Inequalities in colorectal cancer screening participation in the first round of the national screening programme in England

Sociodemographic variations in the uptake of faecal immunochemical tests in primary care: a retrospective study

BACKGROUND

Faecal immunochemical test (FIT) usage for symptomatic patients is increasing, but variations in use caused by sociodemographic factors are unknown. A clinical pathway for colorectal cancer (CRC) was introduced in primary care for symptomatic patients in November 2017. The pathway was commissioned to provide GPs with direct access to FITs.

AIM

To identify whether sociodemographic factors affect FIT return in symptomatic patients.

DESIGN AND SETTING

A retrospective study was undertaken in Nottingham, UK, following the introduction of FIT as triage tool in primary care. It was mandated for all colorectal referrals (except rectal bleeding or mass) to secondary care. FIT was used, alongside full blood count and ferritin, to stratify CRC risk.

METHOD

All referrals from November 2017 to December 2021 were retrospectively reviewed. Sociodemographic factors affecting FIT return were analysed by multivariate logistic regression.

RESULTS

A total of 35 289 (90.7%) patients returned their index FIT, while 3631 (9.3%) did not. On multivariate analysis, males were less likely to return an FIT (odds ratio [OR] 1.11, 95% confidence interval [CI] = 1.03 to 1.19). Patients aged ≥65 years were more likely to return an FIT (OR 0.78 for non-return, 95% CI = 0.72 to 0.83). Unreturned FIT more than doubled in the most compared with the least deprived quintile (OR 2.20, 95% CI = 1.99 to 2.43). Patients from Asian (OR 1.82, 95% CI = 1.58 to 2.10), Black (OR 1.21, 95% CI = 0.98 to 1.49), and mixed or other ethnic groups (OR 1.29, 95% CI = 1.05 to 1.59) were more likely to not return an FIT compared with patients from a White ethnic group. A total of 599 (1.5%) CRCs were detected; 561 in those who returned a first FIT request.

CONCLUSION

FIT return in those suspected of having CRC varied by sex, age, ethnic group, and socioeconomic deprivation. Strategies to mitigate effects on FIT return and CRC detection should be considered as FIT usage expands.

Socioeconomic inequality in organized and opportunistic screening for colorectal cancer: results from the Korean National Cancer Screening Survey, 2009-2021

OBJECTIVES

This study aimed to investigate socioeconomic status (SES)-based inequality in colorectal cancer (CRC) screening in Korea. We assessed whether the rates of opportunistic and organized CRC screening differed according to income and education levels.

METHODS

We analyzed data from the Korean National Cancer Screening Survey of 27,654 cancer-free individuals, aged 50-74 years, from 2009 to 2021. The weighted cancer screening rates with trends were estimated with the average annual percentage change using joinpoint regression. Inequality was calculated in both relative and absolute terms, based on a Poisson regression model.

RESULTS

The organized screening rate increased significantly from 22.1% in 2009 to 53.1% in 2020 and 50.6% in 2021, with an average annual change of 8.6% (95% confidence interval [CI], 4.9 to 12.5). In contrast, no significant trend was observed for opportunistic screening. The SES inequality in opportunistic screening uptake was indicated by a slope index of inequality (SII) of 9.74% (95% CI, 6.36 to 13.12), relative index of inequality (RII) of 2.18 (95% CI, 1.75 to 2.70) in terms of education level; and an SII of 7.03% (95% CI, 4.09 to 9.98), RII of 1.81 (95% CI, 1.41 to 2.31) in terms of measured income. Although there was an increasing trend in income inequality, no significant SES inequalities were observed in the overall estimates for organized screening.

CONCLUSIONS

Organized CRC screening is effective in improving the participation rate, regardless of SES. However, significant inequalities were found in opportunistic screening, suggesting room for improvement in the overall equity of CRC screening.

Benefit of Biennial Fecal Occult Blood Screening on Colorectal Cancer in England: A Population-Based Case-Control Study

BACKGROUND

The English national bowel cancer screening program offering a guaiac fecal occult blood test began in July 2006. In randomized controlled trials of guaiac fecal occult blood test screening, reductions in mortality were accompanied by reductions in advanced stage colorectal cancer (CRC). We aimed to evaluate the effect of participation in the national bowel cancer screening program on stage-specific CRC incidence as a likely precursor of a mortality effect.

METHODS

In this population-based case-control study, cases were individuals diagnosed with CRC aged 60-79 years between January 1, 2012, and December 31, 2013. Two controls per case were matched on geographic region, gender, date of birth, and year of first screening invitation. Screening histories were extracted from the screening database. Conditional logistic regression with correction for self-selection bias was used to estimate odds ratios (odds ratios corrected for self-selection bias [cOR]) and 95% confidence intervals (CIs) by Duke stage, sex, and age.

RESULTS

14 636 individuals with CRC and 29 036 without were eligible for analysis. The odds of CRC (any stage) were increased within 30 days of a screening test and decreased thereafter. No reduction in CRC (any stage) among screened individuals compared with those not screened was observed (cOR = 1.00, 95% CI = 0.89 to 1.15). However, screened individuals had lower odds of Duke stage D CRC (cOR = 0.68, 95% CI = 0.50 to 0.93). We estimate 435 fewer Duke D CRC by age 80 years in 100 000 people screened biennially between ages 60 and 74 years compared with an unscreened cohort.

CONCLUSION

The impact of colorectal screening on advanced CRC incidence suggests that the program will meet its aim of reducing mortality.

Colorectal Cancer Screening Program in Songjiang district, Shanghai between 2015 and 2017: Evaluation of participation rate and the associated factor

Little is known about the participation rate of newly implemented colorectal cancer (CRC) screening programs in China. Our goals were to identify factors associated with nonparticipation for CRC screening in Songjiang District, Shanghai. We analyzed individuals included in an observational cohort study from 4 towns (Xin Qiao, She Shan, Mao Gang, and Zhong Shan) in Songjiang District. The participation rate was calculated for the CRC screening program based on a fecal immunochemical test and a risk assessment questionnaire between 2015 and 2017 inclusive. Of the 27,130 individuals eligible for inclusion in this study, 20,863 (76.9%) participated in CRC screening at least once during 2015 and 2017. The factors linked with nonparticipation were; being male (odds ratio [OR] 0.87, 95% confidence interval [CI] 0.82-0.93, P < .01), unmarried (OR 0.71, 95% CI 0.64-0.80, P < .01), having a high education level (middle school, OR 0.82, 95% CI 0.74-0.90, P < .01, high school or above, OR 0.64, 95% CI 0.57-0.73, P < .01), absence of chronic disease (OR 0.90, 95% CI 0.85-0.96, P < .01), and living in 2 out of the 4 towns covered (Xin Qiao, OR 0.72, 95% CI 0.66-0.78, P < .01, Zhong Shan, OR 0.29, 95% CI 0.26-0.31, P < .01). The current study revealed several associated factors with nonparticipation for the CRC screening in Songjiang district. These findings will help identify target populations that require an individualized approach to increase the participation rate.

A scoping review of risk-stratified bowel screening: current evidence, future directions

PURPOSE

In this scoping review, we examined the international literature on risk-stratified bowel screening to develop recommendations for future research, practice and policy.

METHODS

Six electronic databases were searched from inception to 18 October 2021: Medline, Embase, PsycINFO, CINAHL, Cochrane Database of Systematic Reviews and Cochrane Central Register of Controlled Trials. Forward and backwards citation searches were also undertaken. All relevant literature were included.

RESULTS

After de-deduplication, 3,629 records remained. 3,416 were excluded at the title/abstract screening stage. A further 111 were excluded at full-text screening stage. In total, 102 unique studies were included. Results showed that risk-stratified bowel screening programmes can potentially improve diagnostic performance, but there is a lack of information on longer-term outcomes. Risk models do appear to show promise in refining existing risk stratification guidelines but most were not externally validated and less than half achieved good discriminatory power. Risk assessment tools in primary care have the potential for high levels of acceptability and uptake, and therefore, could form an important component of future risk-stratified bowel screening programmes, but sometimes the screening recommendations were not adhered to by the patient or healthcare provider. The review identified important knowledge gaps, most notably in the area of organisation of screening services due to few pilots, and what risk stratification might mean for inequalities.

CONCLUSION

We recommend that future research focuses on what organisational challenges risk-stratified bowel screening may face and a consideration of inequalities in any changes to organised bowel screening programmes.

Socioeconomic differences in participation and diagnostic yield within the Dutch national colorectal cancer screening programme with faecal immunochemical testing

Background

CRC mortality rates are higher for individuals with a lower socioeconomic status (SES). Screening could influence health inequalities. We therefore aimed to investigate SES differences in participation and diagnostic yield of FIT screening.

Methods

All invitees in 2014 and 2015 in the Dutch national CRC screening programme were included in the analyses. We used area SES as a measure for SES and divided invitees into quintiles, with Quintile 1 being the highest SES. Logistic regression analysis was used to compare the participation rate, positivity rate, colonoscopy uptake, positive predictive value (PPV) and detection rate across the SES groups.

Results

Participation to FIT screening was significantly lower for Quintile 5 (67.0%) compared to the other Quintiles (73.0% to 75.1%; adjusted OR quintile 5 versus quintile 1: 0.73, 95%CI: 0.72–0.74), as well as colonoscopy uptake after a positive FIT (adjusted OR 0.73, 95%CI: 0.69–0.77). The detection rate per FIT participant for advanced neoplasia gradually increased from 3.3% in Quintile 1 to 4.0% in Quintile 5 (adjusted OR 1.20%, 95%CI 1.16–1.24). As a result of lower participation, the yield per invitee was similar for Quintile 5 (2.04%) and Quintile 1 (2.00%), both being lower than Quintiles 2 to 4 (2.20%-2.28%).

Conclusions

Screening has the potential to reduce health inequalities in CRC mortality, because of a higher detection in participants with a lower SES. However, in the Dutch screening programme, this is currently offset by the lower participation in this group.

Intentions to participate in cervical and colorectal cancer screening during the COVID-19 pandemic: A mixed-methods study

Worldwide, cancer screening faced significant disruption in 2020 due to the COVID-19 pandemic. If this has led to changes in public attitudes towards screening and reduced intention to participate, there is a risk of long-term adverse impact on cancer outcomes. In this study, we examined previous participation and future intentions to take part in cervical and colorectal cancer (CRC) screening following the first national lockdown in the UK. Overall, 7543 adults were recruited to a cross-sectional online survey in August-September 2020. Logistic regression analyses were used to identify correlates of strong screening intentions among 2319 participants eligible for cervical screening and 2502 eligible for home-based CRC screening. Qualitative interviews were conducted with a sub-sample of 30 participants. Verbatim transcripts were analysed thematically. Of those eligible, 74% of survey participants intended to attend cervical screening and 84% intended to complete home-based CRC screening when next invited. Thirty percent and 19% of the cervical and CRC samples respectively said they were less likely to attend a cancer screening appointment now than before the pandemic. Previous non-participation was the strongest predictor of low intentions for cervical (aOR 26.31, 95% CI: 17.61-39.30) and CRC (aOR 67.68, 95% CI: 33.91-135.06) screening. Interview participants expressed concerns about visiting healthcare settings but were keen to participate when screening programmes resumed. Intentions to participate in future screening were high and strongly associated with previous engagement in both programmes. As screening services recover, it will be important to monitor participation and to ensure people feel safe to attend.

Transient elastography in patients at risk of liver fibrosis in primary care: a follow-up study over 54 months

Background

Liver fibrosis assessment services using transient elastography are growing in primary care. These services identify patients requiring specialist referral for liver fibrosis, and provide an opportunity for recommending lifestyle change. However, there are uncertainties regarding service design, effectiveness of advice given, and frequency of follow-up.

Aim

To assess the following: (a) effectiveness of standard care lifestyle advice for weight management and alcohol consumption; (b) uptake for liver rescan; and (c) usefulness of a 4.5-year time interval of rescanning in monitoring progression of liver fibrosis.

Design & setting

Analysis of patient outcomes 4.5 years after the first ‘liver service’ attendance that included transient elastography in five GP practices in Southampton, UK.

Method

Outcomes included weight, alcohol consumption, rescan uptake, time interval between scans, and change in liver fibrosis stage.

Results

A total of 401 participants were recontacted. Mean standard deviation (± SD) weight loss was 1.2 kg±8.4 kg (P = 0.005); Alcohol Use Disorders Identification Test (AUDIT) grade increased by 7.8% (P ≤0.001). A total of n = 116/401 participants were eligible for liver rescanning and n = 59/116 (50.9%) agreed to undergo rescanning. Mean ± SD time interval between scans was 53.6±3.4 months. Liver fibrosis progressed from mild (≥6.0 kPa–8.1 kPa) to significant fibrosis (8.2 kPa–9.6 kPa) in 3.4% of patients; from mild to advanced fibrosis (9.7 kPa–13.5 kPa) and cirrhosis (≥13.6 kPa) in 15.3% of patients, and did not progress in 81.3%. No baseline factors were independently associated with liver fibrosis progression at follow-up.

Conclusion

Rescan recall attendance and adherence to lifestyle changes needs improving. Optimum time interval between scans remains uncertain. After a mean interval of 53.6 months between scans, and with no specific predictors indicated, a substantial minority (18.7%) experienced a deterioration in fibrosis grade.

Income-based inequality in nationwide general health checkup participation in Japan

OBJECTIVE

In Japan, it is mandatory for employers to provide general health checkup opportunities to employees. Although many companies have subsidized checkups for employees' dependent family members, their participation is low. We assessed income-based inequality in the participation of employees' dependents in the general health checkup.

STUDY DESIGN

This is a cross-sectional descriptive study. Annual participation rate in general health checkup and various factors including income, age, and sex were collected and analyzed to examine the income-based inequality of participation rate in general health checkup.

METHODS

The data for the present study were sourced from the Fukuoka Branch of the Japan Health Insurance Association, a large medical insurer in Japan. We extracted data of 196,057 dependents aged 40-74 years. We conducted a multiple logistic regression analysis using participation from April 2015 to March 2016 as dependent variable and income category ranging from 1 (lowest) to 4 (highest) between April and June 2015 as independent variable (adjusted for sex and age). We computed slope index of inequality (SII) and relative index of inequality (RII) based on income category.

RESULTS

Higher the income, the more likely were dependents to participate in the general health checkup. SII for the participation rate of general health checkup ranged between -0.02 (95% confidence interval [CI]: -0.07 to 0.03) and 0.06 (0.03-0.09) for men; 0.03 (0.01-0.06) and 0.10 (0.09-0.11) for women. RII for the participation rate of general health checkup ranged between -0.19 (95% CI: -0.66 to 0.29) and 0.88 (0.15-1.61) for men; 0.22 (0.05-0.39) and 0.68 (0.60-0.76) for women. The highest inequality existed for men in their 50s and 60s and women in their 50s; the lowest inequality was among men and women aged 70-74 years.

CONCLUSION

There was income-based inequality in participation in the general health checkup among dependents (family members) of the insured persons. The degree of inequality differed with age group. It cannot be explained solely by financial barrier among low-income group, rather it may reflect Japanese unique context in medical insurance system.

Are socio-economic inequalities in breast cancer survival explained by peri-diagnostic factors?

BACKGROUND

Patients living in more deprived localities have lower cancer survival in England, but the role of individual health status at diagnosis and the utilisation of primary health care in explaining these differentials has not been widely considered. We set out to evaluate whether pre-existing individual health status at diagnosis and primary care consultation history (peri-diagnostic factors) could explain socio-economic differentials in survival amongst women diagnosed with breast cancer.

METHODS

We conducted a retrospective cohort study of women aged 15-99 years diagnosed in England using linked routine data. Ecologically-derived measures of income deprivation were combined with individually-linked data from the English National Cancer Registry, Clinical Practice Research Datalink (CPRD) and Hospital Episodes Statistics (HES) databases. Smoking status, alcohol consumption, BMI, comorbidity, and consultation histories were derived for all patients. Time to breast surgery was derived for women diagnosed after 2005. We estimated net survival and modelled the excess hazard ratio of breast cancer death using flexible parametric models. We accounted for missing data using multiple imputation.

RESULTS

Net survival was lower amongst more deprived women, with a single unit increase in deprivation quintile inferring a 4.4% (95% CI 1.4-8.8) increase in excess mortality. Peri-diagnostic co-variables varied by deprivation but did not explain the differentials in multivariable analyses.

CONCLUSIONS

These data show that socio-economic inequalities in survival cannot be explained by consultation history or by pre-existing individual health status, as measured in primary care. Differentials in the effectiveness of treatment, beyond those measuring the inclusion of breast surgery and the timing of surgery, should be considered as part of the wider effort to reduce inequalities in premature mortality.

Factors Related to Non-participation in the Basque Country Colorectal Cancer Screening Programme

Background: Despite the high participation rates in the Basque Country, colorectal cancer screening programme (Spain), there is still a part of the population that has never participated. Since it is essential to ensure equal access to health services, it is necessary to identify the determinants of health and socio-economic factors related to non-participation in the screening programme. Methods: Cross sectional descriptive study including all invited population in a complete round between 2015 and the first trimester of 2017. Health risk factors available in medical records and their control have been analyzed using univariate and multivariate analyses. Results: 515,388 people were invited at the programme with a 71.9% of fecal immunochemical test participation rate. Factors that increase the risk of non-participation are: being men (OR = 1.10, 95% CI 1.09-1.12); younger than 60 (OR = 1.18, 95% CI 1.17-1.20); smoker (OR = 1.20, 95% CI 1.18-1.22); hypertensive (OR = 1.14, 95% CI 1.12-1.15) and diabetic (OR = 1.40, 95% CI 1.36-1.43); having severe comorbidity (OR = 2.09, 95% CI 2.00-2.19) and very high deprivation (OR = 1.15, 95% CI 1.12-1.17), as well as making <6 appointments to Primary Care in 3 years (OR = 2.39, 95% CI 2.33-2.45). Still, the area under the curve (AUC) indicates that there are more factors related to non-participation. Conclusions: The participation in the Basque Country colorectal cancer-screening Programme is related to some risk factors controlled by Primary Care among others. Therefore, the involvement of these professionals could improve, not only the adherence to the CRC screening, but also other health styles and preventive interventions.

Improving Colorectal Cancer Screening in a Rural Setting: A Randomized Study

INTRODUCTION

Colorectal cancer screening has been shown to prevent or detect early colorectal cancer and reduce mortality; yet, adherence to screening recommendations remains low, particularly in rural settings.

STUDY DESIGN

RCT.

SETTING/PARTICIPANTS

Adults (n=7,812) aged 50-75 years and due for colorectal cancer screening in a largely rural health system were randomly assigned to either the intervention (n=3,906) or the control (n=3,906) group in September 2016, with analysis following through 2018.

INTERVENTION

A mailed motivational messaging screening reminder letter with an option to call and request a free at-home fecal immunochemical screening test (intervention) or the standard invitation letter detailing that the individual was due for screening (control). Multifaceted motivational messaging emphasized colorectal cancer preventability and the ease and affordability of screening, and communicated a limited supply of test kits.

MAIN OUTCOME MEASURES

Colorectal cancer screening participation within 6 months after mailed invitation was ascertained from the electronic medical record.

RESULTS

Colorectal cancer screening participation was significantly improved in the intervention (30.1%) vs the usual care control group (22.5%; p<0.001). Individuals randomized to the intervention group had 49% higher odds of being screened over follow-up than those randomized to the control group (OR=1.49, 95% CI=1.34, 1.65). A total of 13.2 screening invitations were needed to accomplish 1 additional screening over the usual care. Of the 233 fecal immunochemical test kits mailed to participants, 154 (66.1%) were returned, and 18 (11.7%) tested positive.

CONCLUSIONS

A mailed motivational messaging letter with a low-cost screening alternative increased colorectal cancer screening in this largely rural community with generally poor adherence to screening recommendations. Mailed colorectal cancer screening reminders using motivational messaging may be an effective method for increasing screening and reducing rural colorectal cancer disparities.

Socioeconomic Inequalities in Colorectal Cancer Survival in Southern Spain: A Multilevel Population-Based Cohort Study

BACKGROUND

Colorectal cancer (CRC) is the most frequently diagnosed cancer in Spain. Socioeconomic inequalities in cancer survival are not documented in Spain. We aim to study the association of socioeconomic inequalities with overall mortality and survival among CRC patients in southern Spain.

METHODS

We conducted a multilevel population-based cohort study, including CRC cases for the period 2011-2013. The study time-to-event outcome was death, and the primary exposure was CRC patients' socioeconomic status assessed by the Spanish deprivation index at the census tract level. We used a mixed-effects flexible hazard model, including census tract as a random intercept, to derive overall survival estimates by deprivation.

RESULTS

Among 3589 CRC patients and 12,148 person-years at risk (pyr), 964 patients died before the end of the follow-up. Mortality by deprivation showed the highest mortality rate for the most deprived group (96.2 per 1000 pyr, 95% CI: 84.0-110.2). After adjusting for sex, age, cancer stage, and the area of residence, the most deprived had a 60% higher excess mortality risk than the less deprived group (excess mortality risk ratio: 1.6, 95% CI: 1.1-2.3).

CONCLUSIONS

We found a consistent association between deprivation and CRC excess mortality and survival. The reasons behind these inequalities need further investigation in order to improve equality cancer outcomes in all social groups.

The impact of socioeconomic deprivation on the uptake of colorectal cancer screening in London

OBJECTIVE

Screening programmes based on the faecal occult blood test (FOBT) can reduce mortality from colorectal cancer (CRC). However, a significant variation exists in uptake of the test within the UK. Disproportionate uptake risks increasing inequity during staging at diagnosis and survival from CRC. This study aims to evaluate the impact of socioeconomic deprivation on the uptake of CRC screening (FOBT) in London.

METHODS

A retrospective review of the "Vanguard RM Informatics" database was performed to identify eligible individuals for CRC screening across all general practices across London over 30 months (2014-2017). The postcodes of the general practices were used to obtain the deprivation data via the "Indices of Deprivation" database. A Spearman's rho correlation was performed to quantify the impact of the deprivation variables on FOBT uptake.

RESULTS

Overall, 697,402 individuals were eligible for screening across 1359 London general practices, within 5 Clinical Commissioning Groups (CCGs); 48.4% (range: 13%-74%) participated in CRC screening with the lowest participation rates in North West (46%) and North East (47%) London CCGs. All indices of deprivation had a significant correlation with the uptake of FOBT (p < 0.01).

CONCLUSION

This is the largest study across London to date demonstrating a significant positive correlation between deprivation indices and FOBT uptake, highlighting areas of particular risk. Further studies are imperative to quantify the impact of deprivation on CRC morbidity and mortality, together with focused strategies to reduce socioeconomic inequalities in screening in these high risk areas.

Variations of health check attendance in later life: results from a British birth cohort study

BACKGROUND

Older adults are advised to attend a number of preventive health checks to preserve health and identify risk factors for disease. Previous research has identified a number of health and social factors, labelled as predisposing, enabling and need factors, using Andersen's Behavioural Model of Health Service Use, that are associated with health care utilisation. We aimed to assess associations between factors from childhood and adulthood, and health check attendance in later life in a British birth cohort study.

METHODS

For 2370 study members from the MRC National Survey of Health and Development (NSHD), health check attendance was assessed at age 68. Study members were asked if they: attended blood pressure and cholesterol checks, had their eyes tested, received the influenza vaccine, attended colon cancer screening and dental checks. Health and social factors from childhood and adulthood were used in binomial regression models to test associations with health check attendance in men and women.

RESULTS

Health check attendance was high; 41% reported attending all six health checks within the recommended time frame. In multivariable models, being a non-smoker and having more health conditions in adulthood were associated with greater health check attendance in men and women. In women, childhood socioeconomic advantage, being more physically active in midlife and previously attending screening procedures, and in men, greater self-organisation in adolescence and being married were associated with attending more health checks in later life, following adjustments for childhood and adulthood factors.

CONCLUSIONS

A number of predisposing, enabling and need factors from childhood and adulthood were found to be associated with health check attendance at age 68, demonstrating the relevance of applying a life course perspective to Andersen's model in investigating health check attendance in later life. Health related factors were found to be stronger correlates of health check attendance than socioeconomic factors.

Association of Skin Cancer Risk and Protective Behaviors with Health Literacy Among Young Adults in the USA

BACKGROUND

The goal of this study was to investigate the association of health literacy with skin cancer risk and protective behaviors among young adults at moderate to high risk of skin cancer, the most common cancer.

METHOD

A US national sample of 958 adults, 18-25 years old, at moderate to high risk of developing skin cancer, completed a survey online. Behavioral outcomes were ultraviolet (UV) radiation exposure (e.g., indoor and outdoor tanning, sunburn) and protective (e.g., sunscreen use, sunless tanning) behaviors. Multivariable regression analyses were conducted to determine whether health literacy (a four-item self-report measure assessing health-related reading, understanding, and writing) was associated with behavioral outcomes while controlling for demographic factors.

RESULTS

Higher health literacy was independently associated with less sunbathing, odds ratio (OR) = 0.77, 95% confidence interval (CI) = 0.60-0.98; less indoor tanning, OR = 0.38, CI = 0.31-0.48; and less use of tanning oils, OR = 0.54, CI = 0.43-0.69. However, health literacy was also associated with a lower likelihood of wearing long pants, OR = 0.76, CI = 0.58-0.99, or a hat, OR = 0.68, CI = 0.53-0.87, when outdoors. On the other hand, higher health literacy was associated with higher incidental UV exposure, OR = 1.69, CI = 1.34-2.14, and a greater likelihood of ever having engaged in sunless tanning, OR = 1.50, CI = 1.17-1.92.

CONCLUSION

Interestingly, higher health literacy was associated with lower levels of intentional tanning yet also higher incidental UV exposure and lower skin protection among US young adults. These findings suggest that interventions may be needed for young adults at varying levels of health literacy as well as populations (e.g., outdoor workers, outdoor athletes/exercisers) who may be receiving large amounts of unprotected incidental UV.

Market segmentation tools provide insights into demographic variations in bowel cancer screening uptake

Background

The National Health Service Bowel Cancer Screening Programme (NHS BCSP) aims to detect individuals who have precancerous polyps or early stage cancer, when it is easier to treat. To be effective, a screening uptake of at least 52% is required. Variations in uptake by demographic characteristic are reported and the aim of this study was to better understand who participates in the NHS BCSP, to inform action to address inequalities in screening uptake.

Methods

Invitation-level data for the Derbyshire population were supplied by the NHS BCSP Eastern Hub for the period 1 April 2014 to 31 March 2016. Data were linked by postal code to the Mosaic Public Sector Segmentation tool. Descriptive analysis using 14 groups and 61 types within Mosaic was undertaken to offer insight into the demographic, lifestyle and behavioural traits of people living in small geographies against their screening uptake, with a particular focus on identifying population groups with an uptake below 52% and so at risk of health inequalities.

Results

180 176 screening invitations were dispatched with an overall uptake of 60.55%. Six Mosaic groups have an uptake below the 52% acceptable level: urban cohesion, rental hubs, transient renters, family basics, vintage value and municipal tenants. These groups are characterised by high levels of social-rented accommodation, multicultural urban communities and transient populations.

Conclusion

Segmentation tools offer an effective way to generate novel insights into bowel cancer screening uptake and develop tailored strategies for working with identified communities to increase participation.

The "sphere of care": A qualitative study of colorectal cancer patient and caregiver experiences of support within the cancer treatment setting

Introduction

Colorectal cancer is associated with considerable physical and psychosocial burden. Whilst social support is known to facilitate psychological adjustment to cancer, patients’ and caregivers’ experiences of social support within a treatment setting and their perceptions of the role of the treating team in providing this support is unknown. Specifically, there is a gap in the research that explores in detail who people affected by colorectal cancer consider to be supportive, and the function, timing and nature of this support, whilst receiving treatment. This study explored both patients’ and caregivers’ a) experiences of social support and how this relates to their experience of treatment; and b) what facilitates support in the treatment setting.

Methods

Individual interviews (N = 20) were conducted with patients diagnosed with colorectal cancer and caregivers of such patients. Audiotaped interviews were transcribed verbatim and analysed using the framework method.

Results

Three major themes emerged from the data: a) treating team as a source of support, highlighting the importance of connection with the treating team; b) changes in existing social supports, encompassing issues regarding distance in interpersonal relationships as a consequence of cancer; and c) differing dimensions of support, exploring the significance of shared experience, practical, financial, and emotional support.

Conclusions

Patients and caregivers perceived the treating team as a major source of support. Support from the treating team was particularly important in the context of the changes that occur as a result of a diagnosis of colorectal cancer and the effects of subsequent treatment. Incidental support from others encountered in the treatment setting was also experienced and was equally important to both patients and caregivers. This has implications for the way health care professionals respond to both patients and caregivers in the treatment setting in terms of communication, interventions and environment.

Postoperative Outcomes of Screen-Detected vs Non-Screen-Detected Colorectal Cancer in the Netherlands

Importance

The nationwide fecal immunochemical test-based screening program has influenced surgical care for patients with colorectal cancer (CRC) in the Netherlands, although these implications have not been studied in much detail so far.

Objective

To compare surgical outcomes of patients diagnosed as having CRC through the fecal immunochemical test-based screening program (screen detected) and patients with non-screen-detected CRC.

Design, Setting, and Participants

This was a population-based comparative cohort study using the Dutch ColoRectal Audit and analyzed all Dutch hospitals performing CRC resections. Patients who underwent elective resection for CRC between January 2011 to December 2016 were included.

Interventions

Colorectal cancer surgery.

Main Outcomes and Measures

Postoperative nonsurgical complications, postoperative surgical complications, postoperative 30-day or in-hospital mortality, and complicated course (postoperative complication resulting in a hospital stay >14 days and/or a reintervention and/or mortality). A risk-stratified comparison was made for different postoperative outcomes based on screening status (screen detected vs not screen detected), cancer stage (I-IV), and for cancer stage I to III also on age (aged ≤70 years and >70 years) and American Society of Anesthesiologists score (I-II and III-IV). To determine any residual case-mix-corrected differences in outcomes between patients with screen-detected and non-screen-detected cancer, univariable and multivariable logistic regression analyses were performed.

Results

In total, 36 242 patients with colon cancer and 17 416 patients with rectal cancer were included for analysis. Compared with patients with non-screen-detected CRC, screen-detected patients were younger (mean [SD] age, 68 [5] vs 70 [11] years), more often men (3777 [60%] vs 13 506 [57%]), and had lower American Society of Anesthesiologists score (American Society of Anesthesiologists score III+: 838 [13%] vs 5529 [23%]). Patients with stage I to III colon cancer who were screen detected had a significantly lower mortality and complicated course rate compared with non-screen-detected patients. For patients with rectal cancer, only a significant difference was found in mortality rate in patients with a cancer stage IV disease, which was higher in the screen-detected group. Compared with non-screen-detected colon cancer, an independent association was found for screen-detected colon cancer on nonsurgical complications (adjusted odds ratio, 0.81; 95% CI, 0.73-0.91), surgical complications (adjusted odds ratio, 0.80; 95% CI, 0.72-0.89), and complicated course (adjusted odds ratio, 0.80; 95% CI, 0.71-0.90). Screen-detected rectal cancer had significantly higher odds on mortality.

Conclusions and Relevance

Postoperative outcomes were significantly better for patients with colon cancer referred through the fecal immunochemical test-based screening program compared with non-screen-detected patients. These differences were not found in patients with rectal cancer. The outcomes of patients with screen-detected colon cancer were still better after an extensive case-mix correction, implying additional underlying factors favoring patients referred for surgery through the screening program.

Disparities In Cancer Care And Costs At The End Of Life: Evidence From England's National Health Service

In universal health care systems such as the English National Health Service, equality of access is a core principle, and health care is free at the point of delivery. However, even within a universal system, disparities in care and costs exist along a socioeconomic gradient. Little is known about socioeconomic disparities at the end of life and how they affect health care costs. This study examines disparities in end-of-life treatment costs for cancer patients in England. Analyzing data on over 250,000 colorectal, breast, prostate, and lung cancer patients from multiple national databases, we found evidence illustrating that disparities are driven largely by the greater use of emergency inpatient care among patients of lower socioeconomic status. Even within a system with free health care, differences in the use of care create disparities in cancer costs. While further studies of these barriers is required, our research suggests that disparities may be reduced through better management of needs through the use of less expensive and more effective health care settings and treatments.

Socioeconomic and ethnic inequities within organised colorectal cancer screening programmes worldwide

OBJECTIVE

Colorectal cancer (CRC) screening programmes can reduce CRC mortality. However, the implementation of a screening programme may create or exacerbate socioeconomic and ethnic health inequities if participation varies by subgroup. We determined which organised programmes characterise participation inequities by socioeconomic and ethnic subgroups, and assessed the variation in subgroup participation among programmes collecting group-specific data.

DESIGN

Employing a literature review and survey among leaders of national or regional screening programmes, this study identified published and unpublished data on participation by socioeconomic status and ethnicity. We assessed programmes offering faecal occult blood tests (FOBT) for screening. Primary outcome was screening participation rate.

RESULTS

Across 24 organised FOBT-screening programmes meeting the inclusion criteria, participation rates ranged from 21% to 73%. Most programmes (13/24, 54%) did not collect data on participation by socioeconomic status and ethnicity. Among the 11 programmes with data on participation by socioeconomic status, 90% (28/31 publications) reported lower participation among lower socioeconomic groups. Differences across socioeconomic gradients were moderate (66% vs 71%) to severe (35% vs 61%). Only six programmes reported participation results by ethnicity. Ethnic differences were moderate, though only limited data were available for evaluation.

CONCLUSIONS

Across organised CRC screening programmes worldwide, variation in participation by socioeconomic status and ethnicity is often not assessed. However, when measured, marked disparities in participation by socioeconomic status have been observed. Limited data were available to assess inequities by ethnicity. To avoid exacerbating health inequities, screening programmes should systematically monitor participation by socioeconomic status and ethnicity, and investigate and address determinants of low participation.

The association between long-term conditions and uptake of population-based screening for colorectal cancer: results from two English cohort studies

Introduction

Uptake of screening for colorectal cancer (CRC) can reduce mortality, and population-based screening is offered in England. To date, there is little evidence on the association between having a long-term condition (LTC) and CRC screening uptake. The objective of this study was to examine the association between having an LTC and uptake of CRC screening in England with the guaiac fecal occult blood test, with a particular focus on common mental disorders.

Methods

The study was a preregistered secondary analysis of two cohorts: first, a linked data set between the regional Yorkshire Health Study (YHS) and the National Health Service National Bowel Cancer Screening Program (BCSP, years 2006–2014); second, the national English Longitudinal Study of Ageing (ELSA, years 2014–2015). Individuals eligible for BCSP screening who participated in either the YHS (7,142) or ELSA Wave 7 (4,099) were included. Study registration: ClinicalTrials.gov, number NCT02503969.

Results

In both the cohorts, diabetes was associated with lower uptake (YHS odds ratio [OR] for non-uptake 1.35, 95% CI 1.03–1.78; ELSA 1.33, 1.03–1.72) and osteoarthritis was associated with increased uptake (YHS 0.75, 0.57–0.99; ELSA 0.76, 0.62–0.93). After controlling for broader determinants of health, there was no evidence of significantly different uptake for individuals with common mental disorders.

Conclusion

Two large independent cohorts provided evidence that uptake of CRC screening is lower among individuals with diabetes and higher among individuals with osteoarthritis. Further work should compare barriers and facilitators to screening among individuals with either of these conditions. This study also demonstrates the benefits of data linkage for improving clinical decision-making.

Small-area geographic and socioeconomic inequalities in colorectal tumour detection in France

The aim of this study was to assess the impact of area deprivation and primary care facilities on colorectal adenoma detection and on colorectal cancer (CRC) incidence in a French well-defined population before mass screening implementation. The study population included all patients aged 20 years or more living in Côte d'Or (France) with either colorectal adenoma or invasive CRC first diagnosed between 1995 and 2002 and who were identified from the Burgundy Digestive Cancer Registry and the Côte d'Or Polyp Registry. Area deprivation was assessed using the European deprivation index on the basis of the smallest French area available (Ilots Regroupés pour l'Information Statistique). Healthcare access was assessed using medical density of general practitioners (GPs) and road distance to the nearest GP and gastroenterologist. Bayesian regression analyses were used to estimate influential covariates on adenoma detection and CRC incidence rates. The results were expressed as relative risks (RRs) with their 95% credibility interval. In total, 5399 patients were diagnosed with at least one colorectal adenoma and 2125 with invasive incident CRC during the study period. Remoteness from GP [RR=0.71 (0.61-0.83)] and area deprivation [RR=0.98 (0.96-1.00)] independently reduced the probability of adenoma detection. CRC incidence was only slightly affected by GP medical density [RR=1.05 (1.01-1.08)] without any area deprivation effect [RR=0.99 (0.96-1.02)]. Distance to gastroenterologist had no impact on the rates of adenoma detection or CRC incidence. This study highlighted the prominent role of access to GPs in the detection of both colorectal adenomas and overall cancers. Deprivation had an impact only on adenoma detection.

Fundamental causes of accelerated declines in colorectal cancer mortality: Modeling multiple ways that disadvantage influences mortality risk

BACKGROUND

Improvements in colorectal cancer (CRC) mortality reflect the distribution of effective preventions. Social inequalities often generate unequal diffusion of medical interventions, resulting in disparate outcomes while preventions are being disseminated throughout the population. This study used a novel method to examine whether Race (Black versus White) and SES influenced when rates of CRC mortality started to decline, and how rapidly they did so.

METHOD

Mortality counts from 1968-2010 were derived from death certificates of U.S. residents aged 25 + years. Individuals' race, age, county of residence, and sex were collected from death certificates. County-level SES was measured using the decennial U.S. census. Layered joinpoint regression was used to model CRC mortality trends over time. Acceleration in rates of historical decline were used to indicate preventability within counties.

RESULTS

Black race was associated with a 4.1-year delay in colonoscopy-attributable declines in CRC mortality and each standard deviation unit change in SES with a 5.7-year delay in such mortality. Following the onset of a decline, colonoscopy-attributable mortality change was slower by 0.5% among Blacks, and 2.0%/standard deviation in SES. Modifying the rapidity of colonoscopy uptake could have averted 12-14,000 and 83-86,000 deaths among Blacks and residents of lower SES counties, respectively.

CONCLUSIONS

Successful interventions do not uniformly benefit the U.S.

POPULATION

This study highlighted the notable impact that substantial delays in the provision of interventions, and in the relative rapidity of dissemination, and estimated the extent to which there was a preventable loss of life concentrated amongst the most disadvantaged. A more egalitarian delivery of life-saving interventions could drastically reduce mortality by improving effectiveness of interventions while also addressing inequalities in health.

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.

Accessibility of standardized information of a national colorectal cancer screening program for low health literate screening invitees: A mixed method study

OBJECTIVE

To explore the accessibility of standardized printed information materials of the national Dutch colorectal cancer screening program among low health literate screening invitees and to assess the effect of the information on their knowledge about colorectal cancer and the screening program.

METHODS

Linguistic tools were used to analyze the text and design characteristics. The accessibility, comprehensibility and relevance of the information materials were explored in interviews and in observations (n=25). The effect of the information on knowledge was assessed in an online survey (n=127).

RESULTS

The materials employed a simple text and design. However, respondents expressed problems with the amount of information, and the difference between screening and diagnostic follow-up. Knowledge significantly increased in 10 out of 16 items after reading the information but remained low for colorectal cancer risk, sensitivity of testing, and the voluntariness of colorectal cancer screening.

CONCLUSION

Despite intelligible linguistic and design characteristics, screening invitees with low health literacy had problems in accessing, comprehending and applying standard information materials on colorectal cancer screening, and lacked essential knowledge for informed decision-making about participation.

PRACTICE IMPLICATIONS

To enable equal access to informed decision-making, information strategies need to be adjusted to the skills of low health literate screening invitees.

Socioeconomic inequalities in breast and cervical screening coverage in England: are we closing the gap?

OBJECTIVE

Health policy in the UK is committed to tackling inequalities in cancer screening participation. We examined whether socioeconomic inequalities in breast and cervical cancer screening participation in England have reduced over five years.

METHODS

Cross-sectional analyses compared cervical and breast screening coverage between 2007/8 and 2012/13 in Primary Care Trusts (PCTs) in England in relation to area-level income deprivation.

RESULTS

At the start and the end of this five year period, there were socioeconomic inequalities in screening coverage for breast and cervical screening. Inequalities were highest for breast screening. Over time, the coverage gap between the highest and lowest quintiles of income deprivation significantly reduced for breast screening (from 12.3 to 8.3 percentage points), but not for cervical screening (5.3 to 4.9 percentage points).

CONCLUSIONS

Efforts to reduce screening inequalities appear to have resulted in a significant improvement in equitable delivery of breast screening, although not of cervical screening. More work is needed to understand the differences, and see whether broader lessons can be learned from the reduction of inequalities in breast screening participation.

New algorithm for constructing area-based index with geographical heterogeneities and variable selection: An application to gastric cancer screening

To optimally allocate health resources, policy planners require an indicator reflecting the inequality. Currently, health inequalities are frequently measured by area-based indices. However, methodologies for constructing the indices have been hampered by two difficulties: 1) incorporating the geographical relationship into the model and 2) selecting appropriate variables from the high-dimensional census data. Here, we constructed a new area-based health coverage index using the geographical information and a variable selection procedure with the example of gastric cancer. We also characterized the geographical distribution of health inequality in Japan. To construct the index, we proposed a methodology of a geographically weighted logistic lasso model. We adopted a geographical kernel and selected the optimal bandwidth and the regularization parameters by a two-stage algorithm. Sensitivity was checked by correlation to several cancer mortalities/screening rates. Lastly, we mapped the current distribution of health inequality in Japan and detected unique predictors at sampled locations. The interquartile range of the index was 0.0001 to 0.354 (mean: 0.178, SD: 0.109). The selections from 91 candidate variables in Japanese census data showed regional heterogeneities (median number of selected variables: 29). Our index was more correlated to cancer mortalities/screening rates than previous index and revealed several geographical clusters with unique predictors.

Knowledge and Informed Decision-Making about Population-Based Colorectal Cancer Screening Participation in Groups with Low and Adequate Health Literacy

Objective. To analyze and compare decision-relevant knowledge, decisional conflict, and informed decision-making about colorectal cancer (CRC) screening participation between potential screening participants with low and adequate health literacy (HL), defined as the skills to access, understand, and apply information to make informed decisions about health. Methods. Survey including 71 individuals with low HL and 70 with adequate HL, all eligible for the Dutch organized CRC screening program. Knowledge, attitude, intention to participate, and decisional conflict were assessed after reading the standard information materials. HL was assessed using the Short Assessment of Health Literacy in Dutch. Informed decision-making was analyzed by the multidimensional measure of informed choice. Results. 64% of the study population had adequate knowledge of CRC and CRC screening (low HL 43/71 (61%), adequate HL 47/70 (67%), p > 0.05). 57% were informed decision-makers (low HL 34/71 (55%), adequate HL 39/70 (58%), p > 0.05). Intention to participate was 89% (low HL 63/71 (89%), adequate HL 63/70 (90%)). Respondents with low HL experienced significantly more decisional conflict (25.8 versus 16.1; p = 0.00). Conclusion. Informed decision-making about CRC screening participation was suboptimal among both individuals with low HL and individuals with adequate HL. Further research is required to develop and implement effective strategies to convey decision-relevant knowledge about CRC screening to all screening invitees.

The Lung Screen Uptake Trial (LSUT): protocol for a randomised controlled demonstration lung cancer screening pilot testing a targeted invitation strategy for high risk and 'hard-to-reach' patients

BACKGROUND

Participation in low-dose CT (LDCT) lung cancer screening offered in the trial context has been poor, especially among smokers from socioeconomically deprived backgrounds; a group for whom the risk-benefit ratio is improved due to their high risk of lung cancer. Attracting high risk participants is essential to the success and equity of any future screening programme. This study will investigate whether the observed low and biased uptake of screening can be improved using a targeted invitation strategy.

METHODS/DESIGN

A randomised controlled trial design will be used to test whether targeted invitation materials are effective at improving engagement with an offer of lung cancer screening for high risk candidates. Two thousand patients aged 60-75 and recorded as a smoker within the last five years by their GP, will be identified from primary care records and individually randomised to receive either intervention invitation materials (which take a targeted, stepped and low burden approach to information provision prior to the appointment) or control invitation materials. The primary outcome is uptake of a nurse-led 'lung health check' hospital appointment, during which patients will be offered a spirometry test, an exhaled carbon monoxide (CO) reading, and an LDCT if eligible. Initial data on demographics (i.e. age, sex, ethnicity, deprivation score) and smoking status will be collected in primary care and analysed to explore differences between attenders and non-attenders with respect to invitation group. Those who attend the lung health check will have further data on smoking collected during their appointment (including pack-year history, nicotine dependence and confidence to quit). Secondary outcomes will include willingness to be screened, uptake of LDCT and measures of informed decision-making to ensure the latter is not compromised by either invitation strategy.

DISCUSSION

If effective at improving informed uptake of screening and reducing bias in participation, this invitation strategy could be adopted by local screening pilots or a national programme.

TRIAL REGISTRATION

This study was registered with the ISRCTN (International Standard Registered Clinical/soCial sTudy Number: ISRCTN21774741) on the 23rd September 2015 and the NIH ClinicalTrials.gov database (NCT0255810) on the 22nd September 2015.

Factors associated with completion of bowel cancer screening and the potential effects of simplifying the screening test algorithm

Background:

The primary colorectal cancer screening test in England is a guaiac faecal occult blood test (gFOBt). The NHS Bowel Cancer Screening Programme (BCSP) interprets tests on six samples on up to three test kits to determine a definitive positive or negative result. However, the test algorithm fails to achieve a definitive result for a significant number of participants because they do not comply with the programme requirements. This study identifies factors associated with failed compliance and modifications to the screening algorithm that will improve the clinical effectiveness of the screening programme.

Methods:

The BCSP Southern Hub data for screening episodes started in 2006–2012 were analysed for participants aged 60–69 years. The variables included age, sex, level of deprivation, gFOBt results and clinical outcome.

Results:

The data set included 1 409 335 screening episodes; 95.08% of participants had a definitively normal result on kit 1 (no positive spots). Among participants asked to complete a second or third gFOBt, 5.10% and 4.65%, respectively, failed to return a valid kit. Among participants referred for follow up, 13.80% did not comply. Older age was associated with compliance at repeat testing, but non-compliance at follow up. Increasing levels of deprivation were associated with non-compliance at repeat testing and follow up. Modelling a reduction in the threshold for immediate referral led to a small increase in completion of the screening pathway.

Conclusions:

Reducing the number of positive spots required on the first gFOBt kit for referral for follow-up and targeted measures to improve compliance with follow-up may improve completion of the screening pathway.

Associations between contextual factors and colorectal cancer screening in a racially and ethnically diverse population in Texas

BACKGROUND

Colorectal cancer is the third most commonly diagnosed cancer and the third leading cause of cancer death in the United States. Increased attention has been given to understanding the role of local contexts on cancer screening behaviors. We examined the associations between multiple tract-level socioeconomic measures and adherence to colorectal cancer screening (CRCS) in Harris County and the City of Houston, Texas.

METHODS

We conducted a cross-sectional multilevel study linking individual-level data on CRCS from the 2010 Health of Houston Survey with contextual data from the U.S. Census and the U.S. Department of Housing and Urban Development. We examined tract-level poverty, education, employment, income inequality, and foreclosure measures across 543 Census tracts. Analyses were limited to individuals aged 50-74 years (N=1720).

RESULTS

Overall, 58.0% of the sample was adherent to any recommended CRCS test. In bivariate analyses, increasing levels of area poverty, low education, unemployment, and foreclosures were associated with lower odds of adherence to CRCS. After controlling for individual-level covariates, only tract-level unemployment remained associated with adherence to CRCS (adjusted OR=0.80; 95% CI: 0.66-0.99; P=.037).

CONCLUSIONS

Neighborhood socioeconomic disadvantage is increasingly recognized as a determinant of health, and our study suggests that the contextual effect of area unemployment may extend to cancer screening outcomes. Our finding is important to cancer control planners because we identified a contextual marker of disparity that can be used to target local interventions to promote CRCS and thereby reduce cancer disparities among non-adherent individuals who reside in communities with high unemployment rates.

Piloting the Impact of Three Interventions on Guaiac Faecal Occult Blood Test Uptake within the NHS Bowel Cancer Screening Programme

This study evaluated the impact of three interventions on uptake of the guaiac faecal occult blood test (gFOBT) in Greater London. The interventions were designed to improve awareness and understanding of the NHS Bowel Cancer Screening Programme (BCSP) and assist stool sampling. Logistic regression analysis of BCSP London data (N = 205,541 invitees aged 60–74) compared uptake at 12 weeks between intervention groups and a control group, sent kits as usual between January-April 2013 and January-April 2014. An endorsement flyer, included with gFOBT kits, had no impact on uptake (P = 0.68). In 60–69-year-olds, there was a small but significant increase in modelled uptake amongst invitees sent both the flyer and a kit enhancement pack compared with controls (45.1% versus 43.4%, OR = 1.07, P = 0.047). In North East London, the flyer together with outdoor advertising was associated with a small but significant increase (45.6% versus 43.4%, OR = 1.09, P = 0.027). The largest increases were seen when all three interventions (flyer, pack, and advertising) were combined (49.5% versus 43.4%, OR = 1.28, P < 0.001). The increased uptake in the intervention groups was largest in “first-timers” and smaller amongst previous nonresponders and previously screened invitees.

Social inequalities in a population based colorectal cancer screening programme in the Basque Country

BACKGROUND

While it is known that a variety of factors (biological, behavioural and interventional) play a major role in the health of individuals and populations, the importance of the role of social determinants is less clear. The effect of social inequality on population-based screening for colorectal cancer (CRC) could limit the value of such programmes. The present study aims to determine whether such inequalities exist.

METHODS

Data was obtained from the population-based screening programme administered in the Autonomous Community of the Basque Country, Spain, with a target population aged 50 to 69, first invited to participate between 2009 and 2011. The magnitude of inequality was analysed using the odds ratio (taking the least disadvantaged socioeconomic quintile as the reference population), the population attributable risk and the relative index of inequality, based on the regression, which is the ratio of the rates in the most and least disadvantaged socioeconomic groups.

RESULTS

The target population comprised 242,394 people, with the test kit successfully sent to 95.1 % (230,510). The overall response rate was 64.3 % (67.1 in women and 61.4 % men). Among women, the highest participation was in the third quintile (71.5 %) and the lowest in the first - the least disadvantaged (65.7 %). The lowest and highest rates of people with identified lesions were in the second and fourth quintiles (14.7/1000 and 17.0/1000 respectively). Among men, the response rate was lowest in the fifth - most disadvantaged - quintile (60.2 %). The highest rate of identified lesions was in the fifth quintile; 38 % higher than the first (55.7/1000 compared to 41.0/1000).

CONCLUSIONS

Sex and socioeconomic group influence the rate of participation in the CRC programme and the rate of lesions found in the participants. Any public health programme is morally and ethically obliged to strive for equity and effectiveness. Improving participation of men and socially disadvantaged groups should be taken in account.

Understanding low colorectal cancer screening uptake in South Asian faith communities in England--a qualitative study

Background

Colorectal cancer screening uptake within the South Asian population in England is approximately half that of the general population (33 % vs 61 %), and varies by Muslim (31.9 %), Sikh (34.6 %) and Hindu (43.7 %) faith background. This study sought to explore reasons for low uptake of CRC screening in South Asian communities and for the variability of low uptake between three faith communities; and to identify strategies by which uptake might be improved.

Methods

We interviewed 16 ‘key informants’ representing communities from the three largest South Asian faith backgrounds (Islam, Hinduism and Sikhism) in London, England.

Results

Reasons for low colorectal cancer screening uptake were overwhelmingly shared across South Asian faith groups. These were: limitations posed by written English; limitations posed by any written language; reliance on younger family members; low awareness of colorectal cancer and screening; and difficulties associated with faeces. Non-written information delivered verbally and interactively within faith or community settings was preferred across faith communities.

Conclusions

Efforts to increase accessibility to colorectal cancer screening in South Asian communities should use local language broadcasts on ethnic media and face-to-face approaches within community and faith settings to increase awareness of colorectal cancer and screening, and address challenges posed by written materials.

Optimising colorectal cancer screening acceptance: a review

The study aims to review available evidence concerning effective interventions to increase colorectal cancer (CRC) screening acceptance. We performed a literature search of randomised trials designed to increase individuals' use of CRC screening on PubMed, Embase, Cochrane Database of Systematic Reviews and Database of Abstracts of Reviews of Effects. Small (≤ 100 subjects per arm) studies and those reporting results of interventions implemented before publication of the large faecal occult blood test trials were excluded. Interventions were categorised following the Continuum of Cancer Care and the PRECEDE-PROCEED models and studies were grouped by screening model (opportunistic vs organised). Multifactor interventions targeting multiple levels of care and considering factors outside the individual clinician control, represent the most effective strategy to enhance CRC screening acceptance. Removing financial barriers, implementing methods allowing a systematic contact of the whole target population, using personal invitation letters, preferably signed by the reference care provider, and reminders mailed to all non-attendees are highly effective in enhancing CRC screening acceptance. Physician reminders may support the diffusion of screening, but they can be effective only for individuals who have access to and make use of healthcare services. Educational interventions for patients and providers are effective, but the implementation of organisational measures may be necessary to favour their impact. Available evidence indicates that organised programmes allow to achieve an extensive coverage and to enhance equity of access, while maximising the health impact of screening. They provide at the same time an infrastructure allowing to achieve a more favourable cost-effectiveness profile of potentially effective strategies, which would not be sustainable in opportunistic settings.

Cancer survival differences between South Asians and non-South Asians of England in 1986-2004, accounting for age at diagnosis and deprivation

BACKGROUND

South Asian migrants show lower cancer incidence than their host population in England for most major cancers. We seek to study the ethnic differences in survival from cancer.

METHODS

We described and modelled the effect of ethnicity, time, age and deprivation on survival for the five most incident cancers in each sex in South Asians in England between 1986 and 2004 using national cancer registry data. South Asian ethnicity was flagged using the validated name-recognition algorithm SANGRA (South Asian Names and Group Recognition Algorithm).

RESULTS

We observed survival advantage in South Asians in earlier periods. This ethnic gap either remained constant or narrowed over time. By 2004, age-standardised net survival was comparable for all cancers except three in men, where South Asians had higher survival 5 years after diagnosis: colorectal (58.9% vs 53.6%), liver (15.0% vs 9.4%) and lung (15.9% vs 9.3%). Compared with non-South Asians, South Asians experienced a slower increase in breast and prostate cancer survival, both cancers associated with either a screening programme or an early diagnosis test. We did not find differential patterns in survival by deprivation between both ethnicities.

CONCLUSIONS

Considering recent survival trends, appropriate action is required to avoid deficits in cancer survival among South Asians in the near future.

Added value of screening for CKD among the elderly or persons with low socioeconomic status

BACKGROUND AND OBJECTIVE

Three screening approaches were compared for their ability to detect CKD cases, and identify patients with CKD who have a higher rate of incident cardiovascular disease (CVD) events and renal function decline. Approach 1 was the traditional CKD screening approach, targeting only individuals with known diabetes, hypertension, or CVD history. Approach 2 was defined as Approach 1+elderly, and Approach 3 as Approach 1+low-socioeconomic status (SES) individuals.

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

Data on 3411 individuals from the general population in The Netherlands were examined. Individuals aged >60 years were classified as elderly. Persons with low SES was defined as those with primary school or below primary school education. CKD was diagnosed during outpatient clinic visits. Individuals were followed for 9.4±2.6 years during four screening rounds.

RESULTS

At baseline, 16%, 29%, and 25% of the general population was to be screened and 36%, 59%, and 51% of the CKD (n=263) cases were detected in Approaches 1, 2, and 3, respectively. The numbers of individuals needed to screen to detect one CKD case were 5.6 in Approach 1 and 6.5 each in Approach 2 and 3. In Approach 2 the hazard ratio for incident CVD events was 1.87 (95% confidence interval [95% CI], 1.35 to 2.61) in detected and 1.92 (95% CI, 1.01 to 3.64) in undetected CKD cases compared with persons without CKD, whereas in Approach 3 these values were 2.31 (95% CI, 1.64 to 3.25) and 1.28 (95% CI, 0.77 to 2.13), respectively. In Approach 2, the rate of renal function decline was -1.37 ml/min per 1.73 m(2) per year in detected and -1.13 ml/min per 1.73 m(2) per year in undetected CKD cases. In Approach 3, these figures were -1.41 and -1.14 ml/min per 1.73 m(2) per year, respectively.

CONCLUSIONS

Adding persons with low SES, rather than adding elderly persons, to the traditional high-risk groups may help detect more persons with CKD who have a higher rate of future CVD events and renal function decline.

A new reliable index to measure individual deprivation: the EPICES score

BACKGROUND

Deprivation is associated with inequalities in health care and higher morbidity and mortality. To assess the reliability of a new individual deprivation score, the EPICES score and to analyse the association between the Townsend index, the Carstairs index and the EPICES score and causes of death in one French administrative region.

METHODS

Eligible patients were 16 years old or more who had come for consultation in Health Examination Centres of the French administrative region of Nord-Pas-de-Calais. An ecological study was performed between 2002 and 2007 in the 392 districts of this administrative region. The EPICES score was compared with the Townsend and the Carstairs indices. These three measurements of deprivation were compared with social characteristics, indicators of morbidity, health-care use and mortality and specific causes of death. The Pearson correlation coefficients were calculated to assess the reliability of the EPICES score. The association between deprivation and mortality was assessed by comparison of the standardized mortality ratio (SMR) between the most and least deprived districts.

RESULTS

The EPICES score was strongly correlated with the Townsend and Carstairs indices and with the health indicators measured. SMR increased with deprivation and the higher the deprivation the higher the SMR for all-cause mortality, premature and avoidable deaths and for most specific causes of death.

CONCLUSION

The individual deprivation EPICES score is reliable. Deprivation was related to excess death rate, which clearly indicates that deprivation is a determinant factor that should be considered systematically by health policy makers and health-care providers.

An ongoing case-control study to evaluate the NHS Bowel Cancer Screening Programme

BACKGROUND

Colorectal cancer is the third most common cause of cancer death in both males and females in England. A national bowel cancer screening programme was rolled out in England between 2006 and 2010. In the post-randomised controlled trials epoch, assessment of the impact of the programme using observational studies is needed. This study protocol was set up at the request of the UK Policy Research Unit in Cancer Awareness, Screening and Early Diagnosis to evaluate the effect of the current bowel cancer screening programme on incidence of advanced primary colorectal cancer.

METHODS/DESIGN

All incident cases of primary colorectal cancer in England will be included. Cases will be matched to controls with respect to sex, age, area of registration and year of first invitation to screening. Each evaluation round will cover a 2-year period, starting from January 2012, and ongoing thereafter. In the first instance, a pilot will be carried out in a single region. Variables related to colorectal tumour pathology will be obtained to enable selection and matching of cases and controls, and to allow analyses stratification by anatomical subsite within the bowel. Cases at Duke's stage B or worse will be considered as "advanced stage". The influence of sex will also be investigated. The incidence ratio observed in randomised controlled trials between controls (not invited) and non-attender invitees will be used to correct for self-selection bias overall. Screening participation at other national screening programmes (cervical, breast) will also be collected to derive a more contemporaneous adjustment factor for self-selection bias and assess consistency in self-selection correction in female patients.Full ethical approval was obtained from the Health Research Authority.

DISCUSSION

The case-control design is potentially prone to a number of biases. The size of the planned study, the design specifications and the development of analytical strategies to cope with bias should enable us to obtain accurate estimates of reduction in incidence of advanced stage disease. The results of analyses by sex and anatomical subsite may highlight the potential need for sex-specific recommendations in the programme.

Predictors of adherence to repeat fecal occult blood test in a population-based colorectal cancer screening program

Background:

Socio-economic, environmental factors and general practitioner (GP) involvement may influence adherence to repeat faecal occult blood testing (FOBT) of organised colorectal cancer (CRC) screening. The aim of the study was to identify predictors of adherence to repeat testing.

Methods:

The populationcomprised people eligible for the third round of a CRC screening programme in a French district (n=118 905). Multilevel logistic regression analysis was performed to identify individual and area-level characteristics associated with ‘compliant participants' participating in the all three rounds vs ‘occasional participants' participating in one or two rounds.

Results:

Compared to ‘occasional participants', ‘compliant participants' were more likely to participate after receiving a FOBT kit from their GP (odds ratio (OR), 10.7; 95% CI, 10.01–11.5) vs FOBT received at home, and were less likely to live in socio-economically deprived areas (OR, 0.75; 0.70–0.80) and urban areas (OR, 0.94; 0.88–1.00).

Conclusions:

As for a screening round participation, strategies aimed at improving the participation to a screening programme should target GPs and people living in socially deprived areas.

The mediation of social influences on smoking cessation and awareness of the early signs of lung cancer

BACKGROUND

Whilst there has been no clear consensus on the potential for earlier diagnosis of lung cancer, recent research has suggested that the time between symptom onset and consultation can be long enough to plausibly affect prognosis. In this article, we present findings from a qualitative study involving in-depth interviews with patients who had been diagnosed with lung cancer (n = 11), and people who were at heightened risk of developing the disease (n = 14).

METHODS

A grounded theory methodology was drawn upon to conduct thematic and narrative based approaches to analysis.

RESULTS

The paper focuses on three main themes which emerged from the study: i) fatalism and resignation in pathways to help-seeking and the process of diagnosis; ii) Awareness of smoking risk and response to cessation information and advice. iii) The role of social and other networks on help-seeking. Key findings included: poor awareness among participants of the symptoms of lung cancer; ambivalence about the dangers of smoking; the perception of lung cancer as part of a homogenisation of multiple illnesses; close social networks as a key trigger in help-seeking.

CONCLUSIONS

We suggest that future smoking cessation and lung cancer awareness campaigns could usefully capitalise on the influence of close social networks, and would benefit from taking a 'softer' approach.

The effect of a supplementary ('Gist-based') information leaflet on colorectal cancer knowledge and screening intention: a randomized controlled trial

Guided by Fuzzy Trace Theory, this study examined the impact of a ‘Gist-based’ leaflet on colorectal cancer screening knowledge and intentions; and tested the interaction with participants’ numerical ability. Adults aged 45–59 years from four UK general practices were randomly assigned to receive standard information (‘The Facts’, n = 2,216) versus standard information plus ‘The Gist’ leaflet (Gist + Facts, n = 2,236). Questionnaires were returned by 964/4,452 individuals (22 %). 82 % of respondents reported having read the information, but those with poor numeracy were less likely (74 vs. 88 %, p < .001). The ‘Gist + Facts’ group were more likely to reach the criterion for adequate knowledge (95 vs. 91 %; p < .01), but this was not moderated by numeracy. Most respondents (98 %) intended to participate in screening, with no group differences and no interaction with numeracy. The improved levels of knowledge and self-reported reading suggest ‘The Gist’ leaflet may increase engagement with colorectal cancer screening, but ceiling effects reduced the likelihood that screening intentions would be affected.

Evaluation of a service intervention to improve awareness and uptake of bowel cancer screening in ethnically-diverse areas

BACKGROUND

Uptake of bowel cancer screening is lowest in London, in populations of lower socio-economic status, and in particular ethnic or religious groups.

METHODS

We report on the evaluation of two interventions to improve uptake in an area including populations of low socio-economic status and considerable ethnic diversity. The interventions were face-to-face health promotion on bowel cancer screening at invitees' general practice and health promotion delivered by telephone only. Nine large general practices in East London were chosen at random to offer face-to-face health promotion, and nine other large practices to offer telephone health promotion, with 24 practices of similar size as comparators. Data at practice level were analysed by Mann-Whitney-Wilcoxon tests and grouped-logistic regression.

RESULTS

There were 2034 invitees in the telephone intervention practices, 1852 in the face-to-face intervention practices and 5227 in the comparison practices. Median gFOBt kit uptake in the target population (aged 59-70) was 46.7% in the telephone practices, 43.8% in the face-to-face practices and 39.1% in the comparison practices. Significant improvements in the odds of uptake were observed following telephone intervention in both males (OR=1.39, 95% CI=1.20-1.61, P<0.001) and females (OR=1.49, 95% CI=1.29-1.73, P<0.001), while the face-to-face intervention mainly impacted uptake in males (OR=1.23, 95% CI=1.10-1.36), P<0.001) but did not lead to a significant increase in females (OR=1.12, 95% CI=0.96-1.29, P=0.2).

CONCLUSIONS

Personally delivered health promotion improved uptake of bowel cancer screening in areas of low socio-economic status and high ethnic diversity. The intervention by telephone appears to be the most effective method.

Participation and detection rates by age and sex for colonoscopy versus fecal immunochemical testing in colorectal cancer screening

PURPOSE

To compare two strategies for colorectal cancer screening: one-time colonoscopy versus fecal immunochemical testing (FIT) (and colonoscopy for positive) every 2 years, in order to determine which strategy provides the highest participation and detection rates in groups of sex and age.

METHODS

This analysis was performed with data from the first screening round within the COLONPREV study, a population-based, multicenter, nationwide trial carried out in Spain. Several logistic regression models were applied to identify the influence of the screening test on participation rates and detection of proximal and distal neoplasms, as well to identify the influence of age and sex: women aged 50-59 years, women aged 60-69 years, men aged 50-59 years, and men aged 60-69 years.

RESULTS

Participation was higher in women than in men, especially among women aged 50-59 years (25.91 % for colonoscopy and 35.81 % for FIT). Crossover from colonoscopy to FIT was higher among women than men, especially among those aged 60-69 years (30.37 %). In general, detection of any neoplasm and advanced adenoma was higher with colonoscopy than with FIT, but no significant differences were found between the two strategies for colorectal cancer detection. Detection of advanced adenoma in both arms was lower in women [specifically in women aged 50-59 years (OR 0.31; 95 % CI 0.25-0.38) than in men aged 60-69 years]. Women aged 50-59 years in the colonoscopy arm had a higher probability of detection of advanced adenoma (OR 4.49; 95 % CI 3.18-6.35), as well as of detection of neoplasms in proximal and distal locations (proximal OR 19.34; 95 % CI 12.07-31.00; distal OR 11.04; 95 % CI 8.13-15.01) than women of the same age in the FIT arm. These differences were also observed in the remaining groups but to a lesser extent.

CONCLUSION

Women were more likely to participate in a FIT-based strategy, especially those aged 50-59 years. The likelihood of detection of any neoplasm was higher in the colonoscopy arm for all the population groups studied, especially in women aged 50-59 years. Distinct population groups should be informed of the benefits of each screening strategy so that they may take informed decisions.

The impact of national policy on the early diagnosis of cancer

Since the mid-90s UK governments and other policy makers have sought to develop policy that addresses the need for improved outcomes for people diagnosed with cancer. However, the strategies for cancer in Scotland, Wales and Northern Ireland are different to the policy on cancer produced under the English government. This article will examine policy developments in the English health service aimed at achieving early diagnosis of cancer with particular reference to the Cancer Reform Strategy (2007). The role of socioeconomic factors and the need for policy to address a range of cancers due to their differences in pathology and therefore diagnosis and treatment will also be considered.

Social deprivation does not affect lung cancer stage at presentation or disease outcome

INTRODUCTION

Lung cancer mortality rates are higher in more deprived populations. This may simply reflect higher incidence of the disease, or additionally delayed presentation and worse outcomes amongst more deprived patients. Low socio-economic status (SES) has also been linked to cancer fatalism which might account for such differences. We determined the interaction between SES, patient's characteristics at presentation with lung cancer, and disease outcome at a large UK teaching hospital.

METHODS

Stage, PS at presentation, treatment and survival data, index of multiple deprivation score and ACORN group (geo-demographic segmentation tool) were analysed for 1432 patients.

RESULTS

There were no significant differences in stage or PS distribution by IMD quintile or ACORN group. When patients with stage I/II disease were considered, there were no differences in IMD or ACORN group for those undergoing or not undergoing surgical resection. Similarly when the whole cohort was considered, there were no differences in these parameters between those receiving and not receiving any anti-cancer therapy. There was a non-significant trend to lower IMD score (i.e. less deprivation) in the stage IIIb/IV patients receiving palliative chemotherapy compared to those not receiving chemotherapy. There was no significant difference in median survival or one-year survival according to IMD quintile or ACORN group.

CONCLUSION

In our patient cohort, deprivation does not appear to affect stage or performance status at presentation, nor survival from lung cancer. If cancer fatalism is more prevalent in deprived populations, this does not appear to lead to later diagnosis nor worse disease outcome.

Determinants of participation in organized colorectal cancer screening in Isère (France)

BACKGROUND AND AIMS

In France, participation in organized colorectal cancer screening remains low. The objective of this study was to identify the determinants of participation in colorectal cancer screening in Isère, a French administrative entity.

METHODS

This study examined the target population invited for screening between 2007 and 2008 in Isère. The statistical analysis method was based on a two-level logistic regression model: the first was the individual level relative to the individuals invited for screening and the second was an aggregate level corresponding to the socioeconomic level of an invited person's residence area (IRIS: "Ilot regroupé pour l'Information Statistique"; Regrouped statistical information block). The evaluation of the socioeconomic level was based on the Townsend deprivation.

RESULTS

Participation varied depending on sex, age, and health insurance plan. The people residing in the least deprived IRISes participated more than individuals residing in the most deprived IRISes. The multilevel analysis showed a 24% difference in participation between the least and the most deprived IRISes.

CONCLUSIONS

The use of socioeconomic data on the IRIS geographical unit has identified, socially and geographically, the populations that participate the least, although this reflects "mean" behaviors. These results could be used to set up targeted actions to encourage participation in these populations.