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Background & Aims: Colorectal cancer (CRC) deaths occur when patients do not receive screening or have inadequate follow up of abnormal results, or when the screening test itself fails. We have few data on the contribution of each to CRC-associated deaths or factors associated with these events. Methods: We performed a retrospective cohort study of patients in the Kaiser Permanente Northern and Southern California systems (55–90 years old) who died from CRC from 2006 through 2012 and had ≥5 years of enrollment prior to diagnosis. We compared data from patients with a matched cohort of cancer-free patients in the same system. Receipt, results, indications, and follow up of CRC tests in the 10-year period prior to diagnosis were obtained from electronic databases and chart audits. Results: Among 1750 CRC deaths, 75.9% (n=1328) occurred in patients who were not up to date in screening and 24.1% (n=422) occurred in patients who were up to date. Failure to screen was associated with fewer visits to primary care physicians. Among 3486 cancer-free patients, 44.6% were up to date on their screening. Patients who were up to date in their screening had reduced risk of CRC death (odds ratio [OR], 0.38; 95% CI, 0.33–0.44). Failure to screen, or failure to screen at appropriate intervals, occurred in a 67.8% of patients who died from CRC vs 53.2% of cancer-free patients; failure to follow up on abnormal results occurred in 8.1% of patients who died from CRC vs 2.2% of cancer-free patients. CRC death was associated with higher odds of failure to screen or failure to screen at appropriate intervals (OR, 2.40; 95% CI, 2.07–2.77) and failure to follow up on abnormal results (OR, 7.26; 95% CI, 5.26–10.03). Conclusions: Being up to date on screening substantially reduces risk of CRC death. In 2 healthcare systems with high rates of screening, most people who died from CRC had failures in the screening process that could be rectified, such as failure to follow up on abnormal findings; these significantly increased risk for CRC death.

Background

Aims Screening colonoscopy’s effectiveness in reducing risk of death from right colon cancers remains unclear. Methodological challenges of existing observational studies addressing this issue motivated the design of ‘Effectiveness of Screening for Colorectal Cancer in Average-Risk Adults (SCOLAR)’. Methods SCOLAR is a nested case–control study based on two large integrated health systems. This affords access to a large, well-defined historical cohort linked to integrated data on cancer outcomes, patient eligibility, test indications and important confounders. Results We found electronic data adequate for excluding ineligible patients (except family history), but not the detailed information needed for test indication assignment. Conclusion The lessons of SCOLAR’s design and implementation may be useful for future studies seeking to evaluate the effectiveness of screening tests in community settings.

Purpose: Research on genomic medicine integration has focused on applications at the individual level, with less attention paid to implementation within clinical settings. Therefore, we conducted a qualitative study using the Consolidated Framework for Implementation Research (CFIR) to identify system-level factors that played a role in implementation of genomic medicine within Implementing GeNomics In PracTicE (IGNITE) Network projects. Methods: Up to four study personnel, including principal investigators and study coordinators from each of six IGNITE projects were interviewed using a semi-structured interview guide that asked interviewees to describe study site(s), progress at each site, and factors facilitating or impeding project implementation. Interviews were coded following CFIR inner-setting constructs. Results: Key barriers included: (1) limitations in integrating genomic data and clinical decision support tools into electronic health records; (2) physician reluctance towards genomic research participation and clinical implementation due to a limited evidence base; (3) inadequate reimbursement for genomic medicine; (4) communication among and between investigators and clinicians; (5) lack of clinical and leadership engagement. Conclusion: Implementation of genomic medicine is hindered by several system-level barriers to both research and practice. Addressing these barriers may serve as important facilitators for studying and implementing genomics in practice.