Colorectal cancer screening with faecal immunochemical test: Patterns of participation

OBJECTIVE

To evaluate participation and participation patterns in a population-based screening programme for colorectal cancer (CRC) using the faecal immunochemical test (FIT).

METHODS

All individuals invited to three consecutive screening rounds in the population-based CRC screening between October 2015 and December 2020 in the Stockholm-Gotland Region, Sweden were included. Patterns of participation were assessed.

RESULTS

The study included 26 541 individuals which resulted in 79 623 screening events. The overall uptake rate was 71.5% and women had a significantly higher participation rate. The participation rate increased significantly between the first and third screening round for both men and women, and the increase was larger among men than women (66.1 to 70.7% vs. 73.1 to 75.4%). In total, 80.9% participated at least once. Consistent participation was the most common participation pattern (61.0%). The probability of attending all three consecutive rounds after initial participation was 87.7%. Over the three rounds, 17.4% participated after a reminder letter. Screening individuals attending after a reminder letter had a higher proportion of drop-outs in the following screening round compared to initial participants (15.4% vs 6.2%).

CONCLUSION

A constant and high participation rate was observed in population-based FIT-screening for CRC. Initial participation was a strong predictor for continuous participation. The need for a reminder letter before participation was a risk factor for subsequent drop-out.

Routine Fecal Occult Blood Screening and Colorectal Cancer Mortality in Sweden

Importance

Population-based colorectal cancer (CRC) screening programs are implemented worldwide, but there are difficulties evaluating their effectiveness. The magnitude of routine CRC screening effectiveness regarding cancer-specific mortality is unclear.

Objective

To evaluate cancer-specific mortality associated with early vs late or no invitation for routine CRC screening using fecal occult blood testing.

Design, Setting, and Participants

This prospective cohort study was performed in the region of Stockholm-Gotland, Sweden, between January 1, 2008, and December 31, 2021. All individuals of the target population of screening born from 1938 to 1954 were included. Data were analyzed from December 12, 2022, to June 25, 2023.

Exposures

Individuals were invited early (2008-2012), late (2013-2015), or not at all to screening with biennial guaiac-based fecal occult blood test. The early invitation group was considered the exposure group and the late or no invitation group was considered the control group.

Main Outcomes and Measures

The main outcome was cancer-specific mortality, defined as CRC registered in the Cancer Register with CRC as underlying cause of death in the Cause of Death Register. Excess mortality was calculated as all-cause deaths among the individuals with CRC subtracted from the expected number of deaths had they not had CRC. Poisson regression analysis based on deaths and person-years was used to estimated mortality rate ratio (RR) with 95% CIs, adjusted for follow-up years and attained age.

Results

In total, 379 448 individuals (193 436 [51.0%] female) were invited for CRC screening, including 203 670 individuals in the exposure group and 175 778 in the control group. The mean screening participation rate was 63.3%, and there was a maximum of 14 years follow-up. There were 834 CRC deaths in 2 190 589 person-years in the exposure group, compared with 889 CRC deaths in 2 249 939 person-years in the control group. Individuals who underwent early CRC screening had reduced adjusted risk of CRC mortality (RR, 0.86; 95% CI, 0.78-0.95) and excess mortality (RR, 0.84; 95% CI, 0.75-0.93).

Conclusions and Relevance

This prospective cohort study of routine screening with fecal occult blood testing found a 14% decrease in CRC mortality associated with screening. The true association of screening with reduced mortality is expected to be higher due to some coexistence of testing in the control group and CRC deaths diagnosed more than 2 years after screening.

How do women comply with cancer screenings? A study in four regions of France

BACKGROUND

This article looks at the behaviour of women facing different cancer screening options available to them from the age of 50 onward. The study was conducted in 2019 in four departments of the French territory with the objective of identifying the factors that influence acceptance of a population-based screening proposal.

METHODS

A questionnaire was sent to women who had received three invitations to organised screenings (OS) for both breast and colorectal cancer. The categories of participants in both OS were designed from data from the regional cancer screening coordination centres in each department. Participation in opportunistic cervical cancer screening was evaluated as self-reported data.

RESULTS

4,634 questionnaires were returned out of the 17,194 sent, giving a global return rate of 27%. The highest rate of return (73.5%) was obtained from women who had participated at least once in both breast and colorectal cancer OS. An intermediate rate was obtained from women participating in breast cancer OS only (18.7%). Poor levels of return came from women who had participated in colorectal cancer OS only (3.6%) and from non-participants (4.1%). Our results suggest that women with lower educational levels tend to be the most regular attendants at OS (50.3%), compared to highly educated women (39.7%). 11.8% of women were overdue in their opportunistic cervical cancer screening. This percentage rose to 35.4% in the category of non-participants. In addition, women's comments provide a better understanding of the reasons for irregular attendance and non-participation.

CONCLUSION

Overall, similar behaviours towards screening were observed in the four departments. Our analysis suggests that participation in one cancer OS increases the likelihood of participating in others. This adhesion could be an interesting lever for raising women's awareness of other cancer screenings.

Engaging lower screening groups: a field experiment to evaluate the impact of a multiwave national campaign on participation in the National Bowel Cancer Screening Program

OBJECTIVES

This field study evaluated a multiwave media campaign that aired in 2019 to promote participation in the Australian National Bowel Cancer Screening Program (NBCSP), which provides free biennial mailed-out immunochemical faecal occult blood test (iFOBT) kits to Australians aged 50-74 years.

DESIGN

Adjusted negative binomial regression models determined rate ratios of iFOBT kits returned during and following three campaign waves compared with 2018 (baseline). Interaction terms determined whether effects differed by gender×age group, socioeconomic status (SES) and previous participation.

SETTING

Australia.

PARTICIPANTS

All Australians eligible for the NBCSP (men and women aged 50-74 years) who returned an iFOBT kit between 1 January 2018 and 30 October 2019.

INTERVENTIONS

A multiwave national integrated media campaign to promote participation in the NBCSP.

MAIN OUTCOME MEASURES

iFOBT kit return rate and number of iFOBT kits returned during and immediately following campaign activity overall and within historically lower screening groups (men, 50-59 years old; lower SES; never participants).

RESULTS

The rate of iFOBT kits returned increased significantly during all three campaign waves, with evidence of carry-over effects of the second wave coinciding with a general practitioner mail-out strategy (all p<0.001). At each wave, effects were observed among men and women in the younger (50-59 years old) age group, but were less consistent for the older age group. Each SES group and both never and previous participants had increased return rates at each wave, but increases were stronger among mid-higher SES and those who had never participated. An estimated 93 075 extra iFOBT kits were returned due to the campaign.

CONCLUSIONS

The campaign increased participation, especially among those who were younger and never previously screened-key groups to recruit given reparticipation rates of over 80%. Ongoing investment in national integrated media campaigns of sufficient duration and intensity can increase bowel cancer screening and ultimately save lives.

Subsequent participation in organized FIT based screening following screen-derived colonoscopy - A Danish nationwide cohort study

Introduction

In the Danish National Colorectal Cancer (CRC) screening program, participants with screen-detected low-risk adenomas are invited to a new faecal immunochemical test (FIT) screening after two years. However, participation rate in next FIT screening is unknown. We aimed to investigate this subsequent participation rate within the Danish CRC screening program.

Methods

This nationwide register-based study included participants aged 50-72 years registered with FIT screening in the Danish CRC screening program between January 1, 2016, and June 30, 2017. Participants were included if their index FIT was negative or if it was positive and the subsequent colonoscopy detected low-risk adenomas. Invitees were categorized as subsequent participants if they returned a FIT within 135 days following the invitation to screening. We estimated the relative risk for participation depending on screening outcome, age, and sex.

Result

415,107 with a negative result and 5,550 with low-risk adenomas were included. 86.0% (85.9;86.1) of the invitees with a negative result participated in the subsequent screening, while 71.8% (70.6;73.0) of the invitees with low-risk adenomas participated subsequently. The risk of participation in the subsequent screening was significantly lower among all age groups of men and women with low-risk adenomas compared to similar groups with negative results.

Conclusion

Invitees with low-risk adenomas detected at their initial colonoscopy are less likely to participate in the subsequent screening than invitees with negative results. This association was found in all age groups and for both sexes. Further studies are necessary to assess whether non-attendance is more pronounced in specific subgroups.

Sociodemographic features and patterns of non-participation in colorectal cancer screening in Finland

BACKGROUND

Colorectal cancer (CRC) screening was run as a randomized health services programme in Finland between 2004 and 2016. This study evaluates sociodemographic features and patterns of non-participation among men and women invited to be screened.

METHODS

The study population in this register-based study includes 233 211 men and women invited to guaiac faecal occult blood test screening on consecutive screening rounds (n = 708 621 invitations). A generalized estimating equation (GEE) was used to estimate incidence rate ratios (IRR) between sociodemographic features and non-participation.

RESULTS

The overall proportion of non-participation was 31.6% and was higher in men (38.8%) than in women (24.6%). Birth cohort, education, marital status and country of birth were associated with non-participation. The birth cohort of 1950-54 was less likely to participate than the birth cohort of 1940-44. Men and women with primary education were more likely non-participants (IRR 1.26, CI 1.23-1.29 and IRR 1.22, CI 1.18-1.26, respectively) than men or women with tertiary education. Further, unmarried persons and immigrants had an increased risk of non-participation. Initial non-participation predicted subsequent behaviour, since, e.g. ∼80% of first-round non-participants also remained non-participants in the second round.

CONCLUSION

Education, gender and marital status had a significant effect on non-participation in the CRC screening programme. As high and comprehensive participation is essential for a successful screening programme, attention should be paid in ensuring participation of all sociodemographic groups. Special efforts should be invested in those not participating in the first invitational round, since initial non-participation predicts non-participation to subsequent invitations.

Decision-making about participation in colorectal cancer screening in Sweden: Autonomous, value-dependent but uninformed?

OBJECTIVE

To investigate knowledge, values and preferences, and involvement among screening participants and non-participants in relation to colorectal cancer (CRC) and screening decision.

METHODS

Individuals (N = 2748) from the Screening of Swedish Colons trial were invited to respond to the SCREESCO questionnaire, assessing information/knowledge, values/preferences, and involvement.

RESULTS

Respondents' (screening participants, n = 1320; non-participants, n = 161) knowledge varied across items; 90 % recognised faecal blood as a CRC symptom, but less than half cited overweight, smoking, alcohol, and physical inactivity as risk factors. Incidence and case fatality were often over- and underestimated, respectively (>45 and 40 %). Non-participants were more uncertain about their CRC risk (p = 0.015) and less convinced that screening reduces the risk of dying from CRC (p < 0.001). In decision-making, screening participants took most into consideration the importance of early detection and CRC worry, and non-participants the risk of discomfort and complications due to the screening examination (p < 0.001). Most individuals made the decision without involving others.

CONCLUSION

For informed and shared decisions, efforts need to be made to increase public knowledge about CRC and to develop interventions to support individuals in decision-making.

PRACTICE IMPLICATIONS

These results can inform and guide future initiatives to facilitate high quality decisions and CRC screening uptake in Sweden.

Differential effects of colorectal cancer screening across sociodemographic groups in Denmark: a register-based study

INTRODUCTION

Colorectal cancer (CRC) does not affect different sociodemographic groups uniformly. CRC screening programmes could seek to reduce this inequality; however, the screening programmes themselves might be subject to differential participation across sociodemographic groups. This study investigates the sociodemographic inequality at all steps in Denmark's nationwide CRC screening programme: screening participation, faecal immunochemical test (FIT) results, colonoscopy compliance, CRC diagnosis, and cancer stage.

MATERIAL AND METHODS

This cohort study includes all first-time invitees from the beginning of the Danish population-based CRC screening programme from 1 March 2014 to 31 December 2017.

RESULTS

Sixty-four percent of the invitees participated in the screening programme, and of those 7% were FIT-positive. After being invited to further diagnostic procedures, 90% responded to the invitation, and among those 5% were CRC-positive. Among those diagnosed with CRC, 9% were stage IV. Through multivariable analyses, we identified sociodemographic inequalities in all steps of the screening programme from returning a stool sample to being diagnosed with CRC. Specifically, we identified inequalities across sex, age, migration status, relationship status, the screening status of one's partner, education, income, and use of health services. Women were more likely to participate compared to men (RR = 1.13; 95% CI: 1.12-1.13), but had a lower risk of a positive FIT result (RR = 0.67; 95% CI: 0.66-0.68) and of a CRC diagnosis (RR = 0.88; 95% CI: 0.82-0.93) compared to men. The likelihood of participating as well as the risk of positive FIT results and CRC diagnosis increased with age.

CONCLUSION

All steps of the screening programme were subject to sociodemographic inequalities. Interventions are needed to target groups identified as having lower uptake as well as high-risk of being FIT- and/or CRC-positive. These groups include males, individuals aged 60+ years and individuals who do not visit their GP regularly.

Impact of the introduction of a new policy of direct faecal immunochemical home screening test provision in a national bowel screening programme, both during and outside of advertising campaigns

BACKGROUND

BowelScreen, The National Bowel Screening Programme in Ireland, offers free colorectal screening to persons aged 60-69 through a home Faecal Immunochemical Test (FIT) kit. 40.2% uptake in the first screening round was below the programme standard (≥50.0%). To improve uptake, an intervention saw FIT kits sent directly to previously screened clients rather than by the usual invitation process comprising a letter of invitation followed by a FIT kit if requested. The intervention proved successful and was fully implemented into the programme for subsequent clients. Despite the improved uptake it was noted over time that the unsatisfactory FIT rate was approaching the programme standard (≤3%). The aim of this study is to compare uptake by two invite methods occurring contemporaneously alongside advertising and to compare unsatisfactory rates before and after full FIT-Direct implementation.

METHODS

Percentage uptake and 95% confidence intervals (CI) were calculated for each invite method before and after advertising and compared using two-proportion z-tests. Rate ratios and 95% CI compared the unsatisfactory FIT rate before and after full-FIT Direct implementation.

RESULTS

Uptake was significantly higher amongst FIT-Direct compared with Usual-Invite clients during (91.0% vs 84.9%, p < 0.0001) and outside advertising (93.8% vs 85.3%, p < 0.0001). The unsatisfactory FIT rate was 2.3 times higher (95% CI: 1.84-2.92, p < 0.0001) after full FIT-Direct implementation compared with before.

CONCLUSIONS

The FIT-Direct intervention had an overall positive effect on uptake. After adjusting for advertising, uptake of FIT was higher outside advertising periods. Monitoring of the unsatisfactory rate is ongoing; a communication enhancement strategy may be required should this persist.

Do we know the effects of colorectal cancer screening? A short communication on selective uptake and differential effects of colorectal cancer screening in Scandinavia

Colorectal cancer (CRC) contributes extensively to the overall cancer burden, with substantial and increasing social inequality in both incidence and survival. In several countries, this social inequality in incidence and survival has been increasing over time, and the increase is expected to continue. To overcome this, it is advised to implement nationwide CRC screening programmes, as these are effective in detecting possible signs of CRC, hence identifying earlier-stage cancer and reducing mortality. However, little is known about the distribution of these effects across population groups. It is possible that the outcomes of CRC screening are not equally distributed among participants, but rather that the screening programme serves some population groups better than others. The aim of this short communication based on published data is to describe the status of selective uptake according to sociodemographic and economic factors in CRC screening in Scandinavia. Furthermore, we raise questions that need to be addressed in future research in order to grasp the full effects of the screening programme and ultimately to ensure high uptake as well as participation in subsequent diagnostic procedures across population groups.

A Systematic Review of Repeat Fecal Occult Blood Tests for Colorectal Cancer Screening

Screening with fecal occult blood tests (FOBT) reduces colorectal cancer mortality. Failure to complete repeat tests may compromise screening effectiveness. We conducted a systematic review of repeat FOBT across diverse health care settings. We searched MEDLINE, Embase, and the Cochrane Library for studies published from 1997 to 2017 and reported repeat FOBT over ≥2 screening rounds. Studies (n = 27 reported in 35 articles) measured repeat FOBT as (i) proportion of Round 1 participants completing repeat FOBT in Round 2; (ii) proportion completing two, consecutive FOBT; or (iii) proportion completing ≥3 rounds. Among those who completed FOBT in Round 1, 24.6% to 89.6% completed repeat FOBT in Round 2 [median: 82.0%; interquartile range (IQR): 73.7%-84.6%]. The proportion completing FOBT in two rounds ranged from 16.4% to 80.0% (median: 46.6%; IQR: 40.5%-50.0%), and in studies examining ≥3 rounds, repeat FOBT ranged from 0.8% to 64.1% (median: 39.2%; IQR: 19.7%-49.4%). Repeat FOBT appeared higher in mailed outreach (69.1%-89.6%) compared with opportunistic screening (24.6%-48.6%). Few studies examined correlates of repeat FOBT. In summary, we observed a wide prevalence of repeat FOBT, and prevalence generally declined in successive screening rounds. Interventions that increase and maintain participation in FOBT are needed to optimize effectiveness of this screening strategy.

Impact of a mass media campaign on participation in the Australian bowel cancer screening program

Objective

To examine the effect of a mass media campaign designed to increase bowel cancer screening participation.

Methods

We assessed weekly participation, from January 2015 to December 2017, in the Australian National Bowel Cancer Screening Program in Victoria, where a seven-week campaign aired in mid-2017, and in the adjacent comparison state of South Australia. Participation, defined as the number of immunochemical faecal occult blood tests returned out of those invited by the Screening Program in the past 16 weeks, was analysed using negative binomial regression.

Results

Compared with non-campaign weeks, there was an increase in the return rate in the campaign state during campaign weeks (adjusted return rates non-campaign weeks = 34.4% vs. campaign weeks = 45.3%, p < 0.01), not observed in the comparison state (38.3% vs. 40.3%, p > 0.05). The increase in the return rate was significantly greater in the campaign state (Rate Ratio of Campaign/Non-Campaign weeks = 1.31, p < 0.01) than the comparison state (1.05, p > 0.05, interaction p < 0.001), and did not differ significantly by age, sex or socio-economic area. The relative increase was greater among never-participants (Rate Ratio of Campaign/Non-Campaign weeks = 1.24) than previous-participants (1.16), interaction p < 0.001).

Conclusions

This mass media campaign increased bowel cancer screening participation, including from never and low participation subgroups. To maximize participation and ensure equitable population benefit, repeated campaigns that reach eligible people about bowel cancer risks and potential life-saving benefits of screening should be standard.