Impact of socioeconomic factors on surveillance colonoscopy

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Overall, Australians from the two lowest socioeconomic status (SES) groups are 1.2 times more likely to be diagnosed with colorectal cancer (CRC) compared with those from the two highest SES groups and those from the lowest SES are 1.3 times more likely to die from CRC than those from the highest SES.[1]

Rurality also contributes to disadvantage; people living in very remote areas are less likely to be diagnosed with CRC but more likely to die from CRC than those living in other regions suggesting that this group do not reap the benefits of early CRC detection that those in major cities and regions do.[1]

It was demonstrated in a study in the United States that lower uptake of screening and treatment in low, compared to high, SES groups leads to the disparity in mortality due to CRC in these populations.[2]

The primary objective of surveillance is to reduce the incidence and mortality of subsequent CRC. There are several ways the impact of low SES on surveillance can be mitigated:

  • Prevention – education to reduce adenoma or cancer occurrence/ recurrence
  • Participation – engagement to ensure participation in evidence-based surveillance
  • Preparation – ensuring effective bowel preparation to enable a high quality colonoscopy
  • Postponement – understanding and agreement to defer colonoscopy when the risks outweigh the benefits due to comorbidities or life expectancy.

Effective communication between consumers and healthcare providers, and within healthcare teams, has been linked to improved consumer health outcomes.[3] Effective communication is relevant to all four of these aspects of surveillance.

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Overview of evidence (non-systematic literature review)

No systematic reviews were undertaken for this topic. Practice points are based on selected evidence and guidelines (see Guideline development process).


Colorectal cancer is predominantly a lifestyle disease.[4][5][6] Lifestyle modification is important for the prevention of colorectal polyps, especially advanced and multiple adenomas, which are established precursors of colorectal cancer.

The key question in the context of surveillance is whether individuals identified as being at increased risk by prior colonoscopy, who are then enrolled in surveillance, can benefit from lifestyle modifications, given the time needed to show benefit. There is evidence that this is the case for some risk factors.[6] There is an obligation to inform patients of the evidence and support effective action to address these risk factors. For patients of low SES, this can be a particular challenge because of both social and economic barriers. However, the individual gains will be greater because of the higher prevalence of most risk factors for CRC among lower SES groups.[7] Beneficial changes include smoking cessation, weight reduction, increased physical activity and improved diet. The benefits will have more impact at a population than individual level.[8] For instance, data from the Nurses’ Health Study and Health Professional Follow-up Study show that weight loss in men but not post-menopausal women was associated with decreased CRC risk within 4 years.[9] Low SES may be associated with a higher prevalence of these at-risk behaviours but also influence an individual’s capacity to benefit from these interventions. These data are from population studies and do not provide information for familial cancer syndromes or those with inflammatory bowel disease (IBD).

Lifestyle factors also appear to be important in CRC recurrence.[10][11]Time since smoking cessation has been significantly associated with a decreased risk of some CRCs and the likelihood of synchronous cancers.[12][13][14] This finding is particularly relevant to lower SES and Indigenous populations because of their higher rates of smoking.

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Clinicians should advise patients that modification of lifestyle factors can reduce their risk of polyp recurrence and colorectal cancer.

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The doctor-patient relationship has a strong influence on acceptance of colonoscopy.[3][15] The need for colonoscopy will need to be discussed with all patients, but more specific attention will need to be directed to socio-economically deprived patients. They will benefit by being encouraged to comply with the recommendations of guidelines such as these.

Patients in the three target groups for surveillance colonoscopy covered by these guidelines will have already received treatment for their underlying condition (in adenoma follow-up or following resection for CRC) or had diagnosis of their disease (IBD). Any barriers to health system access and provision of appropriate care should have been identified in the course of initial management, allowing them to complete their primary treatment. Surveillance in these patients will in large part be fulfilled by maintaining their effective engagement. Those most at risk of being lost to follow-up should be identified and include those from low SES backgrounds.[16][17][18]

Marital status has also been shown to influence likelihood of participating in surveillance, with individuals having a current partner being more likely to participate[19][20]

Aboriginal and Torres Strait Islander participants, participants who live in regional and remote regions, and participants who live in areas of lower socioeconomic status, have higher rates of positive screening results but lower rates of follow-up colonoscopies than other participants.[21]

For colonoscopy, other procedural factors also need to be considered, anticipated and managed.[22][23][15] In a Dutch study of compliance with colonoscopic surveillance among patients with familial adenomatous polyposisAn autosomal dominant inherited condition in which numerous polyps form mainly in the colon., poor compliance was associated significantly with perceived self-efficacy, use of sedatives during colonoscopy, pain after surveillance colonoscopy and low perceived benefits of surveillance.[24]Back to top


There is increasing recognition of the relationship between the quality of bowel preparation and adenoma detection rates.[25][26] Identifying and addressing the needs of those with poor health literacy due to education, ethnicity or comorbidities is clearly pivotal to achieving a high-quality surveillance colonoscopy, which depends on adequate bowel preparation.[27][28][29][30]
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Information and instructions for bowel preparation and colonoscopy need to be tailored to meet the needs of most Australians who have inadequate or poor health literacy.

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Phasing out

Years of public health efforts to raise awareness of the benefits of CRC screening make discussions about ceasing screening sound counter-intuitive.[31] Socioeconomic factors may influence the effectiveness of conversations about having no further colonoscopy, particularly due to low health literacy or high cultural expectations of continued surveillance. Evidence suggests that the context of these discussions may influence their success in older people.[32] A trusting relationship, communications over a long period and messages that are less direct, such as 'This test would not help you live longer', have been shown to be more effective than messages that directly address limited life expectancy.[32] Decision aids may also be useful.[33] Discussions should be based on the likely risks and benefits of the procedure for the individual and the final decision on the patient’s informed preference.

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  18. Mansouri D, McMillan DC, Grant Y, Crighton EM, Horgan PG. The impact of age, sex and socioeconomic deprivation on outcomes in a colorectal cancer screening programme. PLoS One 2013;8(6):e66063 Abstract available at
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  24. Douma KF, Bleiker EM, Aaronson NK, Cats A, Gerritsma MA, Gundy CM, et al. Long-term compliance with endoscopic surveillance for familial adenomatous polyposis. Colorectal Dis 2010 Dec;12(12):1198-207 Abstract available at
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  26. Kahi CJ, Boland CR, Dominitz JA, Giardiello FM, Johnson DA, Kaltenbach T, et al. Colonoscopy surveillance after colorectal cancer resection: recommendations of the US multi-society task force on colorectal cancer. Gastrointest Endosc 2016 Mar;83(3):489-98.e10 Abstract available at
  27. Radaelli F, Paggi S, Repici A, Gullotti G, Cesaro P, Rotondano G, et al. Barriers against split-dose bowel preparation for colonoscopy. Gut 2017 Aug;66(8):1428-1433 Abstract available at
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  33. Lewis CL, Golin CE, DeLeon C, Griffith JM, Ivey J, Trevena L, et al. A targeted decision aid for the elderly to decide whether to undergo colorectal cancer screening: development and results of an uncontrolled trial. BMC Med Inform Decis Mak 2010 Sep 17;10:54 Abstract available at

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