Bowel cancer screening

Unlike the other cancer screening programmes in the UK, participating in bowel cancer screening does not involve any contact with a health professional. 

Evidence suggests that there are interventions that can support an increase in participation of bowel cancer screening, which is lower than seen in other cancer screening programmes, while promoting informed consent.  Research shows that primary care involvement can significantly increase participation in bowel cancer screening [1-4]. 

CRUK Primary Care Good Practice Guides offer practical advice to primary care to support people to make an informed decision about participating in bowel cancer screening.

 

Intervention	Evidence
GP endorsement letter Enhanced patient leaflet	A GP-endorsed letter, or enhanced patient leaflet alongside the screening kit appear to have the largest effect on bowel cancer screening uptake. When combined, these interventions increase uptake by up to 12% [1]. Since this study, a GP endorsement banner has been introduced on both pre-invite and invite letters across England. A study by Raine et al. provides further evidence for the effectiveness of GP endorsement in increasing bowel cancer screening uptake. This large-scale study included 80% of GP practices in England, added a simple GP endorsement banner to the standard screening invitation letter. Overall uptake increased by 0.7%, which although appears to be a small increase, could mean up to 40,000 extra people screened if rolled out nationally [2]. The Practice Endorsed Additional Reminder Letter (PEARL) project similarly assessed the impact of GP-endorsement on bowel screening uptake, this time in the context of a reminder letter. Overall, bowel screening uptake was 3% higher in practices which used the intervention, compared to other practices which did not [3]
Telephone advice* Face to face health promotion*	Shown to increase uptake by around 8% and 5% respectively, when used in combination with a GP endorsement letter which was sent 2 weeks after their screening due date [4]. The project that incorporated these activities took place in areas of low socio-economic status and high ethnic diversity, suggesting potential to address inequalities in screening uptake.  Cancer Research UK Bowel Screening Good Practice Guide has a sample telephone script that you can use to engage your eligible population.
Enhanced reminder letters Advertising/health marketing	Enhanced reminder letters with a banner have not only shown to increase uptake, but also reduce the socio-economic gradient in bowel screening uptake [5]. The enhanced version of the leaflet directly addresses perceived barriers to completing the test and provides practical tips. This strategy is supported by previous research showing that providing detailed instructions on the collection, storage and return of screening kits can increase the proportion of people taking part [6,7]. The content was developed with advice from an expert steering group and was extensively piloted. Download this data(link is external) CRUK Bowel Screening Good Practice Guide has a template GP endorsement letter that you can use to engage your eligible population.
Text reminders	No increased uptake overall, but it did increase uptake in non-responders [8]   CRUK Bowel Screening Good Practice Guide has a template text reminder that you can use to engage your eligible population.

 

*Only tested in combination with other elements

References:

1. Hewitson P, Ward A, Heneghan C, et al. Primary care endorsement letter and a patient leaflet to improve participation in colorectal cancer screening: results of a factorial randomised trial. Brit J Cancer         2011;9;105(4):475-80.
2. Raine R, Duffy SW, Wardle J et al Impact of general practice endorsement on the social gradient in uptake in bowel cancer screening. Br J Cancer. 2016 Feb 2;114(3):321-63.
3. Benton SC, Butler P, Allen K, et al. GP participation in increasing uptake in a national bowel cancer screening programme: the PEARL project. Br J Cancer. 2017;116(12):1551–1557. doi:10.1038/bjc.2017.129
4. Shankleman J, Massat N, Khagram L et al. Evaluation of a service intervention to improve awareness and uptake of bowel cancer screening in ethnically-diverse areas Brit J Cancer 2014;23;111(7):1440-7.
5. Wardle J, von Wagner C, Kralj-Hans I et al Effects of evidence-based strategies to reduce the socioeconomic gradient of uptake in the English NHS Bowel Cancer Screening Programme (ASCEND): four cluster-randomised controlled trials. Lancet. 2016 Feb 20; 387(10020): 751–759.
6. Stokamer CL, Tenner CT, Chaudhuri J, et al. Randomised controlled trial of the impact of intensive patient education on compliance with feacal occult blood testing. J Gen Intern Med. 2005;20(3):278-82.
7. Miller DP Jr, Kimberly JR Jr, Case LD et al. Using a computer to teach patients about feacal occult blood screening. A randomised trial.  J Gen Intern Med. 2005;20(11):984-8.
8. Hirst Y. Skrobanski H. Kerrison RS. Kobayashi LC. Counsell N. Djedovic N. et al. Text-message reminders in colorectal cancer screening (TRICCS): a randomised controlled trial. British Journal of Cancer 2017, 116(11): 1408-14

 

Considerable research has taken place to try and understand the barriers that may prevent those eligible from engaging with the bowel cancer screening programme.

Understanding who is not attending screening and the barriers preventing them from participating is important when looking at ways to support engagement with the programme. The reasons for non-attendance may be complex and several factors may be at place. 

Some of these barriers include:

• Fear and denial around the test outcome [1-4]
• A misconception that the test is not applicable if you don’t have any apparent symptoms of bowel cancer [1,2,5,6]
• Concerns around the practicalities and cleanliness of the test [3,5-8]
• Individual perceived risk being low or consideration of future consequences of bowel cancer [2,3,6,7]
• The fact that it takes place away from the usual health care settings [1,3]
• Low health literacy and numeracy [9,10]
• Gender - on the whole, males were less likely to take part in screening [11,12]
• People from lower socioeconomic group [13,14,15]
• People from ethnic minor communities – note disparity varies by ethnic minority group [16,17]
• People with severe mental illness [18]

Some people face barriers after deciding to participate in bowel cancer screening and receiving a positive FIT and may decide not to attend further tests (usually colonoscopy). 

Health professionals may have a role in providing information to support people to make an informed decision about attending any further tests *. Barriers have been researched [19]:

• Concerns about the procedure (concerns about doing the bowel preparation and fear about pain and discomfort
• Anxiety and denial
• Cognitive abilities and ability to make an informed decision
• Perceived risk and perceived mortality

References:

1. Palmer CK, Thomas MC, von Wagner C et al. Reasons for non-uptake? and subsequent participation in the NHS Bowel Cancer Screening Programme: a qualitative study. Br J Cancer. 2014;110(7):1705-11.
2. Ekberg M, Callender M, Hamer H et al. Exploring the decision to participate in the National Health Service Bowel Cancer Screening Programme. Eur J Cancer Prev. 2014;23(5):391-7.
3. Miles A, Rainbow S, von Wagner C. Cancer fatalism and poor self-rated health mediate the association between socioeconomic status and uptake of colorectal cancer screening in England. Cancer Epidemiol Biomarkers Prev. 2011;20(10):2132-40.
4. Hall NJ, Rubin GP, Dobson C et al. Attitudes and beliefs of non-participants in a population-based screening programme for colorectal cancer. Health Expect. 2015;18(5):1645-1657.
5. von Wagner C, Good A, Smith SG, et al. Responses to procedural information about colorectal cancer screening using faecal occult blood testing: the role of consideration of future consequences. Health Expect. 2012;15(2):176-86.
6. Bennett K., von Wagner C, Robb, K. Supplementing factual information with patient narratives in the cancer screening context: a qualitative study of acceptability and preferences. Health Expect. 2015;18(6):2032-2041.
7. Kobayashi LC, Wardle J, von Wagner C. Limited health literacy is a barrier to colorectal cancer screening in England: evidence from the English Longitudinal Study of Ageing. Prev Med. 2014;61:100-5.
8. Gale CR, Deary IJ, Wardle J et al. Cognitive ability and personality as predictors of participation in a national colorectal cancer screening programme: the English Longitudinal Study of Ageing. J Epidemiol Community Health. 2015;69(6):530-5.
9. Kobayashi LC, Wardle J, von Wagner C. Limited health literacy is a barrier to colorectal cancer screening in England: evidence from the English Longitudinal Study of Ageing. Prev Med. 2014;61:100-5.
10. Gale CR, Deary IJ, Wardle J et al. Cognitive ability and personality as predictors of participation in a national colorectal cancer screening programme: the English Longitudinal Study of Ageing. J Epidemiol Community Health. 2015;69(6):530-5.
11. White, A., Ironmonger, L., Steele, R.J.C. et al. A review of sex-related differences in colorectal cancer incidence, screening uptake, routes to diagnosis, cancer stage and survival in the UK. BMC Cancer 18, 906 (2018). https://doi.org/10.1186/s12885-018-4786-7
12. Condon, L., Curejova, J., Morgan, D.L. et al. Knowledge and experience of cancer prevention and screening among Gypsies, Roma and Travellers: a participatory qualitative study. BMC Public Health 21, 360 (2021). https://doi.org/10.1186/s12889-021-10390-y
13. Lo SH, Halloran S, Snowball J, et al. Colorectal cancer screening uptake over three biennial invitation rounds in the English bowel cancer screening programme. Gut 2015;64:282-291.
14. McCowan, C., McSkimming, P., Papworth, R. et al. Comparing uptake across breast, cervical and bowel screening at an individual level: a retrospective cohort study. Br J Cancer 121, 710–714 (2019). https://doi.org/10.1038/s41416-019-0564-9
15. Lal N, Singh HK, Majeed A, Pawa N. The impact of socioeconomic deprivation on the uptake of colorectal cancer screening in London. J Med Screen. 2021 Jun;28(2):114-121. doi: 10.1177/0969141320916206.
16. Sekhon Inderjit Singh HK, Lal N, Majeed A, Pawa N. Ethnic disparities in the uptake of colorectal cancer screening: An analysis of the West London population. Colorectal Dis. 2021 Jul;23(7):1804-1813. doi: 10.1111/codi.15682.
17. Kerrison, R.S., Prentice, A., Marshall, S. et al. Ethnic inequalities in older adults bowel cancer awareness: findings from a community survey conducted in an ethnically diverse region in England. BMC Public Health 21, 513 (2021). https://doi.org/10.1186/s12889-021-10536-y
18. Public Health England (2021). Severe mental illness (SMI): inequalities in cancer screening uptake report
19. Kerrison RS, Travis E, Dobson C, Whitaker KL, Rees CJ, Duffy SW, von Wagner C. Barriers and facilitators to colonoscopy following fecal immunochemical test screening for colorectal cancer: A key informant interview study. Patient Educ Couns. 2021 Sep 17:S0738-3991(21)00631-5. doi: 10.1016/j.pec.2021.09.022.

Bowel cancer screening uptake is lower than other national cancer screening programmes, and there are considerable inequalities between areas and across different demographic groups.

In the UK, although gaps in data availability persist, there is evidence that participation in all three of the cancer screening programmes is lower in:

• more ethnically diverse communities [1]
• people from more deprived groups [2]
• people in vulnerable groups, such as those with learning disabilities [1]
• people with severe mental illness [3, 4]

Taking part in screening is an individual choice, but it must be a choice that is equally available to all. 

We believe it is crucial to reduce inequalities in cancer screening uptake and as a minimum ensure that interventions do not exacerbate inequalities. CRUK has developed a guide that offers practical tips to help reduce inequalities, as well as signposting to further resources and information. 

References

1. Young B, Robb KA. Understanding patient factors to increase uptake of cancer screening: a review. Future Oncol. 2021 Aug 11. doi: 10.2217/fon-2020-1078. Epub ahead of print.
2. https://www.cancerresearchuk.org/sites/default/files/cancer_inequalities...
3. Woodhead, C., Cunningham, R., Ashworth, M. et al. Cervical and breast cancer screening uptake among women with serious mental illness: a data linkage study. BMC Cancer 16, 819 (2016). https://doi.org/10.1186/s12885-016-2842-8
4. https://www.gov.uk/government/publications/severe-mental-illness-inequalities-in-cancer-screeninguptake/severe-mental-illness-smi-inequalities-in-cancer-screening-uptake-report

Here you can find resources and examples of good practice that can support you to plan and deliver bowel cancer screening informed participation.

CRUK is committed to informed choice with respect to screening participation. Screening has both benefits and harms, and these must be communicated appropriately.

Primary Care Good Practice Guide

Cancer Research UK aims to share examples of good practice. It is up to each individual practice to explore what methods they wish to facilitate and to take responsibility to compliance with data protection processes as appropriate.

Our Primary Care good practice guides provide support to health professionals in primary care to get them thinking about how they can support their practice population to participate in bowel cancer screening, through informed choice

These guides offer an overview of the bowel cancer screening programme, some practical tips and templates such as GP template letters, text and phone call scripts.

Animated videos to support completing the bowel cancer screening test

An animated video which explains how to complete the bowel cancer screening test kit. There is a subtitled version too.

PHE Screening animations

You can also find short animations produced by PHE Screening which explain how to use your bowel cancer screening kit here Subtitles are available in English, as well as Arabic, Bengali, Chinese (simplified and traditional), Farsi, Gujarati, Polish, Portuguese, Punjabi and Urdu. A British Sign Language version is also available.

Infographic – how to do bowel screening

A step-by-step infographic on how to complete the bowel cancer screening test kit and practical tips how to collect the poo sample.

GP Endorsement/Primary Care Involvement

Improving Uptake Project

In Phase 1 of the Improving Bowel Cancer Screening Project, all GP practices in Pennine Lancashire were asked to contact 5+ patients who had not responded to their screening invitation. They chose to either telephone or send a letter, or discuss opportunistically face to face during a consultation. The practices were asked to review these patients 3-4 months later to see if they had subsequently attended, and review the result. GPs were also provided with an information pack and training.

Key findings:

• Practices were incentivised to take part. Any that demonstrated innovative methods of increasing patient participation were eligible to apply for additional payment
• Approximately 76 practices returned figures which were then collated and summarised
• 1,009 patients who had not initially participated in bowel screening were contacted
• 15.9% of patients subsequently requested replacement bowel screening kits and returned them to the screening hub
• Subsequent participation was more likely if there had been face to face discussion (35%) than telephone advice (20%), letter (11%) or unknown method of contact (8%)

Location: Pennine Lancashire, Blackburn with Darwen and East Lancashire CCGs

Date: 2014/15

Contact: Dr Neil Smith, Cancer Clinical Lead, neil.smith2@nhs.net

Download report Download presentation

 

Automatic Email Request

In Phase 2 of the project in Lancashire, more links were established between the Bowel Cancer Screening Programme hub (for the North West & Midlands) and each GP Practice via the EMIS web record system. This enabled the direct electronic transfer of registered patients’ bowel screening results from the hub to each practice and also the option for practices to order a replacement test kit on behalf of a previous non-responder via email. Practices were similarly incentivised to take part in Phase 2 of the project.

Key findings:

• Preliminary data (as at February 2017) shows that 729 requests were made for replacement kits and 317 patients (44%) completed them, 7 abnormal results were recorded from 38 practices
• The project demonstrates that a large regional screening hub based in an acute hospital setting can work collaboratively with primary care professionals at a local level to achieve health improvement and a good outcome
• Phase 3 of the project will build on the work already achieved, sharing evidential learning with others and expanding as appropriate

Location: Pennine Lancashire – Blackburn with Darwen and East Lancashire CCGs

Date: 2016/17

Contact: Dr Neil Smith, Cancer Clinical Lead, neil.smith2@nhs.net

Download report

 

Call for a Kit Clinic

The ‘Call for a Kit’ intervention was set up in Lancashire to address previous non-responders. Those who have not completed the kit are invited to an appointment at their GP practice with the BCSP health promotion team. They are shown the kit and a DVD on how to complete it. Questions and anxieties are addressed, and if they agree to complete the test and require a replacement kit, the team phone the screening hub and order a kit on their behalf.

Key findings:

• 84% of people invited to the clinic actually attend in person; 91% of people attending the clinic have a kit ordered; 58% of people who attended subsequently completed the kit
• Gender specific clinics were also offered to patients, this worked well and helped subjects overcome issues around cultural dignity, discussing sensitive body parts and aided discussions on how to collect poo
• The clinic offered 5 different languages to engage with patients who actually attended
• Next steps include running the Call for a Kit clinics in next cohort of lowest uptake GP practices in each CCG

Location: Lancashire

Date: 2015/16

Contact: Shahida Hanif, BCSP Health Promotion Specialist, Shahida.Hanif@bfwhospitals.nhs.uk

Download report Download evaluation

 

Community Awareness Activities

Early Presentation Symptoms

A community-led engagement campaign (the Cancer Collaborative) was set up in North East Lincolnshire to work with healthcare professionals and to raise awareness of the signs and symptoms of cancer. When the bowel screening programme started, the activity was extended to include messages around screening. It draws upon the local experiences and knowledge of communities and practitioners to identify a wide range of solutions that will work locally.

Key findings:

• Marketing and community involvement materials were developed following audience testing
• Badges and stickers which could be worn by health professionals were developed and used as a prompt for conversation with patients
• Bowel screening uptake in North East Lincolnshire increased from 55.2% in 2008 to 59.9% in 2013
• Consistent ‘reminding’ of the key messages to the local target population has been seen to increase uptake in bowel screening
• In planning for the future, the team continue to monitor activity and work with primary care to focus on low uptake areas.

Location: North East Lancashire

Date: 2015

Contact: Julie Grimmer, Collaborative Programme Manager, julie.grimmer@nhs.net

Download report

Till Receipt Awareness Campaign

Four 99p Stores in Merseyside were chosen to run a bowel screening awareness campaign based on their central locations, and due to their diverse population customer group. The campaign included awareness messages printed on the reverse side of till receipts, which were used at the main till banks. The till receipt included messaging such as: ‘Over 60? Do your bit – return your screening kit. Bowel screening saves lives.’

Key findings:

• Till receipt campaigns can be a low cost option to marketing awareness messages 
• There were a number of limitations with the project, which included: difficulties with evaluation e.g. linking increases in participation directly with the campaign, other campaigns running at the same time
• It is recommended that healthcare partners pay close attention to contracting, ensuring all parties are clear on their commitments and expectations from the start.

Location: Merseyside

Date: 2014

Contact: Marie Coughlin, Screening and Immunisation Manager, marie.coughlin@nhs.net

Download report

Barbers Pilot Project

The barber’s project in Blackburn with Darwen was developed, facilitated and delivered by Sadiq Patel who is a BCSP Community Engagement Officer. Ten barbers were recruited to take part in the pilot within two low uptake, high ethnic minority areas. The barbers were supported to plan one week’s bowel cancer screening campaign within their salons and record data on the numbers engaged. They also recorded the key issues raised by local communities.

Key findings:

• The project was incentivised and barbers received an award once the project was completed
• Trained volunteers were involved in raising awareness at the barber shops during peak times, including holding weekly information stands in each shop
• Over 1,600 men were engaged within the salons by the ten barbers (1,099 of these men were below 60, and 671 were between 60-75)
• The project allowed for 1,770 bowel screening materials to beistributed
• Utilising barbers in engaging with specific communities was seen to be worthwhile.

Location: Lancashire, Blackburn and Darwen CCG

Date: 2014

Contact: Sadiq Patel, BCSP Community Engagement Officer, Sadiq.Patel@bwdcvs.org.uk

Download report

Primary care health professionals will be notified as to whether a person has participated in the bowel cancer screening programme and if so, whether they had a positive or negative result. A numerical value of the FIT result will not be given.

Safety netting patients:

• Even in patients with a negative FIT screening result, it’s important that GPs continue to be alert to the possibility of bowel cancer and if people are displaying symptoms consider a symptomatic FIT test
• GPs should also remind people to be aware of key signs and symptoms of bowel cancer, and to seek medical advice if they notice anything new or unusual, even if they’ve recently taken part in bowel cancer screening and had a negative result.

The use of FIT in screening vs symptomatic:

There are important key differences in the use of FIT for screening asymptomatic people through the bowel cancer screening programme compared to being used to investigate symptomatic patients.
For further information, see our FIT key differences infographics.

In England, the Primary Care Network (PCN) GP Contract for Early Diagnosis requires PCNs to: Contribute to improving local uptake of National Cancer Screening Programmes by working with local system partners to agree the PCN contribution to local efforts to improve uptake in bowel cancer screening and follow up on non-responders to invitations.

This must build on any existing actions across the PCN’s Core Network Practices and include at least one specific action to engage a group with low participation locally.

For more information see

The FIT test looks for hidden traces of blood in the poo and is intended for people without any signs or symptoms of bowel cancer.

The UK National Screening Committee (NSC) has recommended in the UK that screening for bowel cancer should be offered, using the faecal-immunochemical test for people aged between 50 and 74, every 2 years, with a threshold of 20μg/g.

FIT sensitivity threshold

FIT measures micrograms of human haemoglobin per gram of faeces. The definition of a positive or negative result can be changed by altering the numerical FIT threshold. As a general statement, the lower the threshold, the more sensitive the test will be and the more cases of cancer and adenoma that will be detected and ultimately deaths from bowel cancer averted [1]

In Scotland, the threshold of FIT is 80μg/g, which has a higher detection rate for advanced adenomas but a comparable cancer detection rate to gFOBT screening.

In England, FIT has a threshold of 120 μg/g and in Wales and Northern Ireland, FIT has a threshold of 150μg/g.   Following the UK NSC recommendation, there are plans in these nations to optimise FIT, by reducing the sensitivity threshold

FIT age reduction

In England and Wales, people age 50–59-year-olds will be invited to participate, in the bowel cancer screening programme, as a phased approach over the next few years. Therefore, people may now receive a test before they turn 60.

 

References:

1.  https://www.isdscotland.org/Health-Topics/Cancer/Publications/2019-08-06/2019-08-06-Bowel-Screening-Publication-Report.pdf