Matters of fact and politics: Generating expectations of cancer screening

Attitudes to reducing cervical screening frequency among UK women: A qualitative analysis

OBJECTIVE

Cervical cancer remains a significant health threat amongst women globally despite most cervical cancers being preventable through screening and Human Papilloma Virus (HPV) vaccination. With the introduction of HPV testing and vaccination, evidence suggests that the frequency of cervical screening for women can be reduced. However, there is limited evidence on women's attitudes to possible changes to the cervical screening programme. This study explored attitudes, perceptions and beliefs of women in the United Kingdom (UK) regarding potential changes to the National Cervical Screening Programme.

METHOD

Forty-four women were interviewed between November 2018 and March 2019. Reflexive thematic analysis was used to identify key themes.

RESULTS

Most participants were opposed to any reduction in cervical screening frequency. Reasons included perceptions that disease would develop undetected, disempowerment, increased anxiety, reduced motivation to attend, and inefficient use of health care resources. Women perceived that they were ill-informed about the reasons for the proposed change, and that access to evidence for the basis of proposed changes may persuade them to accept reduced screening frequency. Women believed that cervical screening is a test for cancer and that HPV vaccination does not provide reliable protection against cervical cancer. These beliefs suggest that women's perception that they require more information about the basis for reduced screening frequency is correct.

CONCLUSION

Any changes to cervical screening frequency need to ensure public support and trust through a robust public health initiative clearly identifying the rationale for any changes.

Implementing organized colorectal cancer screening programs in Europe-protocol for a systematic review of determinants and strategies

BACKGROUND

With a high mortality of 12.6% of all cancer cases, colorectal cancer (CRC) accounts for substantial burden of disease in Europe. In the past decade, more and more countries have introduced organized colorectal cancer screening programs, making systematic screening available to entire segments of a population, typically based on routine stool tests and/or colonoscopy. While the effectiveness of organized screening in reducing CRC incidence and mortality has been confirmed, studies continuously report persistent program implementation challenges. This systematic review will synthesize the literature on organized CRC screening programs. Its aim is to understand what is currently known about the barriers and facilitators that influence the implementation of these programs and about the implementation strategies used to navigate these determinants.

METHODS

A systematic review of primary studies of any research design will be conducted. CENTRAL, CINAHL, EMBASE, International Clinical Trials Registry Platform, MEDLINE, PsycINFO, and Scopus will be searched. Websites of (non-)government health care organizations and websites of organizations affiliated with authors of included studies will be screened for unpublished evaluation reports. Existing organized CRC screening programs will be contacted with a request to share program-specific grey literature. Two researchers will independently screen each publication in two rounds for eligibility. Included studies will focus on adult populations involved in the implementation of organized CRC screening programs and contain information about implementation determinants/ strategies. Publications will be assessed for their risk of bias. Data extraction will include study aim, design, location, setting, sample, methods, and measures; program characteristics; implementation stage, framework, determinants, strategies, and outcomes; and service and other outcome information. Findings will be synthesized narratively using the three stages of thematic synthesis.

DISCUSSION

With its sole focus on the implementation of organized CRC screening programs, this review will help to fill a central knowledge gap in the literature on colorectal cancer screening. Its findings can inform the decision-making in policy and practice needed to prioritize resources for establishing new and maintaining existing programs in the future.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO (CRD42022306580).

The ubiquity of uncertainty in low back pain care

Despite clinicians being important actors in the context of uncertainty, their experiences navigating uncertainty remain largely unexplored. Drawing on a theory-driven post-qualitative approach, we used Mol's logic of choice/care as a lens through which we made sense of interviews with 22 clinicians who work with patients who experience low back pain (LBP). Our analysis suggests that uncertainty is ubiquitous in LBP care and not limited to particular domains. Clinicians navigated uncertainty when considering patients' personal and social contexts; making therapeutic decisions; navigating emotions and mental health; communicating with, and educating, patients, among others. These uncertainties are intertwined with clinical aspects such as treatment choices and evidence-based education about LBP. At times, clinicians resolved these uncertainties by producing certainty at the cost of attending to human aspects of care. We argue that epistemic shifts, theorisation and practical engagement with theory in training, research and clinical practice may prompt clinicians to embrace uncertainty and enact the logic of care.

"A lot can happen in five years": Women's attitudes to extending cervical screening intervals

OBJECTIVE

Evidence suggests that cervical screening intervals can be extended and lifetime cervical screening for human papillomavirus (HPV)-vaccinated women could be reduced. This study examines UK women's attitudes to extending screening intervals and assesses associations between knowledge, risk perception and HPV vaccination status, and acceptability of changes.

METHODS

Using a convenience sampling strategy, an anonymous mixed-methods online survey was used and data recorded from 647 women (mean age = 28.63, SD = 8.69).

RESULTS

Across the full sample, 46.1% of women indicated they would wait 5 years for their next cervical screening, while 60.2% of HPV-vaccinated women would be unwilling to have as few as three cervical screens in a lifetime. Multivariate analysis revealed those who are regular screened, those who intend to attend when invited, and those who perceive greater personal risk of cervical cancer are less likely to accept a 5-year screening interval. Qualitative findings relating to benefits of extending intervals included convenience of less tests, less physical discomfort, and psychological distress. Concerns identified included the likelihood of developing illness, increased psychological distress relating to what may be happening in the body, and worries about increased risk of cervical cancer.

CONCLUSION

Women need clear and specific information about HPV timelines, their relationship with cancer risk, and the rationale for extending screening intervals.

Searching for diagnostic certainty, governing risk: Patients' ambivalent experiences of medical testing

Diagnosis is pivotal to medicine's epistemic system: it serves to explain individual symptoms, classify them into recognizable conditions and determine their prognosis and treatment. Medical tests, or investigative procedures for detecting and monitoring disease, play a central role in diagnosis. While testing promises diagnostic certainty or a definitive risk assessment, it often produces uncertainties and new questions which call for yet further tests. In short, testing, regardless of its specific application, is imbued with meaning and emotionally fraught. In this article, we explore individuals' ambivalent experiences of testing as they search for diagnostic certainty, and the anxieties and frustrations of those for whom it remains elusive. Combining insights from sociological work on ambivalence and the biopolitics of health, and drawing on qualitative interviews with Australian healthcare recipients who have undergone testing in the context of clinical practice, we argue that these experiences are explicable in light of the contradictory impulses and tensions associated with what we term 'bio-subjectification'. We consider the implications of our analysis in light of the development of new tests that produce ever finer delineations between healthy and diseased populations, concluding that their use will likely multiply uncertainties and heighten rather than lessen anxieties.

Diagnosing uncertainty: The challenges of implementing medical screening programs for minority sub-populations in Canada

The social science literature on medical screening has documented a notable disjuncture between the promises of population-based screening programs and the complex realities of their rollout in everyday practice. We contribute to this scholarship by examining how healthcare providers confront numerous uncertainties associated with the implementation of anal cancer screening programs in Canada given the absence of standardized national evidence-based guidelines. The data was derived from in-depth interviews conducted with 13 physicians and 2 clinical researchers about anal cancer screening for gay, bisexual and other men who have sex with men living with HIV, the minority sub-population at the highest risk for HPV-associated anal cancer. Despite having unknown utility and low specificity, an initial anal Pap test was used to triage patients into anal dysplasia clinics for high-resolution anoscopy. This process led to technological scepticism toward the Pap's accuracy, diagnostic ambiguity related to the interpretation of the cytology results and increased patient anxiety regarding abnormal results. Physicians navigated a tension between wanting to avoid exposing their patients to additional uncertainties caused by screening and pre-cancer treatment and wanting to ensure that their patients did not develop anal cancer under their care. A high number of abnormal anal Pap results paradoxically reintroduced some of the capacity issues that the Pap was meant to resolve, as the existing dysplasia clinics were incapable of seeing all patients with abnormal results. We define this sequence as the epistemic-capacity paradox, a dynamic whereby seeking evidence to improve healthcare capacity simultaneously produces evidence that introduces capacity challenges and generates additional uncertainty. The epistemic-capacity paradox demonstrates the limitations of evidence-based medicine frameworks at determining best practices in the context of rarer health conditions affecting minority sub-populations, where smaller population numbers and limited institutional support pose systemic challenges to the acquisition of sufficient evidence.