Mobile health in colorectal cancer screening

INTRODUCTIONOver the past two decades, the advent of internet and smartphone provided a fertile platform for the development of mobile health (mHealth), technologies. Colorectal cancer (CRC) is the third most common cancer and the fourth most common cause of cancer death worldwide. Although CRC screening by fecal immunochemical tests (FIT) and colonoscopy is proven to be effective in reducing its incidence and mortality, this huge burden remains a challenge with several unresolved issues which may be improved by the use of mobile health technologies.Firstly, FIT is a cost-effective colorectal cancer screening tool. However, longitudinal adherence, a critical factor to the success to any FIT-based screening program, is often poor.Secondly, the rapidly increasing demand of screening colonoscopy in recent years increased the burden on outpatient-based colonoscopy. Nonattendance of outpatient colonoscopy is a well-established issue.Thirdly, high-quality bowel preparation is important, especially for colonoscopy following positive FIT in CRC screening as this population have a significantly increased CRC risk.OBJECTIVES1. To investigate the impact of text reminder sent via WhatsApp Messenger on the longitudinal adherence of FIT-based CRC screening program;2. To study the effectiveness of using Short Message Service (SMS) reminder prior in patients scheduled for outpatient colonoscopy on their nonattendance rate; and3. To assess the effect of reinforced education delivered by WhatsApp Messenger on the bowel preparation quality of screening colonoscopy following positive FIT.METHODS1. Subjects from an opportunistic FIT screening program who had a negative FIT the year prior were randomly allocated (1:1) to receive either a one-off reminder via the WhatsApp Messenger (WR) 1-month prior the due appointments or no reminder (NR). All subjects were blinded to the study participation and group allocation. At 24 months after randomization, a crossover of intervention was performed to those remained in the FIT program. The primary outcome was FIT adherence, defined as FIT pick-up and return on time. The secondary outcome was FIT adherence after crossover.2. Patients who scheduled for an outpatient colonoscopy and had access of SMS were recruited from three clinics in Hong Kong. Patients were randomized to SMS group and standard care (SC) group. All patients were given a written appointment slip on the booking date. In addition, patients in SMS group received a SMS reminder 7 – 10 days prior to their colonoscopy appointment. Patients’ demographics, attendance, colonoscopy completion and bowel preparation quality were recorded. Logistic regression was performed to identify predictors of nonattendance.3. Patients undergoing screening colonoscopy for positive FIT were randomized to receive either WhatsApp Reinforced Education (WRE) or No Reinforced Education (NRE) (1:1). Patients in WRE group received one-off reinforced education of bowel preparation in text and video formats via WhatsApp Messenger four days prior colonoscopy while NRE group received standard-of-care only. Primary outcome was the bowel preparation adequacy rate as evaluated by Aronchick Scale. Secondary outcomes included, adequacy rate as evaluated by Boston Bowel Preparation Scale (BBPS) and other colonoscopy outcomes. Risk factors of inadequate bowel preparation inadequacy were identified by logistic regression.RESULTS1. A total of 500 subjects were randomized to receive WR (n=250) or NR (n=250). Three were excluded (1 died and 2 had colonoscopy) from analysis. Both the FIT pick-up rate (80.3% vs 59.3%, p<0.001) and return rate (79.9% vs 57.3%, p<0.001) were significantly higher in the WR group when compared to NR group. After crossover of intervention (n=452), WR group again had higher FIT pick-up rate (79.1% vs 52.9%, p<0.001) and return rate (78.2% vs 52.4%, p<0.001).2. From November 2013 to October 2019, a total of 2225 eligible patients were recruited. 1079 patients were allocated to SMS group and 1146 to SC group. The nonattendance rate of patients in SMS group was significantly lower than that in SC group (8.9% vs 11.9%, p=0.022). There were no significant differences in their baseline characteristics, colonoscopy completion rate and bowel preparation quality. A trend toward a higher rate of adequate bowel preparation was observed in the SMS group when compared with SC group (69.9% vs. 65.8%, p=0.053). Independent predictors for nonattendance included younger age, underprivilege and existing diabetes.3. From June 2017 to April 2019, 685 eligible patients were randomized to WRE (n=343) and NRE (n=342) groups. Patients who received WRE had higher bowel preparation adequacy rate as evaluated by Aronchik Scale (83.4% vs 75.4%, p=0.010) and BBPS (94.2%vs88.9%, p=0.013). Patients in WRE group had higher mean BBPS score (8.15vs7.98, p=0.038). Adenoma detection rate was higher in WRE group but without statistical significance (71.4%vs67.5%, p=0.27). Male gender and diabetes were risk factors of bowel preparation inadequacy.CONCLUSIONS1. Text reminder sent via mobile messengers improve the longitudinal adherence of FIT-based opportunistic CRC screening program. Routine use of this technology in CRC screening should be considered. quality. A trend toward a higher rate of adequate bowel preparation was observed in the SMS group when compared with SC group (69.9% vs. 65.8%, p=0.053). Independent predictors for nonattendance included younger age, underprivilege and existing diabetes.3. From June 2017 to April 2019, 685 eligible patients were randomized to WRE (n=343) and NRE (n=342) groups. Patients who received WRE had higher bowel preparation adequacy rate as evaluated by Aronchik Scale (83.4% vs 75.4%, p=0.010) and BBPS (94.2%vs88.9%, p=0.013). Patients in WRE group had higher mean BBPS score (8.15vs7.98, p=0.038). Adenoma detection rate was higher in WRE group but without statistical significance (71.4%vs67.5%, p=0.27). Male gender and diabetes were risk factors of bowel preparation inadequacy.CONCLUSIONS1. Text reminder sent via mobile messengers improve the longitudinal adherence of FIT-based opportunistic CRC screening program. Routine use of this technology in CRC screening should be considered.2. A SMS reminder for outpatient colonoscopy is effective in reducing the nonattendance rate and may potentially improve the bowel preparation quality.3. Reinforced education by mobile messenger improves the bowel preparation quality of screening colonoscopy following positive FIT. It is readily incorporable in clinical practice because of its low setup cost.背景在過去二十年間，互聯網及智能電話的出現為流動健康(mHealth)技術的發展提供了一個成熟的平台 。大腸癌（CRC）是全球第三常見癌症，亦是死亡率排行第四的癌症。雖然利用大便隱血測試（FIT）及大腸鏡檢查進行大腸癌篩查已證實能有效減低大腸癌的發病率和死亡率，但是大腸癌這巨大包袱仍然是一個有多項問題未解決的難題，而mHealth技術可能可以改善這些問題。首先，FIT是具成本效益的大腸癌篩查工具。可是，其依從性（大便測試篩查計劃成功與否的重要因素）通常不理想。第二，隨著近年大腸鏡篩查需求的增加，對門診大腸鏡檢查的負擔同時增加，而門診大腸鏡檢查病人的缺席是一個已知的問題。第三，在大腸癌篩查中，FIT結果呈陽性的人群有明顯較多的大腸癌風險，高質素的腸道預備對他們的大腸鏡檢查尤其重要 。目的1. 調查以WhatsApp發出的短訊提示對以FIT為主的大腸癌篩查計劃依從性的影響；2. 研究電話短訊（SMS）提示對提升門診大 腸鏡檢查病人缺席率的成效； 及3. 透過WhatsApp發出的加強教育對於FIT結果 呈 陽性病人的大腸鏡篩查中腸道預備質素的影響方法1. 參與了機會性大腸癌篩查計劃並且於前一年FIT結果呈陰性的人士會被隨機分配去接受（1：1）於覆檢到期前一個月以WhatsApp發出的一次性提示（WR）或者沒有提示（NR）。所有受試者都被遮盲，不知道研究的參與和分派組別。隨機分組24個月後， 仍然留在篩查計劃的受試者進行交叉干預 。研究主要目的是FIT依從性，其定義為按時領取及交回FIT，研究次要目的是交叉干預後的FIT依從性。2. 從三間香港的門診去招募已安排門診大腸鏡檢查以及可接收SMS的病人，隨後隨機分組到SMS組和標準護理(SC)組。所有病人均會獲派一張印有檢查日期的預約便條。SMS組的病人於大腸鏡檢查7至10天前會額外收到一個SMS提示。病人的個人資料、出席率、大腸鏡檢查完成率、腸道預備質素均會被紀錄。此外，缺席的預測因素會利用邏輯回歸去找出。3. 已安排大腸鏡篩查的FIT結果呈陽性病人會被招募並隨機分組（1：1）去接受WhatsApp加強教育（WRE）或沒有加強教育（NRE）。WRE組的病人於大腸鏡檢查4天前會收到透過WhatsApp發送的文字及錄影形式一次性加強教育，而NRE組的病人則只有常規護理。研究主要目的是以Aronchick 量表評分的腸道預備質素，次要目的包括以Boston量表（BBPS）評分的腸道預備質素及其他大腸鏡檢查發現。此外，腸道預備不足的風險因素會利用邏輯回歸去找出。結果1. 總共500位受試者被隨機分組去接受WR（n=250）或NR（n=250）。隨後，有三位受試者被排除出數據分析（一位死亡及兩位已接受大腸鏡檢查）。WR組的FIT領取率（80.3% vs 59.3%, p<0.001）及交回率（79.9% vs 57.3%, p<0.001）都明顯較NR組高。交叉干預後，WR組的FIT領取率（79.1% vs 52.9%, p<0.001）及交回率（78.2% vs 52.4%, p