1. Ruggli M.1), Stebler D.1), Besancon L.1), Vaucher F.1)
Colorectal cancer screening in pharmacy: a campaign in the Swiss pharmacies
Ruggli M.1), Stebler D.1), Besancon L.1), Vaucher F.1)
1) pharmaSuisse, Swiss Association of Pharmacists, Bern-Liebefeld, Switzerland
Contact:
AIMS OF THE CAMPAIGN:
Colorectal cancer is the third most common cancer worldwide and the second leading cause of cancer-related deaths.[1] In Switzerland, the incidence of colorectal cancer ranks third in males and second in females, with about 4,100 patients newly diagnosed every year, resulting in 1,600 deaths yearly, a third being among patients younger than 70 years of age.[2]
Faecal immunochemical testing (FIT) is an accepted strategy for colorectal cancer screening in the average-risk population. Although FIT is less effective than colonoscopy or sigmoidoscopy for neoplastic detection, evidence suggests that it may be better accepted and this higher acceptance may offset its lower detection capacity. Even if the Swiss authorities support colorectal cancer screening, the participation in colorectal cancer screening in Switzerland is very low and presently not offered systematically. To respond to this situation, pharmaSuisse (the Swiss association of pharmacists) launched in 2016 a preventive service in community pharmacies through a 6 week campaign to offer the Swiss people a low threshold screening opportunity. This campaign was associated with a study to evaluate its impact in terms of effectiveness, appropriateness, and cost/benefit ratio.
METHOD:
771 community pharmacies from all over Switzerland took part in the 2016 campaign. The campaign targeted men and women between 50 and 75 years of age, who had not had a colonoscopy over the last 10 years. Through a questionnaire, pharmacists evaluated the risk factors and delivered a stool-based test, faecal immunochemical test (FIT) when appropriate (i.e. to individuals without elevated and additional risk factors). pharmaSuisse selected as a stool test OC Sensor Test, a well evaluated and widely used FIT without particular restrictions on diet or medication use. The patient collected a stool sample at home and sent it in a prepaid envelope to the laboratory contracted for the whole Switzerland. Through a dedicated online platform, the lab shared the results with the pharmacist, who could then inform the patient. If the test results were positive, the patient was referred to a GP or gastroenterologist for a colonoscopy. In case of negative result, the pharmacist gave lifestyle advice and offered the opportunity to be invited for a new screening in two years.
This service was usually charged 30 CHF (25€); this fee included the FIT and lab analysis and was usually paid out-of-the pocket by the customer, as only one major health insurance scheme covered this service.
In order to be able to offer the service, participating pharmacists had to complete an online training on the colon cancer, the stool test, the screening service and the campaign.
RESULTS:
Within 6 weeks, 23,024 individuals were screened in pharmacies using the questionnaire. 97% of them were in the focussed age group, 61% were women. In comparison with the general Swiss population, the screened population was slightly healthier (figure 1).
52% of participants stated they had been informed about the opportunity of colorectal cancer screening in community pharmacy through the media coverage or through the campaign organised by pharmaSuisse. 47% of them reported that if it wasn’t for the implemented campaign, they would probably not have taken a screening.
Targeted population for the screening
Patients between 50 and 75 years of age, without colonoscopy over the last 10 years
Risk assessment
N= 23,024
Samples analysed
N = 21,071
Positive tests, visit to a medical doctor recommended
N = 1,510
Elevated risks N=760
Referral to GP: N=632 (83%)
Referral to specialist N=128 (17%)
Provision of FITs
N= 22,264 3%
97% 7%
Negative tests
N=20,191
93%
Samples not sent by patients
N=563
Figure 1: Comparison of study population with the average Swiss population
Figure 2: Campaign results
As shown on figure 2, 760 patients (3%) were found with elevated risk factors through the pre-test questionnaire and were referred directly to a physician. All other patients (22,264 ; 97%) received a FIT, out of which 21,701 (97%) collected a sample and sent it back to the laboratory. Of all tests analysed, 20,191 (93%) were negative. 1,510 patients with a positive result were referred to a physician or a gastroenterologist for a colonoscopy.
Based on the literature,[3]-[4] we estimate that 5% (3-11) of patients with the positive stool tests effectively had colorectal cancer and 31% [24-38] suffered from advanced adenoma.
In total, 2,270 persons (10%) were referred to a medical doctor: 760 for additional investigations in relation with their elevated and additional risk factors (determined through the questionnaire), and 1,510 because of the positive stool test.
If we assume that 2/3 patients followed this recommendation and had eventually a colonoscopy, we can estimate that thanks to the campaign, 58 [33-114] cases of colon cancer were diagnosed and 364 [ ] advanced adenoma were detected. Our evaluation also shows that colorectal screening in Swiss pharmacies is very likely to be cost-saving.
CONCLUSIONS:
The 2016 campaign results have demonstrated the feasibility and high acceptance of patients for this service. Currently this service is only covered by one health insurance scheme but the evidence was relevant to engage with public health authorities and helped position pharmacies as partners in health promotion and prevention. At national level, the Swiss national cancer strategy recognised the important role of pharmacists in preventing colon cancer.[2] At local level, health authorities from Cantons are developing their local prevention programmes on colon cancer, and so far all of them have integrated pharmacists in their programmes.
Based on these positive results, it was decided to sustain the provision of this screening service: 500 Swiss pharmacies offer this service all year long, while 350 community pharmacies offer this service only during the campaign organised every two years. pharmaSuisse organised the 2018 campaign from 1st March to 14th April and Swiss patients were able to access this screening service in 850 pharmacies (out of 1770 Swiss community pharmacies; 50%).
REFERENCES:
1 Ferlay J, Soerjomataram I, Ervik M et al. GLOBOCAN 2012v1.0 Cancer Incidence and Mortality Worldwide: IARC Cancerbase No 11. Lyon: International Agency for Research on Cancer, 2013.
[2] Kramis K, Ruckstuhl B, Wyler M. Nationale Strategie Gegen Krebs 2014–2017 [National Cancer Strategy ]. Bern: Dialog Nationale Gesundheitspolitik [National Health Policy Dialog], 2013.
[3] Quintero E, Castells A, Bujanda L, Cubiella J, Salas D, Lanas Á et al. Colonoscopy versus Fecal Immunochemical Testing in Colorectal-Cancer Screening. New England Journal of Medicine 2012: 366(8), 697–706.
[4] de Wijkerslooth T, Stoop E, Bossuyt P, Meijer G, van Ballegooijen M, van Roon A et al. (2012). Immunochemical Fecal Occult Blood Testing Is Equally Sensitive for Proximal and Distal Advanced Neoplasia. American Journal of Gastroenterology 2012 Oct; 107(10):