Cost of diagnostic and therapeutic management of colorectal cancer according to stage at diagnosis in the Calvados Département, France.

Screening for colorectal cancer is a high priority of public health in France, as in other Western countries. In spite of its effectiveness, shown by randomized studies, no national program of colorectal screening using fecal occult blood test has yet implemented, due mainly to the low sensitivity of the screening test and to the weak participation of the target population. Economic studies can make a useful contribution to helping the decision makers of public health. One of the advantages to the organization of a screening program is a financial saving generated by advance in diagnosis. To investigate this hypothesis this study assessed the cost of the management of colorectal cancer according to its stage of extension using medical data from a specialized cancer registry and economic data from the national Social Security System. No significant decrease in the first-year costs of treating colorectal cancer was found with advance of diagnosis. The average cost for the first year of management of colorectal cancer after diagnosis was of Euro 21,918. According to the stage of diagnosis, the highest average cost was for the subjects with a cancer with lymph node involvement, with a cost of Euro 31,110. Cancers with an invasion limited to the submucosa or visceral metastases had an equivalent cost, respectively, of Euro 17,579 and of Euro 17,384. With a limited power due to low strength, these results suggest that the organization of a colorectal cancer screening program does not significantly reduce in the first year the total cost of management of this cancer. However, the organization of such screening remains a public health priority, prevention aiming only to allow subjects to live in good health as long as possible,and not to save money.

[Mass screening for colorectal cancer in France. Experience in 165,000 people in the department of Calvados]. / Le dépistage de masse du cancer colorectal en France. Expérience auprès de 165,000 personnes dans le Calvados.

OBJECTIVES: Screening for colorectal cancer is a major public health problem in France as in most developed countries. Several controlled trials are on-going in Europe. The aim of the study was to determine requirements for success of mass-screening for colorectal cancer in France. METHODS: A mass-screening program has been conducted between April 1991 and June 1994 in the department of Calvados for 164,364 people aged 45-74 years. The screening test was first proposed by general practitioners and occupational doctors during appointments. Secondly, a postal invitation to obtain the test, free of charge, by doctor or chemist, was sent. RESULTS: Global participation rate was 43.4%; 40.2% of tests were distributed during the first phase, 47.1% during the second phase and 12.7% were distributed by a private health institute. Participation was higher for females (47.1%) than males (39.2%) and for urban districts (46.5%) than rural districts (24.4%). In case of positive test, colonoscopy has been more frequently achieved in urban districts and when test has been distributed by a physician. Positivity rate was 2.8%. Positive predictive value was 8.0% for a cancer and 13.5% for an adenoma larger than 1 cm. Because both positivity rate and positive predictive value were higher for males than females and increased with age, rate of cancer or large adenoma screened was almost three times higher for males than females and markedly increased with age. CONCLUSIONS: In France, different recruitment methods have to be used to reach a satisfactory participation to a mass-screening campaign. Such a program requires involvement of general practitioners and close coordination between practitioners and health care insurance agencies.

Haemoccult test properties according to type and number of positive slides in mass screening for colorectal cancer.

Despite encouraging results from recent studies, there is still no consensus to undertake mass screening using the Haemoccult test in the general population. The success of mass screening for colorectal cancer depends among other things on Haemoccult test properties. In on-going screening programmes, the Haemoccult test consists of six slides and a test is considered positive if at least one slide is coloured. The aim of this work was to study the influence of the type and number of positive slides on the Haemoccult test's positive predictive value and characteristics of screened lesions. This work focuses on 63,958 first tests in a mass screening programme in Calvados (France) among people aged 45-74 years. There was a linear relation between the positive predictive value for cancer or an adenoma larger than 1 cm and the number of positive slides (P < 10(-4)). The positive predictive value for cancer or large adenoma was significantly higher when 4-6 slides were positive (44.3%) than when only 1-3 were positive (19.1%) (P < 10(-4)). In this latter group, the subjects in whom tumours were detected were younger and had significantly less extensive cancers. Borderline tests (no slides positive and at least one slide with a blue coloration confined to the edges) had a positive predictive value for cancer or an adenoma larger than 1 cm no different to that of tests with 1-3 positive slides. Subjects with borderline results were markedly younger than the others and had less extensive cancers and rectal localisation more often than the others. Our results suggest that (1) increasing the number of positive slides required to declare a test positive leads to an increase in the positive predictive value but is not to be recommended because of the sensitivity of the test and (2) considering borderline Haemoccult tests as positive in on-going and future mass screening campaigns would allow an increase in the sensitivity of the test, especially for rectal cancer and low extensive tumours without any decrease in its positive predictive value.

Participants' characteristics in a French colorectal cancer mass screening campaign.

BACKGROUND: Participation by the target population is clearly a key element in the success of mass screening programs for colorectal cancer. In France, involvement of general practitioners in test distribution is essential to reach a satisfactory participation rate, but other forms of recruitment also have to be organized. The aim of this study was to determine the influence of demographic characteristics such as sex, age, and place of residence on the participation rate in a French mass screening according to different recruitment methods. METHODS: The Hemoccult IIR test was proposed in three consecutive ways: spontaneously by general practitioners and occupational doctors during appointments (phase 1), by postal invitation (phase 2), and finally by direct mailing of the test (phase 3). The target population consisted of 11,947 people between 45 and 74 years of age, living in a district of the French county of Calvados, between March 1991 and April 1993. RESULTS: The overall participation rate was 51.3%. Forty-nine percent of all the tests were done during phase 1, 31% during phase 2, and 20% during phase 3. The overall participation rate varied essentially according to the place of residence, from 65.5% in urban areas and 48.9% in intermediate areas to 27.7% in rural areas. The overall participation rate was also higher for females (57%) than for males (45%) and for those 60 years and older (53.9%) than for those below this age (49.2%). The proportion of tests done during phase 1 was lowest among the youngest and the oldest age groups (37.5% in the 45- to 49-year class and 45.2% in the 70- to 74-year class) and among people living in the rural environment (respectively 55.3%, 45.5%, and 35.9% in urban, intermediate, and rural areas). CONCLUSIONS: This study shows that place of residence strongly influences the global participation rate in mass screening for colorectal cancer in France, whereas sex and age have little influence. Recruitment methods complementary to distribution by general practitioners must be organized, especially for the youngest and oldest age groups (45-49 years and 70-74 years) and above all for people living in rural areas. The social, cultural, and psychological reasons for these differences remain to be investigated, with the aim of adapting mass screening strategies to the different population groups.

Involvement of general practitioners in mass screening. Experience of a colorectal cancer mass screening programme in the Calvados region (France).

Good compliance with screening programmes is essential and experience from ongoing studies points to the importance of involving general practitioners (GPs). The aim of this study was to evaluate factors influencing the participation of GPs in a screening programme, as well as acceptance of the test by the population. Fifty GPs were randomly chosen among the 117 practices of three districts in Calvados (France) where haemoccult test-based mass screening for colorectal cancer was underway. Each GP was asked to fill in a personal questionnaire as well as a detailed record for each patient between 45 and 74 years seen in the practice during a 1-week period. The GPs offered the test to 95% of the patients. The overall refusal rate was 7.8%, and was higher in women than in men (9.9% vs 5.9%; P < 0.05). Manual workers had a lower refusal rate than other occupational groups (2.5% vs 8.5%; P < 0.05). The GP's motivation was an important factor in patient compliance: the refusal rate was 5.4% in the case of highly motivated GPs, against 20.0% when the GP was poorly motivated (P < 0.01). GP motivation was higher in urban than in rural areas (P < 0.05) but did not depend on sex, age or the duration or type of practice. According to the GPs, motivating factors were the perceived need for screening, involvement in planning the campaign, and regular feedback. Conversely, a lack of time and the possibility of false-negative results were the most important impediments. This study demonstrates that patient compliance is closely linked to practitioner motivation.(ABSTRACT TRUNCATED AT 250 WORDS)