Testing innovative strategies to reduce the social gradient in the uptake of bowel cancer screening: a programme of four qualitatively enhanced randomised controlled trials

Background

Bowel cancer screening reduces cancer-specific mortality. There is a socioeconomic gradient in the uptake of the English NHS Bowel Cancer Screening Programme (BCSP), which may lead to inequalities in cancer outcomes.

Objective

To reduce socioeconomic inequalities in uptake of the NHS BCSP’s guaiac faecal occult blood test (gFOBt) without compromising uptake in any socioeconomic group.

Design

Workstream 1 explored psychosocial determinants of non-uptake of gFOBt in focus groups and interviews. Workstream 2 developed and tested four theoretically based interventions: (1) ‘gist’ information, (2) a ‘narrative’ leaflet, (3) ‘general practice endorsement’ (GPE) and (4) an ‘enhanced reminder’ (ER). Workstream 3 comprised four national cluster randomised controlled trials (RCTs) of the cost-effectiveness of each intervention.

Methods

Interventions were co-designed with user panels, user tested using interviews and focus groups, and piloted with postal questionnaires. RCTs compared ‘usual care’ (existing NHS BCSP invitations) with usual care plus each intervention. The four trials tested: (1) ‘gist’ leaflet (n = 163,525), (2) ‘narrative’ leaflet (n = 150,417), (3) GPE on the invitation letter (n = 265,434) and (4) ER (n = 168,480). Randomisation was based on day of mailing of the screening invitation. The Index of Multiple Deprivation (IMD) score associated with each individual’s home address was used as the marker of socioeconomic circumstances (SECs). Change in the socioeconomic gradient in uptake (interaction between treatment group and IMD quintile) was the primary outcome. Screening uptake was defined as the return of a gFOBt kit within 18 weeks of the invitation that led to a ‘definitive’ test result of either ‘normal’ (i.e. no further investigation required) or ‘abnormal’ (i.e. requiring referral for further testing). Difference in overall uptake was the secondary outcome.

Results

The gist and narrative trials showed no effect on the SECs gradient or overall uptake (57.6% and 56.7%, respectively, compared with 57.3% and 58.5%, respectively, for usual care; allp-values > 0.05). GPE showed no effect on the gradient (p = 0.5) but increased overall uptake [58.2% vs. 57.5% in usual care, odds ratio (OR) = 1.07, 95% confidence interval (CI) 1.04 to 1.10;p < 0.0001]. ER showed a significant interaction with SECs (p = 0.005), with a stronger effect in the most deprived IMD quintile (14.1% vs. 13.3% in usual care, OR = 1.11, 95% CI 1.04 to 1.20;p = 0.003) than the least deprived (34.7% vs. 34.9% in usual care OR = 1.00, 95% CI 0.94 to 1.06;p = 0.98), and higher overall uptake (25.8% vs. 25.1% in usual care, OR = 1.07, 95% CI 1.03 to 1.11;p = 0.001). All interventions were inexpensive to provide.

Limitations

In line with NHS policy, the gist and narrative leaflets supplemented rather than replaced existing NHS BCSP information. This may have undermined their effect.

Conclusions

Enhanced reminder reduced the gradient and modestly increased overall uptake, whereas GPE increased overall uptake but did not reduce the gradient. Therefore, given their effectiveness and very low cost, the findings suggest that implementation of both by the NHS BCSP would be beneficial. The gist and narrative results highlight the challenge of achieving equitable delivery of the screening offer when all communication is written; the format is universal and informed decision-making mandates extensive medical information.

Future work

Socioculturally tailored research to promote communication about screening with family and friends should be developed and evaluated.

Trial registration

Current Controlled Trials ISRCTN74121020.

Funding

This project was funded by the National Institute for Health Research (NIHR) Programme Grants for Applied Research programme and will be published in full inProgramme Grants for Applied Research; Vol. 5, No. 8. See the NIHR Journals Library website for further project information.

Abstract S5-03: Menopausal symptoms as predictors of long-term adherence in the International breast cancer intervention study (IBIS-1)

Tamoxifen reduces the risk of breast cancer among women at increased risk of the disease. The effectiveness of the drug is dependent on its appropriate use for the duration of therapy. Adherence for the full course of preventive therapy ranges from 60-80%. Early discontinuation is largely attributed to side-effects, but no studies have validated this using 5-year follow-up data. We assessed the role of menopausal side-effects on long-term adherence in the UK arm of the International Breast Cancer Intervention Study (IBIS-1).

In the IBIS-1 trial, 4279 women in the UK were randomised to placebo vs. tamoxifen (20mg/day). A total of 292 were excluded (breast cancer, death, or other cancer), leaving 3987 to be included in the analysis (2000 placebo arm, 1987 tamoxifen arm). Adherence was calculated using data from six monthly clinical visits during the trial. Adherence (&lt;4.5 years, ≥4.5 years) was calculated using the Kaplan-Meier estimator. Our main objective was to investigate the effect of menopausal side effects experienced during the first six months on adherence overall and by treatment arm. All analyses were adjusted for age, Tyrer-Cuzick risk, smoking, hormone replacement therapy use, menopausal status, baseline symptoms, and treatment.

Overall, 66.8% of women were adherent for at least 4.5 years (placebo: 71.5% vs. tamoxifen: 62.1%, p&lt;0.001). Highest drop-out rates were found within the first 12 months of follow-up, and a significant difference in adherence between treatment arms was observed thereafter (p&lt;0.05). A low number of women experienced nausea/vomiting (5.0%) and headaches (7.0%), while higher proportions reported gynaecological symptoms (irregular bleeding/vaginal dryness/vaginal discharge, 13.8%) and hot flushes (31.5%). Women reporting nausea/vomiting (OR=1.82 [95% CI, 1.35-2.47], p&lt;0.001) and headaches (OR=1.41 [1.08-1.84], p=0.01) were significantly more likely to be non-adherent at 4.5 years. Long-term adherence was not significantly affected for those who reported hot flushes (OR=1.10 [0.94-1.30], p=0.2) or gynaecological symptoms (OR=1.18 [0.99-1.41], p=0.07) compared with their counterparts. Nausea/vomiting was significantly associated with non-adherence in both the placebo (OR=1.82 [1.16-2.87], p=0.009) and tamoxifen (OR=1.84 [1.22-2.76], p=0.004) arms. Headaches were associated with non-adherence in the placebo arm (OR=1.70 [1.16-2.50], p=0.006), while gynaecological symptoms were only significant in the tamoxifen arm (OR=1.30 [1.05-1.63], p=0.02). The majority of side effects were of mild or moderate severity and we observed significant trends for lower adherence with increasing severity for all symptoms (p&lt;0.05 to &lt;0.001).

In the IBIS-I trial, we observed a significant effect of common menopausal symptoms on long-term adherence. These effects were largely similar between tamoxifen and placebo arms, suggesting women are attributing age-related menopausal symptoms to preventive therapy. To ensure women experience the full benefit of preventive therapy, interventions are required to support the management of menopausal symptoms and to promote adherence. The higher rate of drop-out in the early months of the trial suggests early intervention may be an effective way to promote long-term adherence.

Citation Format: Smith SG, Sestak I, Forbes J, Howell A, Cuzick JJ. Menopausal symptoms as predictors of long-term adherence in the International breast cancer intervention study (IBIS-1) [abstract]. In: Proceedings of the 2016 San Antonio Breast Cancer Symposium; 2016 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2017;77(4 Suppl):Abstract nr S5-03.

Glucagon-like peptide-1 receptor expression on human eosinophils and its regulation of eosinophil activation

BACKGROUND

Glucagon-like peptide-1 (GLP-1) and its receptor are part of the incretin family of hormones that regulate glucose metabolism. GLP-1 also has immune modulatory roles.

OBJECTIVES

To measure the expression of the GLP-1 receptor (GLP-1R) on eosinophils and neutrophils in normal and asthmatic subjects and evaluate effects of a GLP-1 analog on eosinophil function.

METHODS

Peripheral blood samples were taken from 10 normal and 10 allergic asthmatic subjects. GLP-1R expression was measured on eosinophils and neutrophils. Subsequently, the asthmatic subjects underwent allergen and diluent inhalation challenges, and GLP-1R expression was measured. Purified eosinophils, collected from mild asthmatic subjects, were stimulated with lipopolysaccharide (LPS) and a GLP-1 analog to evaluate eosinophil cell activation markers CD11b and CD69 and cytokine (IL-4, IL-5, IL-8 and IL-13) production.

RESULTS

Glucagon-like peptide-1 receptor is expressed on human eosinophils and neutrophils. Eosinophil, but not neutrophil, expression of GLP-1R is significantly higher in normal controls compared to allergic asthmatics. The expression of GLP-1R did not change on either eosinophils or neutrophils following allergen challenge. A GLP-1 analog significantly decreased the expression of eosinophil-surface activation markers following LPS stimulation and decreased eosinophil production of IL-4, IL-8 and IL-13, but not IL-5.

CONCLUSION AND CLINICAL RELEVANCE

Glucagon-like peptide-1 receptor is expressed on human eosinophils and neutrophils. A GLP-1 analog attenuates LPS-stimulated eosinophil activation. GLP-1 agonists may have additional adjunctive indications in treating persons with concomitant type 2 diabetes mellitus and asthma.

A national cluster-randomised controlled trial to examine the effect of enhanced reminders on the socioeconomic gradient in uptake in bowel cancer screening

BACKGROUND

The NHS Bowel Cancer Screening Programme in England offers biennial guaiac faecal occult blood testing (gFOBt). There is a socioeconomic gradient in participation and socioeconomically disadvantaged groups have worse colorectal cancer survival than more advantaged groups. We compared the effectiveness and cost of an enhanced reminder letter with the usual reminder letter on overall uptake of gFOBt and the socioeconomic gradient in uptake.

METHODS

We enhanced the usual reminder by including a heading 'A reminder to you' and a short paragraph restating the offer of screening in simple language. We undertook a cluster-randomised trial of all 168 480 individuals who were due to receive a reminder over 20 days in 2013. Randomisation was based on the day of invitation. Blinding of individuals was not possible, but the possibility of bias was minimal owing to the lack of direct contact with participants. The enhanced reminder was sent to 78 067 individuals and 90 413 received the usual reminder. The primary outcome was the proportion of people adequately screened and its variation by quintile of Index of Multiple Deprivation. Data were analysed by logistic regression with conservative variance estimates to take account of cluster randomisation.

RESULTS

There was a small but statistically significant (P=0.001) increase in participation with the enhanced reminder (25.8% vs 25.1%). There was significant (P=0.005) heterogeneity of the effect by socioeconomic status with an 11% increase in the odds of participation in the most deprived quintile (from 13.3 to 14.1%) and no increase in the least deprived. We estimated that implementing the enhanced reminder nationally could result in up to 80 more people with high or intermediate risk colorectal adenomas and up to 30 more cancers detected each year if it were implemented nationally. The intervention incurred a small one-off cost of £78 000 to modify the reminder letter.

CONCLUSIONS

The enhanced reminder increases overall uptake and reduces the socioeconomic gradient in bowel cancer screening participation at little additional cost.

A qualitative systematic review of factors influencing parents' vaccination decision-making in the United Kingdom

BACKGROUND

High uptake of vaccinations is crucial for disease prevention. Although overall uptake of childhood immunisations is high in the United Kingdom (UK), pockets of lower uptake remain. Novel systematic methods have not been employed when reviewing the qualitative literature examining parents' vaccination decisions.

AIMS

We aimed to conduct a qualitative systematic review of studies in the UK to understand factors influencing parental decisions to vaccinate a child.

METHODS

On 12/2/14 we searched PsycINFO, MEDLINE, CINAHL plus, Embase, Social Policy and Practice and Web of Science for studies using qualitative methods and reporting reasons why parents in the UK had or had not immunised their child. Participant quotes and authors' interpretations of qualitative data were extracted from the results of articles. Thematic synthesis was used to develop higher-order themes (conducted in 2015).

RESULTS

34 papers were included. Two types of decision-making had been adopted: non-deliberative and deliberative. With non-deliberative decisions parents felt they had no choice, were happy to comply and/or relied on social norms. Deliberative decisions involved weighing up the risks and benefits, considering others' advice/experiences and social judgement. Emotions affected deliberative decision-making. Trust in information and vaccine stakeholders was integral to all decision-making. Practical issues affected those who intended to vaccinate.

CONCLUSIONS

Parents adopted two different approaches to decision-making about childhood vaccinations. By understanding more about the mechanisms underpinning parents' vaccination behaviour, in collaboration with vaccine stakeholders, we can better design interventions to enhance informed uptake.

Mild Visual Impairment and Its Impact on Self-Care Among Older Adults

OBJECTIVE

To determine the prevalence of mild visual impairment (MVI) among urban older adults in primary care settings, and ascertain whether MVI was a risk factor for inadequate performance on self-care health tasks.

METHOD

We used data from a cohort of 900 older adults recruited from primary care clinics. Self-management skills were assessed using the Comprehensive Health Activities Scale, and vision with corrective lenses was assessed with the Snellen. We modeled visual acuity predicting health task performance with linear regression.

RESULTS

Normal vision was associated with better overall health task performance ( p = .004). Individuals with normal vision were more likely to recall health information conveyed via multimedia ( p = .02) and during a spoken encounter ( p = .04), and were more accurate in dosing multi-drug regimens ( p = .05).

DISCUSSION

MVI may challenge the performance of self-care behaviors. Health care systems and clinicians should consider even subtle detriments in visual acuity when designing health information, materials, and devices.

Inequalities in cancer screening participation: examining differences in perceived benefits and barriers

OBJECTIVE

Inequalities exist in colorectal cancer (CRC) screening uptake, with people from lower socioeconomic status backgrounds less likely to participate. Identifying the facilitators and barriers to screening uptake is important to addressing screening disparities. We pooled data from 2 trials to examine educational differences in psychological constructs related to guaiac fecal occult blood testing.

METHODS

Patients (n = 8576) registered at 7 general practices in England, within 15 years of the eligible age range for screening (45-59.5 years), were invited to complete a questionnaire. Measures included perceived barriers (emotional and practical) and benefits of screening, screening intentions, and participant characteristics including education.

RESULTS

After data pooling, 2181 responses were included. People with high school education or no formal education reported higher emotional and practical barriers and were less likely to definitely intend to participate in screening, compared with university graduates in analyses controlling for study arm and participant characteristics. The belief that one would worry more about CRC after screening and concerns about tempting fate were strongly negatively associated with education. In a model including education and participant characteristics, respondents with low emotional barriers, low practical barriers, and high perceived benefits were more likely to definitely intend to take part in screening.

CONCLUSIONS

In this analysis of adults approaching the CRC screening age, there was a consistent effect of education on perceived barriers toward guaiac fecal occult blood testing, which could affect screening decision making. Interventions should target specific barriers to reduce educational disparities in screening uptake and avoid exacerbating inequalities in CRC mortality.

T regulatory cell phenotypes in peripheral blood and bronchoalveolar lavage from non-asthmatic and asthmatic subjects

BACKGROUND

An unresolved issue in T regulatory cells' cell biology is the lack of consensus on phenotypic markers that accurately define the natural Treg (nTreg) population.

OBJECTIVES

To examine nTreg frequency and functional capacity in healthy controls and their frequency in asthmatic subjects using three different phenotypic strategies. We hypothesized that phenotypically different nTreg are quantitatively and functionally different.

METHODS

Thirty-four healthy, non-asthmatic and 17 asthmatic subjects were studied. Three nTreg phenotypes were defined as follows: nTreg1 (CD4(+) CD25(+) Foxp3(+) ), nTreg2 (CD4(+) CD25(+) CD127(low) Foxp3(+) ), and nTreg3 (CD4(+) CD25(high) Foxp3(+) ). The flow cytometric determination of nTreg frequency in peripheral blood (PB) and bronchoalveolar lavage (BAL) was performed using fluorescently labelled antibodies. Peripheral blood nTreg functional capacity was assessed using a CFSE-based suppression assay.

RESULTS

There was a significantly lower frequency of PB nTreg3 compared to nTreg2 and nTreg1 (P < 0.05). Both nTreg2 and nTreg3 had a significantly greater suppressive capacity than nTreg1 at T responder (Tresp) to nTreg ratios of 16 : 1 up to 1 : 1 (P < 0.01). Asthmatics exhibited a significantly lower PB nTreg3 and nTreg1 frequency than healthy controls (P < 0.05). There were no differences between healthy controls and asthmatic subjects when comparing BAL nTreg frequency.

CONCLUSIONS AND CLINICAL RELEVANCE

Phenotypically different nTreg subsets are quantitatively and functionally different and are variably observed in asthma. The CD4(+) CD25(high) Foxp3(+) phenotype was the least frequent, but demonstrated the greatest suppression, and was significantly lower in PB of asthmatic subjects. Consequently, it is imperative that nTreg phenotypes be clearly defined and that the interpretation of their frequency and function be phenotype specific.

The associations between objective numeracy and colorectal cancer screening knowledge, attitudes and defensive processing in a deprived community sample

We examined associations between numeracy and sociocognitive factors associated with colorectal cancer screening uptake (n = 964). Nearly half (45.7%) of the respondents incorrectly answered a numeracy question (low numeracy). Low numeracy respondents were less knowledgeable about colorectal cancer (p < .001), less positive towards screening (emotional, p < .001 and practical, p = .001) and less likely to intend to participate in screening (p = .001). They also reported greater defensive processing of cancer information (p = .001). Sociocognitive factors fully mediated the relationship between numeracy and screening intention. Addressing numeracy issues may reduce inequalities in CRC screening participation, but communication strategies could be limited by the tendency process cancer information defensively.

Cancer Fatalism, Literacy, and Cancer Information Seeking in the American Public

Information seeking is an important behavior for cancer prevention and control, but inequalities in the communication of information about the disease persist. Conceptual models have suggested that low health literacy is a barrier to information seeking, and that fatalistic beliefs about cancer may be a mediator of this relationship. Cancer fatalism can be described as deterministic thoughts about the external causes of the disease, the inability to prevent it, and the inevitability of death at diagnosis. This study aimed to examine the associations between these constructs and sociodemographic factors, and test a mediation model using the American population-representative Health Information and National Trends Survey (HINTS 4), Cycle 3 (n = 2,657). Approximately one third (34%) of the population failed to answer 2/4 health literacy items correctly (limited health literacy). Many participants agreed with the fatalistic beliefs that it seems like everything causes cancer (66%), that one cannot do much to lower his or her chances of getting cancer (29%), and that thinking about cancer makes one automatically think about death (58%). More than half of the population had "ever" sought information about cancer (53%). In analyses adjusted for sociodemographic characteristics and family cancer history, people with limited health literacy were less likely to have ever sought cancer information (odds ratio [OR] = 0.63; 0.42-0.95) and more frequently endorsed the belief that "there's not much you can do . . ." (OR = 1.61; 1.05-2.47). This fatalistic belief partially explained the relationship between health literacy and information seeking in the mediation model (14% mediation). Interventions are needed to address low health literacy and cancer fatalism to increase public interest in cancer-related information.

Clinician-Reported Barriers to Implementing Breast Cancer Chemoprevention in the UK: A Qualitative Investigation

AIMS

The use of tamoxifen and raloxifene as preventive therapy for women at increased risk of breast cancer was approved by the National Institute for Health and Care Excellence (NICE) in 2013. We undertook a qualitative investigation to investigate the factors affecting the implementation of preventive therapy within the UK.

METHODS

We recruited general practitioners (GPs) (n = 10) and clinicians working in family history or clinical genetics settings (FHCG clinicians) (n = 15) to participate in semi-structured interviews. Data were coded thematically within the Consolidated Framework for Implementation Research.

RESULTS

FHCG clinicians focussed on the perceived lack of benefit of preventive therapy and difficulties interpreting the NICE guidelines. FHCG clinicians felt poorly informed about preventive therapy, and this discouraged patient discussions on the topic. GPs were unfamiliar with the concept of preventive therapy, and were not aware that they may be asked to prescribe it for high-risk women. GPs were reluctant to initiate therapy because it is not licensed, but were willing to continue a prescription if it had been started in secondary or tertiary care.

CONCLUSIONS

Barriers to implementing preventive therapy within routine clinical practice are common and could be addressed by engaging all stakeholders during the development of policy documents.

Evaluating the impact of a community-based cancer awareness roadshow on awareness, attitudes and behaviors

Improving public awareness of cancer and encouraging health behavior change are important aspects of cancer control. We investigated whether a community-based roadshow was an effective way of communicating with the public about cancer and encouraging behavior change. Data were from 1196 people who completed questionnaires at a Cancer Research UK Cancer Awareness Roadshow in 2013. Of these, 511 (43%) completed questionnaires immediately before their visit (pre-visit group) and 685 (57%) completed questionnaires immediately after their visit (post-visit group). Among the post-visit sample, 217 (32%) were retained after two months. Self-reported data were available on risk factor and symptom awareness, help-seeking barriers, use of healthcare services and health behaviors. Compared with the pre-visit sample, the post-visit group had greater awareness of cancer risk factors and was more positive about aspects of help-seeking but awareness of potential symptoms was similar. Most effects were maintained over two months. Intentions to eat more fruit and vegetables and to exercise more were comparable between the groups but more people in the post-visit sample intended to quit smoking. At 2-month follow-up, smoking prevalence had significantly reduced but fruit and vegetable consumption decreased and there was no change to physical activity. User of weight loss services and general practitioner visits were high at follow-up and largely attributed to the Roadshow. The Cancer Research UK Roadshow appears to improve risk factor awareness, promote positive attitudes towards help-seeking and increase smoking cessation. This approach could be a useful building block for additional cancer prevention and control strategies.

Factors affecting uptake and adherence to breast cancer chemoprevention: a systematic review and meta-analysis

BACKGROUND

Preventive therapy is a risk reduction option for women who have an increased risk of breast cancer. The effectiveness of preventive therapy to reduce breast cancer incidence depends on adequate levels of uptake and adherence to therapy. We aimed to systematically review articles reporting uptake and adherence to therapeutic agents to prevent breast cancer among women at increased risk, and identify the psychological, clinical and demographic factors affecting these outcomes.

DESIGN

Searches were carried out in PubMed, CINAHL, EMBASE and PsychInfo, yielding 3851 unique articles. Title, abstract and full text screening left 53 articles, and a further 4 studies were identified from reference lists, giving a total of 57. This review was prospectively registered with PROSPERO (CRD42014014957).

RESULTS

Twenty-four articles reporting 26 studies of uptake in 21 423 women were included in a meta-analysis. The pooled uptake estimate was 16.3% [95% confidence interval (CI) 13.6-19.0], with high heterogeneity (I(2) = 98.9%, P < 0.001). Uptake was unaffected by study location or agent, but was significantly higher in trials [25.2% (95% CI 18.3-32.2)] than in non-trial settings [8.7% (95% CI 6.8-10.9)] (P < 0.001). Factors associated with higher uptake included having an abnormal biopsy, a physician recommendation, higher objective risk, fewer side-effect or trial concerns, and older age. Adherence (day-to-day use or persistence) over the first year was adequate. However, only one study reported a persistence of ≥ 80% by 5 years. Factors associated with lower adherence included allocation to tamoxifen (versus placebo or raloxifene), depression, smoking and older age. Risk of breast cancer was discussed in all qualitative studies.

CONCLUSION

Uptake of therapeutic agents for the prevention of breast cancer is low, and long-term persistence is often insufficient for women to experience the full preventive effect. Uptake is higher in trials, suggesting further work should focus on implementing preventive therapy within routine care.

Reducing the Social Gradient in Uptake of the NHS Colorectal Cancer Screening Programme Using a Narrative-Based Information Leaflet: A Cluster-Randomised Trial

Objective. To test the effectiveness of adding a narrative leaflet to the current information material delivered by the NHS English colorectal cancer (CRC) screening programme on reducing socioeconomic inequalities in uptake. Participants. 150,417 adults (59-74 years) routinely invited to complete the guaiac Faecal Occult Blood test (gFOBt) in March 2013. Design. A cluster randomised controlled trial (ISRCTN74121020) to compare uptake between two arms. The control arm received the standard NHS CRC screening information material (SI) and the intervention arm received the standard information plus a supplementary narrative leaflet, which had previously been shown to increase screening intentions (SI + N). Between group comparisons were made for uptake overall and across socioeconomic status (SES). Results. Uptake was 57.7% and did not differ significantly between the two trial arms (SI: 58.5%; SI + N: 56.7%; odds ratio = 0.93; 95% confidence interval: 0.81-1.06; p = 0.27). There was no interaction between group and SES quintile (p = 0.44). Conclusions. Adding a narrative leaflet to existing information materials does not reduce the SES gradient in uptake. Despite the benefits of using a pragmatic trial design, the need to add to, rather than replace, existing information may have limited the true value of an evidence-based intervention on behaviour.

Effects of evidence-based strategies to reduce the socioeconomic gradient of uptake in the English NHS Bowel Cancer Screening Programme (ASCEND): four cluster-randomised controlled trials

BACKGROUND

Uptake in the national colorectal cancer screening programme in England varies by socioeconomic status. We assessed four interventions aimed at reducing this gradient, with the intention of improving the health benefits of screening.

METHODS

All people eligible for screening (men and women aged 60-74 years) across England were included in four cluster-randomised trials. Randomisation was based on day of invitation. Each trial compared the standard information with the standard information plus the following supplementary interventions: trial 1 (November, 2012), a supplementary leaflet summarising the gist of the key information; trial 2 (March, 2012), a supplementary narrative leaflet describing people's stories; trial 3 (June, 2013), general practice endorsement of the programme on the invitation letter; and trial 4 (July-August, 2013) an enhanced reminder letter with a banner that reiterated the screening offer. Socioeconomic status was defined by the Index of Multiple Deprivation score for each home address. The primary outcome was the socioeconomic status gradient in uptake across deprivation quintiles. This study is registered, number ISRCTN74121020.

FINDINGS

As all four trials were embedded in the screening programme, loss to follow-up was minimal (less than 0·5%). Trials 1 (n=163,525) and 2 (n=150,417) showed no effects on the socioeconomic gradient of uptake or overall uptake. Trial 3 (n=265 434) showed no effect on the socioeconomic gradient but was associated with increased overall uptake (adjusted odds ratio [OR] 1·07, 95% CI 1·04-1·10, p<0·0001). In trial 4 (n=168 480) a significant interaction was seen with socioeconomic status gradient (p=0·005), with a stronger effect in the most deprived quintile (adjusted OR 1·11, 95% CI 1·04-1·20, p=0·003) than in the least deprived (1·00, 0·94-1·06, p=0·98). Overall uptake was also increased (1·07, 1·03-1·11, p=0·001).

INTERPRETATION

Of four evidence-based interventions, the enhanced reminder letter reduced the socioeconomic gradient in screening uptake, but further reducing inequalities in screening uptake through written materials alone will be challenging.

FUNDING

National Institute for Health Research.

Abstract P4-04-16: Characterization of an autologous tumor cell vaccine against breast cancer in mice

The vast majority of breast cancer-related deaths are due to progressive recurrences of non-metastatic disease. Current adjuvant therapies aimed at preventing breast cancer recurrence are ineffective for tens of thousands of women each year. In addition, current adjuvant therapies carry significant co-morbidities. Active, specific immune-based strategies have the potential to train a patient's immune system to recognize and eliminate occult metastases. Here, we explore autologous tumor cell vaccines (ATCVs) as a strategy to prevent tumor recurrence and improve survival. Because &gt;90% of breast cancer patients undergo resection, autologous tumor cells are readily available for the production of personalized vaccine. Patient-specific vaccination is particularly attractive for breast cancer which is highly heterogeneous. The major disadvantage of ATCVs, is poor immunogenicity.

Thus, in order to develop an effective, immunogenic ATCV against breast cancer, we wanted to understand the features of immunogenicity. In this study, we evaluated the immunogenicities of two murine breast cancer cell lines, EMT6 and 4T1. For tumor protection studies, BALB/c female mice were given priming and booster vaccinations, ten days apart, with 1,000,000 irradiated (100Gy) cells. Ten days after the booster vaccination, mice were challenged with live tumor cells. Mice vaccinated with EMT6 cells were completely protected against a live EMT6 challenge in 80% of mice. However, mice vaccinated with irradiated 4T1 cells failed to provide any protection against a live 4T1 challenge. Most interestingly, when mice were vaccinated with a mixture of irradiated EMT6 and 4T1 cells, the protective response against EMT6 challenge was significantly diminished as 60% of mice developed tumors. This finding implied that non-immunogenic 4T1 cells released one or more immunosuppressive factors that inhibited anti-EMT6 immunity. Thus, we investigated the levels of different immunosuppressive cytokines, GM-CSF, IL-6, MCP-1, TGF-β and VEGF released by both 4T1 and EMT6 cells before and after irradiation.

Of the different cytokines measured, we found that only GM-CSF is produced at significantly higher levels by 4T1 cells than EMT6 cells. Since at higher levels (&gt;200pg/ml) GM-CSF can induce the accumulation of large amounts of myeloid derived suppressor cells (MDSCs) in the tumor site and lymphoid organs, we believe it to be the reason for the failure of the hybrid vaccine. Future studies will determine if blocking GM-CSF production by 4T1 cells will decrease the accumulation of MDSCs and subsequently increase anti-tumor immunity.

Citation Format: Ravindranathan S, Kurtz SL, Smith SG, Koppolu B, Nguyen KG, Zaharoff DA. Characterization of an autologous tumor cell vaccine against breast cancer in mice. [abstract]. In: Proceedings of the Thirty-Eighth Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2015 Dec 8-12; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2016;76(4 Suppl):Abstract nr P4-04-16.

Abstract P3-13-03: Multicenter clinical trial of percutaneous laser ablation for early stage primary breast cancer. Results of 49 cases with radiographic and pathological correlation

Introduction: Percutaneous laser ablation of early stage primary breast cancer remains investigational. A multicenter, international clinical trial (NCT01478438) was completed to determine feasibility of this technique.

Methods: Patients with a single focus of biopsy proven infiltrating ductal carcinoma measuring 20 mm or less by pre-ablation MRI were treated by image-guided percutaneous laser ablation. A laser diode source (805 nominal nanometer wavelength) was used to perform the thermal ablation. Thermal sensors placed at the periphery of the tumor measured achievement of predefined temperature levels, indicating successful ablation. The patients were evaluated by post-ablation mammogram, ultrasound and MRI at 4 weeks post-ablation, after which they underwent surgical excision. Pathology specimens were evaluated by hematoxylin & eosin, CK 8/18, Ki-67 and estrogen receptor staining.

Results: Forty-nine of the 61 enrolled patients (ages 42-77, mean age 64 years) undergoing percutaneous laser ablation have finished protocol analysis and are reported in this series. Ablation was considered complete by the treating physician in all cases. The mean tumor size was 11.3 mm. The mean laser time was 15.7 minutes. There were no serious adverse events. Seven patients (14%) reported mild adverse events (pain, blisters, lump). Post-ablation cell viability was determined by MRI and by changes in CK 8/18, Ki67 and estrogen receptor staining. A post-ablation discordance between MRI and pathology was found in evaluation of 4 patients (8%). Three patients (6%) were considered "false negative" with a post-ablation residual tumor burden of less than 2mm which was not detected by MRI. One patient (2%) had a complete pathologic ablation but positive MRI ("false positive"). One patient (2%) had adjacent residual DCIS, visible in retrospect on the pre-ablation MRI and was considered a screening failure. Eight patients (16%) were found to have residual invasive cancer by both post-ablation MRI and pathologic analysis. Complete ablation was confirmed in 36 patients (73%) when evaluated by both post-ablation MRI and pathologic analysis.

Conclusion: Percutaneous laser ablation holds promise as an alternative to lumpectomy in the treatment of early stage breast cancer. There is a strong correlation (92%) between findings on post-ablation MRI and changes in CK 8/18, Ki67 and estrogen receptor staining in this series. Additional trials are necessary to determine the long-term curative potential of this technique.

Citation Format: Schwartzberg BS, Abdelatif OMA, Lewin JM, Bernard JM, Brehm JL, Bu-Ali HM, Cawthorn SJ, Chen-Seeto M, Feldman SM, Govindarajulu S, Jones LI, Juette A, Kavia S, Maganini RO, Pain SJ, Shere MH, Shriver CD, Smith SG, Valencia A, Whitacre EB, Whitney R. Multicenter clinical trial of percutaneous laser ablation for early stage primary breast cancer. Results of 49 cases with radiographic and pathological correlation. [abstract]. In: Proceedings of the Thirty-Eighth Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2015 Dec 8-12; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2016;76(4 Suppl):Abstract nr P3-13-03.

Abstract PD1-08: Factors affecting uptake and adherence to breast cancer chemoprevention: A systematic review and meta-analysis

Chemoprevention is a risk reduction option for women who have increased risk of breast cancer. Selective Estrogen Receptor Modulators (SERMs) have been extensively tested, and alternative agents are being evaluated. Long-term adherence to chemoprevention is critical to obtaining the drug's full benefit. We systematically reviewed articles reporting uptake rates and adherence among healthy adult women, who were prescribed medication to prevent primary breast cancer. We also extracted data on the clinical, socio-demographic and psychological predictors of uptake and adherence.

Searches were performed in PubMed, CINAHL, EMBASE, and PsychInfo, yielding 3851 unique articles. Title, abstract and full text screening left 53 articles that met inclusion criteria, and a further 4 studies were identified from reference lists, giving a total of 57. The mean quality score using the Mixed Methods Appraisal Tool was 3 out of 4.

Thirty-one articles reported uptake, of which 14 tested predictors, and 23 reported adherence of which 11 tested predictors. Seven studies reported qualitative data. Most studies (50) involved SERMs, but 5 tested Aromatase Inhibitors, 1 tested Aspirin, 1 tested a statin. Twenty studies included data from a clinical setting, 35 reported trial data, and 2 reported both.

Twenty-four studies reporting 26 instances of uptake in 21,423 women were included in a meta-analysis. The pooled uptake estimate was 16.3% (95% CI, 13.6-19.0), with high heterogeneity (I^2=98.9%, p&lt;0.0001). Uptake was unaffected by study location or agent, but was significantly higher in trials (25.2% [95% CI, 18.3-32.2]) than in clinical settings (8.7% [95% CI, 6.8-10.9]). Factors associated with higher uptake in two or more studies included having an abnormal biopsy, a physician recommendation, higher objective risk, fewer side-effect or trial-related concerns, and older age. Heterogeneity in data collection prevented a meta-analysis of adherence. Data suggested adequate day-to-day adherence among women who initiated treatment, with 5/6 studies reporting ≥80% of medications being taken appropriately. Persistence over 3-12 months was also high, with 5/7 studies reporting that ≥80% women were still taking chemoprevention. Long-term persistence was lower, with only 1/10 studies reporting a persistence of ≥80% by 5-years. Factors associated with lower adherence or persistence included allocation to Tamoxifen (vs. placebo or Raloxifene), depression, smoking, and older age. Objective and subjective risk was a theme in all qualitative studies, although other topics involved in decision-making included concerns about medications (6/7), low knowledge (3/7), lack of information (2/7), and trial-related issues (2/7).

Chemoprevention uptake for the prevention of breast cancer is low, and long-term adherence is often insufficient for the full preventive effect. Uptake rates were higher in trials than in clinical settings, suggesting further work should focus on implementing chemoprevention within routine patient care. Further research is warranted to identify factors amenable to modification and to improve informed decision-making surrounding chemoprevention.

Citation Format: Smith SG, Sestak I, Forster A, Partridge A, Side L, Horne R, Wardle J, Cuzick J. Factors affecting uptake and adherence to breast cancer chemoprevention: A systematic review and meta-analysis. [abstract]. In: Proceedings of the Thirty-Eighth Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2015 Dec 8-12; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2016;76(4 Suppl):Abstract nr PD1-08.

Impact of general practice endorsement on the social gradient in uptake in bowel cancer screening

BACKGROUND

There is a socioeconomic gradient in the uptake of screening in the English NHS Bowel Cancer Screening Programme (BCSP), potentially leading to inequalities in outcomes. We tested whether endorsement of bowel cancer screening by an individual's general practice (GP endorsement; GPE) reduced this gradient.

METHODS

A cluster-randomised controlled trial. Over 20 days, individuals eligible for screening in England from 6480 participating general practices were randomly allocated to receive a GP-endorsed or the standard invitation letter. The primary outcome was the proportion of people adequately screened and its variation by quintile of Index of Multiple Deprivation.

RESULTS

We enrolled 265,434 individuals. Uptake was 58.2% in the intervention arm and 57.5% in the control arm. After adjusting for age, sex, hub and screening episode, GPE increased the overall odds of uptake (OR=1.07, 95% CI 1.04-1.10), but did not affect its socioeconomic gradient. We estimated that implementing GPE could result in up to 165 more people with high or intermediate risk colorectal adenomas and 61 cancers detected, and a small one-off cost to modify the standard invitation (£78,000).

CONCLUSIONS

Although GPE did not improve its socioeconomic gradient, it offers a low-cost approach to enhancing overall screening uptake within the NHS BCSP.

The association between patient activation and accessing online health information: results from a national survey of US adults

BACKGROUND

There are increasing opportunities for the public to access online health information, but attitudinal barriers to use are less well-known. Patient activation is associated with key health outcomes, but its relationship with using online health information is not known.

OBJECTIVE

We examined the relationship between patient activation and the likelihood of accessing a range of different types of online health information in a nationally representative US sample.

DESIGN

Cross-sectional nationally representative survey.

SETTING AND PARTICIPANTS

Data were from an online (n = 2700) and random digit dial telephone survey (n = 700) of US adults (total n = 3400).

MAIN VARIABLES STUDIED

Respondent characteristics and the Patient Activation Measure.

MAIN OUTCOME MEASURES

Self-reported access of five types of online health information in the past 12 months (online medical records, cost estimation tools, quality comparison tools, health information about a specific condition, preventive health information).

RESULTS

Approximately, one-fifth of the sample had accessed their medical record (21.6%), treatment cost estimation tools (17.3%) and hospital and physician quality comparison tools (21.8%). Nearly half of the sample had accessed information about medical conditions or treatments (48.3%) or preventive health and well-being (45.9%). In multivariable analyses adjusted for participant characteristics, respondents with greater patient activation were more likely to have accessed all types of health information other than cost estimation tools.

DISCUSSION AND CONCLUSIONS

Activated people are more likely to make use of online heath information. Increasing patient activation could improve the public's ability to participate in health care and personal health self-management by encouraging health information seeking.

Barriers to preventive therapy for breast and other major cancers and strategies to improve uptake

The global cancer burden continues to rise and the war on cancer can only be won if improvements in treatment go hand in hand with therapeutic cancer prevention. Despite the availability of several efficacious agents, utilisation of preventive therapy has been poor due to various barriers, such as the lack of physician and patient awareness, fear of side effects, and licensing and indemnity issues. In this review, we discuss these barriers in detail and propose strategies to overcome them. These strategies include improving physician awareness and countering prejudices by highlighting the important differences between preventive therapy and cancer treatment. The importance of the agent-biomarker-cohort (ABC) paradigm to improve effectiveness of preventive therapy cannot be overemphasised. Future research to improve therapeutic cancer prevention needs to include improvements in the prediction of benefits and harms, and improvements in the safety profile of existing agents by experimentation with dose. We also highlight the role of drug repurposing for providing new agents as well as to address the current imbalance between therapeutic and preventive research. In order to move the field of therapeutic cancer prevention forwards, engagement with policymakers to correct research imbalance as well as to remove practical obstacles to implementation is also urgently needed.

The Role of Patient Activation in Preferences for Shared Decision Making: Results From a National Survey of U.S. Adults

Studies investigating preferences for shared decision making (SDM) have focused on associations with sociodemographic variables, with few investigations exploring patient factors. We aimed to investigate the relationship between patient activation and preferences for SDM in 6 common medical decisions among a nationally representative cross-sectional survey of American adults. Adults older than 18 were recruited online (n = 2,700) and by telephone (n = 700). Respondents completed sociodemographic assessments and the Patient Activation Measure. They were also asked whether they perceived benefit (yes/no) in SDM in 6 common medical decisions. Nearly half of the sample (45.9%) reached the highest level of activation (Level 4). Activation was associated with age (p < .001), higher income (p = .001), higher education (p = .010), better self-rated health (p < .001), and fewer chronic conditions (p = .050). The proportion of people who agreed that SDM was beneficial varied from 53.1% (deciding the necessity of a diagnostic test) to 71.8% (decisions associated with making lifestyle changes). After we controlled for participant characteristics, higher activation was associated with greater perceived benefit in SDM across 4 of the 6 decisions. Preferences for SDM varied among 6 common medical scenarios. Low patient activation is an important barrier to SDM that could be ameliorated through the development of behavioral interventions.

ABCs or 123s? The independent contributions of literacy and numeracy skills on health task performance among older adults

OBJECTIVE

To investigate the relationship between literacy and numeracy and their association with health task performance.

METHODS

Older adults (n=304) completed commonly used measures of literacy and numeracy. Single factor literacy and numeracy scores were calculated and used to predict performance on an established set of health self-management tasks, including: (i) responding to spoken information; (ii) comprehension of print and (iii) multimedia information; and (iv) organizing and dosing medication. Total and sub-scale scores were calculated.

RESULTS

Literacy and numeracy measures were highly correlated (rs=0.68; ps<0.001). In multivariable models adjusted for age, gender, race, education, and comorbidity, lower literacy (β=0.44, p<0.001) and numeracy (β=0.44, p<0.001) were independently associated with worse overall task performance and all sub-scales (literacy range, β=0.23-0.45, ps<0.001; numeracy range, β=0.31-0.41, ps<0.001). Multivariable analyses with both constructs entered explained more variance in overall health task performance compared with separate literacy and numeracy models (8.2% and 10% respectively, ps<0.001).

CONCLUSION

Literacy and numeracy were highly correlated, but independent predictors of health task performance. These skill sets are complementary and both are important for health self-management.

PRACTICE IMPLICATIONS

Self-management interventions may be more effective if they consider both literacy and numeracy skills rather than focusing on one specific ability.

Health literacy, cognitive function, proper use, and adherence to inhaled asthma controller medications among older adults with asthma

BACKGROUND

We sought to investigate the degree to which cognitive skills explain associations between health literacy and asthma-related medication use among older adults with asthma.

METHODS

Patients aged ≥ 60 years receiving care at eight outpatient clinics (primary care, geriatrics, pulmonology, allergy, and immunology) in New York, New York, and Chicago, Illinois, were recruited to participate in structured, in-person interviews as part of the Asthma Beliefs and Literacy in the Elderly (ABLE) study (n = 425). Behaviors related to medication use were investigated, including adherence to prescribed regimens, metered-dose inhaler (MDI) technique, and dry powder inhaler (DPI) technique. Health literacy was measured using the Short Test of Functional Health Literacy in Adults. Cognitive function was assessed in terms of fluid (working memory, processing speed, executive function) and crystallized (verbal) ability.

RESULTS

The mean age of participants was 68 years; 40% were Hispanic and 30% non-Hispanic black. More than one-third (38%) were adherent to their controller medication, 53% demonstrated proper DPI technique, and 38% demonstrated correct MDI technique. In multivariable analyses, limited literacy was associated with poorer adherence to controller medication (OR, 2.3; 95% CI, 1.29-4.08) and incorrect DPI (OR, 3.51; 95% CI, 1.81-6.83) and MDI (OR, 1.64; 95% CI, 1.01-2.65) techniques. Fluid and crystallized abilities were independently associated with medication behaviors. However, when fluid abilities were added to the model, literacy associations were reduced.

CONCLUSIONS

Among older patients with asthma, interventions to promote proper medication use should simplify tasks and patient roles to overcome cognitive load and suboptimal performance in self-care.