Screening intention of MTs-DNA test for Colorectal Cancer screening and associated factors among hospital-based populations in southeastern China

Abstract

Background

Multi-target stool DNA (MT-sDNA) test can reduce colorectal cancer (CRC) incidence and mortality as a simple, noninvasive screening method. It is crucial to understand people's willingness to accept and willingness to pay for MT-sDNA test for CRC screening.

Methods

A hospital-based study was conducted in the affiliated hospital of medical school of Ningbo University in southeastern China between June 2021 to March 2022. Individuals aged ≥ 40 years from outpatient department, endoscopy center and inpatient department were included. All participants completed a questionnaire to collect detailed information by a face-to-face interview. Characteristics of individuals were described using frequency and percentage. Group comparisons were performed with chi-square test for categorical variable. Multivariate logistic regression analyses were performed to estimate the associations of social-demographic characteristics, lifestyle factors, CRC risk and medical history with screening intention.

Results

Of the 977 participants who completed the interview, 85.06% were willing to accept MTs-DNA test for CRC screening, 82.29% were willing to pay for it. Individuals came from non outpatient source (OR = 3.16, 95% CI: 2.14, 4.68), with moderate risk of CRC (OR = 1.66, 95% CI: 1.10, 2.52) were more likely to accept MTs-DNA test for CRC screening. Those came from non outpatient source (OR = 2.56, 95% CI: 1.79, 3.67), with moderate risk of CRC (OR = 1.98, 95% CI: 1.34, 2.91), with history of polypectomy (OR = 2.20, 95% CI: 1.31, 3.68) and with middle/high school education and graduated from college or above (OR = 1.62, 95% CI: 1.07, 2.46, OR = 2.67, 95% CI: 1.27, 5.60, respectively) were more willing to pay for MTs-DNA test for CRC screening.

Conclusion

The present study found that individuals from non outpatient source, with moderate risk of CRC, with higher education and history of polypectomy were more likely to accept MTs-DNA test or pay for it. It is worth noting that individuals with high risk of CRC were less likely to accept MTs-DNA test and pay for it. Health education interventions should be developed to emphasise the significance of screening and introduce the simple, noninvasive MT-sDNA test to the public, especially those with above characteristics.

Background

Colorectal cancer (CRC) is a major global health burden. It ranks third in morbidity and second in mortality, causing more than 1.9 million new colorectal cancer cases and 935 thousand deaths worldwide and representing about one in 10 cancer cases and deaths^{[1, 2]}. In China, colorectal cancer was one of the top five leading causes of cancer-related death, its incidence and mortality increased rapidly over the past decades and also contributed to massive economic burdens^[3]. Fortunately, it usually takes 5 to 10 years for most CRC to progress from precancerous lesions to cancer^{[4, 5]}, yet it is also largely preventable with evidence-based screening strategies^{[6, 7]}.

Multi-target stool DNA (MT-sDNA) test was approved by the Food and Drug Administration (FDA) and the Centers for Medicare and Medicaid Services for CRC screening^{[8, 9]}. Population-based studies found that its detection of CRCs and adenomas is superior to FIT and does increase patient life-years with regular testing^{[10, 11]}. Due to its attractive characteristics including easy to operate, absence of bowel preparation, safety, privacy and noninvasiveness, it has greater adherence and has been widely used wordwide^{[12, 13]}. The application of MT-sDNA detection products has been increasing exponentially in recent years^[14]. However, the application of MT-sDNA test in China is still at a very early stage.

Numerous studies have shown that patients’ willingness to accept and ability to complete tests are critical in improving CRC screening^[15–17].Vast screening intention of CRC screening method have been published previously^[18–20], but the data for MT-sDNA are very limited. Besides, most published researches on the screening intention of CRC and associated factors were focused on the single variables^[21–24] such as socio-demographic characteristics (age, sex, income, education, family history, etc) and lifestyle factors (smoking/drinking status, body mass index, etc). The Asia-Pacific Colorectal Screening (APCS) score-a comprehensive index^[25] for colorectal cancer risk assessment, has not been analyzed for its association with CRC screening intention in previous studies. Besides, there is still no study has focused on the association between factors and willingness to pay for MTs-DNA test.

Therefore, a hospital-based survey provided us with a unique opportunity to look at the screening intention of MTs-DNA test for CRC srceening in the Chinese population. The aim of the present study was to describe the screening intention (including willingness to accept and willingness to pay) of individuals, and to examine the associations of social-demographic characteristics, lifestyle factors, risk of CRC and relevant medical history with screening intention of MTs-DNA test.

Methods

Study design and population

A descriptive cross-sectional design with convenience sampling was conducted in the Affiliated Hospital of Medical School of Ningbo University. Recruitment participants included individuals aged ≥40 years who had visited outpatient department, endoscopy center and inpatient department between January 2021 to March 2022. Exclusion criteria included those with previous diagnosis of colorectal cancer and cognitive impairment.

All participants completed a questionnaire to collect detailed information by a face-to-face interview. Participants were assured that all data related to their personal information would be kept strictly confidential and anonymous.

Study questionnaire

We used an epidemiological questionnaire to investigate participants’ willingness to accept and willingness to pay for MTs-DNA test for CRC screening. The questionnaire was further revised after discussion and revision by the project team experts and on-site pre-investigation before it was officially used. The questionnaire consists of two parts. The first part included the basic information of participants, including demographic characteristics (age, sex, education, occupation, income, marital status, family history of CRC), lifestyle factors (smoking, alcohol drinking and tea drinking habits), height, weight and history of relevant medical history (diarrhea, constipation, bloody stool, hemorrhoids, polypectomy). The second part included the participants’ willingness to accept and willingness to pay for MTs-DNA test for CRC screening. 

Measurement

Assessment of screening intention of MTs-DNA test for CRC screening

In the present study, we defined screening intention as willingness to accept and willingness to pay for MTs-DNA test for CRC screening. Willingness to accept and williness to pay was assessed by asking participants "How would you accept MTs-DNA test as a screening tool for colorectal cancer?" and "Would you be willing to pay for MTs-DNA test as a colorectal cancer screening option?". Alternative answers included "totally accepted", "acceptable" and "difficult to accept". We categorized the willingness to accept/pay into "Yes" ("totally accepted" and "acceptable") and "No" ("difficult to accept"), and defined "No" as the reference group.

Other covariates

Other covariates including age (40-49, 50-59, ≥60 years old), sex, marital status (married, others), level of education (primary school or below, middle/high school, college or above), occupation (administrative/technician, farmers and workers, unemployment and others), personal income (<10,000, 10,000-59,999, 60,000-109,999 and ≥110,000 yuan per year), family history of colorectal cancer (yes or no), BMI ( (body mass index=weight/height^2), devided into <23, and ≥23 according to APCS assignment criteria), current smoking/alcohol drinking/tea drinking status (yes or no) and type of medical insurance (employee medical insurance, resident medical insurance and others). Participants were further asked if they had the following relevant medical history (yes or no) by question "whether you have the following medical history: diarrhea, constipation, bloody stool, hemorrhoids, polypectomy".

To clarify differences in screening intention among different population sources, we categorized individuals from outpatient department into "outpatient source", those from endoscopy center and inpatient department into "non outpatient source", and defined " outpatient source " as the reference group.

Besides, the APCS score was used to stratify risk for CRC in the present study. The APCS scores were calculated on the basis of age, sex, family history of CRC, smoking status and BMI. Participants’ risk of CRC were stratified into 3 groups: average risk, score 0; moderate risk, score 1–2; and high risk, score 3–6.

Statistical Analysis

Basic characteristics of participants were described using frequency and percentage. Group comparisons were performed with chi-square test for categorical variable. All variables in the chi-square analysis entered in the logistic regression analysis model to estimate the associations of social-demographic characteristics, lifestyle factors, CRC risk and medical history with screening intention. 

All statistical analyses were conducted using SPSS 26.0 statistical software and all p-values refer to two-tailed tests. Forest plot was drawn using R 4.2.0 statistical software. Statistical significance was set at P <0.05.

Results

Characteristics of study population

A total of 1,034 respondents participated in the survey, of which 57 were excluded as they did not complete the questionnaire.

Of 977 eligible individuals interviewed, 34.39% from outpatient clinics, 65.61% from endoscopy center and inpatient department. 25.8% of individuals aged 40-49 years old, 40.74% aged 50-59 years old, 34.19% were ≥ 60 years old and 47.70% were males. 53.12% had attended middle/high school, 19.14% graduated from college and above. Detailed characteristics of individuals are shown in Table 1.

Table 1 Basic characteristics of the study population (N=977)

Predictors of CRC screening intention using MTs-DNA test

Of the 977 participants who completed the interview, 85.06% (831) were willing to accept MTs-DNA test for CRC screening, 82.29% (804) were willing to pay for it. 

As shown in Table 2, individuals who came from outpatient department and with higher risk of CRC were less likely to accept MTs-DNA test for CRC screening and pay for it. 

Individuals who were willing to accept MTs-DNA test for CRC screening were younger, better educated, with higher incomes and without smoking history. Those with history of hemorrhoids, constipation, bloody stool and polypectomy would prefer to accept MTs-DNA test. Individuals who were willing to pay for MTs-DNA test were younger, female, better educated and without smoking history. Those with history of hemorrhoids and polypectomy preferred to pay for MTs-DNA test.

Table 2 Univariate Chi-square analysis of factors associated with CRC screening intention using MT-sDNA test (N=977)

Independent predictors of CRC screening intention using MTs-DNA test

The associations of socio-demographic characteristics, lifestyle factors, CRC risk and medical history with willingness to accept/pay for MTs-DNA test are presented in Figure 1. 

Compared with individuals came from outpatient, those came from non outpatient source were associated 3.16 (95% CI: 2.14, 4.68) times greater likelihood of accept MTs-DNA test and 2.56 (95% CI: 1.79, 3.67) times greater likelihood of pay for MTs-DNA test. 

Individuals with moderate risk of CRC were more likely to accept MTs-DNA test and associated with a higher likelihood of paying for it (OR=1.66, 95% CI: 1.10, 2.52, OR=1.98, 95% CI: 1.34, 2.91, respectively) compared with those at high risk. However, there were no significant difference in willingness to accept and willingness to pay between individuals at average risk and high risk (OR=1.70, 95% CI: 0.66, 4.39, OR=2.33, 95% CI: 0.96, 5.64, respectively). Level of education did not show significant relationship with willingness to accept MTs-DNA test. While individuals with higher education were more likely to pay for it, those with middle/high school education and graduated from college or above were more willing to pay for MTs-DNA test compared with primary school education and below (OR=1.62, 95% CI: 1.07, 2.46, OR=2.67, 95% CI: 1.27, 5.60, respectively). Besides, individuals with history of polypectomy were associated 1.69 (95% CI: 0.99, 2.89) times greater likelihood of accept MTs-DNA test and 2.20 (95% CI: 1.31, 3.68) times greater likelihood of pay for it compared with those without history of polypectomy.

Discussion

To the best of our knowledge, the present study is the first study focused on the association of socio-demographic characteristics, lifestyle factors, CRC risk and relevant medical history with willingness to accept and willingness to pay for MTs-DNA test for CRC screening. We found that 85.06% (n = 977) were willing to accept MTs-DNA test for CRC screening, 82.29% were willing to pay for it. Individuals came from non outpatient source, with moderate risk of CRC, with higher education and with history of polypectomy were more likely to accept MTs-DNA test or pay for it.

The rate of willingness to accept and pay for CRC screening ranged from 67–91% in previous studies, but most studies focused on disease screening intentions or the use of colonoscopy^[26–28]. The present study is the first to focus on people's willingness to accept and pay for MTs-DNA test for CRC screening and found similar results. However, the results may be relatively high than in general population and should be interpreted with cautions. The potiential bias may arise that the participants in the present study covered individuals from not only outpatient department, but also inpatient department and endoscopy center, who may be in worse physical condition than normal individuals or pay much more attention on their own health status. Therefore, studies based on community or other non-hospital source population conducted in general population will be needed in the future to produce supplementary evidence.

Different from previous studies that mostly limited to the association of single variables such as sociodemographic characteristics or lifestyle factors with the screening intention^{[20–22, 29]}, the present study is the first time to use APCS score as a comprehensive evaluation index to explore the association between the overall risk of CRC and the screening intention. We found that willingness to accept and pay for MTs-DNA test decreased as the risk of CRC increased, but the trend became insignificantly after adjusting for other factors. Multivariate regression analysis founded that individuals with moderate risk were more likely to accept and pay for MTs-DNA test compared with those at high risk. This maybe due to that the APCS scores were calculated on the basis of age, sex, family history of CRC, smoking status and BMI^[25]. Individuals at high risk tend to be older, having a history of smoking, be overweight or obese, and be male. People with these characteristics tend to have less awareness of colorectal cancer and pay less attention on their own health status^{[30, 31]}, which may lead to a lower rate of willingness to be screened^[32]. Another possible reason is that they does not know enough about MTs-DNA test technology to believe in the accuracy of the technology. Since epidemiological studies have pointed out that screening tests conducted in high-risk groups can significantly improve screening efficiency and achieve better health economic effects and benefits. The phenomenon that people with higher risk were less willing to undergo screening deserves special attention by the health administrative department. It is urgent to plan health education interventions to raise public awareness of their own CRC risk, emphasise the significance of screening and introduce the simple, noninvasive screeening method for suitable population.

Consistent with previous studies, we found that higher education level was positively associated with the screening intention^{[20, 33]}. Individuals with higher education level tend to pay more attention to their health, better able to acquire information and hold a positive attitude to CRC screening. Efforts to reach individuals with lower levels of education or designing educational materials targeted for these individuals might increase the acceptance of test.

What’s more, the present study also found that individuals from non-outpatient department and with history of polypectomy were more likely to accept and pay for MTs-DNA test for CRC screening, which is consistent with previous studies focused on CRC screening intention^{[34, 35]}. On one hand, this may because the onset of uncomfortable symptoms motivates them to pay more attention on their intestinal health and participate in screening^[36]. On the other hand, those who have done colonoscopy perceived its disadvantages and were more willing to accept MT-sDNA, a simple and non-invasive method for screening^[37].

Limitations

Although the data in the present study was based on population and corrected for established and potential confounding factors (both socio-demographic, lifestyle factors and relevant medical history ), these findings should also be interpreted in light of some limitations. First, the generalization of the results from this study should be considered with caution given the possible sampling selection bias, since the study sample was obtained from a hospital via convenience sampling. Second, due to the limited sample size, some significant positive associations may not be demonstrated in the present study. Third, no respondents’ refusal was captured during the conduct of the survey, that may lead to a higher response rate than other survey. Finally, the study cannot exclude the effects of residual confounding by unmeasured risk factors. Therefore, larger sample size studies with more adjusted confounders are warranted to examine the further association and make a firm complement to the current study. 

Conclusion

The present study found that 85.06% were willing to accept MTs-DNA test for CRC screening and 82.29% were willing to pay for it. Individuals came from non outpatient source, with moderate risk of CRC and with history of polypectomy were more likely to accept MTs-DNA test and pay for it. Individuals with higher education were more likely to pay for it. It is worth noting that individuals with high risk of CRC were less likely to accept MTs-DNA test and pay for it compared with moderate risk group. Generally speaking, findings from the present study reinforce the importance of focusing on the above key characteristics. And from a preventive perspective, indicating the need for a more targeted approach trying to reach these groups to guide them to participant in CRC screening scientifically and actively.

abbreviations

Not applicable

Declarations

Ethics approval and consent to participate

Ethical approval was obtained from the Ethical Review Committee of the the affiliated hospital of medical school of Ningbo University (KY20201111). The study was performed in agreement with the Helsinki declaration and its amendments, and in accordance with local legislation. Subject participation was voluntary, and written informed consent was obtained from all participants prior to the interview.

Consent for publication

Not applicable.

Availability of data and materials

The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request.

Competing interests

The authors declare that they have no competing interest.

Funding

The work was supported by the following grants: Health science and Technology Project of Zhejiang Province (grant number 2021KY1048 and 2022KY1142), the Ningbo Health Young Technical Backbone Talents Training Program (grant number 2020SWSQNGG-02). The funding agency provided guidance on the design of the study and collection, analysis, and interpretation of data.

Authors’ contributions

XS, ZW, LQ, GJ, LL, GH performed data collection and collation. XS performed data analysis, interpreted results and wrote the manuscript. XS, FJ participated in editing the manuscript, and GH, YG helped revise manuscript. All authors read and approved the final manuscript.

Acknowledgements

Not applicable.

Author’s information

¹Department of Preventive Health, The Affiliated Hospital of Medical School of Ningbo University. ²Department of Traditional Chinese Medicine, The Affiliated Hospital of Medical School of Ningbo University. ³Department of Gastroenterology, The Affiliated Hospital of Medical School of Ningbo University. 

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