Evidence on increasing bowel screening uptake

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Bowel cancer screening reduces death from bowel cancer [1]. Promoting an informed choice and understanding the barriers to participation and what can be done to overcome these are key to reducing inequalities across the bowel screening programme. CRUK has produced a guide for health professionals to help reduce inequalities.

The Faecal Immunochemical Test (FIT) has replaced the guaiac Faecal Occult Blood test (gFOBT) as the primary screening test in England, Scotland and Wales, and will be introduced in Northern Ireland in 2020. The FIT test is easier to complete as it only requires one stool sample, however we anticipate that some people will still experience barriers to participation. The available evidence was published when the gFOBT test was the primary test however much of the evidence is still relevant today.  

References:

[1] Scholefield JH, Moss SM, Mangham CM, et al Nottingham trial of faecal occult blood testing for colorectal cancer: a 20-year follow-up Gut 2012;61:1036-1040.

One of the key ways to support uptake of screening is to make the test acceptable to participants [1]. The introduction of FIT into the bowel screening programme is a hugely positive step because amongst other advantages, it only requires participants to take and return one stool sample, rather than the two samples from three separate stools required for guaiac. This may be one of the reasons why uptake is higher for FIT screening than for gFOBT [1-2].

Scotland evaluated the uptake in the year before and after FIT implementation. Uptake has surpassed the standard of 60% for the first time, increasing from 55.4% to 63.9% [3]. The increase in uptake was greater in people from more deprived areas, however, uptake remained lower than in the least deprived areas suggesting inequalities may remain.

References:

  1. Duffy, Stephen William et al. “Rapid review of evaluation of interventions to improve participation in cancer screening services.” Journal of medical screening (2017).
  2. Moss S, Mathews C, Day T et al. Increased uptake and improved outcomes of bowel cancer screening with a faecal immunochemical test: results from a pilot study within the national screening programme in England. Gut doi:10.1136/gutjnl-2015-310691
  3. https://www.isdscotland.org/Health-Topics/Cancer/Publications/2019-08-06/2019-08-06-Bowel-Screening-Publication-Report.pdf

Barriers to bowel screening participation

While FIT will make a positive contribution to bowel screening uptake, we still expect to fall short of that seen in other cancer screening programmes, and inequalities may still exist. Understanding the barriers can help to target interventions to address them.

Considerable research has taken place to try and understand the barriers to bowel screening participation. Several barriers have been identified, these 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]
  • Lower socioeconomic group [12,13]

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. Chapple A, Ziebland S, Hewitson P et al. What affects the uptake of screening for bowel cancer using a faecal occult blood test (FOBt): a qualitative study. Soc Sci Med. 2008;66(12):2425-35.
  4. 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.
  5. O'Sullivan I, Orbell S. Self-sampling in screening to reduce mortality from colorectal cancer: a qualitative exploration of the decision to complete a faecal occult blood test (FOBT). J Med Screen. 2004;11(1):16-22.
  6. 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.
  7. 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.
  8. 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.
  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. Taskila T, Wilson S, Damery S et al. Factors affecting attitudes toward colorectal cancer screening in the primary care population. Br J Cancer. 2009;21;101(2):250-5.
  12. Weller, DP and Campbell C. Uptake in cancer screening programmes: a priority in cancer control. Br J Cancer. 20093;101(Suppl 2):S55–S59.
  13. von Wagner C, Good A, Wright D et al. Inequalities in colorectal cancer screening participation in the first round of the national screening programme in England. Br J Cancer. 2009;101:S60-S63.

Overview of the evidence base

The available evidence shows that several interventions have increased bowel screening uptake, while others show no clear effect on uptake. and others where there wasn't a clear increase in uptake.

     Increases uptake

     More evidence needed

  • GP endorsement letter
  • Enhanced patient leaflet
  • Telephone advice*
  • Enhanced reminder letters
  • Advertising/health marketing
  • Face to face health promotion*
  • Community awareness activities
  • Personal screening stories
  • Numerical/pictorial information
  • Concise summarised 'gist' information
  • Implementation intention style tips in the NHS kit instructions**
  • Text reminders
  • Research questionnaire (decreased uptake)

*Only tested in combination with other elements

**Small increase in the most deprived group, but offset by decrease in the least deprived group

Unlike the other cancer screening programmes in the UK, participating in bowel screening does not involve any contact with a health professional. However, evidence suggests that primary care involvement increases uptake [1-4].

Evidence supporting GP endorsement to promote bowel screening

Telephone advice and face to face health promotion has 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 [1]. 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. The CRUK Bowel Screening Good Practice Guide has a sample telephone script that you can use to engage your eligible population.

A GP-endorsed letter, or enhanced patient leaflet alongside the screening kit appear to have the largest effect on bowel screening uptake. When combined, these interventions increase uptake by up to 12% [2].

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 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 [3].

Evidence supporting GP endorsement to encourage non-responders to participate in bowel screening

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 [4]. 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

The CRUK Bowel Screening Good Practice Guide has a template GP endorsement letter that you can use to engage your eligible population if they have not participated in bowel screening.

References:

  1. 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.
  2. 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.
  3. 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):321-6
  4. 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
  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.

Research questionnaire

Including a research questionnaire alongside a standard bowel screening kit can decrease bowel screening uptake by up to 5% [1]. The decrease in uptake may be due to the questionnaire used in the study adding a large volume of written information to the screening kits that the participants were sent. It is important to consider the impact that any materials you add to the screening kit may have on people’s decision to take part in screening.

A similar peer-reviewed study based in Scotland found no overall effect on uptake when sending a so-called ‘anticipated regret’ questionnaire alongside the bowel screening invitation letter. The intervention questionnaire combined a validated health belief questionnaire with two additional questions asking whether the participant felt they would ‘regret’ it if they did not complete the kit or ‘later wish they had done’ [2].

References:

  1. Watson J, Shaw K, Macgregor M et al. Use of research questionnaires in the NHS Bowel Cancer Screening Programme in England: impact on screening uptake. J Med Screen. 2013;20(4):192-7.
  2. O'Carroll RE, Chambers JA, Brownleeb L et al Anticipated regret to increase uptake of colorectal cancer screening (ARTICS): A randomised controlled trial. SOC SCI MED 2015; 142: 118-127

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