Behavioural Challenges Associated With Risk-Adapted Cancer Screening.

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.Dr Usher Smith is funded by a NIHR Advanced Fellowship NIHR30086

Patients' experience of using colonoscopy as a diagnostic test after a positive FOBT/FIT: a systematic review of the quantitative literature

OBJECTIVES: Faecal occult blood testing (FOBT) and faecal immunochemical testing (FIT) are among the most used screening modalities for colorectal cancer (CRC). Colonoscopy is also widely used as a screening and diagnostic test for adults with a positive FOBT/FIT. Patient experience of colonoscopy is an important component for most CRC screening programmes. Individuals with negative experiences are less likely to engage with colonoscopy in the future and can deter others from attending colonoscopy when invited. This review synthesised data on patient experience with colonoscopy, following a positive result, to provide insights into how to improve patient experience within the English Bowel Cancer Screening Programme. METHODS: MEDLINE, EMBASE and PsycINFO were searched for quantitative questionnaire studies evaluating patient-reported experience with colonoscopy, following a positive screening FOB/FIT result. The search was limited to studies published between 2000 and 2021 (ie, when the first FOBT/FIT screening programmes for CRC were introduced). Data-driven and narrative summary techniques were used to summarise the literature. RESULTS: In total, six studies from the UK (n=4), Spain (n=1) and the Netherlands (n=1) were included in the review (total participants: 152 329; response rate: 68.0-79.3%). Patient experiences were categorised into three 'stages': 'pre-colonoscopy', 'during the test' and 'post-colonoscopy'. Overall, patients reported a positive experience in all six studies. Bowel preparation was the most frequently endorsed issue experienced pre-test (experienced by 10.0-41.0% of individuals, across all studies), pain and discomfort for during the test (experienced by 10.0-21.0% of participants) and abdominal pain and discomfort after the test (these were experienced by 14.8-22% of patients). CONCLUSION: This review highlighted that patient-reported experiences associated with colonoscopy were generally positive. To improve the colonoscopy experience, bowel screening centres should investigate means to: make bowel preparation more acceptable, make colonoscopy less painful and reduce post-colonoscopy symptoms

Trials and Tribulations: when academic research and public health worlds collide

First paragraph: Three years ago, we received funding to develop, trial and evaluate a series of interventions to promote attendance at Bowel Scope Screening (BSS) in Hull, Yorkshire, UK (McGregor et al., 2018). The last of these interventions has now been delivered and in just a couple of months we will receive NHS data (from the Bowel Cancer Screening Programme) which will tell us how successful each intervention has been. While we await the results, we reflect on our trial experience and the difficulties faced in pursuit of improving public health

Trials and Tribulations: when academic research and public health worlds collide

First paragraph: Three years ago, we received funding to develop, trial and evaluate a series of interventions to promote attendance at Bowel Scope Screening (BSS) in Hull, Yorkshire, UK (McGregor et al., 2018). The last of these interventions has now been delivered and in just a couple of months we will receive NHS data (from the Bowel Cancer Screening Programme) which will tell us how successful each intervention has been. While we await the results, we reflect on our trial experience and the difficulties faced in pursuit of improving public health

Uptake of the English Bowel (Colorectal) Cancer Screening Programme: an update 5 years after the full roll-out

Background The initial roll-out of the English Bowel (Colorectal) Cancer Screening programme, during 2006 and 2009, found uptake to be low (54%) and socially graded. The current analysis used data from 2010 to 2015 to test whether uptake is increasing and becoming less socially graded over time. Methods Postcode-derived area-level uptake of 4.4 million first-time invitees, stratified by gender and the year of the first invitation (2010–2015), was generated using the National Bowel Cancer Screening System. Data were limited to people aged 60–64 years. Binomial regression tested for variations in uptake by the year of invitation, gender, region, area-based socio-economic deprivation and area-based ethnic diversity. Results Overall, the first-time colorectal cancer (CRC) screening uptake across 6 years was 52% (n = 2,285,996/4,423,734) with a decline between 2010 and 2015 (53%, 54%, 52%, 50%, 49%, 49% respectively). Uptake continued to be socially graded between the most and the least deprived area-level socio-economic deprivation quintiles (43% vs 57%), the most and the least area-based ethnic diversity quintiles (41% vs 56%) and men and women (47% vs 56%). Multivariate analysis demonstrated the effects of year, deprivation, ethnicity and gender on uptake. The effect of deprivation was more pronounced in the most deprived area quintile between men and women (40% vs 47%) than the least deprived area quintile (52% vs 62% respectively). Conclusion We did not find evidence of change in uptake patterns in CRC screening since its initial launch 10 years ago. The programme is unlikely to realise its full public health benefits and is en route to widening inequalities in CRC outcomes

Testing temporal frames of colorectal cancer risks: evidence from randomized online experiments

Low perceived risk of is associated with a low probability of engaging in risk preventive behaviours. Temporal framing has been suggested to make the risk seem higher, as narrower time frames appear to increase perceived risk and intentions to engage in risk-preventive behaviours. In two online experiments, we tested how manipulating risk information about colorectal cancer (CRC) influenced risk perception and preventive behaviours. 902 men and women aged 45–54 were recruited from an English online panel. Study 1 (N = 132) investigated how communicating CRC mortality instead of incidence rates influences risk perception, using both yearly and daily frames. In study 2 (N = 770), CRC incidence was described as occurring yearly, daily or hourly. The primary outcome measures were risk perception, intention to engage in preventive behaviours and whether participants chose to read information about ways to reduce CRC risk or skip it to finish the survey. Study 1 did not find a difference in intentions based on information about the risk of developing vs the risk of dying of CRC. Study 2 found that, while communicating CRC incidence occurring as every day increased information-seeking behaviour compared to every year and every hour (57.4% vs 45.9% vs 45.6%, p = 0.012), individuals in the daily condition were less likely to get all comprehension questions right (69.9% vs 78.2% vs 85.0%, respectively, p = 0.015). Temporal framing had no impact on perceived risk or intentions to engage in risk-reducing behaviours. While manipulating risk information in terms of temporal framing did not increase perceived risk, it may influence people’s decision to engage with the information in the first place

Persuasion, Adaptation, and Double Identity: Qualitative Study on the Psychological Impact of a Screen-Detected Colorectal Cancer Diagnosis

The NHS Bowel Cancer Screening Programme (BCSP) is aimed at reducing colorectal cancer (CRC) mortality through early detection within a healthy population. This study explores how 5 people (three females) experience and make sense of their screen-detected diagnosis and the psychological implications of this diagnostic pathway. A biographical narrative interview method was used, and transcripts were analysed using a thematic analysis with a phenomenological lens. Themes specifically relating to posttreatment experience and reflections are reported here: Do it: being living proof, Resisting the threat of recurrence, Rationalising bodily change, and Continuing life—“carrying on normally.” Participants described their gratefulness to the BCSP, motivating a strong desire to persuade others to be screened. Furthermore, participants professed a duality of experience categorised by the normalisation of life after diagnosis and treatment and an identification of strength post cancer, as well as a difficulty adjusting to the new changes in life and a contrasting identity of frailty. Understanding both the long- and short-term impacts of a CRC diagnosis through screening is instrumental to the optimisation of support for patients. The results perhaps highlight a particular target for psychological distress reduction, which could reduce the direct and indirect cost of cancer to the patient

The Role of Type 2 Diabetes in Patient Symptom Attribution, Help-Seeking, and Attitudes to Investigations for Colorectal Cancer Symptoms: An Online Vignette Study

Objectives: Type 2 diabetes is associated with a higher risk of colorectal cancer (CRC) and advanced-stage cancer diagnosis. To help diagnose cancer earlier, this study aimed at examining whether diabetes might influence patient symptom attribution, help-seeking, and willingness to undergo investigations for possible CRC symptoms. Methods: A total of 1307 adults (340 with and 967 without diabetes) completed an online vignette survey. Participants were presented with vignettes describing new-onset red-flag CRC symptoms (rectal bleeding or a change in bowel habits), with or without additional symptoms of diabetic neuropathy. Following the vignettes, participants were asked questions on symptom attribution, intended help-seeking, and attitudes to investigations. Results: Diabetes was associated with greater than two-fold higher odds of attributing changes in bowel habits to medications (OR = 2.48; 95% Cl 1.32–4.66) and of prioritising diabetes-related symptoms over the change in bowel habits during medical encounters. Cancer was rarely mentioned as a possible explanation for the change in bowel habits, especially among diabetic participants (10% among diabetics versus 16% in nondiabetics; OR = 0.55; 95% CI 0.36–0.85). Among patients with diabetes, those not attending annual check-ups were less likely to seek help for red-flag cancer symptoms (OR = 0.23; 95% Cl 0.10–0.50). Conclusions: Awareness of possible cancer symptoms was low overall. Patients with diabetes could benefit from targeted awareness campaigns emphasising the importance of discussing new symptoms such as changes in bowel habits with their doctor. Specific attention is warranted for individuals not regularly attending healthcare despite their chronic morbidity

Evaluation of the Call for a Kit intervention to increase bowel cancer screening uptake in Lancashire, England

Objective: To evaluate the ‘Call for a Kit’ health promotion intervention that was initiated in Lancashire, England to improve bowel cancer screening uptake. Methods: Within the intervention, screening non-responders are called and invited to attend a consultation with a health promotion team member at their primary care practice. In this audit, we analysed the proportion of those contacted who attended the in-person clinic versus those who received a phone consultation, the number returning a test kit from in-person versus phone consultations, and the extent to which test kit return was moderated by sociodemographic characteristics. Results: In 2019, 68 practices participated in the intervention which led to 10,772 individuals being contacted; 2464 accepted the invitation to an in-person consultation, of whom 1943 attended. A further 1065 agreed to and attended a consultation over the phone. The 3008 consultations resulted in 2890 test kits being ordered, of which 1608 (55.6%) were returned. The intervention therefore yielded a 14.9% response rate in the total cohort; 71.5% of test kits came from individuals attending the in-person consultation. Women and those registered with a practice in socioeconomically deprived areas were less likely to return the test kit. Individuals with a black, mixed or a non-Indian/Pakistani Asian ethnic background were significantly more likely to accept the offer of an in-person consultation and return the test kit. Conclusion: Our analysis demonstrated the strong likelihood of people returning a test kit after an in-person appointment but also the usefulness of using phone consultations as a safety net for people unable or unwilling to attend in-person clinics