Workgroup IV: public education. UICC International Workshop on Facilitating Screening for Colorectal Cancer, Oslo, Norway (29 and 30 June 2002)

R. Hiatt1,{dagger}, J. Wardle2,{dagger}, S. Vernon3,{ddagger}, J. Austoker4, L. Bistanti5, S. Fox6, R. Gnauck7, D. Iverson8, M. Mandelson9, D. Reading10 and R. Smith11,*

1 National Cancer Institute, Rockville, MD, USA; 2 University College London, London, UK; 3 University of Texas, Houston School of Public Health, Houston, TX, USA; 4 University of Oxford, Oxford, UK; 5 Local Health Authority of Milan, Milan, Italy; 6 University of California at Los Angeles, Los Angeles, CA, USA; 7 Deutsche Klinik fur Diagnostic, Weisbaden, Germany; 8 University of Wollongong, Wollongong, Australia; 9 Group Health Cooperative, Seattle, WA, USA; 10 The Cancer Council Victoria, Carlton Victoria, Australia; 11 American Cancer Society, Atlanta, GA, USA

* Correspondence to: Dr R. Smith, American Cancer Society, 1599 Clifton Road NE, Atlanta, GA 30329, USA. Tel: +1-404-329-7610; Email: robert.smith{at}cancer.org


    Introduction
 Top
 Introduction
 Statement of problem
 Barriers and challenges
 Recommendations
 Summary
 References
 
The Workgroup on public education was brought together to formulate an international perspective on public education for the important public health challenge of increasing colorectal cancer screening. The focus of the group did not include professional education, which is an important channel for public education, since another Workgroup covered that topic. The results of the Workgroup represent an expression of expert opinion and did not include a comprehensive review of the literature. However, the recommendations for further research may stimulate a more in-depth examination of the literature in some areas and generate ideas for investigation.


    Statement of problem
 Top
 Introduction
 Statement of problem
 Barriers and challenges
 Recommendations
 Summary
 References
 
The Workgroup on public education was charged with exploring the question: what strategies can be applied to raise public awareness of the importance of screening? Goals set forth by the Workgroup were limited to: (i) the identification of strategies or interventions that have supporting evidence; and (ii) the identification of gaps where more research is needed.

Although colorectal cancer is among the most common causes of death from cancer in many countries (e.g. the second leading cause in Australia, the UK and the USA) and effective screening is available to reduce mortality, the use of these screening modalities remains low. Even in the USA, where organized efforts to increase colorectal cancer screening have been in place for almost two decades, and substantial improvements in colorectal cancer screening practices in states have been documented [1Go], only 32% of adults over age 50 years have had a fecal occult blood test (FOBT) in the past 2 years and only 34% say they have ever had either a sigmoidoscopy or colonoscopy for any reason [2Go].

The group recognized that an international perspective in addressing public education required an appreciation of the variability of colorectal cancer screening in countries throughout the world [3Go]. For example, public education to increase colorectal cancer screening would be inappropriate in a country without options for screening in the first place. In the sample of countries represented by the Workgroup members, five different approaches to colorectal cancer screening were taking place. In a sixth country, there was no screening whatsoever, a condition unfortunately quite frequent around the world and necessary to include in the broader perspective.

Table 1 illustrates the current status of screening in the represented countries according to whether it is ‘organized’ or ‘opportunistic’. Organized screening refers to situations where a systematic approach to screening is undertaken by a governmental body or formal health-care system. Organized screening at a national level, as in Germany, exists where a national health system covers the service and some sort of central organization, management and, perhaps, evaluation is in place [4Go]. Regional screening programs, as in Italy, work on the same principle but only for a portion of the country. Organized screening may also be limited to specific health-care systems. In the USA some individual health maintenance organizations have adopted organized colorectal cancer screening programs for their members.


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Table 1. Current status of colorectal cancer screening in selected countries

 
Whether or not organized systems of screening exist, ‘opportunistic’ screening is common wherever there is a public demand and individual practitioners have the knowledge and resources to carry it out. Low to substantial levels of opportunistic screening occur in most European countries, Australia and the USA. Finally, to formally answer the question of whether or not an organized national program could be effective in reducing colorectal cancer mortality and have a reasonable cost-effectiveness ratio, at least two countries, the UK and Australia, are conducting feasibility studies of colorectal cancer screening.

To assist in organizing the discussion, the Workgroup used the analytic framework for strategies to promote cancer screening in communities and health-care systems formulated by the US Guide to Community Services (Figure 1) [5Go].



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Figure 1. Analytic framework: strategies to promote cancer screening in communities and health-care settings.

 
This framework describes relevant interventions (e.g. mass media, small group education, etc.) against desired outcomes on a continuum from increased demand for screening, to increased attendance, increased screening and re-screening, and finally to reduced incidence, morbidity and mortality.


    Barriers and challenges
 Top
 Introduction
 Statement of problem
 Barriers and challenges
 Recommendations
 Summary
 References
 
During the Workgroup discussion, a number of barriers were identified that were impeding progress toward increased colorectal cancer screening in the countries represented.

Lack of knowledge
The general level of understanding of the existence of colorectal cancer, individual risk and the benefits of colorectal cancer screening procedures is rather low even in developed countries. In some countries there is still a lack of understanding of the benefits of screening for asymptomatic disease.

Lack of provider recommendation
As with screening for breast and cervical screening, perhaps the most powerful single measure is a health provider's recommendation to get screened. Yet this is not a common practice and reflects a lack of appreciation of the benefits of screening and concerns with logistics and costs.

Multiple screening modalities
There are at least four major options for colorectal cancer screening that are included in the recommendations of major professional organizations: FOBT, sigmoidoscopy, colonoscopy and double-contrast barium enema. A full explanation of these options is too complicated for simple messages to the public or the individual patient. Methods to distill down the message to ‘get screened by any appropriate method’ are still needed.

Competition with other messages
The number of evidence-based prevention recommendations appropriate for delivery in the primary care setting is increasing and includes not just cancer prevention and screening, but also advice about diet, physical activity, immunization, sexually transmitted diseases and vehicular safety. The message to adopt colorectal cancer screening is not, by far, the only message that must be heard.

Need to sustain adherence to screening
Depending on the modality, colorectal cancer screening must be repeated annually or up to every 5–10 years given current recommendations [6Go]. It is not enough for a person to be screened once; the messages appropriate to encourage a person to repeat a colorectal cancer screening test once they have experienced it the first time are not the same as getting a person to initiate the practice.

Informed decision-making
Although there is convincing evidence from controlled trials about the efficacy of both FOBT and sigmoidoscopy in reducing mortality from colorectal cancer, there are also potential harmful effects that include the physical complications of colonoscopy, stress and discomfort of testing and investigations, and the anxiety caused by false-positive screening tests. How best to delivery a succinct and effective message to inform persons being screening of both the risks and benefits of screening is a thorny problem.

Disparities by subpopulation
In countries where data for different race/ethnic, socioeconomic, geographically and age defined groups are available, differences by group in the use of colorectal cancer screening are evident. In the USA in 2000 the National Health Interview Survey reported, for example, that 34% of white respondents but only 31% of blacks and 21% of Hispanics over 50 years of age had had an FOBT within the past 2 years [7Go]. For sigmoidoscopy this same survey revealed that 38% of whites, 30% of blacks and 25% of Hispanics over age 50 years had ever had the procedure. The reasons for these disparities and what to do about them are not clear.

Low level of public and professional enthusiasm
Perhaps because of a lack of understanding of the benefits of colorectal cancer screening, the lack of a clear physician's recommendation, the complexity of the several options or other issues touched on above, and also because the subject of stool and the lower bowel are commonly viewed as unpleasant, there is a general lack of enthusiasm for colorectal cancer screening not seen for mammography, hypertension checks and other preventive procedures.

Facing these barriers or key issues, and keeping in mind the variety of country-specific settings for colorectal cancer screening, a number of challenges present themselves to those engaged in public education efforts. Basically, in parallel to the key issues identified above, these include:

  1. the identification of the optimum methods to increase knowledge about the benefits of colorectal cancer screening for both the general population and high-risk groups (e.g. persons with inflammatory bowel disease or genetic susceptibility);
  2. the education of primary care providers on the benefits and risks of screening;
  3. the minimization of financial disincentives to providers so that the compensation to provide appropriate screening is greater than the costs;
  4. the need for messages to clarify choices among multiple screening modalities;
  5. the best approach to delivering a balanced message that allows an informed decision about getting screening that weighs both the potential benefits and risks, including who delivers this message;
  6. the likelihood that the introduction of new colorectal cancer screening modalities (e.g. colonoscopy) will increase social disparities because only those can afford new and usually expensive technology will receive it;
  7. the requirement for tailored messages early on, both in content and medium, for diverse populations; and
  8. the mobilization of a broader base of support for addressing the burden of colorectal cancer.


    Recommendations
 Top
 Introduction
 Statement of problem
 Barriers and challenges
 Recommendations
 Summary
 References
 
Based on the discussion and the experience of the Workgroup members, a number of recommendations were formulated. The group believes these recommendations are reasonable on the basis of existing evidence, the first goal of the Workgroup. However, the deliberations of the group were not supported by a literature review of the subject. Additional documentation of what is known to improve public education on colorectal cancer screening is needed. The Workgroup expressed the following recommendations and preferences:

  1. Organized population-based programs achieve greater public awareness compared with opportunistic screening. Although their role is critical, if public education is left only to providers, progress will be slow.
  2. Sustained efforts are required to improve public knowledge. This follows from the need for repeated tests, but also because the general lack of enthusiasm for the procedures requires repeated urging.
  3. Primary care providers need education about how to deliver succinct recommendations for screening. Appreciation for the lack of time available in the typical primary care visit, the multiplicity of screening options, and the ‘competition’ with other legitimate prevention message underlies this recommendation.
  4. Support the simple message to ‘get screened’. It is generally agreed that the core of the message is to ‘get screened by any approved method available’. In the broad public setting this message should take precedence over other messages that elaborate on multiple options, and informed decision-making strategies to minimize sociocultural disparities need to be in place early in the process, including framing messages that appeal to different race/ethnic and socioeconomic groups. Informed decision-making processes should be included in public awareness and primary care contact.
  5. Colorectal cancer screening needs to become a priority for professional and governmental organizations. The relative benefits of efforts to improve colorectal cancer screening, which is currently at a low level in most settings, needs to be weighed against efforts for other legitimate prevention activities.

 The second goal of the Workgroup was to identify gaps in knowledge about how best to deliver an effective public education message that can be addressed by further research. Six broad questions that must be addressed were identified that are consistent with the framework developed by the US Guide to Community Prevention Services (Figure 1).

  1. How to develop optimal messages to increase knowledge of the importance of colorectal cancer and screening (e.g. mass media, client reminders, small group education)?
  2. How best to present the message of multiple screening options?
  3. What are the different strategies for initiation and maintenance of colorectal cancer screening?
  4. How do strategies used in other screening programs translate into colorectal cancer screening?
  5. What are the most effective ways to frame messages [e.g. a focus on the reduction of new cancer (incidence) or prevention versus early detection]?
  6. What are the best methods to allow for informed decision-making (e.g. screening, which test)?


    Summary
 Top
 Introduction
 Statement of problem
 Barriers and challenges
 Recommendations
 Summary
 References
 
The advantages of an international perspective include the sharing of ideas and experience between countries. Each country benefits, since none has all the answers. The application of proven methods to improve public education depend on the status of colorectal cancer screening in the country in question, whether or not an organized system is in place. They also require a careful consideration of the available scientific evidence on the efficacy and effectiveness of interventions. Although much can be done to improve public education about colorectal cancer screening, it is also clear that methods to do this optimally require additional cancer control research, primarily in the behavioral sciences and health services.


    Notes
 
{dagger} Co-chairs Back

{ddagger} Rapporteur Back


    References
 Top
 Introduction
 Statement of problem
 Barriers and challenges
 Recommendations
 Summary
 References
 
1. Nelson DE, Bland S, Powell-Griner E et al. State trends in health risk factors and reciept of clinical preventive services among US adults during the 1990s. JAMA 2 2002; 87: 2659–2667.[CrossRef]

2. Breen N, Wagener DK, Brown ML et al. Progress in cancer screening over a decade: results of cancer screening from the 1987, 1992, and 1998 National Health Interview Surveys. J Natl Cancer Inst 2001; 93: 1704–1713.[Abstract/Free Full Text]

3. Rozen P, Winawer SJ, Waye JD. Prospects for the worldwide control of colorectal cancer through screening. Gastrointest Endosc 2002; 55: 755–759.[CrossRef][ISI][Medline]

4. Gnauck R. Screening for colon cancer in Germany. Tumori 1995; 81S: 30–37.

5. Coughlin SS, Tannor B. The Cancer Systematic Review Development Team. Small media interventions: screening for breast, cervical, and colorectal cancers. Presented at the meeting of the Task Force on Community Preventive Services, Feb 26, 27 2003; Atlanta, 2003.

6. Towler BP, Irwig L, Glasziou PP et al. Screeing for colorectal cancer using the faecal occult blood test, Hemoccult (Cochrane Review). In The Cochrane Library, Issue 1. Oxford: Update Software 2002.

7. National Institutes of Health, National Cancer Institute, Cancer Information Service. Available on-line at www.cancer.gov/cis (December 10, 2002, date last accessed).