Colorectal cancer screening with fecal immunochemical testing or primary colonoscopy: An analysis of health equity based on a randomised trial

Strömberg, Ulf; Bonander, Carl; Westerberg, Marcus; Levin, Lars‐Åke; Metcalfe, Chris; Steele, Robert; Holmberg, Lars; Forsberg, Anna; Hultcrantz, Rolf

doi:10.1016/j.eclinm.2022.101398

Cited by 10 publications

(10 citation statements)

References 25 publications

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“…Our comparison between individual and neighbourhood‐level socioeconomic data analysis showed that individual‐level analysis resulted in more pronounced gradients across the socioeconomic strata than neighbourhood‐level analysis, except for diagnostics (pre‐biopsy MRI) where neighbourhood‐level results agreed well with individual‐level results in showing a wide socioeconomic gradient. Previous Swedish studies have shown that neighbourhood level analysis can be valuable for revealing socioeconomic differences in early detection of cancer 21,22 . For prostate cancer, population‐based studies have addressed influence of socioeconomic characteristics (education) on early detection by individual rather than neighbourhood level analysis 23–25 .…”

Section: Discussionmentioning

confidence: 99%

“…Our analysis can be valuable for revealing socioeconomic differences in early detection of cancer. 21,22 For prostate cancer, population-based studies have addressed influence of socioeconomic characteristics (education) on early detection by individual rather than neighbourhood level analysis. [23][24][25] We were unable to find other populationbased studies investigating the influence of income or education on the use of pre-biopsy MRI, but racial and geographical disparities have been reported from the United States.…”

Section: Neigbourhood Level Educationmentioning

confidence: 99%

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Socioeconomic inequality in prostate cancer diagnostics, primary treatment, rehabilitation, and mortality in Sweden

Strömberg,

Berglund,

Carlsson

et al. 2024

Intl Journal of Cancer

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We designed a nationwide study to investigate the association between socioeconomic factors (household income and education) and different aspects of prostate cancer care, considering both individual‐ and neighbourhood‐level variables. Data were obtained from Prostate Cancer data Base Sweden (PCBaSe), a research database with data from several national health care registers including clinical characteristics and treatments for nearly all men diagnosed with prostate cancer in Sweden. Four outcomes were analysed: use of pre‐biopsy magnetic resonance imaging (MRI) in 2018–2020 (n = 11,843), primary treatment of high‐risk non‐metastatic disease in 2016–2020 (n = 6633), rehabilitation (≥2 dispensed prescriptions for erectile dysfunction within 1 year from surgery in 2016–2020, n = 6505), and prostate cancer death in 7770 men with high‐risk non‐metastatic disease diagnosed in 2010–2016. Unadjusted and adjusted odds and hazard ratios (OR/HRs) with 95% confidence intervals (CIs) were calculated. Adjusted odds ratio (ORs) comparing low versus high individual education were 0.74 (95% CI 0.66–0.83) for pre‐biopsy MRI, 0.66 (0.54–0.81) for primary treatment, and 0.82 (0.69–0.97) for rehabilitation. HR gradients for prostate cancer death were significant on unadjusted analysis only (low vs. high individual education HR 1.41, 95% CI 1.17–1.70); co‐variate adjustments markedly attenuated the gradients (low vs. high individual education HR 1.10, 95% CI 0.90–1.35). Generally, neighbourhood‐level analyses showed weaker gradients over the socioeconomic strata, except for pre‐biopsy MRI. Socioeconomic factors influenced how men were diagnosed with prostate cancer in Sweden but had less influence on subsequent specialist care. Neighbourhood‐level socioeconomic data are more useful for evaluating inequality in diagnostics than in later specialist care.

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Section: Discussionmentioning

confidence: 99%

Section: Neigbourhood Level Educationmentioning

confidence: 99%

Socioeconomic inequality in prostate cancer diagnostics, primary treatment, rehabilitation, and mortality in Sweden

Strömberg,

Berglund,

Carlsson

et al. 2024

Intl Journal of Cancer

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“…Nevertheless, social inequalities are evident in participation at both faecal immunochemical test (FIT) and colonoscopy 5 6. The proportion of positive FIT samples and the risk of a following incomplete colonoscopy is higher in lower socioeconomic subgroups 7 8. Why this is, has yet to be determined, but it has been established that lifestyle and health behaviour affects the risk of colorectal cancer 9.…”

Section: Introductionmentioning

confidence: 99%

“… 5 6 The proportion of positive FIT samples and the risk of a following incomplete colonoscopy is higher in lower socioeconomic subgroups. 7 8 Why this is, has yet to be determined, but it has been established that lifestyle and health behaviour affects the risk of colorectal cancer. 9 In a North-American study, socioeconomic status has been identified as a predictor of the diversity in the colonic microbiota.…”

Section: Introductionmentioning

confidence: 99%

Socioeconomic inequalities in interval colorectal cancer are explained by differences in faecal haemoglobin concentration and age: a register-based cohort study

Deding

Kobæk-Larsen

Bøggild

et al. 2023

BMJ Open Gastroenterol

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ObjectiveTo estimate the risk of interval colorectal cancer (CRC) in faecal immunochemical test (FIT) negative screening participants according to socioeconomic status.DesignIn this register-based study, first round FIT negative (<20 µg hb/g faeces) screening participants (biennial FIT, citizens aged 50–74) were followed to estimate interval CRC risk. Multivariate Cox proportional hazard regression models estimated HRs based on socioeconomic status defined by educational level and income. Models were adjusted for age, sex and FIT concentration.ResultsWe identified 829 (0.7‰) interval CRC in 1 160 902 individuals. Interval CRC was more common in lower socioeconomic strata with 0.7‰ for medium-long higher education compared with 1.0‰ for elementary school and 0.4‰ in the highest income quartile compared with 1.2‰ in the lowest. These differences did not translate into significant differences in HR in the multivariate analysis, as they were explained by FIT concentration and age. HR for interval CRC was 7.09 (95% CI) for FIT concentrations 11.9–19.8 µg hb/g faeces, and 3.37 (95% CI) for FIT between 7.2 and 11.8 compared with those <7.2. The HR rose with increasing age ranging from 2.06 (95% CI 1.45 to 2.93) to 7.60 (95% CI 5.63 to 10.25) compared with those under 55 years.ConclusionInterval CRC risk increased with decreasing income, heavily influenced by lower income individuals more often being older and having increased FIT concentrations. Individualising screening interval based on age and FIT result, may decrease interval CRC rates, reduce the social gradient and thereby increase the screening efficiency.

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“…Socioeconomic inequalities in the uptake of organized CRC screening are well documented ( 2-6 ). Investigators have reported a higher proportion of positive test results in lower socioeconomic groups among attendees in biennial guaiac fecal occult blood testing ( 7 ) and biennial FIT ( 5 , 6 ). In contrast, among the positive test results, lower uptake of workup colonoscopy among individuals in lower socioeconomic groups has been observed ( 5 , 6 , 8 ).…”

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confidence: 99%

Colorectal cancer screening with fecal immunochemical testing or primary colonoscopy: inequities in diagnostic yield

Bonander,

Westerberg,

Chauca Strand

et al. 2024

JNCI Cancer Spectrum

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Background Socioeconomic inequalities in the uptake of colorectal cancer screening are well documented, but the implications on health inequity remain unclear. Methods Sixty-year-olds were randomly recruited from the Swedish population between March, 2014, and March, 2020, and invited to either fecal immunochemical testing (FIT) 2 years apart (n = 60,137) or once-only primary colonoscopy (PCOL; n = 30,400). By linkage to Statistics Sweden’s registries, we obtained socioeconomic data. In each defined socioeconomic group, we estimated the cumulative yield of advanced neoplasia (AN) in each screening arm (intention-to-screen analysis). We predicted the probability of exceeding the yield in the PCOL arm after a third round of FIT: Pr{AN_FIT3>AN_PCOL}. Results In the lowest income group, the yield of AN was 1.63% (95% confidence interval [CI] = 1.35% to 1.93%) after two rounds of FIT, in relation to 1.93% (95% CI = 1.49% to 2.40%) in the PCOL arm. We predicted Pr{AN_FIT3>AN_PCOL} = 0.86. In the highest income group, we found a more pronounced yield gap between the two screening strategies, 2.32% (95% CI = 2.15% to 2.49%) vs 3.71% (95% CI = 3.41% to 4.02%), and a very low Pr{AN_FIT3>AN_PCOL} (= 0.02). Conclusions Yields of AN from FIT 2 years apart and PCOL, respectively, were poorer, but differed lesser, in lower socioeconomic groups. The results are valuable for evaluations of health equity in organized screening for colorectal cancer. Clinical Trial Registration ClinicalTrials.gov number NCT02078804.

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Colorectal cancer screening with fecal immunochemical testing or primary colonoscopy: An analysis of health equity based on a randomised trial

Cited by 10 publications

References 25 publications

Socioeconomic inequality in prostate cancer diagnostics, primary treatment, rehabilitation, and mortality in Sweden

Socioeconomic inequality in prostate cancer diagnostics, primary treatment, rehabilitation, and mortality in Sweden

Socioeconomic inequalities in interval colorectal cancer are explained by differences in faecal haemoglobin concentration and age: a register-based cohort study

Colorectal cancer screening with fecal immunochemical testing or primary colonoscopy: inequities in diagnostic yield

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