Including a general practice endorsement letter with the testing kit in the Bowel Cancer Screening Programme: Results of a cluster randomised trial.

OBJECTIVES: To evaluate the effect of general practitioner endorsement accompanying the screening kit rather than with the invitation letter on participation in the NHS Bowel Cancer Screening Programme and on the socioeconomic gradient in participation in the Programme. METHODS: The NHS Bowel Cancer Screening Programme in England is delivered via five regional hubs. In early 2016, we carried out a cluster-randomised trial, with hub-day of invitation as the randomisation unit. We randomised 150 hub-days of invitation to the intervention group, GP endorsement on the letter accompanying the guaiac faecal occult blood testing kit (75 hub-days, 197,366 individuals) or control, usual letter (75 hub-days, 197,476 individuals). The endpoint was participation, defined as return of a valid kit within 18 weeks of initial invitation. Because of the cluster randomisation, data were analysed by a hierarchical logistic regression, allowing a random effect for date of invitation. Socioeconomic status was represented by the index of multiple deprivation. RESULTS: Participation was 59.4% in the intervention group and 58.7% in the control group, a significant difference (p = 0.04). There was no heterogeneity of the effect of intervention by index of multiple deprivation. We found that there was some confounding between date and screening episode order (first or subsequent screen). This in turn may have induced confounding with age and slightly diluted the result. CONCLUSIONS: General practitioner endorsement induces a modest increase in participation in bowel cancer screening, but does not affect the socioeconomic gradient. When considering cluster randomisation as a research method, careful scrutiny of potential confounding is indicated in advance if possible and in analysis otherwise.

Patient attitudes towards faecal immunochemical testing for haemoglobin as an alternative to colonoscopic surveillance of groups at increased risk of colorectal cancer.

OBJECTIVES: To examine attitudes towards an annual faecal immunochemical test for haemoglobin (FIT) versus three-yearly colonoscopic surveillance of individuals at intermediate risk of colorectal cancer (CRC). SETTING: A London hospital. METHODS: Five semi-structured discussion groups were conducted with 28 adults (aged 60-74, 61% female) with different levels of CRC risk and experience of colonoscopy or colonoscopic surveillance. Information was presented sequentially using a step-by-step discussion guide. Results were analyzed using thematic analysis. RESULTS: When evaluating FIT in the context of a surveillance programme, all respondents readily made comparisons with related tests that they had been exposed to previously. Those with no experience of surveillance were enthusiastic about an annual FIT to replace three-yearly colonoscopy, because they felt that the higher testing frequency could improve detection of advanced lesions. Those with experience of colonoscopic surveillance did not perceive FIT to be as accurate as colonoscopy, and therefore either preferred colonoscopy on its own or wanted an annual FIT in addition to three-yearly colonoscopy. CONCLUSIONS: FIT may be well-received as an additional method of surveillance for new patients at intermediate risk of CRC. More research is required to better understand potential barriers associated with FIT surveillance for patients with experience of colonoscopic surveillance.