Elsevier

Preventive Medicine

Volume 55, Issue 6, December 2012, Pages 587-596
Preventive Medicine

Review
How to increase uptake in oncologic screening: A systematic review of studies comparing population-based screening programs and spontaneous access

https://doi.org/10.1016/j.ypmed.2012.10.007Get rights and content

Abstract

Background.

Cervical, breast and colorectal cancer (CRC) screenings are universally recommended interventions. High coverage of the target population represents the most important factor in determining their success. This systematic review aimed at assessing the effectiveness of population-based screening programs in increasing coverage compared to spontaneous access.

Methods.

Electronic databases and national and regional websites were searched. We included all studies on interventions aimed at increasing screening participation published between 1999 and 2009; for those published before, we consulted the Jepson et al. review (2000). We compared spontaneous access (including no intervention) vs population-based screening programs actively inviting the target population. Among the latter, we compared GP-based vs invitation letter-based interventions.

Results.

The invitation letter vs no intervention showed significantly more participation (RR = 1.60 95%CI 1.33–1.92; RR = 1.52 95%CI 1.28–1.82; RR = 1.15 95%CI 1.12–1.19, for breast, cervical and CRC screenings, respectively). GP-based interventions, although more heterogeneous, showed a significant effect when compared with no intervention for breast (RR = 1.74 95%CI 1.25–2.43), but not for cervical and CRC. No significant differences were found between invitation letter-based and GP-based organization (RR = 0.99 95%CI 0.94–1.05; RR = 1.08 95%CI 0.99–1.17, for breast and cervical cancer, respectively).

Conclusion.

Population-based programs are more effective than spontaneous screening in obtaining higher testing uptake. Both invitation letter-based and GP-based programs are effective.

Highlights

► Population-based programs increase test uptake compared to spontaneuos access. ► The effect was observed in different settings and in the three oncologic screening. ► The average increase in uptake was about 50%. ► Invitation letter- based and GP-based programs showed similar effectiveness.

Introduction

Cervical, breast and colorectal cancer (CRC) screenings are universally recommended public health interventions, given the relevance of the disease and the availability of screening tests, which are proven to be effective in reducing mortality as well as incidence rates for cervical cancer and CRC. In order to maximize the impact of screening programs, high test uptake and compliance to diagnostic work up are needed. Uptake represents the most important factor in determining the success of a screening programme (Barratt et al., 2002, Parkin et al., 2008). Many systematic reviews have looked at the evidence supporting various approaches to cancer screening uptake (Bonfill Cosp et al., 2001, Everett et al., 2011, Forbes et al., 2002, Jepson et al., 2000, Khalid-de Bakker et al., 2011, Palència et al., 2010, Vernon, 1997). The findings usually vary according to aspects such as type of test, cancer site and target population. However, population-based organized recruitment strategies as well as tailored invitation approaches seem to show reliable benefits over opportunistic approaches to screening. The World Health Organization and its Cancer Research Agency (IARC) recommend the implementation of population-based screening programs (International Agency for Research on Cancer. IARC, 2002, International Agency for Research on Cancer. IARC, 2005, World Health Organization. WHO, 2006).

Screening programs have been implemented in different ways in industrialized countries. The European Union (EU) currently recommends that cancer screening be offered on a population basis in organized screening programs, with quality controls at all levels (Arbyn et al., 2008, Perry et al., 2006, Segnan et al., 2011, The Council of the European Union, 2003). This recommendation derives from many observational studies that showed a higher effectiveness of organized compared to spontaneous programs. Nevertheless, the scientific community does not univocally support the implementation of population-based invitation strategies and organized screening programs.

The Italian Ministry of Health sponsored an HTA report on methods to increase participation in oncologic screening programs. The aim of this paper is to assess, through a systematic review, the effectiveness of two different types of screening programs – by letter invitation and GP-based – on screening uptake for breast, cervical and colorectal cancers compared to spontaneous testing. We also compare the effectiveness of the two population-based screening models on increasing participation.

Section snippets

Identification of studies: inclusion and exclusion criteria

The target population of cancer screening in Italy is represented by women from 50 to 69 years, (breast cancer screening), women between 25 and 64 years (cervical cancer screening) and by men and women between 50 and 70 years (colorectal cancer screening). We thus included all studies whose target population was identical to these age groups or represented a subset of these groups.

We included all studies on interventions, strategies, or programs aimed at increasing participation in these three

Results

From 5859 potentially relevant citations, titles were identified and screened, and 998 abstracts were selected. Of these, 868 studies were not useful for a quantitative analysis, and 130 were selected for a full-text revision. Thirty-two quantitative studies fulfilled inclusion criteria while 98 irrelevant quantitative studies were excluded, although some were useful for qualitative review (Fig. 1).

In brief, the main reasons for exclusion were related to: studies with patient ages different

Invitation letters vs no intervention (usual care)

Twenty-six studies compared the response to invitation letters to no intervention (usual care): 12 studies regarded cervical cancer screening, 15 mammography screening, and one colorectal cancer screening (Fig. 2). The definition of usual care did not appear to be the same for all authors; in many cases screening tests were still provided for free, and general practitioners (GPs) took part in the program. In other cases, “usual care” indicated the absence of any offer of screening test. In any

Interventions with GP's involvement

Some screening programs take into account whether it was opportune to the opportunity of actively involve GPs in different ways. This model of organizing screening programs also uses the opportunistic contacts between the GP and target people to provide the test, a mode of contact typical of the spontaneous screening model. Consequently, in some cases the distinction between spontaneous screening and organized screening, based on the collaboration between GPs and the screening coordination

Invitation letters vs GP-based organized programs

While there are different methods to utilize the GP reminder, all require coordination of screening activities for the target population. Each GP must therefore adopt the most appropriate measures to increase the participation rate. It is evident that by actively contacting patients, the model becomes an invitation-based programme and can no longer be considered an opportunistic model (Fig. 6).

Data from five interventions for cervical cancer screening were analyzed. Two studies had high-power

GP reminder and invitation letter

The second type of intervention involves reminder systems generated by the GP for non-respondents to the invitation letter sent by the screening program. This is a coordinated effort between screening program management and the GP. Four studies were identified, two on mammographic screening, one on cervical cancer screening, and one that assessed the efficacy of the intervention for both types of screening. Three studies had high power, but none was a pragmatic trial in strict terms.

For

Cost and cost-effectiveness analyses

An automated search for systematic reviews on costs and cost-effectiveness initially retrieved about 600 papers, 48 of which had the scope of an HTA report and 15 focused on comparing population-based with spontaneous screening and GP-based with invitation letter-based programs.

De Gelder and collaborators published the only cost effectiveness model comparing organized mammographic screening with spontaneous mammograms (de Gelder et al., 2009). The model is based on observational data of both

Discussion

Participation of the target population is one of the most important factors influencing the effectiveness of a cancer screening programme in reducing mortality and/or morbidity.

It is in fact necessary to get high rates of participation to make a significant impact on a population's health. This aim should be reached by encouraging “informed” participation of the individual, who should know the benefits, limitations and disadvantages of any screening programme before participating.

The aim of our

Conclusions

Population-based programs are more effective than spontaneous screening is in obtaining higher testing uptake. Both invitation letter-based and GP-based programs are effective, but the former seemed to be more consistently cost-effective.

Contributorship statement

Paolo Giorgi Rossi, Piero Borgia and Gabriella Guasticchi planned the study and defined the methods. Beatriz Jimenez and Giacomo Furnari conducted the paper selection and abstracting. Beatriz Jimenez, Paolo Giorgi Rossi and Laura Camilloni conducted the quality appraisal. Eliana Ferroni, Paolo Giorgi Rossi and Laura Camilloni planned the metanalyses and the single comparisons. Laura Camilloni made the statistical analyses. Paolo Giorgi Rossi, Eliana Ferroni and Laura Camilloni drafted the

Competing interest

None to declare.

Funding statement

This work was funded by Ministry of Health ex art. 12 and 12 bis D. Lgs.502/92.

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