Screening for Bowel Cancer: Increasing Participation via Personal Invitation

Abstract

Background: Participation rates in bowel cancer screening programs in Germany continue to be low. In a model project, a logistically simple procedure for inviting patients to participate was tested as a means of increasing participation.

Methods: A randomized trial was performed involving persons residing in the German federal state of Saarland who had either their 50th or their 55th birthday in the year beginning on 1 April 2012 (18 560 and 16 824 persons, respectively). The 50-year-olds received a written invitation to undergo a test for blood in the stool, either with or without a stool test attached, or else no invitation at all. The 55-year-olds received either an invitation to undergo colonoscopy or no invitation. Participation rates within one year were determined from billing data of the Saarland Association of Statutory Health. Insurance Physicians. The trial was registered in the German Registry of Clinical Trials, no. DRKS00006098.

Results: A written invitation to undergo testing of the stool for blood, together with an accompanying test, increased the participation rate within one year by 62% (from 15% to 25%, p <0.001, especially among men (+158% vs. +39% for women). The participation rate was higher in general among women than among men (33% vs. 17%). On the other hand, a written invitation with no accompanying test did not increase the participation rate. A written invitation to undergo colonoscopic screening increased the participation rate within one year by 32% (5.9% vs 4.4%, p <0.001).

Conclusion: Targeted invitations can markedly increase participation rates in cancer screening. Written invitations to undergo stool testing for blood should be accompanied by an actual test. Further trials should also include information about the number of adenomas and carcinomas detected by screening.

Figure 1

Randomization design of the SAMS study: The numbers of persons randomized are smaller in year 2 than in year 1 because some members of the population had died or moved away from Saarland.

Figure 2

Cumulative uptake of the test for fecal occult blood (gFOBT) during the whole observation period, taking into account the renewed randomization of the study population with mailing of invitations after the end of year 1. Because of the almost identical pattern of utilization within the first 12 months without enclosure of a test kit, the groups “Only year 1” and “No letter year 1” were amalgamated.

Figure 3

Cumulative uptake of screening colonoscopy during the whole observation period, taking into account the renewed randomization of the study population with mailing of invitations after the end of year 1

eFigure

Percentage change in monthly utilization of the screening fecal blood test (gFOBT) or screening colonoscopy by invited persons within a year of invitation in comparison with persons who did not receive an invitation