The authors have declared that no competing interests exist.
Colorectal cancer (CRC) screening by Fecal Immunohistochemical Testing (FIT) followed by colonoscopy reduces colorectal cancer mortality. Barriers to colonoscopy should be minimised.
To compare psychological “risks” of colonoscopy in FIT positive (FIT+) subjects and those with Inflammatory Bowel Disease (IBD).
IBD patients undergoing colonoscopic CRC surveillance were age and gender matched with FIT+ individuals awaiting colonoscopy. Subjects completed Spielberger State and Trait Scales for current levels of anxiety, depression, anger and curiosity, versus long term personality tendencies.
70 IBD respondents were matched with 70 FIT+ respondents, (57% male, mean age 57.6 years). FIT+ subjects demonstrated greater scores for state Anxiety (22.3 vs 20.3 p=0.024), Curiosity (24.3 vs 21.8 p=0.036), Anger (13.7 vs11.5 p=0.037) and Depression (23.8 vs21.2 p=0.002).
FIT+ patients experience more anxiety and depression prior to their colonoscopy than IBD patients, which may reduce colonoscopy uptake and is important to address.
Colonoscopy for the early detection of Colorectal Cancer (CRC) is commonly practised in the setting of long standing Inflammatory Bowel Disease (IBD)
Whilst surveillance colonoscopy has yet to demonstrate convincing CRC mortality reduction amongst IBD patients
Whilst colonoscopic risk data for “hard” outcomes such as mortality, perforation and bleeding are well represented in the literature and appear similar across indications, it is not known whether potential psychological harm associated with the procedure differs by clinical indication. The contrasting health experiences of IBD patients and those without chronic disease could be reasonably expected to produce differing psychological reactions to the need for colonoscopy and the possibility of a cancer diagnosis.
Currently no data exist comparing psychological responses to the need for colonoscopy in those with and without chronic bowel disease, even though these lesser known risks are important determinants of colonoscopy uptake
To investigate and compare psychological parameters and QOL in FIT positive (FIT+) subjects and those with IBD in whom colonoscopy is indicated. Specifically we will examine Quality of Life, the Locus of Control to which subjects attribute health outcomes, and psychological state and trait including anxiety, depression, anger and curiosity.
A cross sectional postal questionnaire study was performed. IBD subjects were identified by interrogation of a tertiary hospital IBD database which includes public and private patients in South Australia currently enrolled in a colonoscopic CRC surveillance program based on IBD duration of more than 8 years and / or coexistent Primary Sclerosing Cholangitis (PSC)
Fecal Immunohistochenical testing in Australia is performed on average risk individuals from the age of 50 as a screening tool to enable early detection of CRC, with colonoscopy the recommended test in individuals returning a positive result
143 patients enrolled in the IBD and 140 patients in the FIT database were mailed a questionnaire exploring their demographics, Quality of Life, Health Locus of Control and psychological state and trait as below.
Subjects in each group were mailed a questionnaire requesting demographic details such as age, gender, country of origin, primary language spoken, occupational status, car and house ownership, highest educational qualification and marital status. The questionnaire also sought data regarding QOL, individuals’ Health Locus of Control and psychological state and traits.
The four week SF 36 questionnaire
The Levenson Multidimensional Locus of Control Scale
The Spielberger State-Trait Personality Inventory
Questionnaires returned within 3 months of mailing were analysed, with one reminder letter sent after one month if no response was received.
This study was approved by the Flinders Clinical Research Ethics Committee (FCREC) of Flinders University, South Australia (314/08). Informed consent on behalf of participants was implied in the form of a completed and returned questionnaire.
All data from completely answered questionnaires were analysed using SPSS v
Respondents who were aged less than 39 or more than 80 years were excluded from the analysis, as well as 4 respondents who had returned an incomplete questionnaire. The remaining participants were matched for gender and as closely as possible for age. There remained 140 subjects in total, 70 FIT+ and 70 with IBD. Response rate was 78/143 (56%) amongst IBD subjects versus 70/140 (50%) FIT subjects (p=0.48). Age, gender and occupational characteristics are presented in
IBD subjects were more likely to describe their occupation as “not working” than FIT+ subjects, who were more likely to report being retired (35.7% vs 11.4%, p<0.01) (
No significant differences were noted between groups in relation to car ownership, housing, educational qualifications or marital status.
FIT +N=70 | IBD N=70 | P value | |
Male | 40 (57%) | 40 (57%) | 1 |
Mean Age (yrs) (+/1 SD) | 58.2(+ 7.4) | 57.1(+ 9.8) | 0.49 |
Age Range (yrs) | 50 – 76 | 40 – 79 | |
Not working | 8 (11.4%) | 25 (35.7%) | <0.01 |
IBD subjects reported poorer QOL than FIT+ subjects across 8 domains of QOL measured by the SF-36 tool. The most affected subareas within the 8 domains included general health, activity and work limitation, satisfaction with the amount of activity achieved, ability to perform duties, bodily pain, energy levels, fatigue, susceptibility to illness, and perceived health compared with others (
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FIT + | 62.69 | 25.258 | 3.019 | <0.01 |
IBD | 47.86 | 25.446 | 3.041 | ||
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FIT + | 71.43 | 45.502 | 5.438 | 0.02 |
IBD | 52.86 | 50.279 | 6.009 | ||
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FIT + | 80 | 40.289 | 4.815 | 0.03 |
IBD | 62.86 | 48.668 | 5.817 | ||
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FIT + | 72.86 | 44.791 | 5.354 | 0.05 |
IBD | 57.14 | 49.844 | 5.958 | ||
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FIT + | 74.13 | 29.116 | 3.505 | 0.05 |
IBD | 64.57 | 26.631 | 3.183 | ||
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FIT + | 52.46 | 27.246 | 3.28 | 0.03 |
IBD | 41.77 | 29.752 | 3.556 | ||
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FIT + | 68.86 | 25.169 | 3.008 | 0.01 |
IBD | 57.23 | 24.899 | 2.976 | ||
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FIT + | 60.29 | 23.638 | 2.846 | <0.01 |
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FIT + | 85.22 | 20.227 | 2.435 | <0.01 |
IBD | 70.36 | 31.362 | 3.748 | ||
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FIT + | 69.93 | 30.189 | 3.634 | <0.01 |
IBD | 51.34 | 33.426 | 3.995 | ||
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FIT + | 60.87 | 22.125 | 2.89 | |
IBD | 46.91 | 24.854 | 2.756 | 0.03 | |
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46.6 | ||||
FIT + | 57.22 | 26.923 | 2.901 | 0.04 | |
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IBD | 49.12 | 27.738 | 2.674 | |
50.8 |
FIT+ subjects demonstrated significantly greater scores for current “state” Anxiety (22.3 vs 20.3 p=0.02), Curiosity (24.3 vs 21.8 p=0.04), Anger (13.7 vs11.5 p=0.04) and Depression (23.8 vs21.2 p<0.01) compared with their IBD counterparts, with both cohorts demonstrating increased anxiety and depression relative to population norms (
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FIT + | 70 | 22.3000 | 6.57697 | .78610 | 0.02 |
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IBD | 70 | 20.3000 | 3.24082 | .38735 | |||
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FIT + | 70 | 24.3286 | 7.70981 | .92150 | 0.04 |
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IBD | 70 | 21.8000 | 6.31446 | .75472 | |||
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FIT + | 70 | 13.6571 | 7.73077 | .92400 | 0.04 |
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IBD | 70 | 11.5286 | 3.44195 | .41139 | |||
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FIT + | 70 | 23.7571 | 5.82457 | .69617 | <0.01 |
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IBD | 70 | 21.2000 | 3.16044 | .37775 | |||
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FIT + | 70 | 16.5143 | 2.97693 | .35581 | 0.60 | 18.63 |
IBD | 70 | 16.2571 | 3.14705 | .37614 | |||
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FIT + | 70 | 18.4000 | 6.29562 | .75247 | 0.61 | 29.48 |
IBD | 70 | 17.9000 | 5.29465 | .63283 | |||
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FIT + | 70 | 12.9429 | 5.00980 | .59879 | 0.11 | 18.90 |
IBD | 70 | 11.6000 | 4.84364 | .57893 | |||
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FIT + | 70 | 11.1429 | 3.68029 | .43988 | 0.46 | 18.06 |
IBD | 70 | 10.7000 | 3.40652 | .40716 |
FIT+ subjects scored significantly higher on the “chance” locus of control than their IBD counterparts (21.8 vs 19.6 p=0.01). This suggests FIT+ subjects are more likely to attribute health events and outcomes to chance than are IBD subjects, who may attribute more responsibility to themselves, their doctors and others, although these other locus of control scores did not significantly differ between groups (
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FIT + | 70 | 26.0143 | 5.08619 | .60792 | 0.15 |
IBD | 70 | 24.6429 | 6.04581 | .72261 | ||
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FIT + | 70 | 21.8429 | 4.40236 | .52618 | 0.01 |
IBD | 70 | 19.5714 | 6.08531 | .72733 | ||
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FIT + | 70 | 18.9000 | 3.53102 | .42204 | 0.96 |
IBD | 70 | 18.9429 | 5.40769 | .64634 |
This is the first study comparing psychological parameters in two different patient groups undergoing colonoscopy to manage their enhanced risk of Colorectal Cancer.
We have demonstrated that FIT positive individuals experience more anxiety and depression prior to colonoscopy, and this may provide a barrier to colonoscopy uptake and render screening at a General Practice level less effective. Our patients undergoing colorectal cancer screening for IBD, whilst having poorer quality of life through their chronic disease, have less psychological distress compared to previously healthy FIT+ patients. This suggests that, whilst the benefit of a surveillance colonoscopy in IBD compared with screen detected FIT positive patients may be lower in terms of reduction of colorectal cancer mortality, the risk of psychological harm is also lower. This helps maintain a favourable risk benefit ratio for colorectal cancer surveillance in patients with inflammatory bowel disease.
The finding of higher levels of anxiety and depression amongst FIT positive individuals awaiting colonoscopy is consistent with population based Danish data
In contrast, state anxiety and depression were not elevated in IBD patients awaiting their surveillance colonoscopy. This is consistent with a Swedish IBD cohort in which 41 patients having colonoscopic surveillance did not report increased anxiety or impaired general health status related to surveillance
A similar UK study, however, demonstrated 24% of IBD subjects feeling frightened and anxious prior to colonoscopy
It is of interest that FIT positive patients were more likely to perceive chance as a significant influence upon their health. In previously well patients, an unexpected potential adverse health finding in the psychologically unprepared may lead to this perception, however a chance locus of control has been associated with negative affect and emotion focused coping rather than problem focused coping and positive affect
This study was affected by several limitations, the most important of which is the 4 month difference in lead time to colonoscopy at the time of survey between cohorts. This may have favoured higher anxiety levels in those whose procedure was imminent. Additionally, the magnitude of difference between Spielberger state scores between cohorts was small, suggesting that FIT subjects suffered only a mild level of increased anxiety and depression compared with IBD subjects, thus the clinical significance of this finding is uncertain. This subtle increase in anxiety may be subclinical and remain undetected unless sought, yet still impact upon the decision to undergo colonoscopy.
More detailed analysis of psychological parameters adjusted for IBD type, extent and duration may also be informative. A participation bias may also apply, favouring those with higher anxiety levels.
Also, whilst the Spielberger test used in this study has been validated amongst English speaking populations in general, it has not been specifically validated in the Australian population. Use of a behaviour specific health locus scale may have improved sensitivity in examining locus of control differences than the more general Levenson scale.
Despite these methodological limitations, this is the first study to suggest indication based differences in psychological reaction to the need for colonoscopy. To minimise anxiety duration and maximise colonoscopy uptake, we recommend expedited colonoscopy as soon as possible after FIT+ diagnosis, along with early and comprehensive patient counselling. Further, larger studies are warranted to explore the impact of psychological reactions on the uptake of colonoscopic colorectal cancer screening.