Delivering colorectal cancer screening integrated with primary health care services in Morocco: Lessons learned from a demonstration project

Abstract

BACKGROUND: Colorectal cancer (CRC) incidence and mortality rates are increasing rapidly in many low-income and middle-income countries. A demonstration project was implemented in Morocco in collaboration with the Ministry of Health to assess the feasibility, acceptability, and challenges of implementing CRC screening through routine primary care facilities. METHODS: The objective of the project was to screen 10,000 men and women aged 50 to 75 years through 10 primary health centers (PHCs) in 2 provinces. All eligible men and women attending the selected PHCs were offered the fecal immunochemical test (FIT). Stool specimens brought to the PHCs were tested immediately by trained nurses. FIT-positive individuals were referred to the National Oncology Institute for colonoscopy. RESULTS: In total, 9763 eligible men and women were screened by FIT between June 2017 and May 2019; most (73.3%) were women. The test was positive in 460 participants (4.7%). Among the individuals who had positive FIT results, 62.6% underwent colonoscopy. The main reasons for noncompliance to colonoscopy were competing life priorities (15.4%), other health problems (13%), and fear of getting a cancer diagnosis (12.3%). As the number of referrals to colonoscopy increased, the waiting time for the procedure increased, resulting in a drop in compliance. The detection rates of advanced adenomas and CRC were 4.0 in 1000 and 0.5 in 1000 individuals screened, respectively. CONCLUSIONS: An effective strategy to reach the target populations (especially men), a pragmatic assessment of the health system's capacity to deal with large numbers of referrals, and a formal cost-effectiveness analysis are essential before making any decision to introduce CRC screening in Morocco.

Global cancer surgery in low‐resource settings: A strengths, weaknesses, opportunities, and threats analysis

“…Indirect approaches, which emphasize external systems or policies that influence surgical cancer care, have also been a source of interest to researchers. For example, a study in Morocco sought to improve early cancer detection rates by providing point‐of‐care fecal immunochemical testing at primary health centers and offering colonoscopies for those who tested positive 56 ; however, only 62.6% of those who tested positive successfully underwent a subsequent colonoscopy, with many patients citing logistical and financial barriers to attending the follow‐up procedure and appointments. Furthermore, the increased burden on the Moroccan surgical infrastructure due to more patients seeking colonoscopies secondary to the positive fecal screening intervention resulted in increased wait times and, as a result, decreased compliance.…”

“…7,16,43 Broader health system gaps Indirect approaches, which emphasize external systems or policies that influence surgical cancer care, have also been a source of interest to researchers. For example, a study in Morocco sought to improve early cancer detection rates by providing point-of-care fecal immunochemical testing at primary health centers and offering colonoscopies for those who tested positive 56 ; however, only 62.6% of those who tested positive successfully underwent a subsequent colonoscopy, with many patients citing logistical and financial barriers to attending the follow-up procedure and appointments.…”

Barriers and recommendations for colorectal cancer screening in Africa

“…Alatise et al [ 22 ] reported that high numbers of false-positive results from FITs generated a large endoscopic burden for a country with a paucity of endoscopic resources. Similarly, Selmouni et al [ 27 ] reported that increased colonoscopy referral led to increased waiting times and thus reduced adherence to follow-up CRC screening by those with an initial positive test result.…”

“…Another barrier to CRC screening in Africa was the lack of patient knowledge [ 13 , 17 , 18 , 20 , 26 , 27 ]. Lussiez et al [ 13 ] reported that 86.2% of physicians interviewed in Ghana identified patients’ lack of awareness of screening, specifically patients not perceiving CRC as a serious health threat, as a barrier to CRC screening.…”

Sustainable infrastructure and risk stratification are needed to appropriately deliver colorectal cancer screening globally

“…In their article in this issue, Selmouni and colleagues report on the feasibility, acceptability, and implementation challenges of delivering an opportunistic colorectal cancer screening program that offers fecal immunochemical testing (FIT) as part of routine primary care in Morocco. 1 The study consented and enrolled nearly 10,000 patients from 10 primary care clinics in 2 Moroccan provinces. Of the 9908 individuals aged 50 to 75 years who completed an FIT, 73.3% were women, 460 (4.7%) had an abnormal test result, and 288 (62.6% of those with an abnormal test) completed a follow-up colonoscopy.…”