Observational Study
Copyright ©The Author(s) 2021. Published by Baishideng Publishing Group Inc. All rights reserved.
World J Gastroenterol. Oct 21, 2021; 27(39): 6689-6700
Published online Oct 21, 2021. doi: 10.3748/wjg.v27.i39.6689
Impact of a colorectal cancer screening program implantation on delays and prognosis of non-screening detected colorectal cancer
Joaquin Cubiella, María Lorenzo, Franco Baiocchi, Coral Tejido, Alejandro Conde, María Sande-Meijide, Margarita Castro
Joaquin Cubiella, Coral Tejido, Department of Gastroenterology, Complexo Hospitalario Universitario de Ourense, Ourense 32005, Orense, Spain
María Lorenzo, Alejandro Conde, María Sande-Meijide, Department of Preventive Medicine, Complexo Hospitalario Universitario de Ourense, Ourense 32003, Orense, Spain
Franco Baiocchi, Department of Gastroenterology, Hospital del Bierzo, Ponferrada 24404, Leon, Spain
Margarita Castro, Dirección Xeral de Saúde Pública, Conselleria de Sanidade, Santiago de Compostela 15703, Spain
Author contributions: Cubiella J, Sande-Meijide M and Castro M contributed to the conception and design of the article; Cubiella J, Sande-Meijide M, Castro M and Lorenzo M contributed to obtaining funding; Lorenzo M, Baiocchi F, Tejido C and Conde A contributed to acquisition of data; Cubiella J contributed to analysis, interpretation of data and drafting the article; all authors made critical revisions related to the manuscript’s important intellectual content and gave final approval of the version of the article to be published.
Supported by the Spain’s Carlos III Health Care Institute by means of project PI17/00837 (Co-funded by European Regional Development Fund/European Social Fund "A way to make Europe"/"Investing in your future").
Institutional review board statement: The study was conducted in accordance with the Declaration of Helsinki, and the protocol was approved by the Ethics Committee of Galicia, Spain (code 2016/274). As long as the study was based on database use, no informed consent was required. The information was accessed according to prevailing European and Spanish legislation.
Informed consent statement: All study participants, or their legal guardian, provided informed written consent prior to study enrollment.
Conflict-of-interest statement: There are no conflicts of interest to report.
Data sharing statement: We will share the data base on demand and according to European legislation.
STROBE statement: The authors have read the STROBE Statement—checklist of items, and the manuscript was prepared and revised according to the STROBE Statement—checklist of items.
Open-Access: This article is an open-access article that was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution NonCommercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/Licenses/by-nc/4.0/
Corresponding author: Joaquin Cubiella, MD, PhD, Doctor, Staff Physician, Statistician, Department of Gastroenterology, Complexo Hospitalario Universitario de Ourense, Rúa Ramón Puga 52-54, Ourense 32005, Orense, Spain. joaquin.cubiella.fernandez@sergas.es
Received: April 14, 2021
Peer-review started: April 14, 2021
First decision: July 14, 2021
Revised: July 15, 2021
Accepted: September 8, 2021
Article in press: September 8, 2021
Published online: October 21, 2021
Processing time: 188 Days and 23.3 Hours
Abstract
BACKGROUND

The implementation of a colorectal cancer (CRC) screening programme may increase the awareness of Primary Care Physicians, reduce the diagnostic delay in CRC detected outside the scope of the screening programme and thus improve prognosis.

AIM

To determine the effect of implementation of a CRC screening programme on diagnostic delays and prognosis of CRC detected outside the scope of a screening programme.

METHODS

We performed a retrospective intervention study with a pre-post design. We identified 322 patients with incident and confirmed CRC in the pre-implantation cohort (June 2014 – May 2015) and 285 in the post-implantation cohort (June 2017 - May 2018) in the Cancer Registry detected outside the scope of a CRC screening programme. In each patient we calculated the different healthcare diagnostics delays: global, primary and secondary healthcare, referral and colonoscopy-related delays. In addition, we collected the initial healthcare that evaluated the patient, the home location (urban/rural), and the CRC stage at diagnosis. We determined the two-year survival and we performed a multivariate proportional hazard regression analysis to determine the variables associated with survival.

RESULTS

We did not detect any differences in the patient or CRC baseline-related variables. A total of 20.1% of patients was detected with metastatic disease. There was a significant increase in direct referral to colonoscopy from primary healthcare (25.5%, 35.8%; P = 0.04) in the post-implantation cohort. Diagnostic delay was reduced by 24 d (106.64 ± 148.84 days, 82.84 ± 109.31 d; P = 0.02) due to the reduction in secondary healthcare delay (46.01 ± 111.65 d; 29.20 ± 60.83 d; P = 0.02). However, we did not find any differences in CRC stage at diagnosis or in two-year survival (70.3%; P = 0.9). Variables independently associated with two-year risk of death were age (Hazard Ratio-HR: 1.06, 95%CI: 1.04-1.07), CRC stage (II HR: 2.17, 95%CI: 1.07-4.40; III HR: 3.07, 95%CI: 1.56-6.08; IV HR: 19.22, 95%CI: 9.86-37.44; unknown HR: 9.24, 95%CI: 4.27-19.99), initial healthcare consultation (secondary HR: 2.93, 95%CI: 1.01-8.55; emergency department HR: 2.06, 95%CI: 0.67-6.34), hospitalization during the diagnostic process (HR: 1.67, 95%CI: 1.17-2.38) and urban residence (HR: 1.44, 95%CI: 1.06-1.98).

CONCLUSION

Although implementation of a CRC screening programme can reduce diagnostic delays for CRC detected in symptomatic patients, this has no effect on CRC stage or survival.

Keywords: Colorectal cancer, Population based screening, Primary healthcare, Diagnostic delay, Prognosis

Core Tip: We have designed a retrospective intervention study with a pre-post design to confirm the hypothesis that the implementation of a colorectal cancer (CRC) screening program may increase the awareness of primary care physicians and, thus, reduce the diagnostic delays in CRC detected outside the screening program and improve prognosis. Our results confirm that the implementation of the CRC screening program reduced the diagnostic delays due to an increase in the direct referrals to colonoscopy from primary healthcare. However, this reduction in the delays had no effect on the stage at diagnosis or in the two year survival. These later results were confirmed in a multivariable Cox regression analysis.