Equal access to colorectal cancer screening
Authors: Marie-Louise Essink-Bot, Evelien Dekker
Journal: The Lancet (2015)

Population-based screening is effective in reducing the burden of colorectal cancer, and organised screening programmes have been implemented in many European countries.1von Karsa L Patnick J Segnan N et al.for the European Colorectal Cancer Screening Guidelines Working GroupEuropean guidelines for quality assurance in colorectal cancer screening and diagnosis.Endoscopy. 2013; 45: 51-59Crossref PubMed Scopus (8) Google Scholar Maximum participation in screening is crucial to achieve the greatest health benefits at population level. As with most cancer screening programmes, however, there is a gradient in uptake of colorectal cancer screening by socioeconomic status, from the most to the least deprived.2Deutekom M van Rijn AF Dekker E Blaauwgeers H Stronks K Essink-Bot ML Uptake of faecal occult blood test colorectal cancer screening by different ethnic groups in the Netherlands.Eur J Public Health. 2009; 19: 400-402Crossref PubMed Scopus (38) Google Scholar, 3von Wagner C Baio G Raine R et al.Inequalities in participation in an organized national colorectal cancer screening programme: results from the first 2.6 million invitations in England.Int J Epidemiol. 2011; 40: 712-718Crossref PubMed Scopus (230) Google Scholar, 4Gupta S Sussman DA Doubeni CA et al.Challenges and possible solutions to colorectal cancer screening for the underserved.J Natl Cancer Inst. 2014; 106: dju032Crossref PubMed Scopus (153) Google Scholar Because colorectal cancer screening results in earlier diagnosis or primary prevention, inequalities in colorectal cancer outcomes between socioeconomic groups are expected to increase with wider implementation of screening programmes.5Cipriano TM Polite BN Achieving health equity in colorectal cancer: a call to action.Am Soc Clin Oncol Educ Book. 2013; 2013: 169-173Crossref Scopus (6) Google Scholar The data on inequality in colorectal cancer screening are predominantly from the USA.4Gupta S Sussman DA Doubeni CA et al.Challenges and possible solutions to colorectal cancer screening for the underserved.J Natl Cancer Inst. 2014; 106: dju032Crossref PubMed Scopus (153) Google Scholar For Europe, analyses from the UK National Health Service Bowel Cancer Screening Programme, in which faecal occult blood testing is offered to individuals aged 60–74 years at no cost, have shown uptake of 35% in the lowest socioeconomic quintile compared with more than 60% in the highest quintile.3von Wagner C Baio G Raine R et al.Inequalities in participation in an organized national colorectal cancer screening programme: results from the first 2.6 million invitations in England.Int J Epidemiol. 2011; 40: 712-718Crossref PubMed Scopus (230) Google Scholar In The Lancet, Jane Wardle and colleagues6Wardle 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. 2015; (published online Dec 8.)http://dx.doi.org/10.1016/S0140-6736(15)01154-XGoogle Scholar present the results of the ASCEND project, which involved various mailed interventions aimed at lessening socioeconomic inequality for participation in the Bowel Cancer Screening Programme in England. Wardle and colleagues did four cluster-randomised controlled trials in which eligible individuals received either standard information about the screening programme or supplemented information in different forms—a leaflet re-presenting the information in a simplified format; a leaflet describing people's experiences of screening and outcomes; a letter with a banner showing the individual's general practice endorsement of the screening programme; or an enhanced reminder letter reiterating the screening offer. 676 391 recipients were included. Neither leaflet was associated with any effect on socioeconomic gradient of uptake of screening or on overall uptake. The endorsement letter did not affect the socioeconomic gradient but was associated with increased overall uptake (adjusted odds ratio [OR] 1·07, 95% CI 1·04–1·10). The enhanced reminder letter showed a significant interaction with socioeconomic status gradient (p=0·005), with a stronger, albeit small, effect in the most deprived quintile (adjusted OR 1·11, 95% CI 1·04–1·20) than in the least deprived (1·00, 0·94–1·06), and overall uptake was also increased (1·07, 1·03–1·11). Regrettably, therefore, the laudable efforts to make the screening invitation more understandable for people from lower socioeconomic groups had little effect, despite earlier evidence supporting general practice endorsement reminder enhancement.7Camilloni L Ferroni E Cendales BJ et al.Methods to increase participation in organised screening programs: a systematic review.BMC Public Health. 2013; 13: 464Crossref PubMed Scopus (154) Google Scholar Where to go from here is unclear. The study illustrates the challenges of reducing inequalities in screening uptake through written strategies alone, even when based on theory and practice. Thus, a uniform mailed screening invitation inevitably implies unequal chances of optimum colorectal cancer screening outcomes. This issue needs consideration because the aim of a population-based colorectal cancer screening programme is beyond equal participation. Rather, it is to offer an equal chance of optimum colorectal cancer outcomes to everyone. Providing equitable preventive care implies the use of equal screening invitation strategies in situations of equal information needs (horizontal equity).8Rice N Smith PC Ethics and geographical equity in health care.J Med Ethics. 2001; 27: 256-261Crossref PubMed Scopus (69) Google Scholar However, that screening invitation strategy might need to differ between subpopulations to achieve equal chances of optimum outcomes (vertical equity) is also implied.8Rice N Smith PC Ethics and geographical equity in health care.J Med Ethics. 2001; 27: 256-261Crossref PubMed Scopus (69) Google Scholar This theory suggests that different invitation strategies would be needed to provide people from all socioeconomic groups with equal chances of benefiting from the screening offer. The only alternative option is to accept socioeconomic inequality in colorectal cancer screening. Strategies to increase awareness of the importance of screening in local communities, for example via general practitioners or telephone support in a variety of languages, might be options worth considering. The second issue that needs to be addressed is related to the factual aim of the screening invitation. Colorectal cancer screening has potential side-effects, including potential harm, associated with follow-up colonoscopy. The importance of disclosing appropriate information to enable target groups to make informed decisions about participation has been emphasised.9Biesecker BB Schwartz MD Marteau TM Enhancing informed choice to undergo health screening: a systematic review.Am J Health Behav. 2013; 37: 351-359Crossref PubMed Scopus (38) Google Scholar Achieving this goal, however, is challenging because of the complexity of cancer screening programmes.1von Karsa L Patnick J Segnan N et al.for the European Colorectal Cancer Screening Guidelines Working GroupEuropean guidelines for quality assurance in colorectal cancer screening and diagnosis.Endoscopy. 2013; 45: 51-59Crossref PubMed Scopus (8) Google Scholar Wardle and colleagues6Wardle 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. 2015; (published online Dec 8.)http://dx.doi.org/10.1016/S0140-6736(15)01154-XGoogle Scholar did not assess the decision-making process, although it seems unlikely that the small effect associated with the enhanced reminder strategy represents an increase in informed participation. That informed non-participation could explain the lack of increased participation in the trials of additional information leaflets seems equally unlikely. Nevertheless, if the generally lower participation among groups with low socioeconomic status was proved to be based on informed autonomous choices to not participate, attempts to reduce the socioeconomic uptake gradient might be undesirable or even immoral. The question at stake is how to promote informed decision making about cancer screening participation effectively, especially in groups with low socioeconomic status. We declare no competing interests. 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 trialsOf four evidence-based interventions, the enhanced reminder letter reduced the socioeconomic gradient in screening uptake, but further reducing inequalities in screening uptake through written materials alone will be challenging. Full-Text PDF Open Access