Comparative educational approaches to screening for colorectal cancer

Methods to increase participation in organised screening programs: a systematic review

BACKGROUND

The European Community recommends the implementation of population-based screening programmes for cervical, breast, and colorectal cancers. This recommendation is supported by many observational studies showing that organised programmes effectively reduce mortality and control the inappropriate use of screening tests. We conducted a systematic review of studies assessing the efficacy of interventions to increase participation in organised population-based screening programs.

METHODS

We included all studies on interventions aimed at increasing screening participation published between 1/1999 and 7/2012. For those published before 1999, we considered the Jepson et al. (2000) review (Health Technol Assess 4:1-133, 2000).

RESULTS

Including studies from the Jepson review, we found 69 with quantitative information on interventions in organised screening: 19 for cervical, 26 for breast, 20 colorectal cancers, and 4 for cervical and breast cancer together.Effective interventions were: postal (breast RR = 1,37 95% Confidence Interval (95% CI): 1.25-1.51; cervical RR = 1.71 95% CI: 1.60-1.83; colorectal RR = 1.33 95% CI: 1.17-1.51) and telephone reminders (with heterogeneous methods for implementation); GP's signature on invitation letter (breast RR = 1.13 95% CI: 1.11-1.16; cervical RR = 1.20 95% CI: 1.10-1.30; colorectal RR = 1.15 95% CI: 1.07-1.24); scheduled appointment instead of open appointment (breast RR = 1.26 95% CI: 1.02-1.55; cervical RR = 1.49 95% CI: 1.27-1.75; colorectal RR = 1.79 95% CI: 1.65-1.93). Mailing a kit for self-sampling cervical specimens increased participation in non-responders (RR = 2.37 95% CI: 1.44-3.90).

CONCLUSION

Although some interventions did prove to be effective, some specific variables may influence their effectiveness in and applicability to organised population-based screening programs.

Uptake of colorectal cancer screening: system, provider and individual factors and strategies to improve participation

Colorectal cancer (CRC) accounts for 9% of all new cancer cases worldwide and affects over 1 million people each year. Screening can reduce the mortality associated with the disease, yet participation rates are suboptimal. Compliers with CRC screening are less deprived; they have higher education than noncompliers and tend to be male, white and married. Likely reasons for nonparticipation encompass several 'modifiable' factors that could be targeted in interventions aimed at increasing participation rates. Successful intervention strategies include organizational changes, such as increasing access to fecal occult blood test (FOBT) kits, providing reminders to healthcare providers or users about screening opportunities, and educational strategies to improve awareness and attitudes towards CRC screening. Multifactor interventions that target more than one level of the screening process are likely to have larger effects. The biggest challenge for future research will be to reduce inequalities related to socio-economic position and ethnicity in the uptake of screening.

Telephone outreach to increase colorectal cancer screening in an urban minority population

OBJECTIVES

We compared the effectiveness of a telephone outreach approach versus a direct mail approach in improving rates of colorectal cancer (CRC) screening in a predominantly Black population.

METHODS

A randomized trial was conducted between 2000 and 2003 that followed 456 participants in the New York metropolitan area who had not had recent CRC screening. The intervention group received tailored telephone outreach, and the control group received mailed printed materials. The primary outcome was medically documented CRC screening 6 months or less after randomization.

RESULTS

CRC screening was documented in 61 of 226 (27.0%) intervention participants and in 14 of 230 (6.1%) controls (prevalence rate difference=20.9%; 95% CI = 14.34, 27.46). Compared with the control group, the intervention group was 4.4 times more likely to receive CRC screening within 6 months of randomization.

CONCLUSIONS

Tailored telephone outreach can increase CRC screening in an urban minority population.

A randomized trial of direct mailing of fecal occult blood tests to increase colorectal cancer screening

BACKGROUND

Although colorectal cancer screening by using a fecal occult blood test (FOBT), flexible sigmoidoscopy, colonoscopy, or barium enema x-ray reduces the incidence of and death from colorectal cancer, the rate of colorectal cancer screening in the general population is low. We conducted a randomized trial consisting of direct mailing of FOBT kits to increase colorectal cancer screening among residents of Wright County, Minnesota, a community in which colorectal cancer screening was promoted.

METHODS

At baseline, we mailed a questionnaire about colorectal cancer screening to a random sample of Wright County residents aged 50 years or older who were randomly selected from the Minnesota State Driver's License and Identification Card database (estimated N = 1451). The sample was randomly allocated into three equal subgroups: one group (control) received only the questionnaire, one group received FOBT kits by direct mail with reminders, and one group received FOBT kits by direct mail without reminders. Study participants were sent a follow-up questionnaire 1 year after baseline. We used the responses to the questionnaires to estimate the 1-year change in self-reported screening rates in each group and the differences in the changes among the groups, along with the associated bootstrap 95% confidence intervals (CIs).

RESULTS

At baseline, the estimated response rate was 86.5%, self-reported adherence to FOBT guidelines was 21.5%, and overall adherence to any colorectal cancer screening test guidelines was 55.8%. The 1-year rate changes in absolute percentage for self-reported adherence to FOBT use were 1.5% (95% CI = -2.9% to 5.9%) for the control group, 16.9% (95% CI = 11.5% to 22.3%) for the direct-mail-FOBT-with-no-reminders group, and 23.2% (95% CI = 17.2% to 29.3%) for the direct-mail-FOBT-with-reminders group. The 1-year rate changes for self-reported adherence to any colorectal cancer screening test were 7.8% (95% CI = 3.2% to 12.0%) for the control group, 13.2% (95% CI = 8.4% to 18.2%) for the direct-mail-FOBT-with-no-reminders group, and 14.1% (95% CI = 9.1% to 19.1%) for the direct-mail-FOBT-with-reminders group.

CONCLUSION

Direct mailing of FOBT kits combined with follow-up reminders promotes more rapid increases in the use of FOBT and nearly doubles the increase in overall rate of adherence to colorectal cancer screening guidelines in a general population compared with a community-wide screening promotion and awareness campaign.

Colorectal cancer screening: clinical applications

Screening for colorectal cancer reduces mortality in individuals aged 50 years or older. A number of screening tests, including fecal occult blood tests, sigmoidoscopy, double-contrast barium enema, and colonoscopy, are recommended by professional organizations for colorectal cancer screening, yet the rates of colorectal cancer screening remain low. Questions regarding the quality of evidence for each screening test, whether screening for individuals at higher risk should be modified, the availability of the tests, and cost-effectiveness are addressed. Many potential barriers to colorectal cancer screening exist for the patient and the physician. Strategies to increase compliance for colorectal cancer screening are proposed.

Participation in colorectal cancer screening: a review

The purpose of this review is to evaluate the published literature on adherence to colorectal cancer (CRC) screening with fecal occult blood testing (FOBT) and sigmoidoscopy. Specifically, the review addresses the following: 1) prevalence of FOBT and sigmoidoscopy; 2) interventions to increase adherence to FOBT and sigmoidoscopy; 3) correlates or predictors of adherence to FOBT and sigmoidoscopy; and 4) reasons for nonadherence. Other objectives are to put the literature on CRC screening adherence in the context of recently reported findings from experimental interventions to change prevention and early detection behaviors and to suggest directions for future research on CRC screening adherence. CRC screening offers the potential both for primary and for secondary prevention. Data from the 1992 National Health Interview Survey show that 26% of the population more than 49 years of age report FOBT within the past 3 years and 33% report ever having had sigmoidoscopy. The Year 2000 goals set forth in Healthy People 2000 are for 50% of the population more than 49 years of age to report FOBT within the past 2 years and for 40% to report that they ever had sigmoidoscopy. Thus, systematic efforts to increase CRC screening are warranted. To date, attempts to promote CRC screening have used both a public health model that targets entire communities, e.g., mass media campaigns, and a medical model that targets individuals, e.g., general practice patients. Most of these efforts, however, did not include systematic evaluation of strategies to increase adherence. The data on FOBT show that the median adherence rate to programmatic offers of FOBT is between 40% and 50%, depending on the type of population offered the test, e.g., patients or employees. Approximately, 50% of those initially offered testing in unselected populations will respond to minimal prompts or interventions. A salient issue for FOBT, however, is whether or not the behavior can be sustained over time. Fewer studies examined adherence to sigmoidoscopy. Adherence was highest in relatives of CRC cases and in employer-sponsored programs offered to workers at increased risk of CRC. At present, we know very little about the determinants of CRC screening behaviors, particularly as they relate to rescreening.

Determinants of persistent compliance with screening for colorectal cancer

Mass population screening for colorectal cancer is currently being evaluated by means of randomized controlled trials. These trials point to the likelihood that, if implemented, the level of both initial and sustained compliance will prevent the full potential of screening being realised. The paper opens by reviewing the evidence on determinants of compliance, both initial and longer term, although little empirical evidence on adherence to repeated screening is currently available. The paper then presents the results of a survey of persistent compliers and non-compliers within the English screening trial, in order to identify those characteristics most closely associated with persistent compliance behaviour. Persistent compliers are found, inter alia, to be of higher socio-economic classes than persistent non-compliers, to have more personal and family experiences of illness and to visit their dentists more regularly. The results suggest that generalized attempts at compliance enhancement would be ineffectual against the prevailing background characteristics of the non-compliant population, and that the more overt targeting of efforts in this respect is to be preferred.

A simple strategy to improve patient adherence to outpatient fecal occult blood testing

Poor patient adherence reduces the effectiveness of fecal occult blood testing for colon cancer. Patients at the inner-city clinic involved in the study have historically completed only one-third of the tests administered to them. The authors studied three ways of returning test kits (by hand, by mail, and by mail with prepaid postage). Among 146 randomly assigned patients, the completion rates were 37%, 57%, and 71%, respectively. The difference was significant between the first and third groups (p = 0.003), and the cost was less for the third group ($1.71 vs $2.24 per completed test). The authors recommend that clinics serving indigent populations use postage-paid return envelopes with fecal occult blood testing to improve its effectiveness and save money.

Adherence to colorectal cancer screening in an HMO population

This study aimed to determine factors that influence fecal occult blood test performance in colorectal cancer screening. A random sample was selected of men and women ages 50 to 74 years of age who had been mailed a fecal occult blood testing kit in a screening program in fall 1986. One year after initial test mailing, sample group members (n = 504) were surveyed by telephone. Four months later, the survey sample received a second fecal occult blood test mailing. Multivariable analysis for subjects with validated past fecal occult blood test status (n = 322) revealed the past testing was positively associated with physician encouragement of screening, age, the belief that cancer is curable, perceived test efficacy, and strong intention to do testing. It also was discovered that persons who felt that they had little control over their health were more likely to have done past testing. Preliminary analysis of prospective adherence showed that the strongest statistically significant independent predictor was past test performance. Prospective adherence among past nontesters (n = 121) was associated with expressed commitment to do fecal occult blood testing and reported presence of colorectal cancer risk factors. Analysis of adherence among past testers (n = 201) revealed that belief in colorectal cancer curability and age were significant predictors. The findings reported here indicate that factors influencing adherence among past nontesters differ from those for past testers. Overall, these results suggest that to increase participation in colorectal cancer screening, physicians and other health professionals should (a) deliver educational messages that increase awareness of risk factors for colorectal cancer and curability of the disease, and (b) elicit from potential screenees a commitment to engage in recommended preventive behaviors. It may also be well to consider "tailoring" messages for past nontesters and past testers, respectively, by emphasizing colorectal cancer risk factors and highlighting curability.

Mass screening for colorectal cancer

A voluntary community colorectal cancer screening project to detect occult blood in the stool of asymptomatic individuals was undertaken; 49,353 Hemoccult II kits were distributed. A total of 23,674 completed kits were returned to a central repository and processed (compliance rate, 48 percent); 851 participants had positive results (3.6 percent). Of the 640 who underwent further medical evaluation, 299 participants (46.7 percent) who had adequate follow-up had no evidence of disease. Diverse disease entities were detected in 341 participants, which was 1.4 percent of those enrolled. Forty-one patients (0.17 percent) showed significant findings that included 29 cancers (0.12 percent) and 12 (0.05 percent) noninvasive malignant polyps. Of the cancers, there were 27 colorectal, one non-Hodgkin's lymphoma, and one carcinoma of the vocal cord. In addition, 107 patients (0.45 percent) had benign polyps and 193 patients (0.82 percent) had various diseases of the gastrointestinal tract and other medical conditions. The cost of the program was modest and the results conformed to those found in previous screening surveys. The heightened public awareness of testing for colorectal disease and the detection of early lesions justifies the guaiac test screening program for mass survey.

Participation of high-risk subjects in colon cancer screening

Siblings of colorectal cancer patients are estimated to be three times more likely to develop colorectal cancer. Although these high-risk siblings are appropriate candidates for colon cancer screening, the factors that affect their participation in screening programs are not known. A study was conducted to examine the factors that might influence participation in fecal occult blood test (FOBT) screening by high-risk siblings of recently diagnosed colon cancer patients and nonhigh-risk control siblings. Siblings were mailed a sample FOBT card, a letter informing them of their risk status, and an invitation to participate in the FOBT screening program. They were later interviewed by telephone about their intention to participate in FOBT screening. FOBT cards were returned by 52.2% of high-risk siblings compared with 37.7% of control siblings (P less than 0.005). Only 24.8% of the cancer siblings thought they were more likely to get colon cancer compared with others their own age, and 27.8% thought they were less likely. Perceived risk of cancer and demographic and health-related factors did not predict compliance beyond membership in the high-risk group. Siblings of colon cancer patients are more likely to participate in screening, and efforts to screen them could have a substantial impact on colorectal cancer. More work is needed to identify the factors responsible for compliance so that effective interventions can be developed.

Medical diagnostic technology in the home

This article studies the issues surrounding the assessment of several home diagnostic tests. First, the authors review the current data and proper use of fecal occult blood and pregnancy tests. Second, they evaluate the roles of blood and urine glucose monitoring in the management of diabetes mellitus and home pressure monitoring in the management of hypertension. The authors conclude that while home measurement of blood pressure or blood sugar can be recommended to improve compliance with medical programs, home fecal occult blood testing, while helpful, has not been fully investigated.

Compliance with fecal occult blood testing: the role of restrictive diets

In this clinical trial, 786 patients screened for colorectal cancer with fecal occult blood testing were assigned to either a "diet" or "no diet" group to examine the effect of advice to restrict intake of red meat and peroxidase-containing vegetables on patient compliance and positivity rates. Restrictive diets did not significantly decrease compliance. Interviews of patients in the "diet" group demonstrated that the majority followed instructions. Positivity rates were similar in the two groups, and clinically significant lesions were found with comparable frequency.

The pros and cons of fecal occult blood testing for colorectal neoplasms

Testing feces for occult blood is widely recommended as a means of detecting subclinical colorectal tumors. Guaiac tests such as Hemoccult are the most widely used, but chemical sensitivity is relatively low and the tests are affected by dietary peroxidases, the state of fecal hydration, and certain drugs. The newly devised HemoQuant and immunologic techniques appear more sensitive and specific, but they require further evaluation before widespread clinical usage can be recommended. Occult blood screening has both merits and weaknesses. Testing does uncover subclinical colorectal cancer, often at a relatively early stage, but whether this actually improves the prognosis remains to be proven. Benign neoplastic polyps are also detected, although it is debatable whether this is a valid rationale for screening. Test sensitivity for malignancy varies from good to moderate, but is poor for benign polyps. Specificity is usually around 97%-98%, yet the predictive value of a positive test for cancer is only about 10%; hence most test-positive individuals are needlessly subjected to invasive colonic investigations. Reported figures on public compliance with occult blood testing vary widely from excellent to poor. Published costs of screening are usually quite low, but these overlook important indirect and hidden expenses and are therefore misleading. On balance, the problems of occult blood testing currently appear to outweight the merits. This could change, however, with the newer testing techniques and with awaited mortality data from controlled clinical trials now underway.

Participation in fecal occult blood screening: a critical review

The factors that influence participation in fecal occult blood screening for colorectal cancer are poorly understood. A better understanding of these factors could lead to better screening products or to educational approaches to increase participation with currently available products. In this article, we review findings from studies that have examined the determinants of participation in fecal occult blood screening. Two components of participation are identified: initial agreement to participate and subsequent compliance with the testing procedures. We conclude that the factors that lead to agreement often differ from those that lead to compliance. Following the literature review, we discuss ways in which recent advances in attitude and behavior research might be used to improve future investigations of the determinants of participation in fecal occult blood screening. Specifically, this research suggests that investigators should focus on beliefs and attitudes associated with the perceived consequences of screening participation rather than on other types of beliefs and attitudes; measure beliefs and attitudes at the same level of specificity as behavior; and distinguish between individuals' initial agreement to participate in screening and their actual participation.

Participation in mass screening for colorectal cancer with fecal occult blood test

A Danish, randomized study with Hemoccult-II, including 60,000 persons between 45 and 74 years old, began in 1985. Methods of increasing acceptability are described for the first 8000. The first 1000 refusals are also analyzed. Written invitations including prestamped envelopes for return of the slides resulted in an acceptability of 58.8%. Two reminders increased the figure to 65.6%. Personal attempts to change the mind of those refusing increased the last figure to 68.9%. Incomplete slides were returned by 49 persons, but on request 43 sent a complete set. All 78 persons with positive tests had colonoscopy, which detected carcinomas in 10 and adenomas in 39. The study confirmed that results of trials from different countries are difficult to compare because of major differences among populations and methods. However, the present results were similar to those obtained in a Swedish study including only persons between 60 and 64 years old.

Factors affecting compliance in colorectal cancer screening. Results of a study performed in Ballarat

Non-compliance in screening programmes for colorectal cancer is likely to be the most important factor limiting the impact of screening on mortality. This study aimed to determine risk factors and correlates of compliance that could be readily identified by general practitioners. A total of 581 eligible subjects aged 40 to 75 years completed a questionnaire that covered demographic factors, personal medical history, family history of colorectal cancer and smoking status. Faecal occult blood tests were then offered by the general practitioner and compliance correlated with responses. The over-all compliance was 44% and increased to 51% for those who accepted the self-testing kit at consultation. For men, compliance increased with increasing level of education and was significantly greater for non-smokers than for smokers. For women, compliance increased with increasing age, and was greater for those with either symptoms and/or a family history of colorectal cancer. A doctor group-practice factor appeared to influence acceptance versus refusal of the test kit from the doctor. A triage approach to screening in general practice may improve over-all compliance and the yield of tumours. With this strategy, patients at high risk (for example, those with a family history of colorectal cancer or in older age groups) are identified first. Particular attention should be given during consultation to those at high risk who have poor compliance profiles (for example male smokers with a family history of colorectal cancer). High-risk subjects with high compliance profiles would need less attention and low-risk individuals would need least attention.

Mass screening for colorectal cancer by testing fecal occult blood

The validity of screening for colorectal cancer by testing for occult blood on 2 successive days was evaluated over a 2-year period beginning April 1980 by testing 9449 individuals without symptoms. The Shionogi slide (Shionogi Pharmaceutical Co., Osaka, Japan), a commercial guaiac-impregnated slide with moderate sensitivity, was used for screening subjects under dietary restriction. Of the 1401 persons (14.8%) who had a positive reaction for occult blood, 858 (61.2%) received further diagnostic examinations, and 265 of them proved to have one or more abnormalities of the gastrointestinal tract. Colorectal cancer was detected in 11 persons and polyps in 91 persons. Eight of the cancers were in an early stage. This screening method was found to be suitable for large-scale mass screening, and appears to have high diagnostic value.

Occult blood screening for colorectal carcinoma: a critical review

The author reviews the literature on occult blood surveillance for colorectal carcinoma. The guaiac-based Hemoccult (SmithKline Diagnostics, Sunnyvale, Calif.) test is the most reliable and widely used. However, testing is complicated by several technical issues that can affect clinical results, and even successful screening programs will miss a high proportion of tumors. Public compliance is often poor, and a number of indirect and "hidden" costs make surveillance programs much more expensive than is usually claimed. Almost all published screening trials are uncontrolled. They generally detect about 3-20 colorectal malignancies for every 10,000 people enrolled, but only about 5%-10% of occult blood reactions are due to cancer. Though screen-detected tumors tend to be at a relatively early stage, this does not imply any benefit of surveillance because of lead time and length biases inherent in the screening process. Only controlled trials can answer the central question of whether screening decreases mortality from bowel cancer. Two such trials are underway, but mortality data are not yet available from either.

Screening for colorectal cancer using the Hemoccult II stool guaiac slide test

Following a series of educational spots on colorectal cancer shown on a local television news program, stool guaiac slide kits (Hemoccult II; Smith Kline Diagnostics) were distributed in shopping malls in Erie County, New York during a 3-day period in February 1982. The tests kits were sold for $1.00 a piece. A total of 8711 persons purchased test kits and 3822 persons (44%) returned slides for testing. One or more slides were positive in 107 persons (2.8%). Ninety of the 107 positive screenees (84%) saw a physician for further evaluation after screening. Eighteen positive screenees had no evidence of pathology which could cause blood in their stool when evaluated by a physician, yielding an overall false-positive rate of less than 0.5%. Seven new cases of colorectal cancer were found through screening. Five of the seven cancers (71%) detected were localized disease (Dukes' Stage A, B1 or B2), and four cases had no symptoms of disease prior to diagnosis. The findings from this study suggest that screening for fecal occult blood using the stool guaiac slide test is effective in detecting some colorectal cancers at an early stage of disease, often before symptoms appear.

Predicting colon cancer screening behavior from health beliefs

A total of 581 people (33% male, 67% female) attending general practitioners completed a questionnaire mainly on health beliefs and were then offered a fecal occult blood test (Hemoccult II) free of charge. Eighty-six percent accepted the general practitioners' offer and took the Hemoccult kit home. Of these, 51% complied (i.e., returned specimens for laboratory testing). The Health Belief Model was found to account for 12% of the variance in screening behavior. Perceived barriers to taking the test and perceived susceptibility to bowel cancer were the only components contributing significantly in the multiple regression analysis. Health Belief Model components that were predictive of initial acceptance of the test offer differed from components predictive of ultimate compliance. The influence upon compliance of family history of colorectal cancer, history of colonic symptoms, smoking habits, perceived attitudes of spouses, attitude to detection tests, and subjective stress related to the threat of bowel cancer were also investigated.

Participation in faecal occult blood screening for colorectal cancer

Chemical faecal occult blood testing has been proposed as a means of screening for colorectal cancer (C.C.) in populations or in identified high-risk groups. The level of public participation is a critical factor in the effectiveness of screening programmes. This study was conducted as a methodological pretest for an intended investigation of factors influencing screening participation. Faecal occult blood screening was offered to 728 employees of a teaching hospital in Sydney, New South Wales and 41% participation was obtained. Both participants and non-participants were questioned on demographic and social background factors, on their experience of C.C. in others, and on their reasons for participating or not participating. Major reasons for participation were: a general feeling of the importance of health checks and screening tests; a belief that it is important to diagnose C.C. early; and the fact that the test was simple and easy to do. Prominent self-acknowledged reasons for non-participation were indifference, procrastination, absence of previous bowel complaints, preference for one's own doctor to do such tests and inconvenience or lack of time. Those more likely to participate were: females; those of Australian or British origin; single, separated or divorced persons; those having two or more dependents and those with personal knowledge of a C.C. patient.

Colorectal cancer screening

The efficacy of Hemoccult screening for colorectal carcinoma is analyzed utilizing five criteria which a screening test should fulfil before it is used for mass screening. The Hemoccult screening protocol has serious weaknesses. It is at best 83% sensitive for cancer and much less sensitive for polyps. An asymptomatic person with one or more positive Hemoccult slides only has a 12% chance of having cancer. In addition, patient acceptance of mass Hemoccult screening is questionable. There is currently little information on potential survival benefits, and Hemoccult screening is expensive with one quarter of all costs incurred in the diagnostic evaluation of false positives. There is insufficient evidence to recommend Hemoccult colorectal cancer screening in asymptomatic persons as a cost-effective practice.

Community change agents and health interventions: hypertension screening

This study explores a community-based approach to health care. Community volunteers were trained and then conducted door-to-door screening for hypertension. Three large apartment complexes were selected for screening. In the two experimental communities, a letter was sent to each household soliciting volunteers who were then trained to measure blood pressure, complete data sheets, gain admittance to houses, and make appropriate recommendations for medical consultation. The residents in the control community received letters informing them of the hours during which they could have their blood pressure checked free of charge in the apartment complex rental office. Chi-square tests on number of apartments screened indicated the experimental door-to-door screening methods was significantly more effective than the control central site method. These results demonstrate that the experimental screening project was a highly effective and inexpensive technique for hypertension screening.

What do family practice residents do in prevention and counselling?

A study was undertaken to measure what family practice residents do in prevention and counselling during routine check-ups on adults. A series of Health Monitoring and Promotion (HMP) measures were used to assess the content of the check-up. The residents were given a sheet of guidelines in an attempt to augment performance of the HMP measures. Using one-way glass, 353 patient encounters were observed. Analysis of 171 encounters before and 182 encounters after the introduction of the guidelines showed that the guidelines positively influenced the residents' behavior by increasing the number of HMP measures performed. Preventive items of a physical nature were carried out 61.2% of the time before the introduction of the guidelines and 69.7% after, with more pronounced improvement when dealing with the 18-39 age group and among men. Similar changes occurred on historical items of a preventive type, but history-taking from women was more positively influenced. Preventive counselling was carried out 20% of the time and was uninfluenced by the guidelines. There was a high level of breast and testicle examination, but a low level of teaching self-examination. Counselling on retirement, lifestyle, 'passages' and similar issues was uninfluenced by the instrument.

Regionalization of cancer control efforts in the u.s.a

The Johns Hopkins Oncology Center, one of the first of the nation's twenty-one Comprehensive Cancer Centers, established a cancer control program to mobilize resources to improve patient care and prevent the occurrence of neoplastic diseases. Initial efforts were based on the results of a series of investigations conducted in four communities. Findings from these studies were then converted into a series of programmatic interventions. The strategy included integrated approaches to creating a community education program within the overall effort.

A mass screening program for colorectal cancer using chemical testing for occult blood in the stool

Following five promotional and educational programs on CBS-TV news in Chicago, 54,101 Hemoccult kits were requested by the public and distributed by seven cancer detection facilities. Only 14,074 individuals completed the test. Six hundred and seventeen or 4.38% were positive. Two hundred and fifteen test positive persons failed to respond to repeated notification. In 123 positives, diagnostic tests by the private physician were considered incomplete. In 33 positives, the private physician did no further testing at all. In 152 positives, no abnormality could be found, but work-up was variable. One hundred and eighty-seven had abnormalities other than cancer, including 40 with polyps. Twenty-seven asymptomatic and two symptomatic cancers were found. Nearly two-thirds had Dukes A or B lesions, while one-third had Dukes C tumors. Public compliance in both completing kits and following through with positive results was low. Physician evaluation of positives was often incomplete. Chemical testing for occult fecal blood, when properly combined with other tests such as proctoscopy, has the potential for lowering mortality from colorectal cancer. Continued public and professional education is needed.