Study: Income, BMI linked to CCE completion
Danish screening data identify clinical and socioeconomic factors that significantly influence the likelihood of a complete colon capsule examination.
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02/19/2026
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by Doug Brunk
Higher income and certain behavioral factors were associated with increased odds of complete colon capsule endoscopy (CCE), while body mass index (BMI) ≥40 and self-reported constipation or laxative use were linked to incomplete examinations among colorectal cancer screening participants, according to a cross-sectional analysis of the CareForColon2015 (CFC2015) trial published in BMJ Open Gastroenterology.
Between August 2020 and December 2022, Danish investigators conducted the CFC2015 trial in Southern Denmark to evaluate the effectiveness of colorectal cancer screening in detecting neoplastic lesions, allowing participants to choose between capsule colon examination and colonoscopy. For this analysis, data from CFC2015 were combined with Danish national registries. The study included participants aged 50 to 75 years who chose CCE following a screening invitation. Univariate and multivariate logistic regression models were used to assess 17 patient characteristics, with adjustment for potential confounders.
Among 1,472 participants with complete covariate data, 1,016 (69.1%) achieved a complete CCE. Completeness required visualization of the anal valve or capsule excretion, cecal valve visualization, no major technical interruptions, and adequate bowel cleansing (fair or better on the Leighton Rex Scale) in all segments. Inadequate bowel cleansing accounted for most incomplete examinations (23.9%).
In multivariable analyses, increasing income was independently associated with higher completion rates. Compared with the lowest income quartile, the highest quartile had an odds ratio (OR) of 1.78 (95% CI, 1.30-2.43) for complete CCE; the third quartile, OR 1.74 (95% CI, 1.26-2.39); and the second quartile, OR 1.43 (95% CI, 1.03-1.97).
Current smokers had higher odds of completion than non-smokers (OR, 1.69; 95% CI, 1.12-2.55). Participants reporting ≥15 units of alcohol weekly also had increased odds (OR, 2.72; 95% CI, 1.52-4.87) compared with nondrinkers.
In contrast, BMI ≥40 was associated with significantly lower odds of complete examination versus BMI 18.5 to <25 (OR, 0.40; 95% CI, 0.17-0.97). Participants reporting constipation during the week before CCE or regular laxative use had reduced odds of completion (OR, 0.65; 95% CI, 0.47-0.90). Daily or weekly pain medication use was associated with lower completion in univariate analysis (OR, 0.55; 95% CI, 0.36-0.82), but this association was not statistically significant after adjustment.
Sex, age group, educational level, exercise, coffee intake, Bristol Stool Form Scale category, fecal immunochemical test concentration, and Charlson Comorbidity Index were not significantly associated with completion in multivariate models. Women had a nonsignificant trend toward higher completion (OR, 1.26; 95% CI, 0.97-1.65).
The researchers noted several limitations of their study, including that the CFC2015 trial was not powered specifically for these subgroup analyses, and some subgroups were small, resulting in wide confidence intervals. In addition, participants chose CCE instead of colonoscopy on their own, which could have affected the results, and some information, like alcohol and medication use, was self-reported.
The investigators characterized the study results as “essential knowledge for clinicians when considering the use of CCE and for the future development of a predictor model of qualified patients for CCE,” they wrote. “Such a model needs to be based on further research, and the included predictors should be decided based on multiple studies. There should preferably be a systematic review with a high level of evidence. Future studies investigating more interventions to support the completion of CCE should likewise be added to the literature.”
Novo Nordisk Scholarship and Agnethe Løvgreens Legat funded the first author. CareForColon2015 was funded by Aage and Johanne Louis-Hansen’s Fond, Odense University Hospital’s innovation fund, the Medtronic Research Foundation, the Danish Cancer Society, and the Health Care Region of Southern Denmark.
Source: BMJ Open Gastroenterology
Summary content
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The guidelines emphasize four-hour gastric emptying studies over two-hour testing. How do you see this affecting diagnostic workflows in practice?
Dr. Staller: Moving to a four-hour solid-meal scintigraphy will actually simplify decision-making. The two-hour reads miss a meaningful proportion of delayed emptying; standardizing on four hours reduces false negatives and the “maybe gastroparesis” purgatory that leads to repeat testing. Practically, it means closer coordination with nuclear medicine (longer slots, consistent standardized meal), updating order sets to default to a four-hour protocol, and educating front-line teams so patients arrive appropriately prepped. The payoff is fewer equivocal studies and more confident treatment plans.
Metoclopramide and erythromycin are the only agents conditionally recommended for initial therapy. How does this align with what is being currently prescribed?
Dr. Staller: This largely mirrors real-world practice. Metoclopramide remains the only FDA-approved prokinetic for gastroparesis, and short “pulsed” erythromycin courses are familiar to many of us—recognizing tachyphylaxis limits durability. Our recommendation is “conditional” because the underlying evidence is modest and patient responses are heterogeneous, but it formalizes what many clinicians already do: start with metoclopramide (lowest effective dose, limited duration, counsel on neurologic adverse effects) and reserve erythromycin for targeted use (exacerbations, bridging).
Several agents, including domperidone and prucalopride, received recommendations against first-line use. How will that influence discussions with patients who ask about these therapies?
Dr. Staller: Two points I share with patients: evidence and access/safety. For domperidone, the data quality is mixed, and US access is through an FDA IND mechanism; you’re committing patients to EKG monitoring and a non-trivial administrative lift. For prucalopride, the gastroparesis-specific evidence isn’t strong enough yet to justify first-line use. So, our stance is not “never,” it’s just “not first.” If someone fails or cannot tolerate initial therapy, we can revisit these options through shared decision-making, setting expectations about benefit, monitoring, and off-label use. The guideline language helps clinicians have a transparent, evidence-based conversation at the first visit.
The guidelines suggest reserving procedures like G-POEM and gastric electrical stimulation for refractory cases. In your practice, how do you decide when a patient is “refractory” to medical therapy?
Dr. Staller: I define “refractory” with three anchors.
1. Adequate trials of foundational care: dietary optimization and glycemic control; an antiemetic; and at least one prokinetic at appropriate dose/duration (with intolerance documented if stopped early).
2. Persistent, function-limiting symptoms: ongoing nausea/vomiting, weight loss, dehydration, ER visits/hospitalizations, or malnutrition despite the above—ideally tracked with a validated instrument (e.g., GCSI) plus nutritional metrics.
3. Objective correlation: delayed emptying on a standardized 4-hour solid-meal study that aligns with the clinical picture (and medications that slow emptying addressed).
At that point, referral to a center with procedural expertise for G-POEM or consideration of gastric electrical stimulation becomes appropriate, with multidisciplinary evaluation (GI, nutrition, psychology, and, when needed, surgery).
What role do you see dietary modification and glycemic control playing alongside pharmacologic therapy in light of these recommendations?
Dr. Staller: They’re the bedrock. A small-particle, lower-fat, calorie-dense diet—often leaning on nutrient-rich liquids—can meaningfully reduce symptom burden. Partnering with dietitians early pays dividends. For diabetes, tighter glycemic control can improve gastric emptying and symptoms; I explicitly review medications that can slow emptying (e.g., opioids; consider timing/necessity of GLP-1 receptor agonists) and encourage continuous glucose monitor-informed adjustments. Pharmacotherapy sits on top of those pillars; without them, medications will likely underperform.
The guideline notes “considerable unmet need” in gastroparesis treatment. Where do you think future therapies or research are most urgently needed?
Dr. Staller: I see three major areas.
1. Truly durable prokinetics: agents that improve emptying and symptoms over months, with better safety than legacy options (e.g., next-gen motilin/ghrelin agonists, better-studied 5-HT4 strategies).
2. Endotyping and biomarkers: we need to stop treating all gastroparesis as one disease. Clinical, physiologic, and microbiome/omic signatures that predict who benefits from which therapy (drug vs G-POEM vs GES) would transform care.
3. Patient-centered trials: larger, longer RCTs that prioritize validated symptom and quality-of-life outcomes, include nutritional endpoints, and reflect real-world medication confounders.
Our guideline intentionally highlights these gaps to hopefully catalyze better trials and smarter referral pathways.
Dr. Staller is with the Division of Gastroenterology, Massachusetts General Hospital and Harvard Medical School, Boston.