As colorectal cancer is the most common cancer type as well as the second most common cause of cancer deaths locally,1 the Hong Kong Government has launched a subsidized colorectal cancer screening program.2 At the Hong Kong Academy of Medicine 25th Anniversary Congress, Professor Martin C.S. Wong, the associate director of Jockey Club School of Public Health and Primary Care, the Chinese University of Hong Kong (CUHK), shared his experience from the territory-wide bowel cancer screening program launched by the CUHK Jockey Club Bowel Cancer Education Center, which provided some insights on how to assess the performance of a colorectal cancer screening program and some key elements that can improve the adherence rate.
The first phase of the government-subsidized colorectal cancer screening program has been launched since August 6, 2018 to allow all asymptomatic Hong Kong residents aged between 61-75 years to undergo a screening test using the fecal occult blood test (FOBT).3 The program will be implemented in three phases to extend the coverage to those aged 50-75 years.3 All participants with a positive test result will be referred to receive a colonoscopy examination to confirm the source of bleeding and remove any polyps that were found during the examination.3,4
Long before the launch of the government-subsidized screening program, CUHK had already launched a territory-wide bowel cancer screening program between May 2008 and December 2012, which was extended for another five years starting from 2013.5,6 With over ten years of experience in running a colorectal cancer screening program, Prof. Wong presented some of the important performance indicators that can be used to assess the performance of any population-based screening program.
The performance indicators selected by Prof. Wong include attendance rate, screening adherence, compliance, positivity rate of FOBT, quality of bowel preparation, complications, and detection of high-risk adenomas. Of note, the uptake rate was not selected because of the self-enrollment nature of this screening program, where the uptake rate will be 100%.
Although the attendance rate to the screening test in the CUHK-organized program was generally high (over 97%), Prof. Wong highlighted the screening compliance to subsequent FOBT (from 97.8% in year 0 [baseline] to <80% in subsequent years) and surveillance colonoscopy (49.1%) were quite poor, which represented the challenges in implementing a long-lasting screening program with good compliance, as many screening experts have already raised this issue out.
In a prospective randomized parallel study that assessed the association between reminder interventions and adherence to colorectal cancer screening program, the FOBT pickup and return rate was significantly higher in participants received an 1-way automated SMS reminder (pickup rate adjusted OR=2.35; 95% CI: 1.50-3.70; return rate adjusted OR=2.39; 95% CI: 1.47-3.88) and telephone reminder by healthcare professionals (pickup rate adjusted OR=6.14; 95% CI: 3.54-10.64; return rate adjusted OR=5.23; 95% CI: 2.92-9.37) compared with the usual care group.7 Another population-based telephone survey found that physician’s recommendation was a major factor associated with colorectal cancer screening test (adjusted OR=23.50; 95% CI: 10.66-51.80).8 The results of the two studies suggested that physician’s recommendation and interactions with healthcare professionals play a vital role in maintaining the screening test adherence rate, which may offer some solutions to improve the sustainability of a colorectal screening program.
“In order for colorectal cancer screening to be successful, we need organized and concerted effort from everybody, not just general practitioners, but every healthcare professionals, to promote colorectal cancer screening in our community,” said Prof. Wong to conclude the key to a successful screening program from his experience.
1. Leading Cancer Sites in Hong Kong in 2016. 2018. Hospital Authority. (Accessed December 28, 2018, at http://www3.ha.org.hk/cancereg/pdf/top10/rank_2016.pdf.)
2. Colorectal Cancer Screening Programme – Background. Department of Health. (Accessed December 28, 2018, at https://www.colonscreen.gov.hk/en/public/programme/background_of_programme.html.)
3. Press Releases – Colorectal Cancer Screening Programme to be launched on August 6. 2018. The Government of the Hong Kong Special Administrative Region. (Accessed December 28, 2018, at https://www.info.gov.hk/gia/general/201807/30/P2018073000294.htm?fontSize=1.)
4. Colorectal Cancer Screening Programme – Standard package of colonoscopy service. Department of Health. (Accessed December 28, 2018, at https://www.colonscreen.gov.hk/en/public/programme/standard_package_of_colonoscopy_service.html.)
5. Information on Press Conference – 20 January 2014. 2014. CUHK Jockey Club Bowel Cancer Education Centre. (Accessed December 28, 2018, at http://www.idd.med.cuhk.edu.hk/bowelcancer/images/stories/Bowelcancer/Script_summary_of_findings-updates_on_20140125.pdf.)
6. Press Releases – CUHK Welcomes the “Pilot Bowel Cancer Screening Programme” and Recommends Subsidizing Residents Aged 61-70 First. 2014. The Chinese University of Hong Kong. (Accessed December 28, 2018, at https://www.cpr.cuhk.edu.hk/en/press_detail.php?id=1881&t=cuhk-welcomes-the-pilot-bowel-cancer-screening-programme-and-recommends-subsidizing-residents-aged-61-70-first.)
7. Wong MC, Ching JY, Lam TY, et al. Association of Interactive Reminders and Automated Messages With Persistent Adherence to Colorectal Cancer Screening: A Randomized Clinical Trial. JAMA Oncol. 2017;3(9):1281-1283.
8. Sung JJ, Choi SY, Chan FK, et al. Obstacles to colorectal cancer screening in Chinese: a study based on the health belief model. Am J Gastroenterol. 2008;103(4):974.