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

Ulf Stromberg*, Carl Bonander, Marcus Westerberg, Lars-Ake Levin, Chris Metcalfe, Robert Steele, Lars Holmberg, Anna Fosberg, Rolf Hultcrantz

*Corresponding author for this work

Research output: Contribution to journalArticle (Academic Journal)peer-review

7 Citations (Scopus)
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Abstract

Background
We have addressed health equity attained by fecal immunochemical testing (FIT) and primary colonoscopy (PCOL), respectively, in the randomised controlled screening trial SCREESCO conducted in Sweden.

Methods
We analysed data on the individuals recruited between March 2014, and March 2020, within the study registered with ClinicalTrials.gov, NCT02078804. Swedish population registry data on educational level, household income, country of birth, and marital status were linked to each 60-year-old man and woman who had been randomised to two rounds of FIT 2 years apart (n = 60,123) or once-only PCOL (n = 30,390). Furthermore, we geo-coded each study individual to his/her residential area and assessed neighbourhood-level data on deprivation, proportion of non-Western immigrants, population density, and average distance to healthcare center for colonoscopy. We estimated adjusted associations of each covariate with the colonoscopy attendance proportion out of all invited to respective arms; ie, the preferred outcome for addressing health equity. In the FIT arm, the test uptake and the colonoscopy uptake among the test positives were considered as the secondary outcomes.

Findings
We found a marked socioeconomic gradient in the colonoscopy attendance proportion in the PCOL arm (adjusted odds ratio [95% credibility interval] between the groups categorised in the highest vs. lowest national quartile for household income: 2·20 [2·01–2·42]) in parallel with the gradient in the test uptake of the FIT × 2 screening (2·08 [1·96–2·20]). The corresponding gradient in the colonoscopy attendance proportion out of all invited to FIT was less pronounced (1·29 [1·16–1·42]), due to higher proportions of FIT positives in socioeconomically disadvantaged groups.

Interpretation
The unintended risk of exacerbating inequalities in health by organised colorectal cancer screening may be higher with a PCOL strategy than a FIT strategy, despite parallel socioeconomic gradients in uptake.

Funding
This work was supported by the Swedish Cancer Society under Grant 20 0719. CB and US provided economic support from the Swedish Research Council for Health, Working life, and Welfare under Grant 2020–00962.
Original languageEnglish
Article number101398
Number of pages10
JournalEClinicalMedicine
Volume47
Early online date16 Apr 2022
DOIs
Publication statusPublished - 26 Apr 2022

Bibliographical note

Funding Information:
This work was supported by the Swedish Cancer Society under Grant 20 0719 . CB and US provided economic support from the Swedish Research Council for Health, Working life, and Welfare under Grant 2020–00962 .

Funding Information:
CB reports a grant from the Swedish Research Council for Health, Working life and Welfare under grant no. 2020–00962 to his institution. CM reports travel and subsistence expenses refunded from the study budget (no external funding of this). US reports grants from the Swedish Cancer Society under grant no. 20–0719 and the Swedish Research Council for Health, Working life and Welfare under grant no. 2020–00962 to his institution. All other authors have nothing to declare.

Publisher Copyright:
© 2022 The Author(s)

Keywords

  • Population
  • Cancer prevention
  • Screening uptake
  • Health equity
  • Socioeconomic status
  • Colorectal cancer

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