Abstract
Colorectal cancer (CRC) is a leading cause of cancer death worldwide, although effective uptake of bowel cancer screening is below 60% in England. This trial investigated the influence of volitional and motivational interventions and their combination on increasing guaiac fecal occult blood testing (gFOBT) screening uptake. In total, 34,633 participants were recruited (via North-East of England bowel cancer screening hub) into a 2×2 factorial cluster randomized controlled trial. Social norm-based motivational intervention (SNA); Implementation intention-based Volitional Help Sheet (VHS); Combined intervention (SNA+VHS); Treatment as usual control. Screening rate (gFOBT kit return rate within 8 weeks of invitation) was the primary outcome. Screening kits were returned by 60% of participants (N=20,847/34,633). A substantial imbalance was observed in participant characteristics, participants in the combined intervention group were younger and more likely to be first time invitees. Adjusted analyses found insufficient evidence that any of the interventions were different to control (Combined: OR = 1.18, 95% CI 0.97-1.44; SNA alone: OR=0.93; 95% CI: 0.76-1.15; VHS alone OR= 0.88; 95% CI: 0.75-1.03). Subgroup analyses demonstrated a significant beneficial effect of the combined intervention in the youngest age group compared to control (OR = 1.27; 95% CI: 1.05-1.54). The study did not support any benefit of either VHS or SNA interventions alone on bowel cancer screening uptake. The combined SNA+VHS intervention was significantly different from control only in the youngest age group in adjusted analyses. However, the magnitude of effect in the youngest age group suggests that further testing of VHS plus SNA interventions in carefully targeted populations may be warranted.
Highlights
Colorectal cancer (CRC) is the fourth most commonly diagnosed cancer in the UK and the third most common worldwide; it is the fourth leading cause of cancer death globally (World Cancer Research Fund Network, 2017)
Social Norms Approach (SNA) + Volitional Help Sheet (VHS) offers the highest quality-adjusted life years (QALYs) gains while VHS alone offers the lowest. These results indicate that VHS and SNA alone were costlier and less effective than usual care
The latter finding suggests that in 97% of potential combinations between different uptake rates, the combined SNA + VHS intervention would be a cost-effective strat egy. These results were observed as the SE of the uptake estimates (0.01 for both interventions) is relatively small given the large sample size. This large-scale cluster randomized controlled trial aimed to inves tigate the influence of two theory based brief behavior change in terventions and their combination on increases in bowel cancer screening uptake in a sample from the North of England, conducted in collaboration with the NHS bowel cancer screening program
Summary
Colorectal cancer (CRC) is the fourth most commonly diagnosed cancer in the UK and the third most common worldwide; it is the fourth leading cause of cancer death globally (World Cancer Research Fund Network, 2017). Interventions to increase CRC screening have demonstrated that receiving an invitation letter via the post along with reminders are effective methods of increasing screening uptake (Rat et al, 2018; Tsipa et al, 2020). These are already components of the NHS BCSP and yet uptake is still sub-optimal. Recent randomized controlled trials (RTCs) have demonstrated that delivery of an imple mentation intention intervention significantly increased uptake of colorectal cancer screening (Neter et al, 2014), including in a low-income and ethnically diverse population (Greiner et al, 2014)
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