Citations

65 Background: There is consensus that the proportion of the average-risk US population up-to-date with CRC screening (58-65%) is insufficient. However, estimates of average risk CRC screening rates are inconsistent and impacted by inclusion of higher-risk individuals, and differing study designs. Accurate measurement of population screening rates is key to addressing gaps in care and assessing the impact of newer CRC screening tests. Methods: The study included individuals aged 50-75 years in a large de-identified claims database, with continuous enrollment during year of analysis, and a variable length baseline enrollment of 1-10 years. Average-risk designation excluded higher risk diagnoses (CRC familial syndromes, colorectal polyp or history of colorectal polyp, history of/current CRC, family history of gastrointestinal cancer, and inflammatory bowel disease). Up-to-date status was assessed within guideline-based time periods: colonoscopy (10 years); FIT or FOBT (annually); mt-sDNA (3 years); flexible sigmoidoscopy/CT colonography (5 years). Analyses assessed the proportion estimated as up-to-date and examined the sensitivity to: a) patient population (average-risk only vs. including higher-risk); b) study design (yearly cross-sectional vs. cohort of 50-year-old patients; c) methods (percent in patients with 10 years of enrollment vs. Kaplan Meier (KM) of censored variable pre-screening period). Results: The cross-sectional analysis average-risk population included 5.3 million individuals. Estimates of the proportion of those up-to-date with screening guidelines for average-risk patients varied by study design, population, and estimation method. KM estimates among the average-risk population (50-75) showed 49-50% were up-to-date in each calendar year. Including higher-risk patients in the KM analysis resulted in 70% up-to-date among the mixed average+higher-risk population. Using a cohort study design (average-risk patients aged 60 with 10 years of baseline data), 65% were up-to-date by age 60. Conclusions: In the base case analysis only half of average risk individuals were up-to-date with CRC screening, a rate lower than typically cited. Sensitivity analyses resulted in substantially different estimates and demonstrate the importance of clearly communicating the methodology used to define the study population. Higher rates quoted in the lay press and medical publications may be based on mixed populations of average+higher-risk individuals or on study designs that do not represent the full population at risk.

60 Background: Several colorectal cancer (CRC) screening options are considered in guidelines for individuals at average-risk (IAR). These options differ in aspects such as invasiveness, recommended frequency, and precision that need to be compared and weighed. This study elicited and compared the relative importance that physicians and IAR place on these screening aspects. Methods: Primary care physicians [PCPs] and gastroenterologists [GIs] who recommended/performed ≥1 screening one month prior to study and adult IAR completed a discrete choice experiment (DCE). Participants repeatedly chose between screening tests described by type of test, frequency, true-positive (TP), true-negative (TN), and adenoma TP (physicians only). The instrument was tested in qualitative (physicians: n=6; IAR: n=6) and quantitative pilots (physicians: n=100; IAR: n=202). A mixed logit model was used to estimate relative attribute importance (RAI) and predicted choice probabilities for colonoscopy, multi-target stool DNA (mt-sDNA), fecal immunochemical test (FIT), and methylated septin 9 (mSEPT9) blood test. Generalizability to the population was confirmed. Results: 1,249 IAR and 400 physicians participated. IAR were 46% male and the mean age was 58.9. Physicians were 79% male and their mean age was 53.4. Preferences were most affected by TP rates (IAR RAI=58%; physicians RAI=42%). Physicians also placed high importance (RAI=41%) on adenoma TP rates. TN rates (IAR RAI=33%; physician RAI=9%), frequency (IAR RAI=6%; physician RAI=2%) and type (IAR RAI=4%; physician RAI=6%) were less important. Despite both IAR and physicians placing most importance on precision, preferences for screening modalities differed. On average, physicians preferred colonoscopy, while IAR preferred mt-sDNA over colonoscopy (p<0.001). Both preferred mt-sDNA and colonoscopy over FIT (p<0.001), with a mSEPT9 blood test being least preferred (p<0.001). Preferences of IAR were heterogeneous with individuals who underwent colonoscopy or sigmoidoscopy screening preferring colonoscopy and the rest preferring mt-sDNA (p<0.001). Conclusions: While both GI and PCPs overwhelmingly preferred colonoscopy, preferences of IAR were heterogenous, with mt-sDNA being preferred on average other modalities. Offering choices in addition to colonoscopy could improve screening uptake. [Table: see text]

27 Background: Colorectal cancer (CRC) is the second most deadly and fourth most frequently diagnosed cancer in the United States. Early detection can improve CRC outcomes, but overall screening rates (62%) remain below the 80% goal set by the National Colorectal Cancer Roundtable. Multiple options are endorsed for average-risk CRC screening, including the multi-target stool DNA (mt-sDNA) test, which includes patient and provider navigation support. Cross-sectional adherence with the mt-sDNA test was previously reported in a large Medicare population (71%). In the current study we investigated cross-sectional adherence with the mt-sDNA test in a broader, national sample of insured patients. Methods: Aggregate data from Exact Sciences Laboratories LLC (ESL; Madison, WI) were retrospectively analyzed in compliance with HIPAA requirements. Study participants included individuals ages 50 years and older who were covered by commercial insurance or Medicare, had a valid mt-sDNA test order placed between January 1–December 31, 2018, and received a test kit shipped from ESL. Cross-sectional adherence, defined as successful completion and return of the test kit within 365 days of the shipment date, was assessed overall and by patient- and provider-level factors. Results: In total, 1,420,460 participants met the study criteria (61.2% women; mean age 65.7 years). Overall cross-sectional adherence was 66.8%. Adherence was 72.1% in participants with Traditional Medicare, 69.1% in participants with Medicare Advantage, and 61.9% in participants with commercial insurance (p<0.001). Adherence increased by participant age (p<0.001): 60.8% for ages 50-64, 71.3% for ages 65-75, and 74.7% for ages 76+ years. For Traditional Medicare patients, ages 65-75, adherence was 73.6%. Participants with mt-sDNA tests ordered placed by gastroenterologists had a higher adherence rate (78.3%) than those with orders placed by primary care clinicians (67.2%) (p<0.001). Adherence rates were highest among patients with ordering providers in the Pacific region (71.4%) and West North Central region (70.1%), and lowest in the Mid-Atlantic region (65.7%), New England (65.2%), West South Central region (64.6%), and Puerto Rico and US territories (60.7%). Conclusions: Novel data from this large, national sample of insured patients demonstrate high cross-sectional adherence with the mt-sDNA test (66.8%), supporting the substantial contribution this guideline-endorsed option plays in average-risk CRC screening. At the patient-level, adherence increased with patient age, and was highest in those covered by Traditional Medicare. Provider-level stratification showed the highest adherence for mt-sDNA tests ordered by gastroenterologists. This study adds to data regarding the impact of accompanying navigation support and at-home convenience of mt-sDNA on screening completion rates.