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    Archive for the 'Screening' Category

    Unpicking the differences between types of cervical screening non-attenders

    By Laura Marlow, on 21 March 2018

    Every year around 28% of women who are eligible for cervical screening do not attend as recommended. Last year we blogged about a paper we had published exploring how these women can be divided into five broad sub-types; 1) unaware of screening, 2) unengaged with screening, 3) undecided about whether to go for screening, 4) decided not to go for screening and 5) decided to go but not yet gone. We also found some patterns in the way these different non-attender types are distributed across different groups of the population. For example, we found that women from ethnic minority groups were more likely to be unaware of screening and older women were more likely to have decided not to go. Understanding these patterns will help us to decide how interventions might be shaped differently for different types of non-attenders. For example, since women from ethnic minority groups are more likely to be unaware of cancer screening, targeted public health campaigns aimed at raising awareness within ethnic minority communities could be beneficial.

    More recently, we have been delving a bit deeper and have tried to unpick some of the psychological and behavioural differences between the most common non-attender groups. Published in the journal Preventive Medicine this week, our new work shows some interesting findings. Most notably we showed that women who are unaware of screening tend to be more fatalistic, both about life in general and about cancer. They also have more negative beliefs about cancer outcomes. Women who had decided not to be screened frequently perceived themselves to be at lower risk of cervical cancer. And for women who were unengaged with screening, both more fatalistic beliefs and lower perceived risk were relevant. Health behaviours also varied between the different groups, with unaware women less likely to have seen a GP recently, and unengaged women less likely to seek out health information and more likely to actively avoid cancer information in the media.

    This work will help us to identify the content of the messages that we might use for specific types of non-attenders. Interventions to raise awareness of screening should include messages that address fatalistic and negative beliefs about cancer. By contrast, information for women who have decided not to be screened may need to ensure they have an accurate knowledge of their risk of cervical cancer and that they understand the benefits of screening. This will help make sure women who decide not to take part are making an informed choice. Our next step it to outline what these interventions might look like – watch this space!

    Cervical screening without a speculum: a future option for older women?

    By Laura Marlow, on 19 February 2018

    In the UK, women are invited for cervical screening (the ‘smear test’) between the ages of 25 and 64, and although uptake is high it has been falling for some years across all age groups (1). A number of studies have focused on improving uptake among younger women (2), but a recent BMJ article called for work to focus on the needs of ‘older’ women too, given that half of all cervical cancer deaths are in women over 50 (3). One particular issue for older women can be that screening becomes more painful following the menopause. Lower oestrogen levels can cause thinning and dryness of the vaginal walls and it’s estimated that half of all post-menopausal women have these symptoms. This can mean that inserting the speculum (the instrument used to open the vagina for examination) is particularly painful for some ‘older’ women. Dr Anita Lim at King’s College London has been awarded funding by Cancer Research UK to explore a different procedure for collecting samples without a speculum. Samples collected without the speculum would be tested for human papillomavirus (HPV) and women would only need to have further examination if they were found to be HPV positive.

    Collaborating with Dr Lim, we led some exploratory work to assess the acceptability of this potential alternative (4). Published online last week in the Journal of Medical Screening, the work included focus groups and interviews with 38 women aged 50-64 who had a variety of cervical screening histories (‘up to date’, ‘overdue’ and ‘never been screened’). As expected, many of the women reported negative experiences of the speculum during cervical screening and found its insertion was sometimes painful, particularly after the menopause. Women were generally positive about the idea of screening without a speculum and thought it would be less invasive than the current procedure. However, some women were concerned that this method could be less accurate, because the swab might touch other areas and collect unwanted cells, and the sample-taker would not be able to clearly see the cervix without a speculum. Women said they would want sufficient information and reassurance, particularly about the effectiveness of non-speculum sampling compared to current cervical screening.

    The findings from this study suggest that HPV testing on clinician-collected samples taken without a speculum could be an acceptable alternative to conventional cervical screening. It might be particularly useful for older women who have had difficulty with the speculum examination, potentially due to post-menopausal changes. Dr Lim will continue to explore the acceptability of introducing clinician-collected non-speculum sampling alongside assessing how well the test works, but preliminary work suggests introducing this procedure could improve screening uptake among 50-64 year-olds who have put off attending.

    1. Screening and Immunisations team. Cervical screening programme: England, 2016-17. Health and Social Care Information Centre, 2017, p. 1 – 76.
    2. Kitchener HC et al. A cluster randomised trial of strategies to increase cervical screening uptake at first invitation (STRATEGIC). Health Technol Assess 2016, 20(68):1-138.
    3. Sherman SM et al. Cervical cancer is not just a young woman’s disease. BMJ 2015, 350:h2729.
    4. Freeman et al. Acceptability of non-speculum clinician sampling for cervical screening in older women: A qualitative study. JMS, in press.

    I’ve never heard of it; I don’t want to; it’s on my list

    By Laura Marlow, on 3 July 2017

    Authors: Amanda Chorley, Laura Marlow, Jo Waller

    One of our previous blogs discussed how rates of cervical screening (aka the smear test, or pap test) have been declining in the UK. Last year, screening uptake rates fell to 72.7%, meaning that over a quarter of women had not been screened as recommended (1). A better understanding of why women are not being screened is vital. If women are making informed decisions not to attend this is perfectly acceptable, but if women do not understand cervical screening or find it difficult to attend for other reasons (e.g. inconvenient appointment times), interventions to address this are important. Treating women who do not attend screening as a single group of “non-participants” means those with very different screening experiences and intentions are considered to be the same. Unsurprisingly this means that “one size fits all” interventions to increase screening participation do not have large effects, as they are unlikely to be suited to individual women’s differing needs.

    In our latest study published in the European Journal of Cancer last week, we used the Precaution Adoption Process Model (PAPM)(2) to try and improve our understanding of the ways in which women who do not attend screening may differ. The PAPM is a model from behavioural science which states that before carrying out a health behaviour (in this case cervical screening), a person must move through a number of stages. A person must first be aware of the health behaviour and engaged with it before they can make a decision whether or not to carry it out. If they do decide to carry out the behaviour, they must then overcome any barriers which may be in the way of this (e.g. getting to the screening appointment). Importantly, the PAPM also includes the possibility for people to make an active decision to not participate in the behaviour. By classifying women according to the PAPM we hoped to identify what the most common type of screening non-participant is, and whether women within a particular group tend to have shared characteristics.

    793 (27%) of the 3113 women we surveyed were either overdue for screening (including those who had never had a smear test) or said they did not plan to go for screening when next invited. Of these non-participating women, just over half said that they do intend to go. These women tended to be younger than women who were up to date with screening, and were more likely to be single and from less affluent backgrounds. Perhaps more surprisingly, given the fact that all should have received an invitation and leaflet about screening as part of the NHS programme, 28% of non-participating women said that they had never heard of cervical screening, smear or pap tests, even after being shown a photo of the procedure. These women were more likely to be younger and from ethnic minority and less affluent backgrounds, and to have English as a second language. Finally, 15% of non-participating women said that they had made a decision not to be screened in the future. These women tended to be older, and most had been screened before. As with the other two groups, they were also more likely to be from less affluent backgrounds.

    The differences between these groups of non-participants show how important it is to consider the different reasons for non-participation. Changes such as more flexible clinic hours or text message reminders may help women who do want to go for screening but have found it hard to get around to it. However, for women who are unaware of cervical screening, more accessible information about the programme is a vital first step towards making an informed choice about whether to participate or not. As we found that unaware women were more likely to be from ethnic minority backgrounds and less likely to speak English as their first language, it may be helpful to provide information in more languages and through TV or radio advertisements rather than just using written materials. Choosing not to be screened is a legitimate choice, and one that needs to be respected by medical professionals. However, in order for women to make an informed choice it is important that they have access to relevant information, including the benefits, risks, and limitations of screening. For some of the women who have decided not to go in the future, it may be the case that they have sought out this information. For other women the decision not to go for further screening may be due to a previous bad experience.

    Our survey goes some way to showing that there is not just one type of cervical screening non-participant, but different groups of women with different experiences, choices, and needs. In the future we hope to look further into these differences, both between and within the different groups described in this post.

    1. Screening and Immunisations team ND. Cervical screening programme: England, 2015-16. Health and Social Care Information Centre, 2016, p. 1 – 76.
    2. Weinstein N. The Precaution Adoption Process. Health Psychology. 1988; 7: 31.

    Early detection or prevention?: What is the main aim of different cancer screening programmes?

    By Moritz P Herle, on 23 May 2017

    by Amanda Chorley and Jo Waller

    Cancer screening programmes, such as breast, cervical, and bowel, are an important tool in the fight against cancer. Many people are aware of the value of early detection of cancer, which breast screening and the Faecal Occult Blood test (FOBt) part of bowel screening offer, which allows for treatment at an earlier stage when it is more likely to be effective. But are people aware that cervical screening and bowel scope screening (also known as flexible sigmoidoscopy, or FS) primarily aim to prevent cancer by identifying and removing abnormalities which may progress into cancer at a later date? This is the question we looked to answer in our recently published paper1 in the Journal of Medical Screening.

    As part of a larger survey on attitudes and behaviours surrounding cancer, we asked 1433 middle aged and older adults what they thought the main purpose of each of these screening programmes was. We found that while the majority of respondents were aware that breast screening (77.9%) and FOBt (73.2%) aimed to detect cancer early, only 17.6% knew that cervical screening primarily aimed to prevent cancer. For bowel scope screening the figure was only 13.8%. Overall only 13 people correctly identified the purpose of all four screening programmes, which is just under 1% of respondents.

    We also looked at whether people had participated in each programme in the past to see whether that had any effect on awareness of the purpose of the programme. People who had been sent a test kit, and those who had completed and returned the kit were more likely to know that FOBt is designed to detect cancer early. For breast screening, only those having participated in screening were more likely to know that it was aimed at early detection. Having received an invitation did not seem to have an effect on knowledge of the purpose of the test.

    However for both cervical screening and bowel scope screening neither those who had received an invitation nor those who had actually participated in the programme were any more likely to be aware of the preventive nature of the programme than respondents who hadn’t been invited or participated. This is despite the leaflets accompanying invitations clearly stating prevention as the main purpose.

    On the one hand it is positive that public health messages on the importance of the early detection of cancer have been so effective, and that the majority of people recognise this to be the purpose of breast screening and FOBt. However, for people to make an informed choice about whether to participate in a screening programme they need an understanding about what the screening test aims to do, as well as any risks and benefits. Our survey suggests that this is not the case for cervical screening and bowel scope. As well as this lack of awareness being an issue for informed choice, it could also have consequences for how people engage with the screening programmes. People may end up avoiding screening tests if they are afraid they might be told they have cancer2, 3. Knowing that some programmes can prevent cancer by finding and removing abnormalities may help to reduce these fears. Other studies have shown that women invited to colposcopy after having an abnormal result from their smear test sometimes mistakenly believe they have cancer4, 5. A better awareness that cervical screening mainly looks for cell abnormalities which can be removed before they have a chance to turn into cancer may help in reducing stress and worry about the abnormal result.

    If leaflets aren’t getting these messages across effectively, one of the priorities for the future will be finding different ways to communicate about cancer screening so that everyone understands what the tests are trying to do.

     

    1. Chorley AJ, Hirst Y, Vrinten C, Wagner Cv, Wardle J and Waller J. Public understanding of the purpose of cancer screening: A population-based survey. J Med Screen. 2017; 0: 0969141317699440.
    2. Vrinten C, Waller J, von Wagner C and Wardle J. Cancer fear: facilitator and deterrent to participation in colorectal cancer screening. Cancer epidemiology, biomarkers & prevention : a publication of the American Association for Cancer Research, cosponsored by the American Society of Preventive Oncology. 2015; 24: 400-5.
    3. Andersen MR, Smith R, Meischke H, Bowen D and Urban N. Breast cancer worry and mammography use by women with and without a family history in a population-based sample. Cancer epidemiology, biomarkers & prevention : a publication of the American Association for Cancer Research, cosponsored by the American Society of Preventive Oncology. 2003; 12: 314-20.
    4. Kavanagh AM and Broom DH. Women’s understanding of abnormal cervical smear test results: a qualitative interview study. BMJ (Clinical research ed). 1997; 314: 1388.
    5. Gray NM, Sharp L, Cotton SC, et al. Psychological effects of a low-grade abnormal cervical smear test result: anxiety and associated factors. British journal of cancer. 2006; 94: 1253-62.