Strömberg U, Bonander C, Westerberg M, Levin L Å, Metcalfe C, Steele R, Holmberg L, Forsberg A, Hultcrantz R
School of Public Health and Community Medicine, Institute of Medicine, Sahlgrenska Academy at University of Gothenburg, PO Box 463, Gothenburg SE-405 30, Sweden.
Department of Mathematics, Uppsala University, Box 480, Uppsala SE-751 06, Sweden.
EClinicalMedicine. 2022 Apr 16;47:101398. doi: 10.1016/j.eclinm.2022.101398. eCollection 2022 May.
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.
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 ( = 60,123) or once-only PCOL ( = 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 proportion 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.
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 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.
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.
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.
在瑞典进行的随机对照筛查试验SCREESCO中，我们分别探讨了粪便免疫化学检测（FIT）和初次结肠镜检查（PCOL）所实现的健康公平性。
我们分析了在ClinicalTrials.gov注册的研究（NCT02078804）中2014年3月至2020年3月招募的个体的数据。瑞典人口登记处关于教育水平、家庭收入、出生国家和婚姻状况的数据与每一位60岁的男性和女性相关联，这些人被随机分为相隔2年进行两轮FIT（n = 60,123）或仅进行一次PCOL（n = 30,390）。此外，我们对每个研究个体的居住区域进行地理编码，并评估邻里层面关于贫困、非西方移民比例、人口密度以及到结肠镜检查医疗中心的平均距离的数据。我们估计了每个协变量与各臂中比例的调整关联；即解决健康公平性的首选结果。在FIT组中，检测接受率以及检测呈阳性者中的结肠镜检查接受率被视为次要结果。
我们发现PCOL组中结肠镜检查参与比例存在明显的社会经济梯度（家庭收入处于全国最高四分位数与最低四分位数的组之间的调整优势比[95%可信区间]：2.20[2.01 - 2.42]），这与FIT×2筛查中比例的梯度（2.08[1.96 - 2.20]）平行。在所有被邀请进行FIT的人群中，结肠镜检查参与比例的相应梯度不太明显（1.29[1.16 - 1.42]），这是因为社会经济弱势群体中FIT呈阳性的比例较高。
尽管在接受率方面存在平行的社会经济梯度，但与FIT策略相比，PCOL策略通过有组织地进行结直肠癌筛查而加剧健康不平等的意外风险可能更高。
这项工作得到了瑞典癌症协会20 0719号资助。CB和US由瑞典卫生、工作生活和福利研究理事会根据2020 - 00962号资助提供了经济支持。
