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Dunlop KLA, Singh N, Robbins HA, Zahed H, Johansson M, Rankin NM, Cust AE. Implementation considerations for risk-tailored cancer screening in the population: A scoping review. Prev Med 2024; 181:107897. [PMID: 38378124 PMCID: PMC11106520 DOI: 10.1016/j.ypmed.2024.107897] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/28/2023] [Revised: 02/10/2024] [Accepted: 02/14/2024] [Indexed: 02/22/2024]
Abstract
BACKGROUND Risk-tailored screening has emerged as a promising approach to optimise the balance of benefits and harms of existing population cancer screening programs. It tailors screening (e.g., eligibility, frequency, interval, test type) to individual risk rather than the current one-size-fits-all approach of most organised population screening programs. However, the implementation of risk-tailored cancer screening in the population is challenging as it requires a change of practice at multiple levels i.e., individual, provider, health system levels. This scoping review aims to synthesise current implementation considerations for risk-tailored cancer screening in the population, identifying barriers, facilitators, and associated implementation outcomes. METHODS Relevant studies were identified via database searches up to February 2023. Results were synthesised using Tierney et al. (2020) guidance for evidence synthesis of implementation outcomes and a multilevel framework. RESULTS Of 4138 titles identified, 74 studies met the inclusion criteria. Most studies in this review focused on the implementation outcomes of acceptability, feasibility, and appropriateness, reflecting the pre-implementation stage of most research to date. Only six studies included an implementation framework. The review identified consistent evidence that risk-tailored screening is largely acceptable across population groups, however reluctance to accept a reduction in screening frequency for low-risk informed by cultural norms, presents a major barrier. Limited studies were identified for cancer types other than breast cancer. CONCLUSIONS Implementation strategies will need to address alternate models of delivery, education of health professionals, communication with the public, screening options for people at low risk of cancer, and inequity in outcomes across cancer types.
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Affiliation(s)
- Kate L A Dunlop
- The Daffodil Centre, The University of Sydney, a joint venture with Cancer Council NSW, Sydney, NSW, Australia; Melanoma Institute Australia, The University of Sydney, Sydney, NSW, Australia.
| | - Nehal Singh
- The Daffodil Centre, The University of Sydney, a joint venture with Cancer Council NSW, Sydney, NSW, Australia
| | - Hilary A Robbins
- International Agency for Research on Cancer, World Health Organization, Lyon, France
| | - Hana Zahed
- International Agency for Research on Cancer, World Health Organization, Lyon, France
| | - Mattias Johansson
- International Agency for Research on Cancer, World Health Organization, Lyon, France
| | - Nicole M Rankin
- Centre for Health Policy, Melbourne School of Population and Global Health, University of Melbourne, Victoria, Australia; Sydney School of Public Health, The University of Sydney, Sydney, NSW, Australia
| | - Anne E Cust
- The Daffodil Centre, The University of Sydney, a joint venture with Cancer Council NSW, Sydney, NSW, Australia; Melanoma Institute Australia, The University of Sydney, Sydney, NSW, Australia
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2
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Rossi SH, Harrison H, Usher-Smith JA, Stewart GD. Risk-stratified screening for the early detection of kidney cancer. Surgeon 2024; 22:e69-e78. [PMID: 37993323 DOI: 10.1016/j.surge.2023.10.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2023] [Revised: 10/22/2023] [Accepted: 10/30/2023] [Indexed: 11/24/2023]
Abstract
Earlier detection and screening for kidney cancer has been identified as a key research priority, however the low prevalence of the disease in unselected populations limits the cost-effectiveness of screening. Risk-stratified screening for kidney cancer may improve early detection by targeting high-risk individuals whilst limiting harms in low-risk individuals, potentially increasing the cost-effectiveness of screening. A number of models have been identified which estimate kidney cancer risk based on both phenotypic and genetic data, and while several of the former have been shown to identify individuals at high-risk of developing kidney cancer with reasonable accuracy, current evidence does not support including a genetic component. Combined screening for lung cancer and kidney cancer has been proposed, as the two malignancies share some common risk factors. A modelling study estimated that using lung cancer risk models (currently used for risk-stratified lung cancer screening) could capture 25% of patients with kidney cancer, which is only slightly lower than using the best performing kidney cancer-specific risk models based on phenotypic data (27%-33%). Additionally, risk-stratified screening for kidney cancer has been shown to be acceptable to the public. The following review summarises existing evidence regarding risk-stratified screening for kidney cancer, highlighting the risks and benefits, as well as exploring the management of potential harms and further research needs.
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Affiliation(s)
- Sabrina H Rossi
- Department of Surgery, University of Cambridge, Cambridge, UK.
| | - Hannah Harrison
- Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
| | - Juliet A Usher-Smith
- Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
| | - Grant D Stewart
- Department of Surgery, University of Cambridge, Cambridge, UK
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3
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Dennison RA, Thomas CV, Morris S, Usher-Smith JA. A discrete choice experiment to understand public preferences and priorities for risk-stratified bowel cancer screening programmes in the UK. Prev Med 2023; 177:107786. [PMID: 37984646 DOI: 10.1016/j.ypmed.2023.107786] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/22/2023] [Revised: 11/10/2023] [Accepted: 11/14/2023] [Indexed: 11/22/2023]
Abstract
OBJECTIVE Public acceptability of bowel cancer screening programmes must be maintained, including if risk stratification is introduced. We aimed to describe and quantify preferences for different attributes of risk-stratified screening programmes amongst the UK population, focussing on who to invite for bowel screening. METHODS We conducted a discrete choice experiment (DCE) including the following attributes: risk factors used to estimate bowel cancer risk (age plus/minus sex, lifestyle factors and genetics); personalisation of risk feedback; risk stratification strategy plus resource implications; default screening in the case of no risk information; number of deaths prevented by screening; and number experiencing physical harm from screening. We used the results of conditional logit regression models to estimate the importance of each attribute, willingness to trade-off between the attributes, and preferences for different programmes using contemporary risk scores and models. RESULTS 1196 respondents completed the survey, generating 21,528 DCE observations. Deaths prevented was the most influential attribute on respondents' decision-making (contributing to 58.8% of the choice), followed by harms experienced (15.9%). For every three additional deaths prevented, respondents were willing to accept an additional screening harm per 100,000 people. Risk factors and risk stratification strategy contributed to just 11.1% and 3.6% of the choice, respectively. Although the influence on decision-making was small, respondents favoured more personalised feedback. CONCLUSIONS Bowel cancer screening programmes that improve cancer outcomes, particularly by preventing more deaths amongst those screened, are most preferred by the public. Optimising risk prediction models, developing public communication, and readying infrastructure should be prioritised for implementation.
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Affiliation(s)
- Rebecca A Dennison
- Primary Care Unit, Department of Public Health and Primary Care, University of Cambridge, Cambridge CB2 0SR, UK.
| | - Chloe V Thomas
- School of Health and Related Research, University of Sheffield, Sheffield S1 4DA, UK
| | - Stephen Morris
- Primary Care Unit, Department of Public Health and Primary Care, University of Cambridge, Cambridge CB2 0SR, UK
| | - Juliet A Usher-Smith
- Primary Care Unit, Department of Public Health and Primary Care, University of Cambridge, Cambridge CB2 0SR, UK
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Toes-Zoutendijk E, de Jonge L, Breekveldt EC, Korfage IJ, Usher-Smith JA, Lansdorp-Vogelaar I, Dennison RA. Personalised colorectal cancer screening strategies: Information needs of the target population. Prev Med Rep 2023; 35:102325. [PMID: 37601828 PMCID: PMC10433032 DOI: 10.1016/j.pmedr.2023.102325] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2023] [Revised: 07/11/2023] [Accepted: 07/12/2023] [Indexed: 08/22/2023] Open
Abstract
Prior faecal Hemoglobin (f-Hb) concentrations of a negative fecal immunochemical test (FIT) can be used for risk stratification in colorectal cancer (CRC) screening. Individuals with higher f-Hb concentrations may benefit from a shorter screening interval (1 year), whereas individuals with undetectable f-Hb concentrations could benefit from a longer screening interval (3 year). Individuals' views on personalised CRC screening and information needed to make a well-informed decision is unknown. We conducted three semi-structured focus groups among individuals eligible for CRC screening (i.e. men and women aged 55 to 75) in the Netherlands. Thematic analysis was used to analyse participants' information need on personalised CRC screening strategies. Fourteen individuals took part. The majority were positive about CRC screening and indicated that they would participate in personalised CRC screening. The rationale for a longer interval among those at lowest risk was, however, unclear for many. The preferred information on individual risk was variable: ranging from full information to only information on the personalised strategy without mentioning the risk. It was not possible to address everyone's need with a single approach. Additional communications, e.g. public media campaigns, billboards, videos on social media, were also suggested as necessary. This study showed that preferences on receiving information on individual CRC risk varied substantially and no consensus was reached. Introducing a personalised screening programme will require careful communication, particularly around the rationale for the strategy, and a layered approach to deliver information.
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Affiliation(s)
- Esther Toes-Zoutendijk
- Department of Public Health, Erasmus MC University Medical Centre, Rotterdam, The Netherlands
| | - Lucie de Jonge
- Department of Public Health, Erasmus MC University Medical Centre, Rotterdam, The Netherlands
| | - Emilie C.H. Breekveldt
- Department of Public Health, Erasmus MC University Medical Centre, Rotterdam, The Netherlands
- Department of Gastroenterology and Hepatology, Netherlands Cancer Institute-Antoni van Leeuwenhoek Hospital, Amsterdam, The Netherlands
| | - Ida J. Korfage
- Department of Public Health, Erasmus MC University Medical Centre, Rotterdam, The Netherlands
| | - Juliet A. Usher-Smith
- Primary Care Unit, Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
| | - Iris Lansdorp-Vogelaar
- Department of Public Health, Erasmus MC University Medical Centre, Rotterdam, The Netherlands
| | - Rebecca A. Dennison
- Primary Care Unit, Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
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Dennison RA, Usher-Smith JA, John SD. The ethics of risk-stratified cancer screening. Eur J Cancer 2023; 187:1-6. [PMID: 37094523 DOI: 10.1016/j.ejca.2023.03.023] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2023] [Revised: 03/08/2023] [Accepted: 03/21/2023] [Indexed: 03/29/2023]
Abstract
Cancer screening programmes aim to save lives and reduce cancer burden through prevention or early detection of specific cancers. Risk stratification, where one or more elements of a screening programme are systematically tailored based on multiple individual-level risk factors, could improve the balance of screening benefits and harms and programme efficiency. In this article, we explore the resulting ethical issues and how they impact risk-stratified screening policymaking using Beauchamp and Childress's principles of medical ethics. First, in line with universal screening programme principles, we acknowledge that risk-stratified screening should be introduced only when the expected total benefits outweigh the harms, and where it has a favourable overall impact compared to alternative options. We then discuss how these are difficult to both value and quantify, and that risk models typically perform differently in sub-populations. Second, we consider whether screening is an individual right and whether it is fair to offer more or less intensive screening to some and not others based on personal characteristics. Third, we discuss the need to maintain respect for autonomy, including ensuring informed consent and considering the screening implications for those who cannot or choose not to participate in the risk assessment. In summary, from an ethical perspective, focusing on population-level effectiveness alone is insufficient when planning risk-stratified screening programmes and the range of ethical principles must be considered.
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Affiliation(s)
- Rebecca A Dennison
- Primary Care Unit, Department of Public Health and Primary Care, University of Cambridge, Cambridge CB2 0SR, UK.
| | - Juliet A Usher-Smith
- Primary Care Unit, Department of Public Health and Primary Care, University of Cambridge, Cambridge CB2 0SR, UK
| | - Stephen D John
- Department of History and Philosophy of Science, University of Cambridge, Cambridge CB2 3RH, UK
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Harrison H, Li N, Saunders CL, Rossi SH, Dennis J, Griffin SJ, Stewart GD, Usher‐Smith JA. The current state of genetic risk models for the development of kidney cancer: a review and validation. BJU Int 2022; 130:550-561. [PMID: 35460182 PMCID: PMC9790357 DOI: 10.1111/bju.15752] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
OBJECTIVE To review the current state of genetic risk models for predicting the development of kidney cancer, by identifying and comparing the performance of published models. METHODS Risk models were identified from a recent systematic review and the Cancer-PRS web directory. A narrative synthesis of the models, previous validation studies and related genome-wide association studies (GWAS) was carried out. The discrimination and calibration of the identified models was then assessed and compared in the UK Biobank (UKB) cohort (cases, 452; controls, 487 925). RESULTS A total of 39 genetic models predicting the development of kidney cancer were identified and 31 were validated in the UKB. Several of the genetic-only models (seven of 25) and most of the mixed genetic-phenotypic models (five of six) had some discriminatory ability (area under the receiver operating characteristic curve >0.5) in this cohort. In general, models containing a larger number of genetic variants identified in GWAS performed better than models containing a small number of variants associated with known causal pathways. However, the performance of the included models was consistently poorer than genetic risk models for other cancers. CONCLUSIONS Although there is potential for genetic models to identify those at highest risk of developing kidney cancer, their performance is poorer than the best genetic risk models for other cancers. This may be due to the comparatively small number of genetic variants associated with kidney cancer identified in GWAS to date. The development of improved genetic risk models for kidney cancer is dependent on the identification of more variants associated with this disease. Whether these will have utility within future kidney cancer screening pathways is yet to determined.
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Affiliation(s)
- Hannah Harrison
- Department of Public Health and Primary CareUniversity of CambridgeCambridgeUK
| | - Nicole Li
- Department of Public Health and Primary CareUniversity of CambridgeCambridgeUK
- Deanary of Biomedical SciencesUniversity of EdinburghEdinburghUK
| | | | - Sabrina H. Rossi
- Department of SurgeryUniversity of CambridgeAddenbrooke’s HospitalCambridgeUK
| | - Joe Dennis
- Department of Public Health and Primary CareUniversity of CambridgeCambridgeUK
| | - Simon J. Griffin
- Department of Public Health and Primary CareUniversity of CambridgeCambridgeUK
| | - Grant D. Stewart
- Department of SurgeryUniversity of CambridgeAddenbrooke’s HospitalCambridgeUK
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7
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Dennison RA, Boscott RA, Thomas R, Griffin SJ, Harrison H, John SD, Moorthie SA, Morris S, Rossi SH, Stewart GD, Thomas CV, Usher‐Smith JA. A community jury study exploring the public acceptability of using risk stratification to determine eligibility for cancer screening. Health Expect 2022; 25:1789-1806. [PMID: 35526275 PMCID: PMC9327868 DOI: 10.1111/hex.13522] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2021] [Revised: 04/26/2022] [Accepted: 04/27/2022] [Indexed: 01/18/2023] Open
Abstract
INTRODUCTION Using risk stratification to determine eligibility for cancer screening is likely to improve the efficiency of screening programmes by targeting resources towards those most likely to benefit. We aimed to explore the implications of this approach from a societal perspective by understanding public views on the most acceptable stratification strategies. METHODS We conducted three online community juries with 9 or 10 participants in each. Participants were purposefully sampled by age (40-79 years), sex, ethnicity, social grade and English region. On the first day, participants were informed of the potential benefits and harms of cancer screening and the implications of different ways of introducing stratification using scenarios based on phenotypic and genetic risk scores. On the second day, participants deliberated to reach a verdict on the research question, 'Which approach(es) to inviting people to screening are acceptable, and under what circumstances?' Deliberations and feedback were recorded and analysed using thematic analysis. RESULTS Across the juries, the principle of risk stratification was generally considered to be an acceptable approach for determining eligibility for screening. Disregarding increasing capacity, the participants considered it to enable efficient resource allocation to high-risk individuals and could see how it might help to save lives. However, there were concerns regarding fair implementation, particularly how the risk assessment would be performed at scale and how people at low risk would be managed. Some favoured using the most accurate risk prediction model whereas others thought that certain risk factors should be prioritized (particularly factors considered as non-modifiable and relatively stable, such as genetics and family history). Transparently justifying the programme and public education about cancer risk emerged as important contributors to acceptability. CONCLUSION Using risk stratification to determine eligibility for cancer screening was acceptable to informed members of the public, particularly if it included risk factors they considered fair and when communicated transparently. PATIENT OR PUBLIC CONTRIBUTION Two patient and public involvement representatives were involved throughout this study. They were not involved in synthesizing the results but contributed to producing study materials, co-facilitated the community juries and commented on the interpretation of the findings and final report.
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Affiliation(s)
- Rebecca A. Dennison
- Primary Care Unit, Department of Public Health and Primary CareUniversity of CambridgeCambridgeUK
| | | | - Rae Thomas
- Institute for Evidence‐Based HealthcareBond UniversityGold CoastQueenslandAustralia
| | - Simon J. Griffin
- Primary Care Unit, Department of Public Health and Primary CareUniversity of CambridgeCambridgeUK
| | - Hannah Harrison
- Primary Care Unit, Department of Public Health and Primary CareUniversity of CambridgeCambridgeUK
| | - Stephen D. John
- Department of History and Philosophy of ScienceUniversity of CambridgeCambridgeUK
| | | | - Stephen Morris
- Primary Care Unit, Department of Public Health and Primary CareUniversity of CambridgeCambridgeUK
| | | | | | - Chloe V. Thomas
- School of Health and Related ResearchUniversity of SheffieldSheffieldUK
| | - Juliet A. Usher‐Smith
- Primary Care Unit, Department of Public Health and Primary CareUniversity of CambridgeCambridgeUK
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Usher-Smith J, von Wagner C, Ghanouni A. Behavioural Challenges Associated With Risk-Adapted Cancer Screening. Cancer Control 2022; 29:10732748211060289. [PMID: 34986038 PMCID: PMC8744170 DOI: 10.1177/10732748211060289] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Cancer screening programmes have a major role in reducing cancer incidence and mortality. Traditional internationally-adopted protocols have been to invite all 'eligible individuals' for the same test at the same frequency. However, as highlighted in Cancer Research UK's 2020 strategic vision, there are opportunities to increase effectiveness and cost-effectiveness, and reduce harms of screening programmes, by making recommendations on the basis of personalised estimates of risk. In some respects, this extends current approaches of providing more intensive levels of care outside screening programmes to individuals at very high risk due to their family history or underlying conditions. However, risk-adapted colorectal cancer screening raises a wide range of questions, not only about how best to change existing programmes but also about the psychological and behavioural effects that these changes might have. Previous studies in other settings provide some important information but remain to be tested and explored further in the context of colorectal screening. Conducting behavioural science research in parallel to clinical research will ensure that risk-adapted screening is understood and accepted by the population that it aims to serve.
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Affiliation(s)
- Juliet Usher-Smith
- The Primary Care Unit, Department of Public
Health and Primary Care, University of Cambridge, Cambridge, UK
| | - Christian von Wagner
- Research Department of Behavioural Science
and Health, Institute of Epidemiology and Health Care
UCL, London, UK
| | - Alex Ghanouni
- Research Department of Behavioural Science
and Health, Institute of Epidemiology and Health Care
UCL, London, UK
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Thomas C, Mandrik O, Saunders CL, Thompson D, Whyte S, Griffin S, Usher-Smith JA. The Costs and Benefits of Risk Stratification for Colorectal Cancer Screening Based On Phenotypic and Genetic Risk: A Health Economic Analysis. Cancer Prev Res (Phila) 2021; 14:811-822. [PMID: 34039685 PMCID: PMC7611464 DOI: 10.1158/1940-6207.capr-20-0620] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2020] [Revised: 03/15/2021] [Accepted: 05/24/2021] [Indexed: 01/07/2023]
Abstract
Population-based screening for colorectal cancer is an effective and cost-effective way of reducing colorectal cancer incidence and mortality. Many genetic and phenotypic risk factors for colorectal cancer have been identified, leading to development of colorectal cancer risk scores with varying discrimination. However, these are not currently used by population screening programs. We performed an economic analysis to assess the cost-effectiveness, clinical outcomes, and resource impact of using risk-stratification based on phenotypic and genetic risk, taking a UK National Health Service perspective. Biennial fecal immunochemical test (FIT), starting at an age determined through risk-assessment at age 40, was compared with FIT screening starting at a fixed age for all individuals. Compared with inviting everyone from age 60, using a risk score with area under the receiver operating characteristic curve of 0.721 to determine FIT screening start age, produces 418 QALYs, costs £247,000, and results in 218 fewer colorectal cancer cases and 156 fewer colorectal cancer deaths per 100,000 people, with similar FIT screening invites. There is 96% probability that risk-stratification is cost-effective, with net monetary benefit (based on £20,000 per QALY threshold) estimated at £8.1 million per 100,000 people. The maximum that could be spent on risk-assessment and still be cost-effective is £114 per person. Lower benefits are produced with lower discrimination risk scores, lower mean screening start age, or higher FIT thresholds. Risk-stratified screening benefits men more than women. Using risk to determine FIT screening start age could improve the clinical outcomes and cost effectiveness of colorectal cancer screening without using significant additional screening resources. PREVENTION RELEVANCE: Colorectal cancer screening is essential for early detection and prevention of colorectal cancer, but implementation is often limited by resource constraints. This work shows that risk-stratification using genetic and phenotypic risk could improve the effectiveness and cost-effectiveness of screening programs, without using substantially more screening resources than are currently available.
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Affiliation(s)
- Chloe Thomas
- School of Health and Related Research, University of Sheffield, Sheffield, United Kingdom.
| | - Olena Mandrik
- School of Health and Related Research, University of Sheffield, Sheffield, United Kingdom
| | - Catherine L Saunders
- The Primary Care Unit, Department of Public Health and Primary Care, School of Clinical Medicine, University of Cambridge, Cambridge, United Kingdom
| | - Deborah Thompson
- Centre for Cancer Genetic Epidemiology, University of Cambridge, Cambridge, United Kingdom
| | - Sophie Whyte
- School of Health and Related Research, University of Sheffield, Sheffield, United Kingdom
| | - Simon Griffin
- The Primary Care Unit, Department of Public Health and Primary Care, School of Clinical Medicine, University of Cambridge, Cambridge, United Kingdom
| | - Juliet A Usher-Smith
- The Primary Care Unit, Department of Public Health and Primary Care, School of Clinical Medicine, University of Cambridge, Cambridge, United Kingdom
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Dunlop K, Rankin NM, Smit AK, Salgado Z, Newson AJ, Keogh L, Cust AE. Acceptability of risk-stratified population screening across cancer types: Qualitative interviews with the Australian public. Health Expect 2021; 24:1326-1336. [PMID: 33974726 PMCID: PMC8369084 DOI: 10.1111/hex.13267] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2021] [Revised: 03/12/2021] [Accepted: 04/10/2021] [Indexed: 01/05/2023] Open
Abstract
BACKGROUND There is mounting evidence of the benefit of risk-stratified (risk-tailored) cancer population screening, when compared to standard approaches. However, shifting towards this approach involves changes to practice that may give rise to implementation challenges. OBJECTIVES To explore the public's potential acceptance of risk-stratified screening across different cancer types, including reducing screening frequency if at low risk and the use of personal risk information, to inform implementation strategies. METHOD Semi-structured interviews were conducted with 40 public participants; half had received personal genomic risk information and half had not. Participants were prompted to consider different cancers. Data were analysed thematically as one dataset. RESULTS Themes included the following: (a) a sense of security; (b) tailored screening is common sense; (c) risk and the need to take action; (d) not every cancer is the same; and (e) trust and belief in health messages. Both groups expressed similar views. Participants were broadly supportive of risk-stratified screening across different cancer types, with strong support for increased screening frequency for high-risk groups. They were less supportive of reduced screening frequency or no screening for low-risk groups. Findings suggest the public will be amenable to reducing screening when the test is invasive and uncomfortable; be less opposed to forgo screening if offered the opportunity to screen at some stage; and view visible cancers such as melanoma differently. CONCLUSIONS Approaching distinct cancer types differently, tailoring messages for different audiences and understanding reasons for participating in screening may assist with designing future implementation strategies for risk-stratified cancer screening.
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Affiliation(s)
- Kate Dunlop
- Daffodil CentreThe University of Sydney, a joint venture with Cancer Council NSWSydneyNSWAustralia
- Melanoma Institute AustraliaThe University of SydneySydneyNSWAustralia
| | - Nicole M. Rankin
- Sydney School of Public Health, The Faculty of Medicine and HealthThe University of SydneySydneyNSWAustralia
| | - Amelia K. Smit
- Daffodil CentreThe University of Sydney, a joint venture with Cancer Council NSWSydneyNSWAustralia
- Melanoma Institute AustraliaThe University of SydneySydneyNSWAustralia
| | - Zofia Salgado
- Daffodil CentreThe University of Sydney, a joint venture with Cancer Council NSWSydneyNSWAustralia
| | - Ainsley J. Newson
- Sydney Health Ethics, Sydney School of Public Health, The Faculty of Medicine and HealthThe University of SydneySydneyNSWAustralia
| | - Louise Keogh
- Melbourne School of Population and Global HealthThe University of MelbourneMelbourneVICAustralia
| | - Anne E. Cust
- Daffodil CentreThe University of Sydney, a joint venture with Cancer Council NSWSydneyNSWAustralia
- Melanoma Institute AustraliaThe University of SydneySydneyNSWAustralia
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11
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Usher‐Smith JA, Harvey‐Kelly LLW, Rossi SH, Harrison H, Griffin SJ, Stewart GD. Acceptability and potential impact on uptake of using different risk stratification approaches to determine eligibility for screening: A population-based survey. Health Expect 2021; 24:341-351. [PMID: 33264472 PMCID: PMC8077132 DOI: 10.1111/hex.13175] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2020] [Revised: 10/15/2020] [Accepted: 11/15/2020] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND Using risk stratification approaches to determine eligibility has the potential to improve efficiency of screening. OBJECTIVES To compare the public acceptability and potential impact on uptake of using different approaches to determine eligibility for screening. DESIGN An online population-based survey of 668 adults in the UK aged 45-79 including a series of scenarios in the context of a potential kidney cancer screening programme in which eligibility was determined by age, sex, age and sex combined, a simple risk score (age, sex, body mass index, smoking status), a complex risk score additionally incorporating family history and lifestyle, or a genetic risk score. OUTCOME MEASURES We used multi-level ordinal logistic regression to compare acceptability and potential uptake within individuals and multivariable ordinal logistic regression differences between individuals. RESULTS Using sex, age and sex, or the simple risk score were less acceptable than age (P < .0001). All approaches were less acceptable to women than men. Over 70% were comfortable waiting until they were older if the complex risk score or genetics indicated a low risk. If told they were high risk, 85% would be more likely to take up screening. Being told they were low risk had no overall influence on uptake. CONCLUSIONS Varying the starting age of screening based on estimated risk from models incorporating phenotypic or genetic risk factors would be acceptable to most individuals and may increase uptake. PATIENT OR PUBLIC CONTRIBUTION Two members of the public contributed to the development of the survey and have commented on this paper.
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Affiliation(s)
- Juliet A. Usher‐Smith
- The Primary Care UnitDepartment of Public Health and Primary CareUniversity of CambridgeCambridgeUK
| | | | - Sabrina H. Rossi
- Department of OncologyUniversity of Cambridge, Addenbrooke’s Hospital, Cambridge Biomedical CampusCambridgeUK
| | - Hannah Harrison
- The Primary Care UnitDepartment of Public Health and Primary CareUniversity of CambridgeCambridgeUK
| | - Simon J. Griffin
- The Primary Care UnitDepartment of Public Health and Primary CareUniversity of CambridgeCambridgeUK
| | - Grant D. Stewart
- Department of SurgeryUniversity of Cambridge, Addenbrooke’s Hospital, Cambridge Biomedical CampusCambridgeUK
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