized lecture. One can expect that FIT will allow not only a reduction of CRC-related mortality, but even a reduction of incidence of CRC by the detection of early lesions and their endoscopic treatment, i.e. prevention of CRC.[4] For all these reasons, there is a real hope of an improved participation/compliance of the target population and of the practitioners in charge of providing the screening tests.
The strengths of CRC screening in France are the generalized screening on the whole territory, the relatively long history and culture of screening, and probably the excellent survey of CRC screening provided by the regional organizations responsible for screening (management structures). Only GPs provide the test to patients : this strength may also become a weakness. Indeed, two important decisions have been made by the National Health Service (Caisse National Assurance Maladie des travailleurs salaries CNAM): first, no test is directly sent to the target population. Secondly, the test is distributed almost only by GPs, despite the fact that management structures are able to provide some tests to patients or doctors. In this setting, there is a risk that a significant proportion of the target population, those people that do not go to the GP, never hear about the CRC screening test, and on the other hand not all GPs are adherent to the screening process, which may also limit the population access to screening.
What does the paper by Jean Faivre and al. [4] add to the present knowledge on CRC screening? The paper deals with the importance of a postal invitation including the screening test. What is this about? The accepted process for FIT screening in France is based on the opportunity for the GP to explain and give the test to all target patients seen in consultation. But some patients are not informed by the GP (group 1) and some others never meet the GP (20 % from the 50-74 aged population in France: group 2). Both of them never get the test, and despite regular information from their regional screening structure by mail, they do not perform the test. Group 1 may represent a significant proportion of the target population as about 30 % (2016 data) of the GP never order FIT tests and probably never recommend FIT to their patients. Moreover, during the 20092014 screening campaigns, a non- responder had been routinely invited by a second incentive letter including a test. Earlier studies demonstrated this improvement in guaiac test based screening campaign.[5] In this issue of Digestive and Liver Diseases, J Faivre and al. showed that applying this process with the FIT, the expected improvement of screening participation represents an increase from 30 % (only GP-based campaign) to 54 % (GP based + second invitation) of participation.
What are the fear and hopes of colorectal cancer screening in France? The fear would be to limit the participation to those 30 % of people in the 16 million target population that were already adherent to the guaiac based screening test. Despite the inherent qualities of FIT over guaiac tests,[6, 7] limiting the screening to 30 % of persons would be an important failure at a population level. This would lead to loss of motivation of management structures, of GPs, of gastroenterologists on the long term and could even lead the government to stop or limit the screening program, which would represent a major failure of the preventive sanitary process, as in any modern European country. The hopes are the evident qualities of the FIT, already reported by a high number of GPs and gastroenterologists impressed by the significant results of colonoscopy, after a positive FIT. This could, on the opposite, improve motivation and adherence of the GPs which is a cornerstone of a large diffusion of the screening test. Some early results from the French sanitary survey in September 2016 reported that 4 million tests have been read (for a target number of 8 million people in one campaign) which is rather reassuring. However a huge work is necessary to comfort and confirm these results, and the INCA committee for the surveillance of screening will remain vigilant that any procedure that can improve screening will be adopted. And the new postal invitation proposed by Faivre and al., although not being the unique solution for a well accepted test, is one important help in this process (to a limited cost estimated at 2 % of the total campaign) and will be supported by all French scientific societies in the near future. However, a lot remains to be done to diffuse screening to the part of the population that is never concerned by any screening campaign, mostly (but not only) characterized by low levels of education and literacy barriers.[8] Innovative solutions are to be developed in this setting. Conflict of Interest The author declares no conflicts of interest.
References 1. Edwards BK, Ward E, Kohler BA, et al Annual report to the nation on the status of cancer, 1975-2006, featuring colorectal cancer trends and impact of interventions (risk factors, screening, and treatment) to reduce future rates. Cancer 116: 544-573. 2. Tazi MA, Faivre J, Dassonville F, et al. Participation in faecal occult blood screening for colorectal cancer in a well defined French population: results of five screening rounds from 1988 to 1996. J Med Screen 1997; 4: 147-151. 3. Faivre J, Dancourt V, Denis B, et al. Comparison between a guaiac and three immunochemical faecal occult blood tests in screening for colorectal cancer. Eur J Cancer 48: 2969-2976. 4. Christine Piette, Gérard Durand, J-F. Bretagne, Jean Faivre. Additional mailing phase for FIT after a medical offer phase: the best way to improve compliance with colorectal cancer screening in France. Dig Liver Dis, in press (2017). 10.1016/j.dld.2016.09.015 5. Faivre J, Dancourt V, Manfredi S, et al. Positivity rates and performances of immunochemical faecal occult blood tests at different cut-off levels within a colorectal cancer screening programme. Dig Liver Dis 44: 700-704. 6. Faivre J, Dancourt V, Lejeune C. Screening for colorectal cancer with immunochemical faecal occult blood tests. Dig Liver Dis 44: 967-973. 7. Lepage C, Hamza S. Faecal immunochemical tests: a valuable tool for colorectal cancer screening. Dig Liver Dis 44: 629-630. 8. Solmi F, Von Wagner C, Kobayashi LC, et al. Decomposing socio-economic inequality in colorectal cancer screening uptake in England. Soc Sci Med 134: 76-86.