GP participation in increasing uptake in a national bowel cancer screening programme: the PEARL project

Perceptions and beliefs of general practitioners on their role in the cancer screening programmes in the Netherlands: a mixed-methods study

BACKGROUND

In the Netherlands, population-based cancer screening programmes (CSPs) are organized aiming at cervical, breast and colorectal cancer. For a CSP to be effective, high participation rates are essential; however, there is an alarming downward trend, including wide regional variation in screening uptake. General practitioner (GP) involvement can have a stimulating effect on screening participation. Current GP involvement is however, limited, varies between the programmes and has changed over time. Unexplored is what GPs think of their role(s) in the CSPs. The aim of this study was therefore to map the perceptions and beliefs of GPs regarding their current and future role in the Dutch CSPs.

METHODS

A mixed-methods sequential explanatory study was conducted in the Leiden/The Hague area of the Netherlands, between the end of 2021 and 2022. A questionnaire was developed and distributed among 110 GPs. The aggregated results obtained from the questionnaires served as starting points for conducting semi-structured interviews, with purposefully selected GPs. With this sequential approach we aimed to further enhance the understanding of the questionnaire data, and delved into the topics that emerged from the questionnaire responses.

RESULTS

In total, 46 GPs completed the online questionnaire (response rate 42%). Subsequent five semi-structured comprehensive interviews were conducted. GPs indicated that they frequently encounter the CSP in their daily practice and consider it important. They also emphasised it is important that GPs remain closely involved with the CSPs in the future. Nevertheless, GPs also repeatedly mentioned that they are not eager to take on more logistical/organizational tasks. They are however willing to empower CSPs in a positive manner.

CONCLUSION

GPs were generally positive about the CSPs and their current role within these programmes. Nevertheless, several options have been proposed to improve the CSPs, especially to increase screening uptake for populations in a socioeconomically disadvantaged position. Since it is of utmost importance to screen those who are most at risk of developing the screening-specific tumours, efforts should be made to achieve this goal.

Managing Colorectal Cancer from Ethology to Interdisciplinary Treatment: The Gains and Challenges of Modern Medicine

Colorectal cancer (CRC) is a common malignant tumor of the gastrointestinal tract, which has become a serious threat to human health worldwide. This article exhaustively reviews colorectal cancer's incidence and relevance, carcinogenesis molecular pathways, up-to-date treatment opportunities, prophylaxis, and screening program achievements, with attention paid to its regional variations and changes over time. This paper provides a concise overview of known CRC risk factors, including familial, hereditary, and environmental lifestyle-related risk factors. The authors take a closer look into CRC's molecular genetic pathways and the role of specific enzymes involved in carcinogenesis. Moreover, the role of the general practitioner and multidisciplinary approach in CRC treatment is summarized and highlighted based on recent recommendations and experience. This article gives a clear understanding and review of the gains and challenges of modern medicine towards CRC. The authors believe that understanding the current patterns of CRC and its revolution is imperative to the prospects of reducing its burden through cancer prevention and cancer-adjusted treatment.

Application of the 'online assessment + FOBT at home' to improve participation and the efficacy of opportunistic screening for colorectal cancer: a retrospective cohort study

BACKGROUND

Colorectal cancer (CRC) screening faces two major challenges: insufficient screening coverage and poor adherence. A smartphone applet named "Early Screening Assistant (ESA)" was developed to create an online risk-assessment and fecal occult blood test (FOBT) at home. This retrospective study was designed to evaluate whether the new CRC screening strategy can improve the colonoscopy participation rate (PR) and lesion detection rate (DR).

METHODS

In total, 6194 individuals who accepted normal health examinations and CRC screening based on the ESA from June 2020 to May 2022 were assigned to the ESA group. Accordingly, 7923 inhabitants who only accepted normal health examinations were assigned to the control group. The colonoscopy PR and neoplastic lesion DR were then compared between the two groups.

RESULTS

Overall, a higher proportion of subjects in the ESA group (285 of 6194 [4.6%]) completed colonoscopy than in the control group (126 of 7923, [1.6%]), p < 0.01). The neoplastic lesion DR also significantly increased in the ESA group (76 of 6194 [1.22%]) compared with the control group (15 of 7923 [0.19%]) (p < 0.01). The adjusted diagnostic sensitivity and specificity of the "Online assessment + FOBT at home" were 41.5% and 62.6% for neoplastic lesions, respectively.

CONCLUSIONS

This retrospective cohort study confirmed that the new CRC screening strategy based on the "Online assessment + FOBT at home" can improve colonoscopy participation and the neoplastic lesion detection rate and may represent a promising screening strategy for CRC.

TRIAL REGISTRATION

This study was registered in China Clinical Trial Registry ( https://www.chictr.org.cn ) on 29/09/2022.

REGISTRATION NUMBER

ChiCTR2200064186.

Uptake of invitations to a lung health check offering low-dose CT lung cancer screening among an ethnically and socioeconomically diverse population at risk of lung cancer in the UK (SUMMIT): a prospective, longitudinal cohort study

BACKGROUND

Lung cancer screening with low-dose CT reduces lung cancer mortality, but screening requires equitable uptake from candidates at high risk of lung cancer across ethnic and socioeconomic groups that are under-represented in clinical studies. We aimed to assess the uptake of invitations to a lung health check offering low-dose CT lung cancer screening in an ethnically and socioeconomically diverse cohort at high risk of lung cancer.

METHODS

In this multicentre, prospective, longitudinal cohort study (SUMMIT), individuals aged 55-77 years with a history of smoking in the past 20 years were identified via National Health Service England primary care records at practices in northeast and north-central London, UK, using electronic searches. Eligible individuals were invited by letter to a lung health check offering lung cancer screening at one of four hospital sites, with non-responders re-invited after 4 months. Individuals were excluded if they had dementia or metastatic cancer, were receiving palliative care or were housebound, or declined research participation. The proportion of individuals invited who responded to the lung health check invitation by telephone was used to measure uptake. We used univariable and multivariable logistic regression analyses to estimate associations between uptake of a lung health check invitation and re-invitation of non-responders, adjusted for sex, age, ethnicity, smoking, and deprivation score. This study was registered prospectively with ClinicalTrials.gov, NCT03934866.

FINDINGS

Between March 20 and Dec 12, 2019, the records of 2 333 488 individuals from 251 primary care practices across northeast and north-central London were screened for eligibility; 1 974 919 (84·6%) individuals were outside the eligible age range, 7578 (2·1%) had pre-existing medical conditions, and 11 962 (3·3%) had opted out of particpation in research and thus were not invited. 95 297 individuals were eligible for invitation, of whom 29 545 (31·0%) responded. Due to the COVID-19 pandemic, re-invitation letters were sent to only a subsample of 4594 non-responders, of whom 642 (14·0%) responded. Overall, uptake was lower among men than among women (odds ratio [OR] 0·91 [95% CI 0·88-0·94]; p<0·0001), and higher among older age groups (1·48 [1·42-1·54] among those aged 65-69 years vs those aged 55-59 years; p<0·0001), groups with less deprivation (1·89 [1·76-2·04] for the most vs the least deprived areas; p<0·0001), individuals of Asian ethnicity (1·14 [1·09-1·20] vs White ethnicity; p<0·0001), and individuals who were former smokers (1·89 [1·83-1·95] vs current smokers; p<0·0001). When ethnicity was subdivided into 16 groups, uptake was lower among individuals of other White ethnicity than among those with White British ethnicity (0·86 [0·83-0·90]), whereas uptake was higher among Chinese, Indian, and other Asian ethnicities than among those with White British ethnicity (1·33 [1·13-1·56] for Chinese ethnicity; 1·29 [1·19-1·40] for Indian ethnicity; and 1·19 [1·08-1·31] for other Asian ethnicity).

INTERPRETATION

Inviting eligible adults for lung health checks in areas of socioeconomic and ethnic diversity should achieve favourable participation in lung cancer screening overall, but inequalities by smoking, deprivation, and ethnicity persist. Reminder and re-invitation strategies should be used to increase uptake and the equity of response.

FUNDING

GRAIL.

Improving colorectal cancer screening - consumer-centred technological interventions to enhance engagement and participation amongst diverse cohorts

The current "Gold Standard" colorectal cancer (CRC) screening approach of faecal occult blood test (FOBT) with follow-up colonoscopy has been shown to significantly improve morbidity and mortality, by enabling the early detection of disease. However, its efficacy is predicated on high levels of population participation in screening. Several international studies have shown continued low rates of screening participation, especially amongst highly vulnerable lower socio-economic cohorts, with minimal improvement using current recruitment strategies. Research suggests that a complex of dynamic factors (patient, clinician, and the broader health system) contribute to low citizen engagement. This paper argues that the challenges of screening participation can be better addressed by (1) developing dynamic multifaceted technological interventions collaboratively across stakeholders using human-centered design; (2) integrating consumer-centred artificial intelligence (AI) technologies to maximise ease of use for CRC screening; and (3) tailored strategies that maximise population screening engagement, especially amongst the most vulnerable.

A health action process approach for developing invitee endorsed interventions to increase mail-out bowel cancer screening

Theory‐based, user‐informed interventions are needed to increase the low participation rates of population‐based faecal occult blood test (FOBT) bowel cancer screening. This study investigated the theoretical fit of the health action process approach (HAPA) for home FOBT screening and measured screening invitees' attitudes towards different intervention strategies. A cross‐sectional sample (n = 377), aged 50–74 years, participated in this study. Two scales were created for this study. The process approach to mail‐out screening (PAMS) scale measured HAPA constructs, and the user ratings of mail‐out screening interventions (UR‐MSI) scale measured attitudes towards different intervention strategies. Structural equation modelling was used to assess the fit of PAMS scale responses to the HAPA model, and descriptive statistics were calculated for UR‐MSI responses. PAMS results showed acceptable model fit, CFI = .968, RMSEA = .050 and explained 49.9% of the variation in FOBT screening participation. Positive ratings of interventions ranged from 20.47%, an intervention prompting planning to complete the FOBT kit, to 72.25%, an intervention promoting the positive health outcome associated with FOBT screening. Intervention strategies should be combined such that they target all factors specified within the HAPA model. User‐informed intervention design should be used to effectively facilitate FOBT uptake in the community.

Including a general practice endorsement letter with the testing kit in the Bowel Cancer Screening Programme: Results of a cluster randomised trial

OBJECTIVES

To evaluate the effect of general practitioner endorsement accompanying the screening kit rather than with the invitation letter on participation in the NHS Bowel Cancer Screening Programme and on the socioeconomic gradient in participation in the Programme.

METHODS

The NHS Bowel Cancer Screening Programme in England is delivered via five regional hubs. In early 2016, we carried out a cluster-randomised trial, with hub-day of invitation as the randomisation unit. We randomised 150 hub-days of invitation to the intervention group, GP endorsement on the letter accompanying the guaiac faecal occult blood testing kit (75 hub-days, 197,366 individuals) or control, usual letter (75 hub-days, 197,476 individuals). The endpoint was participation, defined as return of a valid kit within 18 weeks of initial invitation. Because of the cluster randomisation, data were analysed by a hierarchical logistic regression, allowing a random effect for date of invitation. Socioeconomic status was represented by the index of multiple deprivation.

RESULTS

Participation was 59.4% in the intervention group and 58.7% in the control group, a significant difference (p = 0.04). There was no heterogeneity of the effect of intervention by index of multiple deprivation. We found that there was some confounding between date and screening episode order (first or subsequent screen). This in turn may have induced confounding with age and slightly diluted the result.

CONCLUSIONS

General practitioner endorsement induces a modest increase in participation in bowel cancer screening, but does not affect the socioeconomic gradient. When considering cluster randomisation as a research method, careful scrutiny of potential confounding is indicated in advance if possible and in analysis otherwise.

Ethnic disparities in the uptake of colorectal cancer screening: An analysis of the West London population

AIM

Colorectal cancer (CRC) screening reduces mortality but variation exists in uptake, with poorer uptake in ethnic minority groups. The aim of this work was to evaluate the relationship between ethnicity and uptake of CRC screening in West London.

METHOD

Results of CRC screening from the Central London, West London, Hammersmith and Fulham, Hounslow and Ealing Clinical commissioning group collaborative between 2012 and 2017 were retrospectively analysed. These five clinical commissioning groups (CCGs) are located in West London. Compliance with screening according to ethnic group was evaluated compared with White British as the control.

RESULTS

A total of 155 038 individuals were screened. White British individuals had the highest compliance (52.6%). A maximum difference in compliance of 8.2% was seen between CCGs. The odds of being less likely to participate were significant (p < 0.05) in all ethnic minorities except for Asian Chinese on univariate and multivariate analysis (adjusted OR 1.091, p = 0.88).

CONCLUSION

This is the largest retrospective study focusing on the role of ethnicity in the uptake of CRC screening in England. Poor uptake of screening in all ethnic minorities in West London, with the exception of Asian Chinese individuals in particular, is a novel finding. A mandate to routinely collect ethnicity data, the use of a single more diverse census and further intervention are needed to understand this disparity and reduce health inequity.

From participation to diagnostic assessment: a systematic scoping review of the role of the primary healthcare sector in the National Bowel Cancer Screening Program

Primary health care (PHC) plays a vital support role in organised colorectal cancer (CRC) screening programs by encouraging patient participation and ensuring timely referral for diagnostic assessment follow up. A systematic scoping review of the current evidence was conducted to inform strategies that better engage the PHC sector in organised CRC screening programs. Articles published from 2005 to November 2019 were searched across five databases. Evidence was synthesised and interventions that specifically require PHC involvement were mapped to stages of the CRC screening pathway. Fifty-seven unique studies were identified in which patient, provider and system-level interventions align with defined stages of the CRC screening pathway: namely, identifying/reminding patients who have not responded to CRC screening (non-adherence) (n=46) and follow up of a positive screen referral (n=11). Self-management support initiatives (patient level) and improvement initiatives (system level) demonstrate consistent benefits along the CRC screening pathway. Interventions evaluated as part of a quality-improvement process tended to report effectiveness; however, the variation in reporting makes it difficult to determine which elements contributed to the overall study outcomes. To maximise the benefits of population-based screening programs, better integration into existing primary care services can be achieved through targeting preventive and quality care interventions along the entire screening pathway.

Use of a GP-endorsed non-participant reminder letter to promote uptake of bowel scope screening: A randomised controlled trial in a hard-to-reach population

Previous research suggests that sending non-participants a reminder letter, 1 year after their initial invitation, can improve coverage for bowel scope screening (BSS), also known as flexible sigmoidoscopy screening. We hypothesised that adding a general practitioner's (GPs) endorsement to the reminder letter could improve coverage even further. We conducted a randomised controlled trial in North West London, UK. Participants were screening-eligible men and women who had not responded to their initial BSS invitation at least 12 months prior to the trial period. Eligible adults were randomised in a 1:1 ratio to receive either a GP-endorsed reminder letter, or a standard reminder letter from June to August 2019. Logistic regression models were used to test the effect of the GP endorsement on attendance at BSS, adjusting for sex, clinical commissioning group, and local area socioeconomic deprivation. In total, 1200 participants were enrolled into the study and randomised to either the control (n = 600) or the intervention (n = 600) group. Those who received the GP-endorsed reminder letter were only slightly more likely to attend BSS than those who received the standard reminder letter (4% vs. 3%); this difference was not statistically significant (Adjusted OR = 1.30; 95% CI: 0.69, 2.43). Adding a GP-endorsement to the annual reminder letter did not have an effect on attendance at BSS. One possible explanation for this is that the endorsement used was not personalised enough. Future research should examine stronger GP-endorsements or other methods to promote uptake.

The Impact of a Comprehensive Risk Prediction Model for Colorectal Cancer on a Population Screening Program

BACKGROUND

In many countries, population colorectal cancer (CRC) screening is based on age and family history, though more precise risk prediction could better target screening. We examined the impact of a CRC risk prediction model (incorporating age, sex, lifestyle, genomic, and family history factors) to target screening under several feasible screening scenarios.

METHODS

We estimated the model's predicted CRC risk distribution in the Australian population. Predicted CRC risks were categorized into screening recommendations under 3 proposed scenarios to compare with current recommendations: 1) highly tailored, 2) 3 risk categories, and 3) 4 sex-specific risk categories. Under each scenario, for 35- to 74-year-olds, we calculated the number of CRC screens by immunochemical fecal occult blood testing (iFOBT) and colonoscopy and the proportion of predicted CRCs over 10 years in each screening group.

RESULTS

Currently, 1.1% of 35- to 74-year-olds are recommended screening colonoscopy and 56.2% iFOBT, and 5.7% and 83.2% of CRCs over 10 years were predicted to occur in these groups, respectively. For the scenarios, 1) colonoscopy was recommended to 8.1% and iFOBT to 37.5%, with 36.1% and 50.1% of CRCs in each group; 2) colonoscopy was recommended to 2.4% and iFOBT to 56.0%, with 13.2% and 76.9% of cancers in each group; and 3) colonoscopy was recommended to 5.0% and iFOBT to 54.2%, with 24.5% and 66.5% of cancers in each group.

CONCLUSIONS

A highly tailored CRC screening scenario results in many fewer screens but more cancers in those unscreened. Category-based scenarios may provide a good balance between number of screens and cancers detected and are simpler to implement.

Implementation Strategies for Interventions Aiming to Increase Participation in Mail-Out Bowel Cancer Screening Programs: A Realist Review

Background: Bowel cancer is the third most commonly diagnosed cancer and the third most common cause of cancer-related death, with 1,849,518 new cases of bowel diagnosed and 880,792 deaths reported globally in 2018 alone. Survival can be improved through early detection via national mail-out bowel cancer screening programs; however, participation remains low in many countries. Behavior change is therefore required to increase participation. This realist review aims to (a) identify the behavior change techniques (BCTs) used in each intervention, (b) understand the mechanisms of action (MoAs) responsible for the BCT effectiveness, and (c) apply a behavior change model to inform how MoAs can be combined to increase screening participation.

Methods: We systematically reviewed the literature for interventions aiming to increase participation in mail-out bowel cancer screening. We used a four-stage realist synthesis approach whereby (1) interventions were extracted from each study; (2) BCTs applied in each intervention were identified and coded using the BCT Taxonomy-v1; (3) the Theory and Techniques Tool was used to link BCTs to their MoA; and (4) BCTs and MoAs were categorized according to their effectiveness and what Health Action Process Approach (HAPA) stage of change they would affect.

Results: We identified 68 intervention trials using 26 unique BCTs and 13 MoAs to increase participation. Sixteen BCTs and 10 MoAs were identified within the interventions that successfully increased participation rates. Interventions targeting both stages of the HAPA model had a higher success rate (80%) than those targeting one stage of change (51%). When targeting only one stage, interventions targeting the volitional stage had a higher success rate (71%) than interventions targeting only the motivational stage of change (26%).

Conclusion: Importantly, this review identified a suite of BCTs and MoAs effective for increasing participation in mail-out bowel cancer screening programs. With increased participation in bowel cancer screening leading to improved survival, our findings are key to informing the improvement of policy and interventions that aim to increase screening using specific strategies at key stages of health decision-making.

Non-maleficence and the ethics of consent to cancer screening

Cancer screening programmes cause harm to individuals via overdiagnosis and overtreatment, even where they confer population-level benefit. Screening thus appears to violate the principle of non-maleficence, since it entails medically unnecessary harm to individuals. Can consent to screening programmes negate the moral significance of this harm? In therapeutic medical contexts, consent is used as a means of rendering medical harm morally permissible. However, in this paper, I argue that it is unclear that the model of consent used within therapeutic medicine can be applied unproblematically to preventive medicine. Invitation to screening changes the pragmatic norms and expectations of the patient-doctor encounter such that two key principles of consent may be violated. First, the pragmatics of a medical invitation are such that patients may fail to be adequately informed, since patients appear to assume medical invitations are made with their best interests in mind, even where information to the contrary is outlined. Second, screening invitations may place pressure on patients; in the context of a medical encounter, to make an invitation to screening may constitute an inducement to accept. In order to be sure that a patient's consent to a screening invitation is valid, we must make clear to patients that their decision to accept screening may be shaped not only by how information about screening is presented, but by the pragmatic form of the invitation itself.

A Genomic Test for Colorectal Cancer Risk: Is This Acceptable and Feasible in Primary Care?

INTRODUCTION

Genomic tests can predict risk and tailor screening recommendations for colorectal cancer (CRC). Primary care could be suitable for their widespread implementation.

OBJECTIVE

We aimed to assess the feasibility and acceptability of administering a CRC genomic test in primary care.

METHODS

Participants aged 45-74 years recruited from 4 Australian general practices were offered a genomic CRC risk test. Participants received brief verbal information about the test comprising 45 CRC-associated single-nucleotide polymorphisms, before choosing whether to undertake the test. Personalized risks were given to testers. Uptake and knowledge of the genomic test, cancer-specific anxiety (Cancer Worry Scale), psychosocial impact (Multidimensional Impact of Cancer Risk Assessment [MICRA] score), and impact on CRC screening behaviour within 6 months were measured.

RESULTS

In 150 participants, test uptake was high (126, 84%), with 125 (83%) having good knowledge of the genomic test. Moderate risk participants were impacted more by the test (MICRA mean: 15.9) than average risk participants (mean: 9.5, difference in means: 6.4, 95% confidence interval (CI): 1.5, 11.2, p = 0.01), but all scores were low. Average risk participants' cancer-specific anxiety decreased (mean differences from baseline: 1 month -0.5, 95% CI: -1.0, -0.1, p = 0.03; 6 months -0.6, 95% CI: -1.0, -0.2, p = 0.01). We found limited evidence for genomic testers being more likely to complete the risk-appropriate CRC screening than non-testers (41 vs. 17%, odds ratio = 3.4, 95% CI: 0.6, 34.8, p = 0.19), but some mediators of screening behaviour were altered in genomic testers.

CONCLUSIONS

Genomic testing for CRC risk in primary care is acceptable and likely feasible. Further development of the risk assessment intervention could strengthen the impact on screening behaviour.

Colorectal Cancer in Brunei Darussalam: An Overview and Rationale for National Screening Programme

Colorectal cancer (CRC) is the third most common cancer worldwide after lung and breast cancers, and ranks second in terms of cancer mortality globally. Brunei Darussalam reports high incidence of CRC in the Southeast Asian region and has no formal national screening programme for CRC. Screening for CRC in Brunei Darussalam is offered in an opportunistic fashion for individuals with average or above average risks for CRC, that is, the individual has a positive family history of CRC or neoplasms and is more than 50 years old. Opportunistic screening is widely practiced but this is not standardised. The Ministry of Health in Brunei Darussalam is currently in the process of implementing a CRC screening programme as part of a larger national health screening based on the increasing incidence of non-communicable diseases (NCDs). This review article assesses the situation of CRC in Brunei Darussalam from the 1980s to present day, including incidence of CRC in different age groups, ethnicities and genders; relevant non-modifiable and modifiable risk factors of CRC in Brunei Darussalam setting; and common CRC screening techniques used in Brunei Darussalam as well as other Asia-Pacific countries. The review also discusses the merits of a national CRC screening programme. With the increasing incidence of CRC worldwide and in Brunei Darussalam, national screening for CRC in Brunei Darussalam is an important strategy to lower morbidity and mortality rates. A review of the progress and outcome of the national screening programme will be available a few years after rollout.

Strategies for increasing participation in mail-out colorectal cancer screening programs: a systematic review and meta-analysis

BACKGROUND

Population mail-out bowel screening programs are a convenient, cost-effective and sensitive method of detecting colorectal cancer (CRC). Despite the increased survival rates associated with early detection of CRC, in many countries, 50% or more of eligible individuals do not participate in such programs. The current study systematically reviews interventions applied to increase fecal occult blood test (FOBT) kit return, specifically in population mail-out programs.

METHODS

Five electronic databases (PubMed, PsycINFO, Scopus, CINAHL, and ProQuest Dissertations and Theses) were searched for articles published before the 10th of March 2018. Studies were included if they reported the results of an intervention designed to increase the return rate of FOBT kits that had been mailed to individuals' homes. PRISMA systematic review reporting methods were applied and each study was assessed using Cochrane's Risk of Bias tool. Pooled effect sizes were calculated for each intervention type and the risk of bias was tested as a moderator for sensitivity analysis.

RESULTS

The review identified 53 interventions from 30 published studies from which nine distinct intervention strategy types emerged. Sensitivity analysis showed that the risk of bias marginally moderated the overall effect size. Pooled risk ratios and confidence intervals for each intervention type revealed that telephone contact RR = 1.23, 95% CI (1.08-1.40), GP endorsement RR = 1.19, 95% CI (1.10-1.29), simplified test procedures RR = 1.17, 95% CI (1.09-1.25), and advance notifications RR = 1.09, 95% CI (1.07-1.11) were effective intervention strategies with small to moderate effect sizes. Studies with a high risk of bias were removed and pooled effects remained relatively unchanged.

CONCLUSIONS

Interventions that combine program-level changes incorporating the issue of advance notification and alternative screening tools with the involvement of primary health professionals through endorsement letters and telephone contact should lead to increases in kit return in mail-out CRC screening programs.

SYSTEMATIC REVIEW REGISTRATION

This review is registered with PROSPERO; registration number CRD42017064652.

Geospatial analysis of the influence of family doctor on colorectal cancer screening adherence

BACKGROUND

Despite the well-recognised relevance of screening in colorectal cancer (CRC) control, adherence to screening is often suboptimal. Improving adherence represents an important public health strategy. We investigated the influence of family doctors (FDs) as determinant of CRC screening adherence by comparing each FDs practice participation probability to that of the residents in the same geographic areas using the whole population geocoded.

METHODS

We used multilevel logistic regression model to investigate factors associated with CRC screening adherence, among 333,843 people at their first screening invitation. Standardized Adherence Rates (SAR) by age, gender, and socioeconomic status were calculated comparing FDs practices to the residents in the same geographic areas using geocoded target population.

RESULTS

Screening adherence increased from 41.0% (95% CI, 40.8-41.2) in 2006-2008 to 44.7% (95% CI, 44.5-44.9) in 2011-2012. Males, the most deprived and foreign-born people showed low adherence. FD practices and the percentage of foreign-born people in a practice were significant clustering factors. SAR for 145 (21.4%) FDs practices differed significantly from people living in the same areas. Predicted probabilities of adherence were 31.7% and 49.0% for FDs with low and high adherence, respectively.

DISCUSSION

FDs showed a direct and independent effect to the CRC screening adherence of the people living in their practice. FDs with significantly high adherence level could be the key to adherence improvement.

IMPACT

Most deprived individuals and foreigners represent relevant targets for interventions in public health aimed to improve CRC screening adherence.

Ways to use interventions to increase participation in mail-out bowel cancer screening: a systematic review and meta-analysis

The impact of colorectal cancer can be reduced through nationwide fecal occult blood test (FOBT) screening. Unfortunately, participation in screening programs are low with interventions only increasing participation modestly.

This meta-analysis explores if intervention effectiveness can be increased by targeting specific subpopulations with specific interventions or by combining interventions. Six databases were searched for studies aiming to increase participation in mail-out FOBT screening. To investigate if interventions are more effective for certain subpopulations, the difference in (log) Risk Ratios (RRs) between alternate subpopulations (male vs. female; low vs. high Socioeconomic Status (SES); &lt;65 vs. ≥65 years) was assessed. To investigate if interventions should be combined, uptake rates for single interventions were compared to uptake rates for combined interventions. Cochrane Collaboration tools were used to assess the risk of bias.

Searches found 3,436 articles, with 32 meeting the inclusion criteria. These contained 30 trials that reported uptake rates within subpopulations and 17 trials that combined interventions. Most differences in intervention effects between subpopulations were nonsignificant. Combining interventions led to greater participation, RR = 1.06, confidence interval [1.03; 1.10]. As interventions rarely affect subpopulations differently, targeting them at specific subpopulations may be an ineffective strategy. While individual interventions show modest effects, these results indicate that future programs might overcome this by combining interventions together. Care is needed when selecting interventions to combine as adding some interventions (e.g., additional print materials) can reduce the effectiveness of a combined strategy. Future research should examine methods for effectively combining interventions in nationwide programs to maximize participation.

Impact of a Primary Care intervention on the colorectal cancer early detection programme

AIM

To assess the effectiveness of a telephonic interview performed by primary care professionals among non-participants in the first round of the colorectal cancer early detection programme in the basic urban health area Guineueta in Barcelona, Spain.

PATIENTS AND METHODS

The Primary Healthcare Team of La Guineueta contacted people who did not respond to the invitation to the first round of the colorectal cancer early detection programme using a standardised telephone call protocol. We analysed the impact of the intervention based on participation and diagnosed disease.

RESULTS

We made 3,327 phone calls to 2,343 people. After the intervention the participation rate was 54.9%, which meant an increase of 5.7% with respect to the participation in the usual protocol for the programme (49.2%). The intervention allowed 5cancers, 2high-risk neoplasms and 8low- and intermediate-risk lesions to be diagnosed. An average of 9phone calls was necessary to achieve the participation of one additional person.

DISCUSSION

The telephonic intervention performed by primary care professionals has significantly increased the population participation rate and the detection of neoplasms with respect to the usual colorectal cancer early detection programme protocol.

GPs' perspectives on colorectal cancer screening and their potential influence on FIT-positive patients: an exploratory qualitative study from a Dutch context

Background

In the Dutch colorectal cancer (CRC) screening programme, individuals receive a faecal immunochemical test (FIT) to do at home. After a positive FIT result, a follow-up colonoscopy is recommended to identify CRC or advanced adenomas (AA). GPs may influence their patients’ decisions on adherence to follow-up by colonoscopy.

Aim

To explore GPs’ perspectives on the CRC screening programme and their potential influence on FIT-positive patients to follow up with the recommended colonoscopy.

Design & setting

Semi-structured interviews among GPs in Amsterdam, the Netherlands.

Method

GPs were approached using purposive sampling. Analysis was performed on 11 interviews using open coding and constant comparison.

Results

All interviewed GPs would recommend FIT-positive patients without obvious contraindications to adhere to a follow-up colonoscopy. If patients were likely to be distressed by a positive FIT result, most GPs described using reassurance strategies emphasising a low cancer probability. Most GPs stressed the probability of false-positive FIT results. Some described taking a positive screening result in CRC screening less seriously than one in breast cancer screening. Most GPs underestimated CRC and AA probabilities after a positive FIT result. When told the actual probabilities, some stated that this knowledge might change the way they would inform patients.

Conclusion

These results imply that some of the interviewed GPs have too low a perception of the risk associated with a positive FIT result, which might influence their patients’ decision-making. Simply informing GPs about the actual rates of CRC and AA found in the screening programme might improve this risk perception.

[Cancer prevention and screening: What french GPs could do?]

An effective health system is based on effective primary care, at the center of which is family medicine. Cancer prevention and screening are integral aspects of general practitioners skills. Prevention is linked with the notion of risk. The relationship between the general practitioner and his or her patient reinforces the prevention of the development of preventable risk factors. It also strengthens information on intrinsic risk factors for patients. The protective factors highlighted by the general practitioner can thus reduce the risk a little more. Screening strategies differs across cancers and countries. In France, general practitioner's involvement is important for colorectal cancer screening. The active participation of their general practitioner, strengths patient's adherence and participation. Their role is to inform and collect data for breast cancer screening. Recently organized cervical cancer screening requires greater involvement of general practitioners who can act as both actors and informants. Family medicine is at the heart of cancer prevention and screening. It is a central hub for improving the health of patients in our healthcare system. The general practitioner knows the patient, which gives him an important advantage to accompany him in the prevention and screening of his risk factors.

New insights into colorectal cancer screening and early detection tests

Colorectal cancer (CRC) is a common cancer in both men and women worldwide. Creating a diagnostic panel is necessary for early diagnosis which could lead to a better long-term survival in cancer patients. Colonoscopy every 10 years, starting at age 50, is the preferred CRC screening test. Many studies have been worked on potential diagnostic biomarkers of CRC. In this article, we described the recent evolutions in the development of CRC noninvasive screening assays. Recently, a multifunctional fecal DNA test has been available commercially in the USA. A few other US FDA-approved tests like Epi proColon® (Epigenomics AG, Berlin, Germany) are also available now. Although a new marker class for fecal occult blood test, a novel biomarker based on fecal bacteria in CRC patients and circulating tumor cells are under investigation, there is still a strong need to do more research for CRC screening strategies.