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      Including a general practice endorsement letter with the testing kit in the Bowel Cancer Screening Programme: Results of a cluster randomised trial

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          Abstract

          Objectives

          To evaluate the effect of general practitioner endorsement accompanying the screening kit rather than with the invitation letter on participation in the NHS Bowel Cancer Screening Programme and on the socioeconomic gradient in participation in the Programme.

          Methods

          The NHS Bowel Cancer Screening Programme in England is delivered via five regional hubs. In early 2016, we carried out a cluster-randomised trial, with hub-day of invitation as the randomisation unit. We randomised 150 hub-days of invitation to the intervention group, GP endorsement on the letter accompanying the guaiac faecal occult blood testing kit (75 hub-days, 197,366 individuals) or control, usual letter (75 hub-days, 197,476 individuals). The endpoint was participation, defined as return of a valid kit within 18 weeks of initial invitation. Because of the cluster randomisation, data were analysed by a hierarchical logistic regression, allowing a random effect for date of invitation. Socioeconomic status was represented by the index of multiple deprivation.

          Results

          Participation was 59.4% in the intervention group and 58.7% in the control group, a significant difference ( p = 0.04). There was no heterogeneity of the effect of intervention by index of multiple deprivation. We found that there was some confounding between date and screening episode order (first or subsequent screen). This in turn may have induced confounding with age and slightly diluted the result.

          Conclusions

          General practitioner endorsement induces a modest increase in participation in bowel cancer screening, but does not affect the socioeconomic gradient. When considering cluster randomisation as a research method, careful scrutiny of potential confounding is indicated in advance if possible and in analysis otherwise.

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          Most cited references11

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          Inequalities in participation in an organized national colorectal cancer screening programme: results from the first 2.6 million invitations in England

          An organized, population-based, colorectal cancer screening programme was initiated in England in 2006 offering biennial faecal occult blood testing (FOBT) to adults aged 60-69 years. Organized screening programmes with no associated financial costs to the individual should minimize barriers to access for lower socio-economic status (SES) groups. However, SES differences in uptake were observed in the pilot centres of the UK programme, so the aim of this analysis was to identify the extent of inequalities in uptake by SES, ethnic diversity, gender and age in the first 28 months of the programme. Design Cross-sectional analysis of colorectal cancer screening uptake data. Between October 2006 and January 2009, over 2.6 million adults aged 60-69 years were mailed a first FOBT kit by the five regional screening hubs. Uptake was defined as return of a test kit within 13 weeks. We used multivariate generalized linear regression to examine variation by area-based socioeconomic deprivation, area-based ethnicity, gender and age. Uptake was 54%, but showed a gradient across quintiles of deprivation, ranging from 35% in the most deprived quintile to 61% in the least deprived. Multivariate analyses confirmed an independent effect of deprivation, with stronger effects in women and older people. The most ethnically diverse areas also had lower uptake (38%) than other areas (52-58%) independent of SES, age, gender and regional screening hub. Ethnic disparities were more pronounced in men but equivalent across age groups. More women than men returned a kit (56 vs 51%), but there was also an interaction with age, with uptake increasing with age in men (49% at 60-64 years; 53% at 65-69 years) but not women (57 vs 56%). Overall uptake rates in this organized screening programme were encouraging, but nonetheless there was low uptake in the most ethnically diverse areas and a striking gradient by SES. Action to promote equality of uptake is needed to avoid widening inequalities in cancer mortality.
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            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

            The National Health Service Bowel Cancer Screening Programme (BCSP) in England uses a guaiac-based faecal occult blood test (gFOBt). A quantitative faecal immunochemical test (FIT) for haemoglobin (Hb) has many advantages, including being specific for human blood, detecting Hb at a much lower concentration with a single faecal sample and improved uptake.
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              Is Open Access

              Rapid review of evaluation of interventions to improve participation in cancer screening services

              Objective Screening participation is spread differently across populations, according to factors such as ethnicity or socioeconomic status. We here review the current evidence on effects of interventions to improve cancer screening participation, focussing in particular on effects in underserved populations. Methods We selected studies to review based on their characteristics: focussing on population screening programmes, showing a quantitative estimate of the effect of the intervention, and published since 1990. To determine eligibility for our purposes, we first reviewed titles, then abstracts, and finally the full paper. We started with a narrow search and expanded this until the search yielded eligible papers on title review which were less than 1% of the total. We classified the eligible studies by intervention type and by the cancer for which they screened, while looking to identify effects in any inequality dimension. Results The 68 papers included in our review reported on 71 intervention studies. Of the interventions, 58 had significant positive effects on increasing participation, with increase rates of the order of 2%–20% (in absolute terms). Conclusions Across different countries and health systems, a number of interventions were found more consistently to improve participation in cancer screening, including in underserved populations: pre-screening reminders, general practitioner endorsement, more personalized reminders for non-participants, and more acceptable screening tests in bowel and cervical screening.
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                Author and article information

                Contributors
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                Journal
                Journal of Medical Screening
                J Med Screen
                SAGE Publications
                0969-1413
                1475-5793
                December 2021
                February 27 2021
                December 2021
                : 28
                : 4
                : 419-425
                Affiliations
                [1 ]Department of Surgery and Cancer, Imperial College London, London, UK
                [2 ]Wolfson Institute for Preventive Medicine, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London, UK
                [3 ]Cancer Research UK and UCL Cancer Trials Centre, Cancer Institute, University College London, London, UK
                [4 ]Bowel Cancer Screening Southern Programme Hub, Surrey Research Park, Guildford, UK
                [5 ]Department of Biomedical Sciences, University of Surrey, Guildford, UK
                [6 ]Berkshire and Surrey Pathology Services, Royal Surrey County Hospital, Guildford, UK
                [7 ]Bowel Cancer Screening North East Programme Hub, Queen Elizabeth Hospital, Gateshead, UK
                [8 ]Bowel Cancer Screening Eastern Programme Hub, University of Nottingham, Nottingham, UK
                [9 ]Bowel Cancer Screening London Programme Hub, Northwick Park & St Mark’s Hospitals, Harrow, UK
                [10 ]Bowel Cancer Screening Midlands & North West Programme Hub, Hospital of St Cross, Rugby, UK
                [11 ]Department of Applied Health Research, University College London, London, UK
                Article
                10.1177/0969141321997480
                bbea7018-a6f1-4acd-b2c0-ac56e5a2051a
                © 2021

                http://journals.sagepub.com/page/policies/text-and-data-mining-license

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