Improving uptake of flexible sigmoidoscopy screening: a randomized trial of nonparticipant reminders in the English Screening Programme

Abstract

Background and study aims Uptake of flexible sigmoidoscopy screening in the English Bowel Scope Screening (BSS) Programme is low. The aim of this study was to test the impact of a nonparticipant reminder and theory-based leaflet to promote uptake among former nonresponders (previously did not confirm their appointment) and nonattenders (previously confirmed their appointment but did not attend).

Patients and methods Eligible adults were men and women in London who had not attended a BSS appointment within 12 months of their invitation. Individuals were randomized (1:1:1) to receive no reminder (control), a 12-month reminder plus standard information booklet (TMR-SIB), or a 12-month reminder plus bespoke theory-based leaflet (TMR-TBL) designed to address barriers to screening. The primary outcome of the study was the proportion of individuals screened within each group 12 weeks after the delivery of the reminder.

Results A total of 1383 men and women were randomized and analyzed as allocated (n = 461 per trial arm). Uptake was 0.2 % (n = 1), 10.4 % (n = 48), and 15.2 % (n = 70) in the control, TMR-SIB, and TMR-TBL groups, respectively. Individuals in the TMR-SIB and TMR-TBL groups were significantly more likely to attend screening than individuals in the control group (adjusted odds ratio [OR] 53.7, 95 % confidence interval [CI] 7.4 – 391.4, P < 0.001 and OR 89.0, 95 %CIs 12.3 – 645.4, P < 0.01, respectively). Individuals in the TMR-TBL group were also significantly more likely to attend screening than individuals in the TMR-SIB group (OR 1.7, 95 %CIs 1.1 – 2.5, P = 0.01). Across all groups, former nonattenders were more likely to participate in screening than former nonresponders (uptake was 14.2 % and 8.0 %, respectively; OR 2.5, 95 %CIs 1.4 – 4.4, P < 0.01). The adenoma detection rate among screened adults was 7.6 %, which is comparable to the rate in initial attenders.

Conclusions Reminders targeting former nonparticipants can improve uptake and are effective for both former nonresponders and nonattenders. Theory-based information designed to target barriers to screening added significantly to this strategy.

• References

• 1 Department of Health. NHS Bowel Cancer Screening Programme. Piloting of flexible sigmoidoscopy – Advice to the NHS bidding process. 2012 Available from https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/215205/dh_132468.pdf Accessed 29 May 2015
• 2 Atkin WS, Edwards R, Kralj-Hans I. et al. Once-only flexible sigmoidoscopy screening in prevention of colorectal cancer: a multicentre randomised controlled trial. Lancet 2010; 375: 1624-1633
• 3 McGregor LM, Bonello B, Kerrison RS. et al. Uptake of bowel scope (flexible sigmoidoscopy) screening in the English National Programme: the first 14 months. J Med Screen 2016; 23: 77-82
• 4 Geurts S, Massat N, Duffy S. Likely effect of adding flexible sigmoidoscopy to the English NHS Bowel Cancer Screening Programme: impact on colorectal cancer cases and deaths. Br J Cancer 2015; 113: 142-149
• 5 Senore C, Ederle A, DePretis G. et al. Invitation strategies for colorectal cancer screening programmes: the impact of an advance notification letter. Preventive Med 2015; 73: 106-111
• 6 Holme Ø, Løberg M, Kalager M. et al. Effect of flexible sigmoidoscopy screening on colorectal cancer incidence and mortality: a randomized clinical trial. JAMA 2014; 312: 606-615
• 7 Vernon SW. Participation in colorectal cancer screening: a review. J Natl Cancer Institute 1997; 89: 1406-1422
• 8 Sutton S, Wardle J, Taylor T. et al. Predictors of attendance in the United Kingdom flexible sigmoidoscopy screening trial. J Med Screening 2000; 7: 99-104
• 9 Jones RM, Woolf SH, Cunningham TD. et al. The relative importance of patient-reported barriers to colorectal cancer screening. Am J Preventive Med 2010; 38: 5 , 499–507
• 10 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. Preventive Med 2014; 61: 100-105
• 11 Olynyk JK, Aquilia S, Fletcher DR. et al. Flexible sigmoidoscopy screening for colorectal cancer in average-risk subjects: a community-based pilot project. Med J Australia 1996; 165: 74-76
• 12 Hardcastle J, Farrands P, Balfour T. et al. Controlled trial of faecal occult blood testing in the detection of colorectal cancer. Lancet 1983; 322: 1-4
• 13 Tilley BC, Vernon SW, Myers R. et al. The Next Step Trial: impact of a worksite colorectal cancer screening promotion program. Preventive Med 1999; 28: 276-283
• 14 Kelly RB, Shank JC. Adherence to screening flexible sigmoidoscopy in asymptomatic patients. Med Care 1992; 30: 1029-1042
• 15 Nichols S, Koch E, Lallemand R. et al. Randomised trial of compliance with screening for colorectal cancer. BMJ 1986; 293: 107-110
• 16 Pye G, Christie M, Chamberlain J. et al. A comparison of methods for increasing compliance within a general practitioner based screening project for colorectal cancer and the effect on practitioner workload. J Epidemiol Community Health 1988; 42: 66-71
• 17 Wardle J, Williamson S, McCaffery K. et al. Increasing attendance at colorectal cancer screening: testing the efficacy of a mailed, psychoeducational intervention in a community sample of older adults. Health Psychology 2003; 22: 99
• 18 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; 387: 751-759
• 19 Stone EG, Morton SC, Hulscher ME. et al. Interventions that increase use of adult immunization and cancer screening services: a meta-analysis. Ann Internal Med 2002; 136: 641-651
• 20 Power E, Miles A, von Wagner C. et al. Uptake of colorectal cancer screening: system, provider and individual factors and strategies to improve participation. Future Oncol 2009; 5: 1371-1388
• 21 Senore C, Inadomi J, Segnan N. et al. Optimising colorectal cancer screening acceptance: a review. Gut 2015; 64: 1158-1177
• 22 Lewis CL, Brenner AT, Griffith JM. et al. The uptake and effect of a mailed multi-modal colon cancer screening intervention: a pilot controlled trial. Implement Sci 2008; 3: 32
• 23 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. Br J Cancer 2011; 105: 475-480
• 24 Bevan R, Rubin G, Sofianopoulou E. et al. Implementing a national flexible sigmoidoscopy screening program: results of the English early pilot. Endoscopy 2015; 47: 225-231
• 25 Libby G, Bray J, Champion J. et al. Pre-notification increases uptake of colorectal cancer screening in all demographic groups: a randomized controlled trial. J Med Screening 2011; 18: 24-29
• 26 Allgood PC, Maxwell AJ, Hudson S. et al. A randomised trial of the effect of postal reminders on attendance for breast screening. Br J Cancer 2016; 114: 171-176
• 27 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
• 28 Steele R, Kostourou I, McClements P. et al. Effect of repeated invitations on uptake of colorectal cancer screening using faecal occult blood testing: analysis of prevalence and incidence screening. BMJ 2010; 341: c5531
• 29 Pisera M, Kaminski MF, Kraszewska E. et al. Reinvitation to screening colonoscopy: a randomized-controlled trial of reminding letter and invitation to educational meeting on attendance in nonresponders to initial invitation screening colonoscopy (REINVITE). Eur J Gastroenterol Hepatol 2016; 28: 538-542
• 30 Kerrison RS, McGregor LM, Marshall S. et al. Use of a 12 months’ self-referral reminder to facilitate uptake of bowel scope (flexible sigmoidoscopy) screening in previous non-responders: a London-based feasibility study. Br J Cancer 2016; 114: 751-758
• 31 Power E, Van Jaarsveld CH, McCaffery K. et al. Understanding intentions and action in colorectal cancer screening. Ann Behavioral Med 2008; 35: 285-294
• 32 Halloran SP. Bowel cancer screening. Surgery (Oxford) 2009; 27: 397-400
• 33 Babbie ER. The practice of social research. Belmont, CA: Wadsworth publishing company; 1998
• 34 Kiviniemi MT, Bennett A, Zaiter M. et al. Individual‐level factors in colorectal cancer screening: a review of the literature on the relation of individual‐level health behavior constructs and screening behavior. Psychooncology 2011; 20: 1023-1033
• 35 Rosenstock IM. The health belief model and preventive health behavior. Health Educ Behav 1974; 2: 354-386
• 36 Bandura A. Health promotion by social cognitive means. Health Educ Behav 2004; 31: 143-164
• 37 Ramirez A, Forbes L. Approach to developing information about NHS cancer screening programmes. King’s Health Partners; 2012
• 38 Department for Communities and Local Government. English indices of deprivation. 2010 Available from https://www.gov.uk/government/statistics/english-indices-of-deprivation-2010 Accessed: 10 July 2015
• 39 Ferrer RA, Hall KL, Portnoy DB. et al. Relationships among health perceptions vary depending on stage of readiness for colorectal cancer screening. Health Psychology 2011; 30: 525
• 40 Wardle J, Miles A, Atkin W. Gender differences in utilization of colorectal cancer screening. J Med Screen 2005; 12: 20-27
• 41 von Karsa L, Patnick J, Segnan N. et al. European guidelines for quality assurance in colorectal cancer screening and diagnosis: overview and introduction to the full supplement publication. Endoscopy 2013; 45: 51
• 42 Hudson S, Brazil D, Teh W. et al. Effectiveness of timed and non-timed second appointments in improving uptake in breast cancer screening. J Med Screen 2016; 23: 160-163