Uptake in cancer screening programmes

doi:10.1016/S1470-2045(09)70145-7

The Lancet Oncology

Volume 10, Issue 7, July 2009, Pages 693-699

https://doi.org/10.1016/S1470-2045(09)70145-7 Get rights and content

Summary

For cancer screening programmes to bring about reductions in mortality, a substantial proportion of the population must participate. Programmes with low uptake can be ineffective and can promote inequalities in health-service provision. Strategies to promote uptake are multifaceted, reflecting differences in the cancers targeted, invitees, health-service contexts, and the tests themselves. Accordingly, there is no universal approach. Strategies should accommodate the many factors that can influence uptake and should incorporate the need to promote informed choice. Screening has the potential to cause harm, and there is an ethical imperative to seek out strategies that provide balanced information on cancer screening. Further research is needed to assess newer approaches to promoting uptake, such as IT-based programmes, and to identify strategies that are balanced, self-sustaining, and affordable.

Introduction

Screening is a key strategy for reducing mortality from cancer worldwide. Screening programmes for breast and cervical cancer are widely established in developed countries,1, 2 and screening pilots and programmes for colorectal cancer have emerged over the last decade.³ Although trial evidence is scarce, testing for prostate cancer using the prostate specific antigen (PSA) test is also widespread—particularly in North America.

An increasing number of tests are available to screen for cancer, and existing tests are continually being refined. Screening is offered in many different contexts, including doctors' offices, community settings, and population-based national programmes. An individual's response to a screening invitation can be influenced by their beliefs, attitudes, personal backgrounds, and access to care. Cancer screening is increasingly focused on targeting low-uptake groups, such as those from ethnic minorities (figure 1).

It is difficult to briefly summarise current evidence on cancer screening uptake; what works in a particular combination of test, health-service context, and personal characteristics might not work in another. Nevertheless, many reports have been published on cancer screening uptake and, as new screening technologies and programmes emerge, summarising existing evidence on uptake strategies might inform application in new contexts.

Section snippets

Rationale for screening

Despite vast health-care resources directed towards cancer screening, controversies over its efficacy remain. Although we have relied largely on ecological and descriptive studies to show the effectiveness of cervical screening, it is now generally accepted that there should be evidence of mortality reductions from randomised control trials before screening programmes are introduced. Nevertheless, even when such evidence is convincing, screening always has the potential to cause harm.⁴ Possible

Importance of uptake

Substantial reductions in mortality in cancers that are screened for, such as breast and cervical cancer, are widely attributed to screening activity in recent decades.5, 6, 7, 8 However, reductions in mortality seen in randomised trials can only be reproduced in the wider population if uptake is adequate; higher participation rates should be associated with greater population benefit.⁹ Modelling exercises that predict the effect on cancer mortality of a screening programme are highly dependent

Interventions for increasing uptake

There are many determinants of uptake, including the nature of the test and programme, the health-service context, and the invitee's personal characteristics. Accordingly, research on uptake has a broad focus, as shown in a systematic review commissioned by the UK's Health Technology Assessment Programme.¹² The review found consistent evidence to support organised recruitment strategies that involve scheduled appointments for screening and personalised invitation approaches (from a source such

Screening in low-uptake groups

International studies consistently report low uptake for screening in deprived populations and in some ethnic minority groups.¹² Organisers of screening programmes face many difficulties in promoting uptake in these groups; substantial effort and investment is typically needed to boost recruitment. Nonetheless, it is important in terms of equity that disparities in cancer screening uptake are addressed.

Ethnic differences in breast and bowel screening are seen in the UK, with substantially lower

Promoting informed choice

There has been a growing understanding over the last two to three decades that no screening programme should focus entirely on promoting higher uptake. Indeed, much research is now focused on developing measures of informed choice alongside measures for improving uptake.⁶¹ The concept of “informed uptake” is gaining acceptance worldwide and several outcome measures have been developed. Informed uptake is based on the principle that, ideally, a screening programme needs to achieve uptake rates

Policy and guidelines

International comparisons of screening programmes for common cancers show large variability in methods used and in uptake.³ These differences are not surprising and reflect underlying differences in culture and health-service organisation. In England, national screening programmes are coordinated through the NHS Cancer Screening Services and are guided by evidence-based clinical practice guidelines.

The USA does not have national screening programmes; screening activity is typically organised

Conclusion

Much literature has addressed uptake in cancer screening; this Review focuses on systematic reviews and recent trial-based evidence. Finding common conclusions in these reports is difficult for several reasons. First, the dynamics of each screening test fundamentally differ—for example, fecal occult blood testing for colorectal cancer is a proactive process in which participants collect stool specimens and apply them to test kits, whereas mammography generally involves responding to an

Search strategy and criteria

The Cochrane Library (Issue 4, 2008) was searched using a combination of MeSH terms and text words to identify existing systematic reviews and controlled trials, as adapted from the paper by Jepson and colleagues.¹³ Search terms included “screening”, “population surveillance”, “primary prevention”, “patient acceptance of health care”, and “health promotion”. Studies of interventions to improve uptake or informed uptake of cancer screening, targeted at the population, health professional

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ReviewUptake in cancer screening programmes

Summary

Introduction

Section snippets

Rationale for screening

Importance of uptake

Interventions for increasing uptake

Screening in low-uptake groups

Promoting informed choice

Policy and guidelines

Conclusion

Search strategy and criteria

Patient Educ Couns

Cancer Detect Prev

Patient Educ Couns

Cancer Detect Prev

Prev Med

Prev Med

Cancer Detect Prev

Soc Sci Med

Prev Med

Cancer Detect Prev

Patient Educ Couns

Aust N Z J Public Health

Soc Sci Med

International Breast Cancer Screening Network. International comparison of performance measures for screening mammography: can it be done?

J Med Screen

Human papillomavirus and Papanicolaou tests to screen for cervical cancer

N Engl J Med

International Colorectal Cancer Screening Network. Colorectal cancer screening: a comparison of 35 initiatives in 17 countries

Int J Cancer

Screening for breast cancer with mammography

Cochrane Database Syst Rev

Effect of NHS breast screening programme on mortality from breast cancer in England and Wales, 1990–8: comparison of observed with predicted mortality

Br Med J

Mammography screening and breast cancer mortality in New South Wales, Australia

Cancer Causes Control

Outcomes of screening to prevent cancer: analysis of cumulative incidence of cervical abnormality and modelling of cases and deaths prevented

BMJ

Mass screening programmes and trends in cervical cancer in Finland and the Netherlands

Int J Cancer

Cancer screening

J Epidemiol Community Health

Predicting the impact of the screening programme for colorectal cancer in the UK

J Med Screen

Compliance in screening programmes

BMJ

Progress in cancer screening over a decade: results of cancer screening from the 1987, 1992, and 1998 National Health Interview Surveys

J Natl Cancer Inst

The determinants of screening uptake and interventions for increasing uptake: a systematic review

Health Technol Assess

Interventions targeted at women to encourage the uptake of cervical screening

Cochrane Database Syst Rev

Strategies for increasing women participation in community breast cancer screening

Cochrane Database Syst Rev

A randomized trial of direct mailing of fecal occult blood tests to increase colorectal cancer screening

J Natl Cancer Inst

Appointments timed in proximity to annual milestones and compliance with screening: randomised controlled trial

BMJ

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

Increasing attendance at colorectal cancer screening: testing the efficacy of a mailed, psychoeducational intervention in a community sample of older adults

Health Psychology

Personalised risk communication for informed decision making about taking screening tests

Cochrane Database Syst Rev

Promoting regular mammography screening II. Results from a randomized controlled trial in US women veterans

J Natl Cancer Inst

A randomized controlled trial of the impact of targeted and tailored interventions on colorectal cancer screening

Cancer

Does tailoring matter? Meta-analytic review of tailored print health behavior change interventions

Psychol Bull

Review
Uptake in cancer screening programmes