Cervical screening attendance and cervical cancer risk among women who have sex with women

OBJECTIVES

To describe cervical cancer screening participation among women who have sex exclusively with women (WSEW) and women who have sex with women and men (WSWM) compared with women who have sex exclusively with men (WSEM), and women who have never had sex and compare this with bowel (colorectal) and breast screening participation. To explore whether there is evidence of differential stage 3 cervical intraepithelial neoplasia (CIN3) or cervical cancer risk.

METHODS

We describe cervical, bowel and breast cancer screening uptake in age groups eligible for the national screening programmes, prevalent CIN3 and cervical cancer at baseline, and incident CIN3 and cervical cancer at five years follow-up, among 218,674 women in UK Biobank, a cohort of healthy volunteers from the UK.

RESULTS

Compared with WSEM, in adjusted analysis [odds ratio (95% confidence interval)], WSEW 0.10 (0.08-0.13), WSWM 0.73 (0.58-0.91), and women who have never had sex 0.02 (0.01-0.02) were less likely to report ever having attended cervical screening. There were no differences when considering bowel cancer screening uptake (p = 0.61). For breast cancer screening, attendance was lower among WSWM 0.79 (0.68 to 0.91) and women who have never had sex 0.47 (0.29-0.58), compared with WSEM. There were incident and prevalent cases of both CIN3 and cervical cancer among WSEW and WSWM. Compared with WSEM with a single male partner, among WSEW there was a twofold increase in CIN3 1.91 (1.01 to 3.59); among WSWM with only one male partner, this was 2.25 (1.19 to 4.24).

CONCLUSIONS

These findings highlight the importance of improving uptake of cervical screening among all women who have sex with women and breast screening among WSWM and women who have never had sex.

Development and user-testing of a brief decision aid for aspirin as a preventive approach alongside colorectal cancer screening

BACKGROUND

Several epidemiological and cohort studies suggest that regular low-dose aspirin use independently reduces the long-term incidence and risk of colorectal cancer deaths by approximately 20%. However, there are also risks to aspirin use, mainly gastrointestinal bleeding and haemorrhagic stroke. Making informed decisions depends on the ability to understand and weigh up benefits and risks of available options. A decision aid to support people to consider aspirin therapy alongside participation in the NHS bowel cancer screening programme may have an additional impact on colorectal cancer prevention. This study aims to develop and user-test a brief decision aid about aspirin to enable informed decision-making for colorectal screening-eligible members of the public.

METHODS

We undertook a qualitative study to develop an aspirin decision aid leaflet to support bowel screening responders in deciding whether to take aspirin to reduce their risk of colorectal cancer. The iterative development process involved two focus groups with public members aged 60-74 years (n = 14) and interviews with clinicians (n = 10). Interviews (n = 11) were used to evaluate its utility for decision-making. Analysis was conducted using a framework approach.

RESULTS

Overall, participants found the decision aid acceptable and useful to facilitate decision-making. They expressed a need for individualised risk information, more detail about the potential risks of aspirin, and preferred risk information presented in pictograms when offered different options. Implementation pathways were discussed, including the possibility of involving different clinicians in the process such as GPs and/or community pharmacists. A range of potentially effective timepoints for sending out the decision aid were identified.

CONCLUSION

An acceptable and usable decision aid was developed to support decisions about aspirin use to prevent colorectal cancer.

Analysing the impact of living in a rural setting on the presentation and outcome of colorectal cancer. A prospective single centre observational study

INTRODUCTION

Approximately 17% of the Scottish population lives in a remote or rural location. Current research is contradictory as to whether living a rural location leads to poorer outcomes or affects survival from colorectal cancer (CRC). We aimed to assess if living in a rural location influences outcome of CRC patients in 21st century UK medicine.

METHODS

A prospective single-centre observational study was conducted. All patients who underwent resection for colorectal cancer 2005-2016 in NHS Grampian were included. Patients were split into two groups for comparison (urban post-code vs rural) using the Scottish government two-tier classification system. Tumour location, one-year survival, lymph node involvement and extra-mural vascular invasion was recorded and compared between the groups.

RESULTS

Of 2463 patients, 843 (34.2%) lived in a rural area. Rural patients were more likely to be detected through screening (17.4% versus 14.6%, p = 0.04). There were no differences in pathology between rural and urban groups if detected through screening. However, rural patients detected through symptomatic pathways were more likely to be node positive p = 0.015. On multivariable analysis, rurality did not independently predict for node positive presentation. Furthermore, there were no differences in cumulative survival between the two groups.

CONCLUSION

Although there were some differences in pathological characteristics between rural and urban patients, place of residence did not independently predict for outcome in this cohort. Rurality had previously been shown to impact on outcome up to 20 years ago. Improvements in infrastructure and rural healthcare may have influenced this change.

The impact of personalised risk information compared to a positive/negative result on informed choice and intention to undergo colonoscopy following colorectal Cancer screening in Scotland (PERICCS) - a randomised controlled trial: study protocol

BACKGROUND

In Scotland a new, easier to complete bowel screening test, the Faecal Immunochemical Test (FIT), has been introduced. This test gives more accurate information about an individual's risk of having colorectal cancer (CRC), based on their age and gender, and could lead to fewer missed cancers compared to the current screening test. However, there is no evidence of the effect on colonoscopy uptake of providing individuals with personalised risk information following a positive FIT test. The objectives of the study are: 1) To develop novel methods of presenting personalised risk information in an easy-to-understand format using infographics with involvement of members of the public 2) To assess the impact of different presentations of risk information on informed choice and intention to take up an offer of colonoscopy after FIT 3) To assess participants' responses to receiving personal risk information (knowledge, attitudes to screening/risk, emotional responses including anxiety).

METHODS

Adults (age range 50-74) registered on the Scottish Bowel Screening database will be invited by letter to take part. Consenting participants will be randomised to one of three groups to receive hypothetical information about their risk of cancer, based on age, gender and faecal haemoglobin concentration: 1) personalised risk information in numeric form (e.g. 1 in 100) with use of infographics, 2) personalised information described as 'highest', 'moderate' or 'lowest' risk with use of infographics, and 3) as a 'positive' test result, as is current practice. Groups will be compared on informed choice, intention to have a colonoscopy, and satisfaction with their decision. Follow-up semi-structured qualitative interviews will be conducted, by telephone, with a small number of consenting participants (n = 10 per group) to explore the acceptability/readability and any potential negative impact of the risk information, participants' understanding of risk factors, attitudes to the different scenarios, and reasons for reported intentions.

DISCUSSION

Proving personalised risk information and allowing patient choice could lead to improved detection of CRC and increase patient satisfaction by facilitating informed choice over when/whether to undergo further invasive screening. However, we need to determine whether/how informed choice can be achieved and assess the potential impact on the colonoscopy service.

TRIAL REGISTRATION

The trial is registered on www.isrctn.com on 08/12/2017. Registration no: ISRCTN14254582.

Reducing ethnic inequalities in bowel screening participation in New Zealand: A randomised controlled trial of telephone follow-up for non-respondents

Objective

To test whether a telephone follow-up service for high-needs ethnic groups increases bowel screening participation in non-responders to postal invitations.

Methods

Māori, Pacific, and Asian ethnicity individuals who failed to return a bowel screening test kit within four weeks of it being posted were randomly allocated (1:1) to a telephone active follow-up service or a control group. The active follow-up service made multiple attempts to contact the invitee and provide support. Participation rates at eight weeks’ post-randomisation were compared, and the effect of the intervention on overall participation rates was imputed.

Results

A total of 3828 eligible individuals were allocated to active follow-up and 3773 to the control group. The imputed potential overall increase in participation in the active follow-up group was 2.0% (95% CI = 0.6%–3.4%); however, the impact of follow-up varied significantly by ethnicity and deprivation. The imputed increase in participation was significant for Māori (5.2; CI = 1.8%–8.5%) and Pacific (3.6%; CI = 0.7%–6.4%), but not for Asian ethnicities (0.7%; CI=−1.1%–2.4%). In addition, the imputed increase was significant among high deprivation participants (3.9%; CI = 2.0%–5.9%), but not among low deprivation participants (0.3%; CI=−1.6%–2.2%).

Conclusions

Active follow-up led to higher bowel screening participation in Māori and Pacific but not in Asian ethnicities and was more effective in high deprivation subjects. Active follow-up significantly reduced but did not eliminate ethnic inequalities in bowel screening participation.

Development of an evidence-based brief 'talking' intervention for non-responders to bowel screening for use in primary care: stakeholder interviews

BACKGROUND

Bowel cancer is the third most common cause of cancer death worldwide. Bowel screening has been shown to reduce mortality and primary care interventions have been successful in increasing uptake of screening. Using evidence-based theory to inform the development of such interventions has been shown to increase their effectiveness. This study aimed to develop and refine a brief evidence-based intervention for eligible individuals whom have not responded to their last bowel screening invitation (non-responders), for opportunistic use by primary care providers during routine consultations.

METHODS

The development of a brief intervention involving a conversation between primary care providers and non-responders was informed by a multi-faceted model comprising: research team workshop and meetings to draw on expertise; evidence from the literature regarding barriers to bowel screening and effective strategies to promote informed participation; relevant psychological theory, and intervention development and behaviour change guidance. Qualitative telephone interviews with 1) bowel screening stakeholders and 2) patient non-responders explored views regarding the acceptability of the intervention to help refine its content and process.

RESULTS

The intervention provides a theory and evidence-based tool designed to be incorporated within current primary care practice. Bowel screening stakeholders were supportive of the intervention and recognised the importance of the role of primary care. Interviews highlighted the importance of brevity and simplicity to incorporate the intervention into routine clinical care. Non-responders similarly found the intervention acceptable, valuing a holistic approach to their care. Moreover, they expected their primary care provider to encourage participation.

CONCLUSIONS

A theory-based brief conversation for use in a primary care consultation was acceptable to bowel screening stakeholders and potential recipients, reflecting a health promoting primary care ethos. Findings indicate that it is appropriate to test the intervention in primary care in a feasibility study.

Bowel cancer screening for women at midlife

In Australia one in 15 women will be diagnosed with colorectal cancer in their lifetime because of the high incidences of lifestyle risk factors. The risk could be reduced by taking aspirin. Evidence-based Clinical Practice Guidelines for the prevention, early detection and management of colorectal cancer produced by Cancer Council Australia and approved by the National Health and Medical Research Council recommended that 'population screening in Australia, directed at those at average risk of colorectal cancer and without relevant symptoms, is immunochemical fecal occult blood testing every 2 years, starting at age 50 years and continuing to age 74 years.' Women at high risk because of family history will need more intense screening. At the current 40% participation rate, it is estimated that biennial screening with fecal immunohistochemical tests (FIT) reduces colorectal cancer incidence by 23% and mortality by 36%. The major adverse effects of screening are the psychological impact of a positive FIT that does not prove to be cancer, or adenomas on colonoscopy (47.7%), and the rare side-effects of colonoscopy of hemorrhage, bleeding or even death. A range of factors that could increase a woman's participation rate includes advice to screen from her general practitioner and more information about the nature of the screening tests.

Uptake trends in the Scottish Bowel Screening Programme and the influences of age, sex, and deprivation

Objective Age, sex, and deprivation are known factors influencing colorectal (bowel) cancer screening uptake. We investigated the influence of these factors on uptake over time. Methods Data from the Scottish Bowel Screening Programme (SBoSP) were collected between 2007 and 2014. End-points for analysis were uptake, faecal occult blood test positivity, and disease detection, adjusted for age, sex, deprivation, and year of screening. Results From 5,308,336 individual screening episodes documented, uptake gradually increased with increasing age up to 65-69 and was lower in men than women (52.4% vs. 58.7%, respectively). Deprivation had a significant effect on uptake by men and women of all age groups, with the most deprived least likely to complete a screening test. Uptake has increased with time in both sexes and across the deprivation gradient. The number needed to screen to detect significant neoplasia was significantly lower in men than women overall (170 vs. 365), and this held over all age and deprivation groups. The number needed to screen was also lower in the more deprived population. Conclusions Although lower age, male sex, and increased deprivation are associated with lower bowel cancer screening uptake in Scotland, uptake has increased since SBoSP introduction in all age groups, both sexes, and across the deprivation gradient. Despite a lower uptake, the number needed to screen to find significant disease was lower in men and in those with higher levels of deprivation.

General practitioners' perceptions of population based bowel screening and their influence on practice: a qualitative study

Background

Although largely preventable, Australia has one of the highest rates of bowel cancer in the world. General Practitioners (GPs) have an important role to play in prevention and early detection of bowel cancer, however in Australia this is yet to be optimised and participation remains low. This study sought to understand how GPs’ perceptions of bowel screening influence their attitudes to, and promotion of the faecal occult blood test (FOBT), to identify opportunities to enhance their role.

Methods

Interviews were conducted with 31 GPs from metropolitan and regional New South Wales (NSW), Australia. Discussions canvassed GPs’ perceptions of their role in bowel screening and the national screening program; perceptions of screening tests; practices regarding discussing screening with patients; and views on opportunities to enhance their role. Transcripts were coded using Nvivo and thematically analysed.

Results

The study revealed GPs’ perceptions of screening did not always align with broader public health definitions of ‘population screening’. While many GPs reportedly understood the purpose of population screening, notions of the role of asymptomatic screening for bowel cancer prevention were more limited. Descriptions of screening centred on two major uses: the use of a screening ‘process’ to identify individual patients at higher risk; and the use of screening ‘tools’, including the FOBT, to aid diagnosis. While the FOBT was perceived as useful for identifying patients requiring follow up, GPs expressed concerns about its reliability. Colonoscopy by comparison, was considered by many as the gold standard for both screening and diagnosis. This perception reflects a conceptualisation of the screening process and associated tools as an individualised method for risk assessment and diagnosis, rather than a public health strategy for prevention of bowel cancer.

Conclusion

The results show that GPs’ perceptions of screening do not always align with broader public health definitions of ‘population screening’. Furthermore, the way GPs understood screening was shown to impact their clinical practice, influencing their preferences for, and use of ‘screening’ tools such as FOBT. The findings suggest emphasising the preventative opportunity of FOBT screening would be beneficial, as would formally engaging GPs in the promotion of bowel screening.

Symptoms do not predict colorectal cancer in an FOB screened population

BACKGROUND AND AIMS

The Scottish Bowel Screening Programme aims to detect cancer in asymptomatic individuals. We aimed to measure the prevalence of lower gastrointestinal symptoms in faecal occult blood (FOB) screen-positive patients, to correlate the symptoms with neoplasia and to compare the predictive value of FOB screening with urgent symptomatic referrals in Ayrshire and Arran.

METHODS

Data were collected prospectively on FOB screen-positive patients undergoing colonoscopy. Patients completed a symptom questionnaire. Positive predictive values (PPVs) for detecting neoplasia were calculated and a chi-square test was performed to determine any influence of symptoms in diagnosing neoplasia. Symptomatic patients undergoing colonoscopy via a general practice fast-track system were compared.

RESULTS

A total of 378 FOB screen-positive patients were included. In all, 198 (52%) had colorectal symptoms. Overall, 32 were diagnosed with colorectal cancer and 93 had polyps . FOB positivity and symptoms gave a PPV of 34% for neoplasia. FOB positivity without symptoms gave a PPV of 32% for neoplasia. Urgent referral of symptomatic patients had a lower PPV of 21% for neoplasia (p < 0.001).

CONCLUSION

Half the FOB screen-positive patients had bowel symptoms. Symptoms in these patients had no correlation with an increased rate of neoplasia. The PPV for neoplasia is superior in symptomatic and asymptomatic screen-positive patients when compared to conventional urgent symptom-based referral.