Emily Power

Understanding Intentions and Action in Colorectal Cancer Screening

BackgroundFactors involved in forming intentions to attend cancer screening may be different from those involved in translating intentions into action.PurposeTo test the hypotheses that social cognition variables predict intention better than action, and that life difficulty variables predict action better than intention, in colorectal screening.MethodsParticipants from one center in the UK Flexible Sigmoidoscopy Trial (n = 2,969) were categorized according to their screening intention, measured at baseline, and their subsequent attendance at screening (recorded at the clinic). Differences in factors related to life difficulty (socioeconomic deprivation, health, stress, social support) and social cognition variables were examined, and discriminant analysis was used to identify sets of variables that best differentiated the groups.ResultsSocial cognition variables were strongly associated with intention but only weakly with action. In contrast, factors related to life difficulties (socioeconomic deprivation, poor health status) were better predictors of action than intention.ConclusionSocial cognition variables appeared to be important determinants of screening intentions. Other variables—that may be markers of barriers to implementing plans—were more strongly associated with action. To maximize colorectal screening participation, research is needed to identify a wider range of determinants of attendance.

Patient acceptability of CT colonography compared with double contrast barium enema: results from a multicentre randomised controlled trial of symptomatic patients

ObjectivesTo determine patient acceptability of barium enema (BE) or CT colonography (CTC).MethodsAfter ethical approval, 921 consenting patients with symptoms suggestive of colorectal cancer who had been randomly assigned and completed either BE (N = 606) or CTC (N = 315) received a questionnaire to assess experience of the clinical episode including bowel preparation, procedure and complications. Satisfaction, worry and physical discomfort were assessed using an adapted version of a validated acceptability scale. Non-parametric methods assessed differences between the randomised tests and the effect of patient characteristics.ResultsPatients undergoing BE were significantly less satisfied (median 61, interquartile range [IQR] 54–67 vs. median 64, IQR 56–69; p = 0.003) and experienced more physical discomfort (median 40, IQR 29–52 vs. median 35.5, IQR 25–47; p < 0.001) than those undergoing CTC. Post-test, BE patients were significantly more likely to experience ‘abdominal pain/cramps’ (68% vs. 57%; p = 0.007), ‘soreness’ (57% vs. 37%; p < 0.001), ‘nausea/vomiting’ (16% vs. 8%; p = 0.009), ‘soiling’ (31% vs. 23%; p = 0.034) and ‘wind’ (92% vs. 84%; p = 0.001) and in the case of ‘wind’ to also rate it as severe (27% vs. 15%; p < 0.001).ConclusionCTC is associated with significant improvements in patient experience. These data support the case for CTC to replace BE.

Knowledge of lung cancer symptoms and risk factors in the UK: development of a measure and results from a population-based survey

Objectives To develop and validate a Lung Cancer Awareness Measure (Lung CAM) and explore the demographical and social predictors of lung cancer awareness in the general population. Methods study 1 Symptoms and risk factors for lung cancer were identified from the medical literature and health professional expertise in an iterative process. Test–retest reliability, internal reliability, item analyses, construct validity and sensitivity to changes in awareness of the Lung CAM were assessed in three samples (total N=191). Results study 1 The Lung CAM demonstrated good internal (Cronbachs α=0.88) and test–retest reliability (r=0.81, p<0.001). Validity was supported by lung cancer experts scoring higher than equally educated controls (t(106)=8.7, p<0.001), and volunteers randomised to read lung cancer information scoring higher than those reading a control leaflet (t(81)=3.66, p<0.001). Methods study 2 A population-based sample of 1484 adults completed the Lung CAM in a face-to-face, computer-assisted interview. Results study 2 Symptom awareness was low (average recall of one symptom) and there was little awareness of risk factors other than smoking. Familiarity with cancer, and being from a higher socioeconomic group, were associated with greater awareness. Conclusions Using a valid and reliable tool for assessing awareness showed the UK population to have low awareness of lung cancer symptoms and risk factors. Interventions to increase lung cancer awareness are needed to improve early detection behaviour.

Perceived barriers to flexible sigmoidoscopy screening for colorectal cancer among UK ethnic minority groups: a qualitative study:

Objectives Evidence from existing UK screening programmes indicates disparities in uptake rates between UK ethnic minorities and the white majority population. The aim of this study was to explore barriers to the uptake of flexible sigmoidoscopy (FS) screening among UK ethnic minority populations. Specifically, beliefs about bowel cancer, perceived barriers to the test and ideas about ways to increase uptake were investigated. Methods Nine focus groups were conducted with a total of 53 participants from African-Caribbean, Gujarati Indian, Pakistani and white British communities. The topic guide was based on the Health Belief Model. Discussions were subject to framework analysis. Results Most participants expressed limited awareness of bowel cancer and cited this as a barrier to screening attendance. Anxiety regarding the invasiveness of the test, the bowel preparation and fear of a cancer diagnosis were common barriers across all ethnic groups. Language difficulties, failure to meet religious sensitivities and the expression of culturally influenced health beliefs were all discussed as specific barriers to uptake. Ethnically tailored health promotion and general practitioner involvement were recommended as ways of overcoming such barriers. Conclusions The study was the first attempt to qualitatively explore barriers to FS bowel cancer screening in UK ethnic minorities. Most barriers were shared by all ethnic groups but health educators should supplement approaches designed for the majority to incorporate the specific needs of individual minority groups to ensure equitable access.

Ethnic differences in participation in flexible sigmoidoscopy screening in the UK

Objectives The aim of the study was to examine ethnic differences in participation in colorectal cancer screening by flexible sigmoidoscopy (FS). It assessed both intentions to be screened and actual screening uptake, and considered whether demographic, health and psychosocial factors mediated the ethnic differences. The setting of this study follows a subset of participants from the UK FS Trial. Methods A postal questionnaire assessed ethnicity, demographic characteristics, health, attitudes to screening and FS screening intentions. Data on screening intentions were available for 17,333 adults aged 55–64 years (Sample 1). Screening uptake was recorded in a subsample of 4303 respondents who were subsequently randomized to receive an invitation to screening (Sample 2). Results Screening intentions in Sample 1 were equally high across all the ethnic groups (>80% [13,724/17,042] reported they were interested). In contrast, attendance (Sample 2) was considerably lower among Asians (54% [43/79]) compared with White (69% [2843/4123]) or Black (80% [33/41]) respondents. Multivariate analysis showed that potential explanatory factors, including socioeconomic deprivation, poor health and fearful and fatalistic attitudes did not account for the lower screening attendance among Asians. Conclusion Further research is required to identify explanations for the gap between intentions and behaviour in UK Asians if any future FS screening programme is to be introduced equitably.

Flexible Sigmoidoscopy Screening for Colorectal Cancer: Uptake in a Population-based Pilot Programme:

Objective The aim of this study was is to examine uptake of population-based, flexible sigmoidoscopy (FS) screening delivered by nurses in a socioeconomically and ethnically diverse area of London, England. Methods All adults aged 58 and 59 years registered at 34 general practices in North London (n = 2260) were mailed an invitation to attend FS screening at the local hospital. Results In total, 45% (1024/2260) accepted the invitation and attended, 5% (114/2260) accepted the invitation but failed to attend, 5% (111/2260) accepted the invitation but were unable to attend within the time-frame of the pilot study, 7% (165/2260) declined the offer, 27% (602/2260) did not respond, and 11% (244/2260) were ineligible or did not receive the invitation. Among those eligible to be screened, the uptake rate was 51% (1024/2016). Uptake did not differ by gender, but people living in the most affluent quintile of areas had a substantially higher uptake rate (63%) than those living in the most deprived quintile (38%). Conclusion Uptake of FS screening delivered as a population-based programme was over 50% among the eligible population in a socioeconomically and ethnically diverse area of London. Disparities in uptake should be addressed to avoid exacerbating health inequalities.

Change in public awareness of symptoms and perceived barriers to seeing a doctor following Be Clear on Cancer campaigns in England.

Background:English Be Clear on Cancer (BCOC) campaigns aim to promote early presentation of potential cancer symptoms by (i) giving information on symptoms to look out for, and (ii) emphasising the approachability of the general practitioner (GP). This study examined public awareness of the targeted symptoms and perceived approachability of the GP before and after the national bowel and lung campaigns.Methods:The Cancer Research UK Cancer Awareness Measure (CAM) was included in the Opinions and Lifestyle survey (known then as the ‘Opinions Survey’) run by the Office for National Statistics in October and November 2010 and 2012. Change in awareness of symptoms and barriers to help-seeking related to those targeted in the campaigns between the 2010 and 2012 surveys, was compared with change in awareness of symptoms and barriers not targeted by the campaigns.Results:Recall of ‘persistent cough’ or ‘hoarseness’ as a sign of cancer increased from 18% in 2010 to 26% in 2012 (P<0.001), and ‘change in bowel/bladder habits’ increased from 21% to 43% (P<0.01). Recognition of these symptoms (from a list of symptoms) also increased significantly (both P-values <0.01). Awareness of non-targeted symptoms did not increase (all P-values >0.02). Barriers to visiting the GP targeted in the campaign (the doctor would be difficult to talk to and being worried about wasting the doctor’s time) did not change, although several non-targeted barriers reduced.Conclusions:BCOC campaigns run in England in 2012 were associated with increased public awareness of some key symptoms of lung and bowel cancer. Barriers to visiting the GP that were targeted in the campaign were not reduced, indicating that a different approach may be needed to shift public attitudes towards GPs.

A survey study of women's responses to information about overdiagnosis in breast cancer screening in Britain.

Background:There is concern about public understanding of overdiagnosis in breast cancer screening, and uncertainty about the likely impact on screening participation.Methods:In a population-based survey of 2272 women, we assessed understanding of overdiagnosis and screening intentions before and after exposure to an explanation of overdiagnosis, and one of the three information formats providing an estimate of the rate of overdiagnosis based on the findings of the UK Independent Review.Results:Subjective and objective comprehension of overdiagnosis was moderate across information formats (64% and 57%, respectively). Following overdiagnosis information, 7% of women showed a decrease in screening intention, with a stronger effect among women below screening age (<47 years), and receiving the estimate of the rate of overdiagnosis in a simple ratio format (one life saved to three overdiagnoses).Conclusions:Brief written information on overdiagnosis was incompletely understood, but reduced breast screening intentions in a proportion of women, regardless of comprehension. Subjective comprehension was lower among women who had not yet reached screening age but the deterrent effect was higher.

Ovarian and cervical cancer awareness: development of two validated measurement tools

Background The aim of the study was to develop and validate measures of awareness of symptoms and risk factors for ovarian and cervical cancer (Ovarian and Cervical Cancer Awareness Measures). Methods Potentially relevant items were extracted from the literature and generated by experts. Four validation studies were carried out to establish reliability and validity. Women aged 21–67 years (n=146) and ovarian and cervical cancer experts (n=32) were included in the studies. Internal reliability was assessed psychometrically. Test-retest reliability was assessed over a 1-week interval. To establish construct validity, Cancer Awareness Measure (CAM) scores of cancer experts were compared with equally well-educated comparison groups. Sensitivity to change was tested by randomly assigning participants to read either a leaflet giving information about ovarian/cervical cancer or a leaflet with control information, and then completing the ovarian/cervical CAM. Results Internal reliability (Cronbachs α=0.88 for the ovarian CAM and α=0.84 for the cervical CAM) and test-retest reliability (r=0.84 and r=0.77 for the ovarian and cervical CAMs, respectively) were both high. Validity was demonstrated with cancer experts achieving higher scores than controls [ovarian CAM: t(36)= –5.6, p<0.001; cervical CAM: t(38)= –3.7, p=0.001], and volunteers who were randomised to read a cancer leaflet scored higher than those who received a control leaflet [ovarian CAM: t(49)=7.5, p<0.001; cervical CAM: t(48)= –5.5, p<0.001]. Conclusions This study demonstrates the psychometric properties of the ovarian and cervical CAMs and supports their utility in assessing ovarian and cervical cancer awareness in the general population.

Patient-reported outcomes following flexible sigmoidoscopy screening for colorectal cancer in a demonstration screening programme in the UK.

Objectives Flexible sigmoidoscopy (FS) screening for colorectal cancer will be introduced into the National Cancer Screening Programmes in England in 2013. Patient-reported outcome measures (PROMs) from trial participants indicate high acceptability and no adverse physical or psychological consequences, but this may not generalize to routine screening in the community. This study examined PROMs in a community-based FS screening programme. Methods Eligible adults aged 58–59 (n = 2016) registered at 34 London general practices were mailed a National Health Service-endorsed invitation to attend FS screening. Pain and side-effects were assessed in a ‘morning-after’ questionnaire, and satisfaction was assessed in a three-month follow-up questionnaire. Anxiety, self-rated health and colorectal symptoms were assessed at prescreening and follow-up. Results In total, 1020 people attended screening and were included in the current analyses, of whom 913 (90%) returned the morning-after questionnaire, and 674 (66%) the follow-up questionnaire. The prescreening questionnaire had been completed by 751 (74%) of those who attended. The majority (87%) of respondents reported no pain or mild pain, and the most frequent side-effect (wind) was only experienced more than mildly by 16%. Satisfaction was extremely high, with 98% glad they had the test; 97% would encourage a friend to have it. From prescreening to follow-up there were no changes in anxiety or self-rated health, and the number of colorectal symptoms declined. Satisfaction and changes in wellbeing were not moderated by gender, deprivation, ethnicity or screening outcome. Conclusions PROMs indicate high acceptability of FS screening in 58–59 year olds, with no adverse effects on colorectal symptoms, health status or psychological wellbeing.