1. Comparison of uptake of colorectal cancer screening based on faecal immunochemical testing (FIT) in males and females: A systematic review and meta-analysis Nicholas Clarke, Aoife Osborne, Patricia M Kearney, Linda Sharp Irish Cancer Society Funded PhD Scholar

2. Overview Introduction The problem and aims Methods and search Results Discussion Implications

3. Introduction Colorectal cancer  3 rd most common in women worldwide  2 nd most common in men worldwide  Age standardised incidence 44% higher in men (20.6 vs. 14.3) worldwide  Age standardised mortality 45% higher in men (10.0 vs. 6.9) worldwide (GLOBOCAN, 2012)

4. Colorectal cancer screening Reduction in incidence Reduction in mortality Economic benefit in life years saved Improves QOL

5. Colorectal cancer screening Hospital based screening  Colonoscopy  Flexible sigmoidoscopy  Double-contrast barium enema  Computed tomographic (CT) colonography Home or GP based screening  FOBT  FIT Non-invasive  Faecal DNA testing

6. Colorectal cancer screening FOBT screening uptake higher than more invasive tests (Khalid-de Bakker et al, 2011) FIT uptake higher than FOBT (Vart et al, 2012) Men more likely to participate in endoscopic based tests (Evans et al 2005, Meissner et al, 2006, Javanprast et al, 2010) Men less likely to participate in FOBT based screening (von Wagner et al, 2011, Seef et al, 2004)

7. Given: 1) males at greater risk of developing and dying from CRC 2) FIT increasingly recommended (Von Karsa et al, 2013, Levin et al, 2008), is there a differential uptake between males and females in FIT based screening? Problem

8. Aims To conduct a systematic review of studies containing comparisons of male and female participation rates of FIT based colorectal cancer screening. To determine if factors such as age, number of samples, invitation strategy and reminders impact on differences in uptake

9. Methods RCTs & Observational studies Numbers of males and females invited and screened Inclusion PubMed Embase Databases Meta-analysis & subgroup analysis using Revman Analysis RCTs – Cochrane risk of bias tool Observational studies – Newcastle Ottawa Scale Quality Assessment

10. The Search

11. Results 6 RCTs, 12 cross-sectional, 1 cohort 15 population based Study design 4,789,384 invited 1,396,445 screened Excluding Park et al (2011): 382, 684 invited - 185,283 screened Subjects 10.5% (Park et al, 2011) - 90.1% (Fenocchi et al, 2006) Less than 40% (7 studies) 40-60% (8 studies) Over 60% (4 studies) Uptake rates

12. Study locations 3 1 3 9 3

13. Results – Uptake Meta-analysis 0.83 [0.77, 0.90]

14. Results – RCTs Meta analysis 0.83 [0.71, 0.97]

15. Results – Cross sectional studies meta analysis 0.85 [0.78, 0.94]

16. Results Significantly lower uptake in males Lower uptake across sub-group analysis Situations in which there is no difference in uptake:  Low quality studies  Non population based studies  Studies using advance notification invitations  Studies targeting people over 50 years of age with no upper age limit  Contact with medical professional

17. Discussion Uptake similar when there is contact with medical professional Uptake similar in studies with no upper age limit  Older males may be more inclined to participate  Older men report less disability (White et al, 2011)  Older men may be more health conscious

18. Discussion – Males in health care Absence of male targeted healthcare programmes (White et al, 2011) When males more accepting of screening often see themselves as adhering to physician recommendations (Ritvo et al, 2013) Males often procrastinate about screening (Ritvo et al, 2013)  fatalism  preventative/protective elements of screening

19. Summary & Implications Significantly lower male uptake of FIT based CRC screening Need for targeted gender based strategies to improve uptake in FIT based screening

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21. Acknowledgement This research has been funded by an Irish Cancer Society scholarship grant