A perspective from countries using organized screening programs

Lack of social support, gender and colorectal cancer screening participation across Europe: How do screening programmes mitigate the effect of social support for men and women?

This study investigates how a lack of social support differentially affects men and women's colorectal cancer (CRC) screening participation, considering different screening strategies implemented across European countries. Although health sociology has stressed gender differences in social support and its effects on health behaviours, this was overlooked by cancer screening research. Using a data set of 65,961 women and 55,602 men in 31 European countries, we analysed the effect of social support variables on CRC screening uptake. We found that living alone and lower perceived social support were associated with lower screening uptake for both men and women. These effects were, however, stronger among men. Population-based screening programmes mitigated these effects, particularly for women, but not for men living alone. In countries with opportunistic screening programmes, social support variables remained associated with screening uptake. We conclude that cancer screening interventions should pay attention to social support and its gender-differentiated effects.

The implementation and mechanisms of advance notification for cancer screening: A scoping review

OBJECTIVE

To describe and synthesise information on the content and delivery of advance notifications (information about cancer screening delivered prior to invitation) used to increase cancer screening participation and to understand the mechanisms that may underlie their effectiveness.

METHODS

Searches related to advance notification and cancer screening were conducted in six electronic databases (APA PsycINFO, CINAHL, Cochrane Library, Embase, PubMed, Web of Science) and results were screened for eligibility. Study characteristics, features of the advance notifications (cancer type, format, delivery time, and content), and the effect of the notifications on cancer screening participation were extracted. Features were summarised and compared across effective versus ineffective notifications.

RESULTS

Thirty-two articles were included in this review, reporting on 33 unique advance notifications. Of these, 79% were sent via postal mail, 79% were distributed prior to bowel cancer screening, and most were sent 2 weeks before the screening offer. Twenty-two full versions of the advance notifications were obtained for content analysis. Notifications included information about cancer risk, the benefits of screening, barriers to participation, social endorsement of cancer screening, and what to expect throughout the screening process. Of the 19 notifications whose effect was tested statistically, 68% were found to increase screening (by 0.7%-16%). Effectiveness did not differ according to the format, delivery time, or content within the notification, although some differences in cancer type were observed.

CONCLUSION

Future research should explore the effectiveness of advance notification via alternative formats and for other screening contexts and disentangle the intervention- and person-level factors driving its effect on screening participation.

Breast cancer screening and early diagnosis in China: a systematic review and meta-analysis on 10.72 million women

BACKGROUND

The incidence of breast cancer among Chinese women has gradually increased in recent years. This study aims to analyze the situation of breast cancer screening programs in China and compare the cancer detection rates (CDRs), early-stage cancer detection rates (ECDRs), and the proportions of early-stage cancer among different programs.

METHODS

We conducted a systematic review and meta-analysis of studies in multiple literature databases. Studies that were published between January 1, 2010 and June 30, 2023 were retrieved. A random effects model was employed to pool the single group rate, and subgroup analyses were carried out based on screening model, time, process, age, population, and follow-up method.

RESULTS

A total of 35 studies, including 47 databases, satisfied the inclusion criteria. Compared with opportunistic screening, the CDR (1.32‰, 95% CI: 1.10‰-1.56‰) and the ECDR (0.82‰, 95% CI: 0.66‰-0.99‰) were lower for population screening, but the proportion of early-stage breast cancer (80.17%, 95% CI: 71.40%-87.83%) was higher. In subgroup analysis, the CDR of population screening was higher in the urban group (2.28‰, 95% CI: 1.70‰-2.94‰), in the breast ultrasonography (BUS) in parallel with mammography (MAM) group (3.29‰, 95% CI: 2.48‰-4.21‰), and in the second screening follow-up group (2.47‰, 95% CI: 1.64‰-3.47‰), and the proportion of early-stage breast cancer was 85.70% (95% CI: 68.73%-97.29%), 88.18% (95% CI: 84.53%-91.46%), and 90.05% (95% CI: 84.07%-94.95%), respectively.

CONCLUSION

There were significant differences between opportunistic and population screening programs. The results of these population screening studies were influenced by the screening process, age, population, and follow-up method. In the future, China should carry out more high-quality and systematic population-based screening programs to improve screening coverage and service.

Anticipatory anxiety and participation in cancer screening. A systematic review

OBJECTIVES

To synthesize current evidence on the association between anticipatory anxiety, defined as apprehension-specific negative affect that may be experienced when exposed to potential threat or uncertainty, and cancer screening to better inform strategies to maximize participation rates.

METHODS

Searches related to cancer screening and anxiety were conducted in seven electronic databases (APA PsycINFO, Scopus, Web of Science, Embase, Cochrane Library, PubMed, CINAHL), with potentially eligible papers screened in Covidence. Data extraction was conducted independently by multiple authors. Barriers to cancer screening for any type of cancer and relationships tested between anticipatory anxiety and cancer screening and intention were categorized and compared according to the form and target of anxiety and cancer types.

RESULTS

A total of 74 articles (nparticipants  = 119,990) were included, reporting 103 relationships tested between anticipatory anxiety and cancer screening and 13 instances where anticipatory anxiety was reported as a barrier to screening. Anticipatory anxiety related to a possible cancer diagnosis was often associated with increased screening, while general anxiety showed no consistent relationship. Negative relationships were often found between anxiety about the screening procedure and cancer screening.

CONCLUSION

Anticipatory anxiety about a cancer diagnosis may promote screening participation, whereas a fear of the screening procedure could be a barrier. Public health messaging and primary prevention practitioners should acknowledge the appropriate risk of cancer, while engendering screening confidence and highlighting the safety and comfort of screening tests.

Developing a Health Equity Impact Assessment 'Indigenous Lens Tool' to address challenges in providing equitable cancer screening for indigenous peoples

BACKGROUND

In spite of past efforts to increase screening uptake, the rates of screening-detectable cancers including breast, cervical, colorectal and lung are rising among Indigenous persons in Ontario compared to other Ontarians. The Ontario Ministry of Health has an equity framework, the Health Equity Impact Assessment (HEIA) Tool, that was developed to guide organizations in the provision of more equitable health and social services. Although the HEIA Tool identifies that the health of Indigenous persons may benefit from more equitable provision of health and social services, it provides very little specific guidance on how to apply the HEIA Tool in a culturally relevant way to policies and programs that may impact Indigenous peoples.

DISCUSSION

Guided by the Calls to Action from the Truth and Reconciliation Commission of Canada and the United Nations Declaration on the Rights of Indigenous Peoples, an Indigenous Lens Tool was developed through a collaborative and iterative process with stakeholders at Cancer Care Ontario and with representatives from Indigenous community-based organizations. The Indigenous Lens Tool consists of four scenarios, with supporting documentation that provide context for each step of the HEIA Tool and thereby facilitate application of the equity framework to programs and policies. The document is in no way meant to be comprehensive or representative of the diverse health care experiences of Indigenous peoples living in Canada nor the social determinants that surround health and well-being of Indigenous peoples living in Canada. Rather, this document provides a first step to support development of policies and programs that recognize and uphold the rights to health and well-being of Indigenous peoples living in Canada.

CONCLUSIONS

The Indigenous Lens Tool was created to facilitate implementation of an existing health equity framework within Cancer Care Ontario (now Ontario Health). Even though the Indigenous Lens Tool was created for this purpose, the principles contained within it are translatable to other health and social service policy applications.

Assessment of organization of cervical and breast cancer screening programmes in the Latin American and the Caribbean states: The CanScreen5 framework

BACKGROUND

In the Community of Latin American and Caribbean States (CELAC), breast cancer and cervical cancer are the first and third causes of cancer death among females. The objectives are to assess the characteristics of the cervical and breast cancer screening programmes in CELAC, their level of organization, and the association of screening organization and coverage of essential health services.

METHODS

Representatives of the Ministries of Health of 33 countries were invited to the CanScreen5 project. Twenty-seven countries participated in a "Train The Trainers" programme on cancer screening, and 26 submitted data using standardized questionnaires. Data were discussed and validated. The level of organization of the screening programmes was examined adapting the list of essential elements of organized screening programmes identified in a recently published IARC study.

RESULTS

Twenty-one countries reported a screening programme for cervical cancer and 15 for breast cancer. For cervical cancer, 14 countries dedicated budget for screening (66.7%), and women had to pay in 3 countries for screening (14.3%), 9 for diagnosis (42.9%) and 8 for treatment (38.1%). Only 4 countries had a system to invite women individually (19.0%). For breast cancer, 8 countries dedicated budget for screening (53.3%), and women had to pay for screening in 3 countries (20.0%), diagnosis in 7 (46.7%) and treatment in 6 (40.0%). One country (6.7%) invited women individually. There was variability in the level of organization of both cancer screening programmes. The level of organization of cervical cancer screening and coverage of essential health services were correlated.

CONCLUSION

Large gaps were identified in the organization of cervical and breast cancer screening services. CELAC governments need pragmatic public health policies and strengthened health systems. They should guarantee sustainable funding, and universal access to cancer diagnosis and treatment. Moreover, countries should enhance their health information system and ensure adequate monitoring and evaluation.

Rationale for organized Colorectal cancer screening programs

Colorectal cancer (CRC) is a major health problem and it is expected that the number of persons diagnosed with CRC and CRC-related deaths will continue to increase. However, recent years have shown reductions in CRC incidence and mortality particularly among individuals aged 50 years and older which can be attributed to screening, improvements in patients' management, closer adherence to treatment guideline recommendations and a higher utilization of curative surgery, chemotherapy and radiotherapy. The International Agency for Research on Cancer has concluded that there has been sufficient evidence that biennially screening using a stool-test or once-only endoscopy screening reduces CRC-related mortality. In Europe, between 2008 and 2018, nine countries have successfully implemented a population-based organized program and another six are in the roll-out phase. Population-based organized programs show higher screening participation rates and lower lack of compliance to follow-up testing after a positive screen test compared to opportunistic screening. Moreover, organized programs aim to provide high quality screening thereby reducing the risk of the harms of screening, including over-screening, and complications of screening, and poor follow-up of those who test positive. We describe how population-based organized CRC screening programs are preferred, since they reflect a more appropriate utilization of available resources, reduce inequities in access, and can integrate interventions addressing barriers to screening at the individual and health system levels.

Colorectal cancer screening barriers and facilitators among Jordanians: A cross-sectional study

The factors affecting the adherence of Jordanians to colorectal cancer (CRC) screening remain underexplored. We examined the inhibitory and facilitating factors that influence the uptake of CRC screening among Jordanians. We conducted questionnaire interviews between April 2020 and June 2021 with 861 Jordanians aged 50-75. We analyzed the differences between proportions using the chi-square test. Binary logistic regression was conducted to determine factors associated with awareness of CRC and its screening. Of all participants, 41.7 % were aware of the necessity of screening for CRC, and 27.2 % were aware of at least one of the tests for CRC screening. However, only 17.2 % of participants underwent screening. In the multivariate analysis, participants with higher income (p-value < 0.001, odds ratio[OR] = 1.9, 95 % confidence interval [CI]: 1.4-2.7), higher level of education (p-value < 0.001, OR = 2.6, 95 % CI: 1.8-3.7), family history of colon cancer (p-value < 0.001, OR = 2.8, 95 % CI = 1.7-4.5), and those who had been screened for other cancers (p-value = 0.003, OR = 1.7, 95 % CI: 1.2-2.5) were more aware of the necessity of screening. Concerning barriers to screening, 'feeling well,' lack of physician endorsement, and difficult access to health care were the most commonly reported inhibitory factors (53.9 %, 52.3 %, and 31.9 %, respectively). The most commonly stated incentivizing factor was physician endorsement (82.3 %). Screening rates for CRC in eligible Jordanians remain low, albeit more than one-third of participants are aware of the necessity of screening. Enhanced awareness of barriers and incentivizing factors should help to prioritize national strategies to improve screening rates.

Colorectal Cancer: A Systematic Review of the Current Situation and Screening in North and Central Asian Countries

The prevalence of colorectal cancer (CRC) is increasing in the past few decades. A significant proportion of this increase is from low to middle income countries (LMIC). CRC prevalence is also increasing in North and Central Asian Countries (NCAC). Screening for colorectal cancer has decreased CRC mortality but data regarding screening practices in NCAC is limited.  A literature search was conducted in PubMed/Medline, Embase and Cochrane for current colorectal cancer screening practices in NCAC. Incidence and mortality rates were derived from public health agency websites to calculate age-standardized CRC mortality-to-incidence ratios. Web-based online break-point testing defined as statistical major changes in CRC mortality trends was completed. Among the 677 screened studies, 37 studies met the criteria for inclusion for review. CRC screening in NCAC is not organized, although most countries have cancer registries. The data availability is scarce, and most data is prior to 2017. Most studies are observational. There is minimal data about colonoscopy preparations, adenoma detection and complications rates. The polyp detection rates (PDRs) and adenoma detection rates (ADRs) seem low to optimal in this region. Commonly measured outcomes include participation rate, fecal immunochemical tests (FIT) positivity rate and cost-benefit measures. Lower mortality-to-incidence ratios is seen in countries with screening programs. Kazakhstan and Lithuania with screening programs have achieved breakpoint suggesting major changes in CRC mortality trends. Data about CRC screening varies widely within NCAC. High human developmental index (HDI) countries like Lithuania and Estonia have higher incidence of CRC and mortality. Seven NCAC have CRC screening programs with most utilizing non-invasive methods for screening. Data collection is regional and not organized. The ADR and PDR are low to optimal in this region and cancer detection rates are comparable to other high-income countries (HIC). CRC detection rate is 0.05% for screening in Kazakhstan and 0.2% for screening in Lithuania. Very limited information is available on the actual cost and logistics of implementing a CRC screening program. All NCAC have a cancer registry, with some having a high-quality registry showing national coverage with good validity and completeness. Establishing guideline-based registries and increasing screening efficacy could improve CRC outcomes in NCAC.

Changes in rate and socioeconomic inequality of cervical cancer screening in northeastern China from 2013 to 2018

Objective

Cervical cancer, the fourth leading cancer diagnosed in women, has brought great attention to cervical cancer screening to eliminate cervical cancer. In this study, we analyzed two waves of provincially representative data from northeastern China's National Health Services Survey (NHSS) in 2013 and 2018, to investigate the temporal changes and socioeconomic inequalities in the cervical cancer screening rate in northeastern China.

Methods

Data from two waves (2013 and 2018) of the NHSS deployed in Jilin Province were analyzed. We included women aged 15-64 years old and considered the occurrence of any cervical screening in the past 12 months to measure the cervical cancer screening rate in correlation with the annual per-capita household income, educational attainment, health insurance, and other socioeconomic characteristics.

Results

A total of 11,616 women aged 15-64 years were eligible for inclusion. Among all participants, 7,069 participants (61.11%) were from rural areas. The rate of cervical cancer screening increased from 2013 to 2018 [odds ratio (OR): 1.06; 95% confidence interval (CI): 1.04-1.09, p < 0.001]. In total, the cervical cancer screening rate was higher among participants who lived in urban areas than rural areas (OR: 1.20; 95% CI: 1.03-1.39, p = 0.020). The rate was also higher among those with the highest household income per capita (OR: 1.30; 95% CI: 1.07-1.56, p = 0.007), with higher educational attainment (p < 0.001), and with health insurance (p < 0.05), respectively. The rate of cervical cancer screening was also significantly associated with parity (OR: 1.62; 95% CI: 1.23-2.41, p = 0.001) and marital status (OR: 1.45; 95% CI: 1.15-1.81, p = 0.001) but not ethnicity (OR: 1.41; 95% CI: 0.95-1.36, p = 0.164).

Conclusion

Cervical cancer screening coverage improved from 2013 to 2018 in northeastern China but remains far below the target 70% screening rate proposed by the World Health Organization. Although rural-urban inequality disappeared over time, other socioeconomic inequalities remained.

Mapping Evidence on Management of Cervical Cancer in Sub-Saharan Africa: Scoping Review

Cervical cancer (CC) is the most common viral infection of the reproductive tract and in Sub-Saharan Africa (SSA), its morbidity and mortality rates are high. The aim of this review was to map evidence on CC management in SSA. The scoping review was conducted in accordance with Arksey and O’Malley’s scoping review framework. The review included studies on different aspects of CC management. The review was also done following the steps and guidelines outlined in the PRISMA-Extension for Scoping Reviews (PRISMA-ScR) checklist. The following databases were searched: PubMed, EBSCOhost, Scopus and Cochrane Database of Systematic Review. A total of 1121 studies were retrieved and 49 which were eligible for data extraction were included in the review. The studies were classifiable in 5 groups: 14 (28.57%) were on barriers to CC screening, 10 (20.41%) on factors associated with late-stage presentation at diagnosis, 11 (22.45%) on status of radiotherapy, 4 (8.20%) on status of chemotherapy and 10 (20.41%) on factors associated with high HPV coverage. High HPV vaccine coverage can be achieved using the class school-based strategy with opt-out consent form process. Barriers to CC screening uptake included lack of knowledge and awareness and unavailability of screening services. The reasons for late-stage presentation at diagnosis were unavailability of screening services, delaying whilst using complementary and alternative medicines and poor referral systems. The challenges in chemotherapy included unavailability and affordability, low survival rates, treatment interruption due to stock-outs as well as late presentation. Major challenges on radiotherapy were unavailability of radiotherapy, treatment interruption due to financial constraints, and machine breakdown and low quality of life. A gap in understanding the status of CC management in SSA has been revealed by the study implying that, without full knowledge of the extent of CC management, the challenges and opportunities, it will be difficult to reduce infection, improve treatment and palliative care. Research projects assessing knowledge, attitude and practice of those in immediate care of girls at vaccination age, situational analysis with health professionals and views of patients themselves is important to guide CC management practice.

Factors Influencing Pap Smear Screening Uptake among Women Visiting Outpatient Clinics in Johor

INTRODUCTION

Despite the benefits of cervical cancer screening, Pap smear uptake remains variable in Malaysia, with Johor previously reported as the state with the lowest uptake. This study aims to fill the gap in epidemiological knowledge and assess factors affecting the uptake of Pap smear screening among women in Johor.

METHODS

A cross-sectional study was conducted in several government and private clinics across Johor, including Pagoh, Muar, Batu Pahat, Kulai, and Johor Bahru districts. Data was collected from 452 women using self-administered questionnaires, and logistic regression was performed to determine factors associated with Pap smear uptake.

RESULTS

Findings showed that 48.5% of the women reported having undergone Pap smear screening in the previous 3 years, and 40.0% and 51.3% of respondents accurately answered questions on symptoms and risk factors of cervical cancer, respectively. Increasing age (OR_ad. 2.322, 95% CI 1.708-3.158), being married (OR_adj 4.860, 95% CI 1.100-21.476), parity of ≥5 (OR_adj 8.381, 95% CI 1.326-52.958), young age at first pregnancy (OR_adj 0.932, 95% CI 0.877-0.991), knowledge of cervical cancer symptoms (OR_adj. 1.745, 95% CI 1.065-2.857), support from family (OR_adj 3.620, 95% CI 2.081-6.298), and contraception use (OR_adj 2.220, 95% CI 1.314-3.750) were significantly associated with increased Pap smear uptake among women visiting outpatient clinics in Johor.

CONCLUSION

Pap smear uptake remains suboptimal in Johor, and broad-based awareness campaigns tailored towards improving knowledge of cervical cancer with family involvement are crucial to improving uptake among women in Johor.

The Impact of Morbidity and Disability on Attendance at Organized Breast Cancer-Screening Programs: A Systematic Review and Meta-Analysis

Individuals with morbidity experience worse breast cancer outcomes compared with those without. This meta-analysis assessed the impact of morbidity on breast cancer-screening attendance and subsequent early detection (PROSPERO pre-registration CRD42020204918). MEDLINE, PsychInfo, and CINAHL were searched. Included articles published from 1988 measured organized breast-screening mammography attendance using medical records by women with morbidity compared with those without. Morbidities were assigned to nine diagnostic clusters. Data were pooled using random-effects inverse meta-analyses to produce odds ratios (OR) for attendance. 25 study samples (28 articles) were included. Data were available from 17,755,075 individuals, including at least 1,408,246 participants with one or more conditions;16,250,556 had none. Individuals with any morbidity had lower odds of attending breast screening compared with controls [k = 25; OR, 0.76; 95% confidence interval (CI), 0.70-0.81; P = <0.001; I2 = 99%]. Six morbidity clusters had lower odds of attendance. The lowest were for neurological, psychiatric, and disability conditions; ORs ranged from 0.45 to 0.59 compared with those without. Morbidity presents a clear barrier for breast-screening attendance, exacerbating health inequalities and, includes a larger number of conditions than previously identified. Consensus is required to determine a standardized approach on how best to identify those with morbidity and determine solutions for overcoming barriers to screening participation based on specific morbidity profiles.

Using Facebook to promote the uptake of colorectal cancer screening

Background

The use of social media presents a unique opportunity for cancer screening programs to motivate individuals to get screened. However, we need a better understanding of what types of social media messages for colorectal cancer (CRC) screening are preferred. The objective of this study was to develop social media messages promoting CRC screening uptake to identify messages preferred by the target audience.

Methods

We conducted a qualitative descriptive study and collected data through focus groups with Facebook users of screen-eligible age. Participants were presented with social media messages and asked to provide feedback. Messages were informed by the Health Belief Model, current evidence regarding screening communication and health communication and social media best practices. Focus groups were audio-recorded and transcribed and analysis was completed by two independent coders. If messages generated sufficient discussion, we developed a recommendation regarding the use of the message in a future social media campaign. Recommendations included: strongly consider using this message, consider using this message, proceed with caution, and do not use this message. General considerations about social media campaigns were also noted.

Results

A total of 45 individuals participated in six focus groups. We developed recommendations for 7 out of the 18 messages tested; 1 was classified as strongly consider using this message, 4 as consider using this message and 2 as proceed with caution. The data suggest that participants preferred social media messages that were believed to be credible, educational, and with a positive or reassuring tone. Preferred messages tended to increase awareness about CRC risk and screening and prompted participants to ask questions, and to want to learn more about what they could do to lower their risk. Messages that were viewed as humorous, strange or offensive or that had a negative or excessively fearful tone were less well received by study participants.

Conclusions

Facebook users prefer social media messages for CRC that have a positive or reassuring tone, are educational, and that have a credible ad sponsor. Campaign planners should proceed with caution when considering messages that use humor or a fearful tone to avoid undermining their campaign objectives.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-022-12732-w.

Two randomized controlled trials for colorectal cancer screening invitations developed using a behavioral science approach

The effectiveness of behaviorally informed, targeted invitations to standard invitations and to no invitation (control arm, primary analysis) were compared in the context of an organized colorectal cancer (CRC) screening program. Two multi-arm, pragmatic randomized controlled trials in men (arms: male-specific, unisex, standard invitation, or no invitation) and in women (arms: unisex, standard invitation, or no invitation), were conducted in Ontario, Canada. Eligible persons aged 50-74, due for CRC screening, were randomized. Primary and secondary outcomes were completion of the guaiac fecal occult blood test (gFOBT) and uptake of any colorectal test, respectively, within 5 months of mailing. Impact of invitation type was assessed using logistic regression. Letters were mailed to 75,810 men and women; 38,673 males and 34,453 females were included in the analyses. Men who received the male-specific letter were most likely to screen with gFOBT compared to controls (odds ratio (OR) 7·24, 95% CI: 5·77, 9·09), followed by those receiving the unisex letter (OR 6·75, 95% CI: 5·37, 8·47) and the standard letter (OR 5·99, 95% CI: 4·76, 7·53). Women who received the unisex letter were most likely to be screened with gFOBT compared to controls (OR 7·07, 95% CI: 5·83, 8·59), followed by those receiving the standard letter (OR 6·76, 95% CI: 5·56, 8·21). In both trials, the findings were similar for the secondary outcome. Mailed invitations were effective for both men and women. With greater targeting using the behaviorally informed invitations, the magnitude of benefit relative to no invitation appeared to increase. (ClinicalTrials.gov, NCT02364895).

Nimble Approach: fast, adapting, calculating and ethically mindful approach to managing colorectal cancer screening programmes during a pandemic

OBJECTIVE

To describe a conceptual framework that provides understanding of the challenges encountered and the adaptive approaches taken by organised colorectal cancer (CRC) screening programmes during the initial phase of the COVID-19 pandemic.

DESIGN

This was a qualitative case study of international CRC screening programmes. Semi-structured interviews were conducted with programme managers/leaders and programme experts, researchers and clinical leaders of large, population-based screening programmes. Data analysis, using elements of grounded theory, as well as cross-cases analysis was conducted by two experienced qualitative researchers.

RESULTS

19 participants were interviewed from seven programmes in North America, Europe and Australasia. A conceptual framework ('Nimble Approach') was the key outcome of the analysis. Four concepts constitute this approach to managing CRC screening programmes during COVID-19: Fast (meeting the need to make decisions and communicate quickly), Adapting (flexibly and creatively managing testing/colonoscopy capacity, access and backlogs), Calculating (modelling and actively monitoring programmes to inform decision-making and support programme quality) and Ethically Mindful (considering ethical conundrums emerging from programme responses). Highly integrated programmes, those with highly integrated communication networks, and that managed greater portions of the screening process seemed best positioned to respond to the crisis.

CONCLUSIONS

The Nimble Approach has potentially broad applications; it can be deployed to effectively respond to programme-specific challenges or manage CRC programmes during future pandemics, other health crises or emergencies.

Current and future colorectal cancer screening strategies

Despite strong evidence of effectiveness, colorectal cancer (CRC) screening remains underused. Currently, there are several options for CRC screening, each with its own performance characteristics and considerations for practice. This Review aims to cover current CRC screening guidelines and highlight future blood-based and imaging-based options for screening. In current practice, the leading non-invasive option is the faecal immunochemical test (FIT) based on its high specificity, good sensitivity, low cost and ease of use in mailed outreach programmes. There are currently five blood-based CRC screening tests in varying stages of evaluation, including one that is currently sold in the USA as a laboratory-developed test. There are ongoing studies on the diagnostic accuracy and longitudinal performance of blood tests and they have the potential to disrupt the CRC screening landscape. Imaging-based options, including the colon capsule, MR colonography and the CT capsule, are also being tested in active studies. As the world attempts to recover from the COVID-19 pandemic and adapts to the start of CRC screening among people at average risk starting at age 45 years, non-invasive options will become increasingly important.

Early assessment of the first wave of the COVID-19 pandemic on cancer screening services: The International Cancer Screening Network COVID-19 survey

Screening can decrease the burden of breast, cervical, and colorectal cancers. The COVID-19 pandemic led many countries to suspend cancer screening services as part of their response to the pandemic. The International Cancer Screening Network (ICSN) carried out an online survey to assess the effects of the first wave of the COVID-19 pandemic on cancer screening. A 33-item survey was distributed to 834 email addresses to gather information about settings and assess decision-making processes that led to cancer screening suspension. Information about communication, impact on resources, and patient follow-up was collected. Quantitative data was analyzed as frequencies overall and by setting, while a comment section under each survey item captured nuanced details. Responses were recategorized into 66 settings, representing 35 countries. Most settings suspended cancer screening services (n = 60, 90.9%) in March 2020 (n = 45, 68.2%), guided by a government decision (n = 51, 77.3%). Few settings made the decision whether to suspend services based on a preparedness plan (n = 17, 25.8%). In most settings, professionals were reassigned (n = 41, 62.1%) and infrastructure repurposed (n = 35, 53.0%). The first wave of the COVID-19 pandemic has had profound effects on cancer screening worldwide, including the suspension of services in almost all settings. Most settings were unprepared to deal with the scale of the pandemic but demonstrated flexibility in the response. These results contribute to inform, through experiences and lessons learned, the next steps for the global cancer screening community to further evaluate the impact of COVID-19 and prepare for future disruptions.

The integrated screening action model (I-SAM): A theory-based approach to inform intervention development

Screening can reduce deaths if the people invited participate. However, good uptake is hard to achieve, and our current approaches are failing to engage the most vulnerable. A coherent model of screening behaviour to guide our understanding and intervention development is yet to be established. The present aim was to propose an Integrated Screening Action Model (I-SAM) to improve screening access. The I-SAM synthesises existing models of health behaviour and empirical evidence. The I-SAM was developed following: i) an appraisal of the predominant models used within the screening literature; ii) the integration of the latest knowledge on behaviour change; with iii) the empirical literature, to inform the development of a theory-based approach to intervention development. There are three key aspects to the I-SAM: i) a sequence of stages that people pass through in engaging in screening behaviour (based on the Precaution Adoption Process Model); ii) screening behaviour is shaped by the interaction between participant and environmental influences (drawing from the Access Framework); and iii) targets for intervention should focus on the sources of behaviour - 'capability', 'opportunity', and 'motivation' (based on the COM-B Model). The I-SAM proposes an integrated model to support our understanding of screening behaviour and to identify targets for intervention. It will be an iterative process to test and refine the I-SAM and establish its value in supporting effective interventions to improve screening for all.

Breast cancer screening in Primary Health Care in Brazil: a systematic review

OBJECTIVES

to analyze care strategies for breast cancer screening in Primary Health Care in Brazil.

METHODS

this is a systematic review following the Cochrane Collaboration recommendations.

RESULTS

among 355 manuscripts, five were eligible. The patient navigation program by Community Health Agent stood out with the best result, among the strategies: flexibility of goals considering viability; community engagement; team training; active search of the target population by Community Health Agent; request for mammography by physicians; actions integrated to women's health; monitoring of mammography results, absent users, and population coverage by physician and nurse; and assessment of criteria for requesting screening mammography by means of an information system. The population coverage rate in the program ranged from 23% to 88%.

CONCLUSIONS

Primary Health Care in Brazil presents devices with potential to induce the production of care for breast cancer screening.

Building Capacity for Global Cancer Research: Existing Opportunities and Future Directions

Cancer incidence and mortality are increasing in low- and middle-income countries (LMICs), where more than 75% of global cancer burden will occur by the year 2040. The primary drivers of cancer morbidity and mortality in LMICs are environmental and behavioral risk factors, inadequate prevention and early detection services, presence of comorbidities, and poor access to treatment and palliation. These same drivers also contribute to marked cancer health disparities in high-income countries. Studying cancer in LMICs provides opportunities to better understand and address these drivers to benefit populations worldwide, and reflecting this, global oncology as an academic discipline has grown substantially in recent years. However, sustaining this growth requires a uniquely trained workforce with the skills to pursue relevant, rigorous, and equitable global oncology research. Despite this need, dedicated global cancer research training programs remain somewhat nascent and uncoordinated. In this paper, we discuss efforts to address these gaps in global cancer research training at the US National Institutes of Health.

Inequalities and risk factors related to non-participation in colorectal cancer screening programmes: a systematic review

Background

Colorectal cancer (CRC) screening programmes require high levels of participation in order to reduce mortality. To improve participation rates, it is necessary to identify the health risk factors and social inequalities associated with non-participation.

Methods

A systematic review was conducted between June and September of 2019 in six databases: CINHAL, Medline, Scopus, Social Sciences Citation Index, Embase and PsycINFO. Studies assessing the relationship between health risk factors, participation in preventive activities and participation in CRC screening were included. Methodological assessment was carried out according to the Quality Assessment Tools of the National Heart, Lung and Blood Institute.

Results

A total of nine studies that analyze participation in both organized and opportunistic screening programmes using any type of screening method were finally selected. Data were mainly self-reported although in two studies medical records were also studied. We identified several variables: gender, body mass index, consultation with a doctor or a specialist, educational level, employment, health insurance, residence, ethnicity, age, marital status, income, other preventive activities, obesity, physical activity, smoking, family history of CRC and general health status.

Conclusion

The scarcity of studies linking risk factors, social inequalities and participation in preventive activities for participation in screening in the same study makes it difficult to reach definitive patterns related to non-participation in CRC screening programmes. Nevertheless, being under 60, obese, smoker and sedentary have shown an association with non-participation as well as not visiting a doctor.

Early colorectal cancer detection-Current and evolving challenges in evidence, guidelines, policy, and practices

The understanding at the beginning of the last century that colorectal cancer began as a localized disease that progressed and became systemic, and that most colorectal cancer arose from adenomatous polyps gave rise to aggressive attempts at curative treatment and eventually attempts to detect advanced lesions before they progressed to invasive disease. In the last four decades, steadily greater uptake of screening has led to reductions in colorectal cancer incidence and mortality. However, the fullest potential of screening is not being met due to the lack of organized screening, where a systems approach could lead to higher rates of screening of average and high risk groups, higher quality screening, and prompt followup of adults with positive screening tests. ABSTRACT: Since the beginning of the 20th century, there has been a general understanding that colorectal cancer is a clonal disease that progresses from a localized stage with a favorable prognosis through progressively more advanced stages which have progressively worse prognosis. That understanding led first to determined efforts to detect and treat early stage symptomatic disease, and then to detect pre-symptomatic colorectal cancer and precursor lesions, where there was hope that the natural history of the disease could be arrested and the incidence and premature mortality of colorectal cancer averted. Toward the end of the last century, guidelines for colorectal cancer screening, growth in the number of technical options for screening, and a steady increase in the proportion of the adult population who attended screening contributed to the beginning of a significant decline in colorectal cancer incidence and mortality. Despite this progress, colorectal cancer remains the third leading cause of death among men and women in the United States. Screening for early detection of precursor lesions and localized cancer offers the single most productive opportunity to further reduce the burden of disease, and yet nearly four in five deaths from colorectal cancer are associated with having never been screened, not recently screened, or not followed up for an abnormal screening test. This simple observation is a call to action in all communities to apply existing knowledge to fulfill the potential to prevent avertable incidence and mortality.

Canadian Colorectal Cancer Screening Guidelines: Do They Need an Update Given Changing Incidence and Global Practice Patterns?

Colorectal cancer (CRC) is the third most commonly diagnosed cancer and second leading cause of cancer death in Canada. Organized screening programs targeting Canadians aged 50 to 74 at average risk of developing the disease have contributed to decreased rates of CRC, improved patient outcomes and reduced healthcare costs. However, data shows that recent incidence reductions are unique to the screening-age population, while rates in people under-50 are on the rise. Similar incidence patterns in the United States prompted the American Cancer Society and U.S. Preventive Services Task Force to recommend screening begin at age 45 rather than 50. We conducted a review of screening practices in Canada, framing them in the context of similar global health systems as well as the evidence supporting the recent U.S. recommendations. Epidemiologic changes in Canada suggest earlier screening initiation in average-risk individuals may be reasonable, but the balance of costs to benefits remains unclear.

Impact of postal correspondence letters on participation in cancer screening: a rapid review

The purpose of this rapid review was to identify and synthesize evidence on the impact of postal correspondence letters on participation in cancer screening and to determine whether impact varied by cancer site or inclusion of the participant's physician's name within the letter (i.e., physician-linked). PubMed and the Cochrane Database of Systematic Reviews were searched for English-language systematic reviews and randomized controlled trials (RCTs) published up until October 2019. One reviewer completed citation screening and data extraction with 30% verification by a second reviewer. Systematic reviews and RCTs were appraised using A MeaSurement Tool to Assess systematic Reviews (AMSTAR) 2 and Cochrane Risk of Bias 2.0 tools, respectively, by one reviewer with complete verification by a second reviewer. Findings from systematic reviews and RCTs were examined separately and presented narratively. Six systematic reviews and 18 RCTs of generally low quality were included. Evidence generally demonstrated a positive impact of a letter as compared to no letter or usual practice on screening participation. This finding was consistent for breast cancer and cervical screening participation but inconsistent for colorectal cancer screening participation. Studies comparing physician-linked letters to no letters or usual practice reported similar effect estimates as those examining letters in general. Limited and inconsistent evidence was identified on the impact of physician-linked letters as compared to non-physician-linked letters on screening participation. Evidence identified in this rapid review, and other contextual and implementation considerations, may be useful for jurisdictions considering how to promote cancer screening participation.

Cervical cancer screening invitations in low and middle income countries: Evidence from Armenia

Roughly 90 percent of cervical cancer deaths occur in low- and middle-income countries (LMICs), where the lack of adequate infrastructures hampers screening, while informational, cultural, and socio-economic barriers limit participation in the few programs that do exist. We conducted a field experiment with the Armenian cervical cancer screening program to determine whether, despite these barriers, the simple, economical invitation strategies adopted in high-income countries could enhance screening take-up in LMICs. We find that letters of invitation increase screening take-up, especially when there are follow-up reminders. Different ways of framing messages appear to have no impact. Finally, women in rural areas are more likely to respond to invitation by letter, helping to narrow the urban-rural screening gap.

Facilitating Factors and Barriers of Women's Cancer Screening in Iran: A Systematic Review

Low uptake of women's cancer screening and its facilitating factors and barriers in Iran has been studied so far but no consensus on factors affecting this low uptake has been stated previously. Nevertheless, facilitating factors and barriers of breast cancer and cervical cancer have been reviewed. In this systematic review, Web of Science, PubMed, EMBASE, Scopus, and Google Scholar were the preferred search engines. In addition, the Persian database of Magiran and SIDs and ISC indexed journals were searched with different combinations of Persian keywords compatible with English search. A hand search of key Iranian journals was also accomplished. Through 964 primarily searched articles, finally, after duplicates being removed, the screen of records, and full-text articles assessed for eligibility, only 12 articles were included in the review. Barriers observed mostly were screening not advised by a physician, having no relevant problems or disease, having no knowledge about the procedure, fear from pain or cancer detection, shame from the procedure, and forget to have screening. Facilitators were less focused than barriers and frequently were identified as advised by healthcare professionals, the perceived necessity for screening, and the important identified risk of cancer acquire. Almost all studies focused on individual and interpersonal barriers and facilitators for screening instead of a holistic view on the utilization of screening programs. In future studies on women's cancer screening, facilitating factors and barriers of both supply (health system provision and policy implications) and demand-side (individual and interpersonal factors) of healthcare provision has been strongly recommended.

Breast cancer distant recurrence lead time interval by detection method in an institutional cohort

BACKGROUND

Lead time, the interval between screen detection and when a disease would have become clinically evident, has been cited to explain longer survival times in mammography detected breast cancer cases (BC).

METHODS

An institutional retrospective cohort study of BC outcomes related to detection method (mammography (MamD) vs. patient (PtD)). Cases were first primary invasive stage I-III BC, age 40-74 years (n = 6603), 1999-2016. Survival time was divided into 1) distant disease-free interval (DDFI) and 2) distant disease-specific survival (DDSS) as two separate time interval outcomes. We measured statistical association between detection method and diagnostic, treatment and outcome variables using bivariate comparisons, Cox proportional hazards analyses and mean comparisons. Outcomes were distant recurrence (n = 422), DDFI and DDSS.

RESULTS

39% of cases were PtD (n = 2566) and 61% were MamD (n = 4037). MamD cases had a higher percentage of Stage I tumors [MamD 69% stage I vs. PtD 31%, p < .001]. Rate of distant recurrence was 11% among PtD BC cases (n = 289) vs. 3% of MamD (n = 133) (p < .001). Order of factor entry into the distant recurrence time interval (DDFI) model was 1) TNM stage (p < .001), 2) HR/HER2 status (p < .001), 3) histologic grade (p = .005) and 4) detection method (p < .001). Unadjusted PtD DDFI mean time was 4.34 years and MamD 5.52 years (p < .001), however when stratified by stage, the most significant factor relative to distant recurrence, there was no significant difference between PtD and MamD BC. Distant disease specific survival time did not differ by detection method.

CONCLUSION

We observed breast cancer distant disease-free interval to be primarily associated with stage at diagnosis and tumor characteristics with less contribution of detection method to the full model. Patient and mammography detected breast cancer mean lead time to distant recurrence differed significantly by detection method for all stages but not significantly within stage with no difference in time from distant recurrence to death. Lead time difference related to detection method appears to be present but may be less influential than other factors in distant disease-free and disease specific survival.

AGA White Paper: Roadmap for the Future of Colorectal Cancer Screening in the United States

The American Gastroenterological Association's Center for Gastrointestinal Innovation and Technology convened a consensus conference in December 2018, entitled, "Colorectal Cancer Screening and Surveillance: Role of Emerging Technology and Innovation to Improve Outcomes." The goal of the conference, which attracted more than 60 experts in screening and related disciplines, including the authors, was to envision a future in which colorectal cancer (CRC) screening and surveillance are optimized, and to identify barriers to achieving that future. This White Paper originates from that meeting and delineates the priorities and steps needed to improve CRC outcomes, with the goal of minimizing CRC morbidity and mortality. A one-size-fits-all approach to CRC screening has not and is unlikely to result in increased screening uptake or desired outcomes owing to barriers stemming from behavioral, cultural, and socioeconomic causes, especially when combined with inefficiencies in deployment of screening technologies. Overcoming these barriers will require the following: efficient utilization of multiple screening modalities to achieve increased uptake; continued development of noninvasive screening tests, with iterative reassessments of how best to integrate new technologies; and improved personal risk assessment to better risk-stratify patients for appropriate screening testing paradigms.

The Importance of Cancer Screening

The burden of cancer in the United States is substantial, providing important opportunity and obligation for primary care clinicians to promote cancer prevention and early detection. Without a system of organized screening to support reminders and follow-up of cancer screening, primary care clinicians face challenges in addressing risk assessment, informed/shared decision making, reminders for screening, and tracking adherence to screening recommendations. Tools exist for collecting information about family history, tracking screening adherence, and reminding patients when they are due for screening, and strategies exist for making cancer prevention and early detection an office policy and delegating roles and responsibilities to office staff.

Differences in cervical test coverage by age, socioeconomic status, ethnic origin and municipality type - A nationwide register-based study

An invitational organized cervical cancer screening together with widely spread opportunistic testing has coexisted for decades in Finland. The aim of this study was to examine the coverage of cervical tests by age, socioeconomic status, ethnicity and municipality type within and outside the organized screening program. We had a cohort of women of whom 1,2 million were in the target age range of screening and residing in Finland in 2010-2014. Data on Pap and/or HPV -tests within and outside the screening program were collected from the Mass Screening Registry, the pathology laboratories and the health insurance reimbursement registry and five-year population coverages of tests were reported. The total test coverage was 86.0%; 95% CI, (85.8-86.1), and was notably lower for those with an unknown socioeconomic status and pensioners (68.8%; 95% CI, (67.9-69.6) and 77.1%; 95% CI, (76.5-77.6), respectively) compared to upper-level employers (89.8%; 95% CI, (89.5-90.2)). Coverage was also lower for non-native speaking women (72.4%; 95% CI, (71.8-73.0)) compared to native speakers (86.9%; 95% CI, (86.7-87.0)) and for women living in urban municipalities (85.5%; 95% CI, (85.3-85.7)) compared to semi-urban (87.4%; 95% CI, (87.0-87.8)). Although overall coverage was high, tests within and outside the program seemed to concentrate on women with presumably good access to health services. Tests outside the program were especially common among young women who are at a low risk of invasive cervical cancer. Efforts should be made to reduce excessive opportunistic testing and to increase attendance at the program among hard-to-reach populations.

Mailed fecal immunochemical test outreach for colorectal cancer screening: Summary of a Centers for Disease Control and Prevention-sponsored Summit

Uptake of colorectal cancer screening remains suboptimal. Mailed fecal immunochemical testing (FIT) offers promise for increasing screening rates, but optimal strategies for implementation have not been well synthesized. In June 2019, the Centers for Disease Control and Prevention convened a meeting of subject matter experts and stakeholders to answer key questions regarding mailed FIT implementation in the United States. Points of agreement included: 1) primers, such as texts, telephone calls, and printed mailings before mailed FIT, appear to contribute to effectiveness; 2) invitation letters should be brief and easy to read, and the signatory should be tailored based on setting; 3) instructions for FIT completion should be simple and address challenges that may lead to failed laboratory processing, such as notation of collection date; 4) reminders delivered to initial noncompleters should be used to increase the FIT return rate; 5) data infrastructure should identify eligible patients and track each step in the outreach process, from primer delivery through abnormal FIT follow-up; 6) protocols and procedures such as navigation should be in place to promote colonoscopy after abnormal FIT; 7) a high-quality, 1-sample FIT should be used; 8) sustainability requires a program champion and organizational support for the work, including sufficient funding and external policies (such as quality reporting requirements) to drive commitment to program investment; and 9) the cost effectiveness of mailed FIT has been established. Participants concluded that mailed FIT is an effective and efficient strategy with great potential for increasing colorectal cancer screening in diverse health care settings if more widely implemented.

What Is Organized Screening and What Is Its Value?

Most screening in the United States occurs in an opportunistic fashion, although organized screening occurs in some integrated health care systems. Organized colorectal cancer (CRC) screening consists of an explicit screening policy, defined target population, implementation team, health care team for clinical care delivery, quality assurance infrastructure, and method for identifying cancer outcomes. Implementation of an organized screening program offers opportunities to systematically assess the success of the program and develop interventions to address identified gaps in an effort to optimize CRC outcomes. There is evidence of that organized screening is associated with improvements in screening participation and CRC mortality.

Development of a Group-Based Community Health Worker Intervention to Increase Colorectal Cancer Screening Among Latinos

INTRODUCTION

Latinos are at higher risk of colorectal cancer (CRC) mortality than non-Hispanic Whites due, in part, to disparities in cancer screening. There is a need to evaluate community-based CRC interventions as they may reach underinsured communities and those at highest risk for CRC. This article describes the development of a group-based CRC intervention (Juntos contra el Cancer).

METHOD

Purposive sampling was used to recruit Latino men and women aged 50 to 75 years not-up-to-date with CRC screening. The development of the intervention was guided by the socioecologic framework, a community needs assessment, literature reviews, five focus groups (n = 39) from the target community and feedback from a Community Advisory Board.

RESULTS

Findings from focus groups suggested that a group-based, promotor or community health worker (CHW) led, cancer prevention education with linkages to care would address barriers to CRC screening.

CONCLUSION

Development of community-based CRC screening interventions should be informed by early and sustained community engagement. Interventions led by CHWs with linkages to care are feasible and can reach populations not connected to health care settings.

Morbidity as a Predictor for Participation in the Danish National Mammography Screening Program: A Cross-Sectional Study

Purpose

In this cross-sectional study, we evaluated the association between morbidity and participation in the prevalence round of the Danish national mammography screening program.

Patients and Methods

Morbidity was assessed by the Charlson Comorbidity Index (CCI) score (0, 1-2, and ≥3) and by 19 individual diagnoses. We retrieved data on participation from The Danish Quality Database of Mammography Screening and on diagnoses from The Danish National Patient Registry. We estimated prevalence proportion ratios (PR) with 95% confidence intervals (CI).

Results

In total, 519,009 (79.8%) women participated in the first national breast cancer screening round. Relative to women with a CCI score of 0, the adjusted PRs were 0.96 (95% CI: 0.95-0.96) for a CCI score of 1-2 and 0.80 (95% CI: 0.79-0.81) for a CCI score of ≥3. Compared with no disease, the PRs for a diagnosis of the most prevalent, but less severe diseases, chronic pulmonary disease, cerebrovascular disease, diabetes I and II were 0.93 (95% CI: 0.93-0.94), 0.96 (95% CI: 0.94-0.96), and 0.96 (95% CI: 0.95-0.97), respectively. Among women with low prevalent, but most severe diseases, the PRs were 0.69 (95% CI: 0.60-0.81) for AIDS and 0.73 (95% CI: 0.70-0.76) for metastatic solid tumor.

Conclusion

Women with a high CCI score or one severe chronic condition are less likely to participate in breast cancer screening compared to women without disease. However, these women account for a small proportion of all non-participating women. Thus, it might be most beneficial to maximize breast cancer screening participation in women with less severe although more common morbidities.

Correlates of colorectal cancer screening rates in primary care clinics serving low income, medically underserved populations

INTRODUCTION

Screening for colorectal cancer (CRC) is effective in reducing CRC burden. Primary care clinics have an important role in increasing screening. We investigated associations between clinic-level CRC screening rates of the clinics serving low income, medically underserved population, and clinic-level screening interventions, clinic characteristics and community contexts.

METHODS

Using data (2015-16) from the Centers for Disease Control and Prevention's (CDC) Colorectal Cancer Control Program, we linked clinic-level data with county-level contextual data from external sources. Analysis variables included clinic-level CRC screening rates, four different evidence-based interventions (EBIs) intended to increase screening, clinic characteristics, and clinic contexts. In the analysis (2018), we used weighted ordinary least square multiple regression analyses to associate EBIs and other covariates with clinic-level screening rates.

RESULTS

Clinics (N = 581) had an average screening rate of 36.3% (weighted. Client reminders had the highest association (5.6 percentage points) with screening rates followed by reducing structural barriers (4.9 percentage points), provider assessment and feedback (3.2 percentage points), and provider reminders (<1 percentage point). Increases in the number of EBIs was associated with steady increases in the screening rate (5.4 percentage points greater for one EBI). Screening rates were 16.4 percentage points higher in clinics with 4 EBIs vs. no EBI. Clinic characteristics, contexts (e.g. physician density), and context-EBI interactions were also associated with clinic screening rates.

CONCLUSIONS

These results may help clinics, especially those serving low income, medically underserved populations, select individual or combinations of EBIs suitable to their contexts while considering costs.

Understanding primary care nurses' contribution to cancer early diagnosis: A systematic review

PURPOSE

Primary care nurses can contribute to cancer early diagnosis. The objective of this systematic review was to identify, appraise and synthesise evidence on primary care nurses' contribution towards cancer early diagnosis in developed countries.

METHOD

The following databases were searched in September 2017: MEDLINE, PsychINFO, CINAHL, SCOPUS, and EMBASE. Data were extracted on nurses': knowledge of cancer; frequency of 'cancer early diagnosis-related discussions' with patients; and perceived factors influencing these discussions. Studies were appraised using the Mixed Methods Appraisal Tool.

RESULTS

Twenty-one studies were included from: United States, United Kingdom, Ireland, Spain, Turkey, Australia, Brazil and Middle East. Studies were mostly of low quality (one did not meet any appraisal criteria, 15 met one, four met two, and one met three). Nurses' knowledge of cancer, and their frequency of 'cancer early diagnosis-related discussions', varied across countries. This may be due to measurement bias or nurses' divergent roles across healthcare systems. Commonly perceived barriers to having screening discussions included: lack of time, insufficient knowledge and communication skills, and believing that patients react negatively to this topic being raised.

CONCLUSIONS

Findings suggest a need for nurses to be adequately informed about, and have the confidence and skills to discuss, the topic of cancer early diagnosis. Further high-quality research is required to understand international variation in primary care nurses' contribution to this field, and to develop and evaluate optimal methods for preparing them for, and supporting them in, this.

The impact of depression on adherence to organized and opportunistic breast cancer screening

One in five women will experience depression over her lifetime, and one out of eight will develop breast cancer. We evaluated the effect of depression on adherence to mammography in Switzerland, where opportunistic and organized screening programs coexist. We analyzed data from 3206 women aged 50-69 who participated in the Swiss Health Survey 2012. We compared mammographic rates among women with no to mild versus moderate to severe depressive symptoms. The effect of the type of screening on the odds of undertaking a mammography was calculated using multivariable logistic regression analysis. Women with moderate to severe major depressive symptoms were more likely to have had a mammography in the previous 2 years than their nondepressed or less-depressed counterparts (51 vs. 39.2%, respectively, P = 0.005). In the multivariable analysis, women with no to mild major depression living in cantons with an organized screening program had an adjusted odds ratio of 2.7 (95% confidence interval: 2.30-3.17, P < 0.001) of having had a mammography within the past 24 months compared with those living in the regions with an opportunistic screening. The adjusted odds ratio for women with moderate to severe major depression was 4.21 (95% confidence interval: 2.13-8.33, P < 0.001). In Switzerland. adherence to mammographic screening among women with moderate to severe major depression is higher than among women with no or minimal major depressive symptoms. This increased adherence is even more pronounced in regions with organized screening.

A blueprint for cancer screening and early detection: Advancing screening's contribution to cancer control

From the mid-20th century, accumulating evidence has supported the introduction of screening for cancers of the cervix, breast, colon and rectum, prostate (via shared decisions), and lung. The opportunity to detect and treat precursor lesions and invasive disease at a more favorable stage has contributed substantially to reduced incidence, morbidity, and mortality. However, as new discoveries portend advancements in technology and risk-based screening, we fail to fulfill the greatest potential of the existing technology, in terms of both full access among the target population and the delivery of state-of-the art care at each crucial step in the cascade of events that characterize successful cancer screening. There also is insufficient commitment to invest in the development of new technologies, incentivize the development of new ideas, and rapidly evaluate promising new technology. In this report, the authors summarize the status of cancer screening and propose a blueprint for the nation to further advance the contribution of screening to cancer control.

Differences in colorectal cancer surveillance epidemiology and screening in the WHO European Region

The aim of this study was to describe the Colorectal Cancer (CRC) burden and prevention actions in 53 countries of the World Health Organization (WHO) European Region (ER). Multiple correspondence analysis was applied to examine the association among the following variables: Measures of occurrence; type of screening programme; existence of cancer registries; data quality and; and gross national income (GNI) level. The study demonstrated clear differences according to GNI: low-middle income (LMI) countries show low mortality rates and unorganized screening programme; upper-middle income (UMI) countries show no test offered, incomplete or absent data mortality, and low quality of the method used to estimate incidence and mortality rates; high income (HI) countries show high mortality rates, test offered (FOBT and colonoscopy), the existence of a national registry, screening population-based, insurance of payment policy, and high quality of the method used to estimate incidence and mortality rates. HI countries reflect a strong interest in epidemiological monitoring and produce accurate indicators of disease occurrence. On the other hand, surveillance strategies need to be improved in UMI and LMI countries: As national vital statistics are unavailable, partial or inaccurate, the coverage and completeness of the mortality data are frequently poor, there is a less efficient general organization. In conclusion, it is important to underline that the resources available (as measured by GNI) appear to be major factors in the Colorectal Cancer Surveillance Epidemiology and Screening in the WHO European Region.

The impact of regional screening policies on the diffusion of cancer screening participation in Belgium: time trends in educational inequalities in Flanders and Wallonia

BACKGROUND

We investigate whether the extent of educational inequalities in the use of Pap smears (cervical cancer screening) and mammograms (breast cancer screening) in Belgium has changed over time in accordance with the pattern predicted by diffusion of innovation theory, as well as how the regional cancer screening policies of Flanders and Wallonia influence this pattern.

METHODS

Data were obtained from five successive cross-sectional waves (1997-2001-2004-2008-2013) of the Belgian Health Interview Survey. Final sample sizes consisted of 8988 women aged 25-64 years for cervical cancer screening and 4194 women aged 50-69 years for breast cancer screening. We calculated absolute and relative measures of inequality, more specifically, the slope index of inequality (SII) and the relative index of inequality (RII), and their development over time.

RESULTS

In both Flanders and Wallonia, mammogram use increased greatly between 1997 and 2013, while Pap smear use has remained quite stable over time. Educational inequalities in cervical-cancer screening have been largely persistent over time in both regions. In contrast, educational inequalities in breast cancer screening fluctuated more between 1997 and 2013. Between 1997 and 2001, when the breast cancer screening programme was implemented in Flanders, RII reduced significantly by 45%. Inequality measures did not change significantly in Wallonia, where it is known that most women are screened opportunistically outside the programme.

CONCLUSIONS

By focussing on Belgium, this study demonstrates that regional variations in the support of a national screening programme can result in regional variations in the pattern of diffusion for cancer screening, as well as to the development of inequalities in cancer screening participation. Moreover, the findings demonstrate that high visibility and awareness of the screening programme, as was more the case in Flanders than it was in Wallonia, are required in order to reduce or eliminate educational inequalities in cancer screening participation over time. General practitioners and gynaecologists can play a decisive role in this regard.

Organized screening programmes for breast and cervical cancer in 17 EU countries: trajectories of attendance rates

BACKGROUND

The aim was to analyse participation trajectories in organised breast and cervical cancer screening programmes and the association between socioeconomic variables and participation.

METHODS

A pooled, cross-sectional, time series analysis was used to evaluate secondary data from 17 European countries in 2004-2014.

RESULTS

The results show that the mammographic screening trend decreases after an initial increase (coefficient for the linear term = 0.40; p = 0.210; 95% CI = - 0.25, 1.06; coefficient for the quadratic term = - 0.07; p = 0.027; 95% CI = - 0.14, - 0.01), while the cervical screening trend is essentially stable (coefficient for the linear term = 0.39, p = 0.312, 95% CI = - 0.42, 1.20; coefficient for the quadratic term = 0.02, p = 0.689, 95% CI = - 0.07, 0.10). There is a significant difference among the country-specific slopes for breast and cervical cancer screening (SD = 16.7, p < 0.001; SD = 14.4, p < 0.001, respectively). No association is found between participation rate and educational level, income, type of employment, unemployment and preventive expenditure. However, participation in cervical cancer screening is significantly associated with a higher proportion of younger women (≤ 49 years) and a higher Gini index (that is, higher income inequality).

CONCLUSIONS

In conclusion three messages: organized cancer screening programmes may reduce the socioeconomic inequalities in younger people's use of preventive services over time; socioeconomic variables are not related to participation rates; these rates do not reach a level of stability in several countries. Therefore, without effective recruitment strategies and tailored organizations, screening participation may not achieve additional gains.

Insufficient evidence on health literacy amongst Indigenous people with cancer: a systematic literature review

Background

Indigenous people experience poorer cancer survival outcomes compared with non-Indigenous people. Currently, there is growing awareness of poor health literacy as a determinant of cancer outcomes. However, little attention has been given to researching cancer-related health literacy amongst Indigenous people.

Objectives

To systematically review empirical studies of cancer health literacy amongst Indigenous people worldwide.

Methods

Articles were identified in Medline (1946-2013); Pre-Medline; CINAHL; PsycINFO (1967-2013); PubMed; Current Contents/All Editions (1993-2013); Allied Health and Complimentary Medicine (1985-2013), and in the reference lists of retrieved articles and by expert consultation. 64 abstracts were screened for inclusion and 16 articles were retained.

Results

There is a paucity of high-quality research concerning of health literacy amongst Indigenous cancer patients. No articles used formal measures of health literacy and data on the prevalence of health literacy was not reported. Of the 7 articles describing interventions only one included a control group and the remainder employed quasi-experimental methods.

Conclusions

Research is needed to explore the cultural relevance of existing measures of health literacy and to document the prevalence of health literacy amongst Indigenous people with cancer. A better understanding of Indigenous cancer patients' health literacy is required before health literacy interventions can be designed to improve Indigenous cancer outcomes.

Cervical Cancer Burden and Opportunities for Prevention in a Safety-Net Healthcare System

BACKGROUND

The high prevalence of cervical cancer at safety-net health systems requires careful analysis to best inform prevention and quality improvement efforts. We characterized cervical cancer burden and identified opportunities for prevention in a U.S. safety-net system.

METHODS

We reviewed tumor registry and electronic health record (EHR) data of women with invasive cervical cancer with ages 18+, diagnosed between 2010 and 2015, in a large, integrated urban safety-net. We developed an algorithm to: (i) classify whether women had been engaged in care (≥1 clinical encounter between 6 months and 5 years before cancer diagnosis); and (ii) identify missed opportunities (no screening, no follow-up, failure of a test to detect cancer, and treatment failure) and associated factors among engaged patients.

RESULTS

Of 419 women with cervical cancer, more than half (58%) were stage 2B or higher at diagnosis and 40% were uninsured. Most (69%) had no prior healthcare system contact; 47% were diagnosed elsewhere. Among 122 engaged in care prior to diagnosis, failure to screen was most common (63%), followed by lack of follow-up (21%), and failure of test to detect cancer (16%). Tumor stage, patient characteristics, and healthcare utilization differed across groups.

CONCLUSIONS

Safety-net healthcare systems face a high cervical cancer burden, mainly from women with no prior contact with the system. To prevent or detect cancer early, community-based efforts should encourage uninsured women to use safety-nets for primary care and preventive services.

IMPACT

Among engaged patients, strategies to increase screening and follow-up of abnormal screening tests could prevent over 80% of cervical cancer cases.

Cervical cancer screening in Montreal: Building evidence to support primary care and policy interventions

In Canada, over 40% of invasive cervical cancers occur among women who have never been screened. Although 12% of Canadian women have never been screened, this number can be as high as 43% among certain social groups. Little is published on factors associated with screening uptake and inequalities among women residing in Quebec. Four waves of the Canadian Community Health Survey (2003, 2005, 2008, 2012, N = 6393) were utilized to assess lifetime screening and screening in the previous 3 years among women residing in Montreal. Chi-squared statistics were calculated, Poisson regression was utilized to model prevalence ratios, and prevalence differences were calculated. In total, 13.6% of women had never been screened and 12.1% had not been screened in the previous 3 years. Immigrant status was the strongest predictor of never being screened [recent vs non-immigrant: Prevalence Ratio (PR), 3.9 (95% Confidence Interval (CI): 2.9-5.4)] and not having a primary care physician (PCP) was the strongest predictors of not being screened recently [PR = 3.0 (95% CI: 2.3-3.9)]. The two most common reasons for not being screened were not "know[ing] it was necessary" and not "get[ting] around to it." These results provide a description of sub-populations which might benefit from cervical screening interventions: immigrants and women without a PCP. Interventions targeting access to PCPs, expanding training of non-physicians to conduct screening, organized screening, or autoadministered screening test may mitigate inequalities. Future work should assess their acceptability and feasibility, and evaluate the impact of these types of primary care and policy interventions.

Participants, Physicians or Programmes: Participants' educational level and initiative in cancer screening

This study is an in-depth examination of at whose initiative (participant, physician or screening programme) individuals participate in cervical, breast and colorectal cancer screening across the EU-28. Special attention is paid to (1) the association with educational attainment and (2) the country's cancer screening strategy (organised, pilot/regional or opportunistic) for each type of cancer screened. Data were obtained from Eurobarometer 66.2 'Health in the European Union' (2006). Final samples consisted of 10,186; 5443 and 9851 individuals for cervical, breast, and colorectal cancer, respectively. Multinomial logistic regressions were performed. Surprisingly, even in countries with organised screening programmes, participation in screenings for cervical, breast and colorectal cancer was most likely to be initiated by the general practitioner (GP) or the participant. In general, GPs were found to play a crucial role in making referrals to screenings, regardless of the country's screening strategy. The results also revealed differences between educational groups with regard to their incentive to participate in cervical and breast cancer screening and, to a lesser extent, in colorectal cancer screening. People with high education are more likely to participate in cancer screening at their own initiative, while people with less education are more likely to participate at the initiative of a physician or a screening programme. Albeit, the results varied according to type of cancer screening and national screening strategy.

Screening for prostate cancer: are organized screening programs necessary?

Already in 1991 when the prostate-specific antigen (PSA) test was proposed as a diagnostic test, screening for prostate cancer (PCa) was considered controversial due to the considerable risk of detecting latent PCa. Randomised controlled trials were initiated to assess the potential of PSA-based screening in reducing disease-specific mortality. Harms and benefit were closely monitored and both were confirmed. A reduction in mortality was seen and at the same time the initial fear of unnecessary testing and over diagnosis became reality. This triggered professional organizations to adapt their guidelines and to focus on shared decision making (SDM) and selective screening for those men considered at high risk. Unfortunately implementation of guidelines into daily clinical practice is bothersome. As a result many men are being (re)tested while not being at risk and the potential benefit being unclear. This raises the question on whether PSA screening should be organized in controlled programs. While the PSA test will remain the mainstay of PCa early detection many other additional tests (biomarkers/imaging) are currently being tested in large population-based initiatives as a first step to organized programs in selective groups of men.

Population-based cancer screening programmes in low-income and middle-income countries: regional consultation of the International Cancer Screening Network in India

The reductions in cancer morbidity and mortality afforded by population-based cancer screening programmes have led many low-income and middle-income countries to consider the implementation of national screening programmes in the public sector. Screening at the population level, when planned and organised, can greatly benefit the population, whilst disorganised screening can increase costs and reduce benefits. The International Cancer Screening Network (ICSN) was created to share lessons, experience, and evidence regarding cancer screening in countries with organised screening programmes. Organised screening programmes provide screening to an identifiable target population and use multidisciplinary delivery teams, coordinated clinical oversight committees, and regular review by a multidisciplinary evaluation board to maximise benefit to the target population. In this Series paper, we report outcomes of the first regional consultation of the ICSN held in Agartala, India (Sept 5-7, 2016), which included discussions from cancer screening programmes from Denmark, the Netherlands, USA, and Bangladesh. We outline six essential elements of population-based cancer screening programmes, and share recommendations from the meeting that policy makers might want to consider before implementation.