Impact of socioeconomic factors on surveillance colonoscopy

From Cancer Guidelines Wiki


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

Rurality also contributes to disadvantage; people living in very remote areas are less likely to be diagnosed with CRCColorectal cancer but more likely to die from CRCColorectal cancer than those living in other regions suggesting that this group do not reap the benefits of early CRCColorectal cancer 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, SESSocioeconomic status groups leads to the disparity in mortality due to CRCColorectal cancer in these populations.[2]

The primary objective of surveillance is to reduce the incidence and mortality of subsequent CRCColorectal cancer. There are several ways the impact of low SESSocioeconomic status 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).


ColorectalReferring to the large bowel, comprising the colon and rectum. 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 SESSocioeconomic status, 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 CRCColorectal cancer among lower SESSocioeconomic status 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 CRCColorectal cancer risk within 4 years.[9] Low SESSocioeconomic status 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 (IBDInflammatory bowel disease).

Lifestyle factors also appear to be important in CRCColorectal cancer 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 SESSocioeconomic status and Indigenous populations because of their higher rates of smoking.

Practice pointA recommendation on a subject that is outside the scope of the search strategy for the systematic review, based on expert opinion and formulated by a consensus process.Question mark transparent.png

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 CRCColorectal cancer) or had diagnosis of their disease (IBDInflammatory bowel disease). 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 SESSocioeconomic status 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 polyposis, 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]
Practice pointA recommendation on a subject that is outside the scope of the search strategy for the systematic review, based on expert opinion and formulated by a consensus process.Question mark transparent.png

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 CRCColorectal cancer 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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  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
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