Optimizing the colorectal cancer screening programme using faecal immunochemical test (FIT) in Flanders, Belgium from the “interval cancer” perspective

Background Interval cancer (IC) is a critical issue in colorectal cancer (CRC) screening. We identified factors associated with ICs after faecal immunochemical test (FIT) screening and explored the impact of lowering FIT cut-off or shortening screening interval on FIT-ICs in Flanders. Methods FIT participants diagnosed with a CRC during 2013–2018 were included. Factors associated with FIT-ICs were identified using logistic regression. Distributions of FIT results among FIT-ICs were examined. Results In total, 10,122 screen-detected CRCs and 1534 FIT-ICs were included (FIT-IC proportion of 13%). FIT-ICs occurred more frequently in women (OR 1.58 [95% CI 1.41–1.76]) and ages 70–74 (OR 1.35 [1.14–1.59]). FIT-ICs were more often right-sided (OR 3.53 [2.98–4.20]), advanced stage (stage IV: OR 7.15 [5.76–8.88]), and high grade (poorly/undifferentiated: OR 2.57 [2.08–3.18]). The majority (83–92%) of FIT-ICs would still be missed if FIT cut-off was lowered from 15 to 10 µg Hb/g or screening interval was shortened from 2 to 1 year. Conclusions FIT-ICs were more common in women, older age, right-sided location, advanced stage and high grade. In Flanders, lowering FIT cut-off (to 10 µg Hb/g) or shortening screening interval (to 1 year) would have a minimal impact on FIT-ICs.

Beneficial effects of endoscopic screening on gastric cancer and its optimal screening interval: a population-based study

Background and study aims: The effectiveness of endoscopic screening on gastric cancer (GC) is less investigated and screening interval of repeated screening is yet to be optimized in China. Patients and methods: In a population-based prospective study, we included 375,800 subjects based on the Upper Gastrointestinal Cancer Early Detection Program in Linqu, a GC high-risk area in China, 14,670 of which underwent endoscopic screening(2012-2018). We assessed the associations of the risk of incident GC and GC-specific deaths with endoscopic screening and examined the changes in overall survival (OS) and disease-specific survival (DSS) of GCs by endoscopic screening. The optimal screening interval of repeated endoscopy for early detection of GC was explored. Results: Ever receiving endoscopic screening significantly decreased the risk of invasive GC(age and sex-adjusted RR=0.69, 95%CI:0.52-0.92) and GC-specific deaths(RR=0.33, 95%CI: 0.20-0.56), particularly for non-cardia GC. Repeated screening strengthened the beneficial effect on invasive GC-specific deaths by one-time screening. Among invasive GCs, screening-detected cases had significantly better OS(RR=0.18, 95%CI: 0.13-0.25) and DSS(RR=0.18, 95%CI: 0.13-0.25) than cases in the unscreened group, particularly for those receiving repeated endoscopy. For individuals with intestinal metaplasia or low-grade intraepithelial neoplasia, repeated endoscopy at an interval of less than two years, particularly within one year, significantly enhanced the detection of early GC, compared with repeated screening after two years(P-trend=0.02). Conclusion: Endoscopic screening prevented GC occurrence and death and improved its prognosis in a population-based study. Repeated endoscopy enhanced the effectiveness, for which screening interval needs to be defined in conformity with the severity of gastric lesions.

From Genetics to Histomolecular Characterization: An Insight into Colorectal Carcinogenesis in Lynch Syndrome

Lynch syndrome is a hereditary cancer-predisposing syndrome caused by germline defects in DNA mismatch repair (MMR) genes such as MLH1, MSH2, MSH6, and PMS2. Carriers of pathogenic mutations in these genes have an increased lifetime risk of developing colorectal cancer (CRC) and other malignancies. Despite intensive surveillance, Lynch patients typically develop CRC after 10 years of follow-up, regardless of the screening interval. Recently, three different molecular models of colorectal carcinogenesis were identified in Lynch patients based on when MMR deficiency is acquired. In the first pathway, adenoma formation occurs in an MMR-proficient background, and carcinogenesis is characterized by APC and/or KRAS mutation and IGF2, NEUROG1, CDK2A, and/or CRABP1 hypermethylation. In the second pathway, deficiency in the MMR pathway is an early event arising in macroscopically normal gut surface before adenoma formation. In the third pathway, which is associated with mutations in CTNNB1 and/or TP53, the adenoma step is skipped, with fast and invasive tumor growth occurring in an MMR-deficient context. Here, we describe the association between molecular and histological features in these three routes of colorectal carcinogenesis in Lynch patients. The findings summarized in this review may guide the use of individualized surveillance guidelines based on a patient’s carcinogenesis subtype.

Cost-effectiveness analysis for HbA1c test intervals to screen patients with type 2 diabetes based on risk stratification

Background The best HbA1c test interval strategy for detecting new type 2 diabetes mellitus (T2DM) cases in healthy individuals should be determined with consideration of HbA1c test characteristics, risk stratification towards T2DM and cost effectiveness. Methods State transition models were constructed to investigate the optimal screening interval for new cases of T2DM among each age- and BMI-stratified health individuals. Age was stratified into 30–44-, 45–59-, and 60–74-year-old age groups, and BMI was also stratified into underweight, normal, overweight and obesity. In each model, different HbA1c test intervals were evaluated with respect to the incremental cost-effectiveness ratio (ICER) and costs per quality-adjusted life year (QALY). Annual intervals (Japanese current strategy), every 3 years (recommendations in US and UK) and intervals which are tailored to each risk stratification group were compared. All model parameters, including costs for screening and treatment, rates for complications and mortality and utilities, were taken from published studies. The willingness-to-pay threshold in the cost-effectiveness analysis was set to US $50,000/QALY. Results The HbA1c test interval for detecting T2DM in healthy individuals varies by age and BMI. Three-year intervals were the most cost effective in obesity at all ages—30-44: $15,034/QALY, 45–59: $11,849/QALY, 60–74: $8685/QALY—compared with the other two interval strategies. The three-year interval was also the most cost effective in the 60–74-year-old age groups—underweight: $11,377/QALY, normal: $18,123/QALY, overweight: $12,537/QALY—and in the overweight 45–59-year-old group; $18,918/QALY. In other groups, the screening interval for detecting T2DM was found to be longer than 3 years, as previously reported. Annual screenings were dominated in many groups with low BMI and in younger age groups. Based on the probability distribution of the ICER, results were consistent among any groups. Conclusions The three-year screening interval was optimal among elderly at all ages, the obesity at all ages and the overweight in 45–59-year-old group. For those sin the low-BMI and younger age groups, the optimal HbA1c test interval could be longer than 3 years. Annual screening to detect T2DM was not cost effective and should not be applied in any population.

Recovery strategies following COVID-19 disruption to cervical cancer screening and their impact on excess diagnoses

Background The COVID-19 pandemic has disrupted cervical cancer screening services. Assuming increases to screening capacity are unrealistic, we propose two recovery strategies: one extends the screening interval by 6 months for all and the other extends the interval by 36/60 months, but only for women who have already missed being screened. Methods Using routine statistics from England we estimate the number of women affected by delays to screening. We used published research to estimate the proportion of screening age women with high-grade cervical intraepithelial neoplasia and progression rates to cancer. Under two recovery scenarios, we estimate the impact of COVID-19 on cervical cancer over one screening cycle (3 years at ages 25–49 and 5 years at ages 50–64 years). The duration of disruption in both scenarios is 6 months. In the first scenario, 10.7 million women have their screening interval extended by 6 months. In the second, 1.5 million women (those due to be screened during the disruption) miss one screening cycle, but most women have no delay. Results Both scenarios result in similar numbers of excess cervical cancers: 630 vs. 632 (both 4.3 per 100,000 women in the population). However, the scenario in which some women miss one screening cycle creates inequalities—they would have much higher rates of excess cancer: 41.5 per 100,000 delayed for screened women compared to those with a 6-month delay (5.9 per 100,000). Conclusion To ensure equity for those affected by COVID-19 related screening delays additional screening capacity will need to be paired with prioritising the screening of overdue women.

Cost-effectiveness analysis for HbA1c test intervals to screen patients with type 2 diabetes based on risk stratification.

Background: To determine the best HbA1c test interval strategy for detecting new type 2 diabetes mellitus (T2DM) cases in a healthy population, HbA1c test characteristics, risk stratification towards T2DM and cost effectiveness were considered.Methods: State transition models were built to study the optimal screening interval for new cases of T2DM among each age- and BMI-stratified health population. Age was stratified into 30-44-, 45-59-, and 60-74-year-old age groups, and BMI was also stratified into underweight (<18.5 kg/m2), normal (18.5-25 kg/m2), overweight (25-30 kg/m2) and obesity (≥30 kg/m2). In each model, different HbA1c test intervals were compared to evaluate costs per quality-adjusted life year (QALY) and the incremental cost-effectiveness ratio (ICER). We compared intervals annually (current Japanese strategy), every three years (US and UK recommendations) and tailored to each risk stratification group, based on our previous work. All model parameters, including screening and treatment costs, complications and mortality rates and utilities, were applied from published studies. The willingness-to-pay threshold in the cost-effectiveness analysis was set to US $50,000/QALY.Results: The HbA1c test interval for detecting T2DM in a healthy population varies by age and BMI. Three-year intervals were the most cost effective in obesity at all ages—30-44: $15,034/QALY, 45-59: $11,849/QALY, 60-74: $8,685/QALY—compared with the other two interval strategies. The three-year interval was also the most cost effective in the 60-74-year-old age groups—underweight: $11,377/QALY, normal: $18,123/QALY, overweight: $12,537/QALY—and in the overweight 45-59-year-old group; $18,918/QALY. In other groups, the screening interval for detecting T2DM was found to be longer than three years, as previously reported. Annual screenings were dominated in many groups with low BMI and in younger age groups. Based on the probability distribution of the ICER, QALY does not show much difference among any groups.Conclusions: Annual screening to detect T2DM was not cost effective and should not apply to any population. The three-year screening interval was optimal among all elderly populations, the obesity at all ages and the overweight 45-59-year-old group. For the low BMI and younger age groups, the optimal HbA1c test interval can be longer than three years.

Avaliação do nível de satisfação dos clientes de um restaurante por meio da Teoria da Resposta ao Item

The objective of this work was to create a scale to assess the level of customer satisfaction in a restaurant, using the Two Parameter Logistic Model (2PL) of the Item Response Theory (IRT). For this, a questionnaire was applied to 640 customers, including 28 restaurant attributes related to the indoor and outdoor environments, with food and service. The results shown in most respondents are satisfied with the specified effects, with the most recommended items being payment options, a location in the restaurant and its size and structure. Also note that all items had a good fit with the 2PL, so there is no need to exclude them. Consequently, it was possible to build an interpretable scale with four levels for customer satisfaction. In addition, it was possible to evaluate the questionnaire and identify which latent screening interval is most appropriate. The application of permitted adjustments allows to locate the items on the created scale, as well as to identify those that deserve greater attention in the organizational planning of a restaurant.