Research ArticleOriginal Research

Reasons for No Colonoscopy After an Unfavorable Screening Result in Dutch Colorectal Cancer Screening: A Nationwide Questionnaire

Lucinda S. Bertels, Kristel M. van Asselt, Henk C. P. M. van Weert, Evelien Dekker and Bart J. Knottnerus
The Annals of Family Medicine November 2022, 20 (6) 526-534; DOI: https://doi.org/10.1370/afm.2871

Article Figures & Data

Figures

  • Figure 1.
    Figure 1.

    Dutch CRC screening protocol.

    CRC = colorectal cancer; FIT = fecal immunochemical test.

  • Figure 2.
    Figure 2.

    Overview of inclusion.

    C = colonoscopy; CIC = contraindication and no colonoscopy; CRC = colorectal cancer; FIT = fecal immunochemical test; NC = no colonoscopy and no contraindication; ScreenIT = database of the Netherlands National Institute for Public Health and the Environment, which is the Dutch screening organization.

    a Participants in the Dutch CRC screening program with a positive FIT 4-6 months ago at time of postal mailing of questionnaires.

    b All FIT-positive participants with a positive FIT 4-6 months ago who did not undergo colonoscopy in the Netherlands were sent the questionnaire.

    c Control group that did undergo colonoscopy matched to no colonoscopy group for age, sex, and previous participation in the screening program.

    d Because it was unlikely that 1,495 individuals responded of the 1,500 that were sent the questionnaire (see C), it appeared that a proportion of individuals who were registered as no colonoscopy (see B) did report a colonoscopy and therefore ended up in the colonoscopy group (see C) in this study.

Tables

  • Table 1.

    Demographic Characteristics of CIC Group vs NC and C Groups

    CharacteristicMissing or No Answer %CIC Group (n = 404)NC Group Sig. (2-Tailed)aC Group Sig. (2-Tailed)b
    N%c or MeanP (Mean Difference)dP (Mean Difference)d
    Age, y15NA67.61                    .292                    .001 (1.19)
    Male1418347.3%                    .482                    .02
    Living with partner1528069.3%                    .002 (0.113)                    .054
    Having ≥1 child1529886.6%                    .003 (0.09)                    .686
    Living in urban area1833344.4%                    .07                    .187
    Educational level18
       PrimaryNA  19  4.7%                    .233                    .941
       SecondaryNA11328.0%                    .728                    .569
       Vocational trainingNA10526.0%                    .139                    .001 (−0.081)
       Higher educationNA9423.3%                    .705                    .02
    Sufficient financial resources2825788.6%                    .004 (.092)                    .981
    Not born in the Netherlands13  22  6.3%                    .032                    .979

    • C = colonoscopy; CIC = contraindication no colonoscopy; NA = not applicable; NC = no colonoscopy no contraindication; Sig. = significance level.

    • ↵a Two-tailed independent t test comparing means of CIC group and NC group.

    • ↵b Two-tailed independent t test comparing means of CIC group and C group.

    • ↵c Valid percentages (percentages left when missing data are excluded from the calculation) reported.

    • ↵d Mean difference vs control group stated for variables with a significance level of P < .05.

  • Table 2.

    Reasons for Non–Follow-Up With Colonoscopy

    ReasonNo.%% of Cases
    (Nr = 730)
    Had a recent colonoscopy21114.028.9
    Alternative explanation for positive FITa21414.229.5
    Chronic illness17211.523.6
    Diagnosis of ulcerative colitis/Crohn disease or other reason for regular visits with gastrointestinal specialist or internist130  8.717.8
    Advised against colonoscopy by gastrointestinal specialist or internist  93  6.212.7
    Aversion to colonoscopy  73  4.910.0
    FP advised against colonoscopy  71  4.7  9.7
    Had a second negative FIT  69  4.6  9.5
    Acute illness  63  4.2  8.6
    Undergoing cancer treatment  56  3.7  7.7
    No answer provided  47  3.1  6.4
    Advised against colonoscopy during intake for colonoscopy  44  2.9  6.0
    No symptoms/fecal blood has no meaning  31  2.1  4.2
    Short life expectancy  30  2.0  4.1
    Medical barrier  27  1.8  3.7
    Fear of outcome  25  1.7  3.4
    Practical barrier  24  1.6  3.3
    Want a second FIT  17  1.1  2.3
    Want more personalized care  16  1.1  2.2
    Low perception of risk of CRC  14  0.9  1.9
    Financial consequences of colonoscopy  13  0.9  1.8
    Nonmedical priorities  11  0.7  1.5
    Do not want treatment if CRC is found  11  0.7  1.5
    Distrust screening test, organization, or process  11  0.7  1.5
    Other reason, without contraindication  10  0.7  1.4
    Nurse advised against colonoscopyb    7  0.5  1.0
    Had a second opinion (CT colonography/MRI)    6  0.4  0.8
    Dementia, mental disability, severe psychiatric issues    6  0.4  0.8
    Totalc1,502100.0205.8

    • CRC = colorectal cancer; CT = computed tomography; FIT = fecal immunochemical test; FP = family physician; MRI = magnetic resonance imaging; No. = number of times reason was mentioned; Nr = total number of respondents who reported not undergoing colonoscopy, excluding respondents with recent CRC diagnosis and respondents of whom it was unclear if they underwent colonoscopy.

    • Note: Reasons highlighted in bold were considered a valid contraindication for colonoscopy.30,34

    • % = proportion of all reasons mentioned; % of cases = proportion of Nr that mentioned reason.

    • ↵a Thinking blood in stool was caused by hemorrhoids, fissure, constipation, medication, or other and not underlying neoplasia.

    • ↵b Refers to care personnel, such as district nurses or homecare, without a medical degree.

    • ↵c Most respondents reported >1 reason.

  • Table 3.

    Demographic Characteristics and Descriptive Statistics of CRC Knowledge Items for C and NC Groups

    CharacteristicTotala
    (n = 1,821)    		Missing, %C Groupa
    (n = 1,495)    		NC Groupa
    (n = 326)    		P Value
    (χ2)
    Age, mean, y66.54.766.467.1.66
    Male, No. (%)1,033 (58.9)3.7861 (59.7)172 (55.5).17
    Living with partner, No. (%)1,299 (71.3)4.71,110 (74.2)189 (58.0)<.001
    Having ≥1 child, No. (%)1,475 (84.7)5.41,239 (86.4)236 (76.9)<.001
    Living in urban area, No. (%)720 (42.4)6.8570 (40.5)150 (51.7)<.001
    Educational level, No. (%)6.8.08
       Primary90 (4.7)NA68 (4.8)22 (7.6).1
       Secondary492 (26.7)NA397 (28.2)95 (32.8).34
       Vocational training610 (33.6)NA509 (36.2)101 (34.8).29
       Higher education504 (27.6)NA432 (30.7)72 (24.8).01
    Insufficient financial resources, No. (%)191 (13.0)19.1140 (11.4)51 (20.6).002
    Not born in the Netherlands, No. (%)125 (7.2)4.191 (6.3)34 (11.0).004
    Had ≥1 CRC-related symptom at time of FIT, No. (%)622 (34.2)NA512 (34.2)110 (33.7).86
       Visible blood422 (24.5)5.3335 (23.6)87 (28.5).07
       Tenesmus176 (10.6)9.0156 (11.4)20 (6.8).02
       Stool pattern change190 (11.1)5.9171 (12.1)19 (6.4).004
       Weight loss61 (3.6)6.553 (3.8)8 (2.7).35
    CRC knowledge item, No. (%)b
       CRC always causes symptoms904 (52.8)5.9700 (49.3)204 (69.4)<.001
       Positive FIT usually means cancer417 (24.3)5.8295 (20.8)122 (41.4)<.001
       Screening is meant for persons with symptoms562 (32.9)6.1414 (29.3)148 (50.2)<.001
       Negative FIT ensures absence of cancer806 (47.0)5.8659 (46.4)147 (50.0).26
       Colonoscopy has high risk of complications647 (37.8)6.0460 (32.4)187 (64.0)<.001
       Having symptoms means that cure is not possible371 (21.7)6.0269 (19.0)102 (34.7)<.001
       CRC does not develop over several yearsc933 (54.4)5.8750 (52.7)183 (62.5).002
       Removing polyps does not prevent CRCc621 (36.4)6.2436 (32.7)158 (53.9)<.001
       CRC cannot be cured, even if it is found at an early stagec373 (21.8)6.0281 (19.8)92 (31.3)<.001
       >75% of people with CRC die of it913 (53.2)5.8716 (50.4)197 (67.0)<.001
    High levels of trust in ability to self-detect CRCc251 (14.6)5.8152 (10.7)99 (33.8)<.001

    • C = colonoscopy; CRC = colorectal cancer; FIT = fecal immunochemical test; NA = not applicable; NC = no colonoscopy no contraindication.

    • ↵a Valid percentages (percentages left when missing data are excluded from the calculation) reported.

    • ↵b No. = answers of “true” and “don’t know” combined.

    • ↵c Questions were originally phrased positively (eg, “CRC develops over several years”) but were rephrased in the negative sense for readability.

  • Table 4.

    Results of Logistic Regression Analysis for NC and C Groups

    VariableaβSESig. (P)bORLower
    95% CI    		Upper
    95% CI
    Knowledge-associated factors
       Alternative explanation for blood in stool sample    −1.202    0.179    <.001    0.301    0.212    0.427
       High trust in ability to self-detect CRC by monitoring own body    −0.86    0.22    <.001    0.423    0.274    0.654
       Colonoscopy has high risk of complications    −0.696    0.177    <.001    0.499    0.352    0.706
       Removing polyps does not prevent CRC    −0.524    0.167    .002    0.592    0.427    0.821
    Participant-associated factors
       Negative colonoscopy advice from someone outside medical setting    −1.265    0.387    .002    0.282    0.13    0.616
       Difficulty deciding to undergo colonoscopy    −1.24    0.241    <.001    0.29    0.18    0.466
       Low estimation of personal risk for CRC    −0.81    0.268    .003    0.445    0.261    0.758
       Know others with negative colonoscopy experience    −0.688    0.24    .004    0.502    0.314    0.805
       CRC-related worry (cancer worry scale)      0.096    0.038    .012    1.101    1.022    1.187
       Positive colonoscopy advice from anyone      0.571    0.188    .002    1.77    1.223    2.56
       Had negative colonoscopy experience      0.685    0.246    .005    1.983    1.225    3.212
    Provider-associated factors
       Thinks that FP would support colonoscopy      1.045    0.176    <.001    2.843    2.012    4.016
       Contact with FP regarding FIT outcome    −0.255    0.184    .167    0.775    0.54    1.113
    System-associated factors
       Little opportunity to discuss desirability of colonoscopy    −0.796    0.238    .001    0.451    0.281    0.724
       Uncomfortable with unfamiliar colonoscopy location    −0.758    0.227    .001    0.469    0.3    0.733
       Total trust in 3 dimensions (organization, clinic, FIT)c      0.16    0.053    .004    1.173    1.055    1.305

    • C = colonoscopy; CRC = colorectal cancer; FIT = fecal immunochemical test; FP = family physician; NC = no colonoscopy no contraindication; OR = odds ratio; Sig. = significance level.

    • ↵a Nagelkerke R2 = 0.521 for pooled results.

    • ↵b Results interpreted as statistically significant at P < .05.

    • ↵c Cronbach α = 0.836.

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