Improving uptake of bowel cancer screening (ASCEND)

The English NHS Bowel Cancer Screening Programme (BCSP) offers biennial guaiac faecal occult blood testing (gFOBt) however there is a socioeconomic gradient in participation and socioeconomically disadvantaged groups have worse colorectal cancer survival than more advantaged groups.

We co-designed two simple, zero cost interventions aimed at reducing this gradient and improving uptake overall: a GP endorsement to the screening invitation, and an enhanced reminder letter.

We tested these interventions via cluster-randomised trials embedded in the screening programme:

• • Trial 1 compared the standard invitation with general practice endorsement (GPE) of the programme on the invitation letter.
  • Trial 2 compared the usual reminder letter with an enhanced reminder (ER) which included a banner reiterating the screening offer and a short paragraph restating the offer of screening in simple language.
  • The primary outcome was the proportion of people adequately screened and its variation by deprivation (IMD).

• The enhanced reminder letter reduced the socioeconomic gradient in screening uptake and, in common with general practice endorsement, increased uptake overall.
• For GPE, the 7% increase in the odds of screening all participants, translates into a 1.7% relative increase in the probability of screening among all participants and a one percentage point absolute increase.
• The enhanced reminder was associated with a 3.6% relative increase in the probability of screening and a 0.9 percentage point absolute increase.

Our research has led directly to:

• Both GP endorsement and enhanced reminders being implemented in the BCSP across England
• Up to 59,000 more people taking a bowel cancer test in England each year
• Up to 91 additional people who have bowel cancer being identified each year
• High or medium-risk polyps being detected in up to 245 additional people

In addition, our research has been adapted to achieve further improvements in uptake of bowel and other screening programmes:

• GPE wording was used in a RCT of text message reminders in the BCSP across London which was associated with a 0.6% increase in uptake (Br J Cancer 2017: doi: 10.1038/bjc.2017.117.).
• GP endorsed text messages have been sent to women invited to cervical screening programme in London since October 2018 and have also been sent to women invited for breast screening.
• A ‘call for a kit’ intervention has been specifically designed to use a GP-based invitation for a consultation with a health volunteer, promoting self-referrals in socioeconomically deprived and ethnically diverse areas (Hanif et al 2017).
• The ER was adapted for the bowel scope screening programme at St Mark’s London (Behav Med 2018: doi: 10.1093/abm/kax068; BMJ Open 2018 doi:10.1136/bmjopen-2018-022263; Endoscopy 2017: doi: 10.1055/s-0042-118452). It subsequently became a commissioning for quality and innovation (CQUIN) goal and is being further rolled out to St George’s Hospital in South West London.