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Discordant trends in the incidence of metastatic breast and prostate cancer since the widespread implementation of early-detection efforts may reflect distinct disease dynamics or may result from the different screening strategies used. Patients who present with metastatic cancer serve as powerful motivators for efforts to detect cancer early. Screening offers hope that cancer can be detected in an early, localized phase when it's more amenable to treatment. This hope is based on a paradigm attributed to William Stewart Halsted, which holds that cancer arises at a single location, grows there, and eventually migrates to local lymph nodes and then to more distant organs. If the Halstedian paradigm is correct, effective screening should allow cancers destined to metastasize to be identified at an earlier stage and reduce the incidence of cancers that first . . .

Offering financial incentives to promote or \"nudge\" participation in cancer screening programs, particularly among vulnerable populations who traditionally have lower rates of screening, has been suggested as a strategy to enhance screening uptake. However, effectiveness of such practices has not been established. Our aim was to determine whether offering small financial incentives would increase colorectal cancer (CRC) screening completion in a low-income, uninsured population. We conducted a randomized, comparative effectiveness trial among primary care patients, aged 50-64 years, not up-to-date with CRC screening served by a large, safety net health system in Fort Worth, Texas. Patients were randomly assigned to mailed fecal immunochemical test (FIT) outreach (n=6,565), outreach plus a $5 incentive (n=1,000), or outreach plus a $10 incentive (n=1,000). Outreach included reminder phone calls and navigation to promote diagnostic colonoscopy completion for patients with abnormal FIT. Primary outcome was FIT completion within 1 year, assessed using an intent-to-screen analysis. FIT completion was 36.9% with vs. 36.2% without any financial incentive (P=0.60) and was also not statistically different for the $10 incentive (34.6%, P=0.32 vs. no incentive) or $5 incentive (39.2%, P=0.07 vs. no incentive) groups. Results did not differ substantially when stratified by age, sex, race/ethnicity, or neighborhood poverty rate. Median time to FIT return also did not differ across groups. Financial incentives, in the amount of $5 or $10 offered in exchange for responding to mailed invitation to complete FIT, do not impact CRC screening completion.

A steady decline in cervical cancer incidence and mortality in the United States has been attributed to increased uptake of cervical cancer screening tests such as Papanicolau (Pap) tests. However, disparities in Pap test compliance exist, and may be due in part to perceived barriers or lack of knowledge about risk factors for cervical cancer. This study aimed to assess correlates of cervical cancer risk factor knowledge and examine socio-demographic predictors of self-reported barriers to screening among a group of low-income uninsured women. Survey and procedure data from 433 women, who received grant-funded cervical cancer screenings over a span of 33 months, were examined for this project. Data included demographics, knowledge of risk factors, and agreement on potential barriers to screening. Descriptive analysis showed significant correlation between educational attainment and knowledge of risk factors (r = 0.1381, P < 0.01). Multivariate analyses revealed that compared to Whites, Hispanics had increased odds of identifying fear of finding cancer (OR 1.56, 95 % CI 1.00–2.43), language barriers (OR 4.72, 95 % CI 2.62–8.50), and male physicians (OR 2.16, 95 % CI 1.32–3.55) as barriers. Hispanics (OR 1.99, 95 % CI 1.16–3.44) and Blacks (OR 2.06, 95 % CI 1.15–3.68) had a two-fold increase in odds of agreeing that lack of knowledge was a barrier. Identified barriers varied with age, marital status and previous screening. Programs aimed at conducting free or subsidized screenings for medically underserved women should include culturally relevant education and patient care in order to reduce barriers and improve screening compliance for safety-net populations.

Objective To elicit women’s responses to information about the nature and extent of overdiagnosis in mammography screening (detecting disease that would not present clinically during the woman’s lifetime) and explore how awareness of overdiagnosis might influence attitudes and intentions about screening.Design Qualitative study using focus groups that included a presentation explaining overdiagnosis, incorporating different published estimates of its rate (1–10%, 30%, 50%) and information on the mortality benefit of screening, with guided group discussionsSetting Sydney, AustraliaParticipants Fifty women aged 40–79 years with no personal history of breast cancer and with varying levels of education and participation in screening.Results Prior awareness of breast cancer overdiagnosis was minimal. Women generally reacted with surprise, but most came to understand the issue. Responses to overdiagnosis and the different estimates of its magnitude were diverse. The highest estimate (50%) made some women perceive a need for more careful personal decision making about screening. In contrast, the lower and intermediate estimates (1–10% and 30%) had limited impact on attitudes and intentions, with many women remaining committed to screening. For some women, the information raised concerns, not about whether to screen but whether to treat a screen detected cancer or consider alternative approaches (such as watchful waiting). Information preferences varied: many women considered it important to take overdiagnosis into account and make informed choices about whether to have screening, but many wanted to be encouraged to be screened.Conclusions Women from a range of socioeconomic backgrounds could comprehend the issue of overdiagnosis in mammography screening, and they generally valued information about it. Effects on screening intentions may depend heavily on the rate of overdiagnosis. Overdiagnosis will be new and counterintuitive for many people and may influence screening and treatment decisions in unintended ways, underscoring the need for careful communication.

ABSTRACT BACKGROUND Ongoing efforts to increase colorectal cancer (CRC) screening rates have raised concerns that these exams may be overused, thereby subjecting patients to unnecessary risks and wasting healthcare resources. OBJECTIVE Our aim was to measure overuse of screening and surveillance colonoscopies among average-risk adults, and to identify correlates of overuse. DESIGN, SETTING, AND PARTICIPANTS Our approach was a retrospective cohort study using electronic health record data for patients 50–65 years old with no personal history of CRC or colorectal adenomas with an incident CRC screening colonoscopy from 2001 to 2010 within a multispecialty physician group practice. MAIN OUTCOME MEASURES We measured time to next screening or surveillance colonoscopy and predictors of overuse (exam performed more than one year earlier than guideline recommended intervals) of colonoscopies. KEY RESULTS We identified 1,429 adults who had an incident colonoscopy between 2001 and 2010, and they underwent an additional 871 screening or surveillance colonoscopies during a median follow-up of 6 years. Most follow-up screening colonoscopies (88 %) and many surveillance colonoscopies (49 %) repeated during the study represented overuse. Time to next colonoscopy after incident screening varied by exam findings (no polyp: median 6.9 years, interquartile range [IQR]: 5.1–10.0; hyperplastic polyp: 5.7 years, IQR: 4.9–9.7; low-risk adenoma: 5.1 years, IQR: 3.3–6.3; high-risk adenoma: 2.9 years, IQR: 2.0–3.4, p  < 0.001). In logistic regression models of colonoscopy overuse, an endoscopist recommendation for early follow-up was strongly associated with overuse of screening colonoscopy (OR 6.27, 95 % CI: 3.15–12.50) and surveillance colonoscopy (OR 13.47, 95 % CI 6.61-27.46). In a multilevel logistic regression model, variation in the overuse of screening colonoscopy was significantly associated with the endoscopist performing the previous exam. CONCLUSIONS Overuse of screening and surveillance exams are common and should be monitored by healthcare systems. Variations in endoscopist recommendations represent targets for interventions to reduce overuse.

Cervical cancer poses a significant threat to Korean American women, who are reported to have one of the highest cervical cancer mortality rates in the United States. Studies consistently report that Korean American women have the lowest Pap test screening rates across US ethnic groups. In response to the need to enhance cervical cancer screening in this vulnerable population, we developed and tested a 7-day mobile phone text message-based cervical cancer Screening (mScreening) intervention designed to promote the receipt of Pap tests by young Korean American women. We developed and assessed the acceptability and feasibility of a 1-week mScreening intervention to increase knowledge of cervical cancer screening, intent to receive screening, and the receipt of a Pap test. Fogg's Behavior Model was the conceptual framework that guided the development of the mScreening intervention. A series of focus groups were conducted to inform the development of the intervention. The messages were individually tailored for each participant and delivered to them for a 7-day period at each participant's preferred time. A quasi-experimental research design of 30 Korean American women aged 21 to 29 years was utilized with baseline, post (1 week after the completion of mScreening), and follow-up (3 months after the completion of mScreening) testing. Findings revealed a significant increase in participants' knowledge of cervical cancer (P<.001) and guidelines for cervical cancer screening (P=.006). A total of 23% (7/30) (95% CI 9.9-42.3) of the mScreening participants received a Pap test; 83% (25/30) of the participants expressed satisfaction with the intervention and 97% (29/30) reported that they would recommend the program to their friends, indicating excellent acceptability and feasibility of the intervention. This study provides evidence of the effectiveness and feasibility of the mScreening intervention. Mobile technology is a promising tool to increase both knowledge and receipt of cervical cancer screening. Given the widespread usage of mobile phones among young adults, a mobile phone-based health intervention could be a low-cost and effective method of reaching populations with low cervical cancer screening rates, using individually tailored messages that cover broad content areas and overcome restrictions to place and time of delivery.

BackgroundEarlier diagnosis of lung cancer is key to reducing mortality. New evidence suggests that smokers have negative attitudes to screening and participation in lung cancer screening trials is poor (<1 in 6 of those eligible). Understanding participation is important since uptake in screening trials is likely to predict uptake in screening programmes. A qualitative study of people accepting and declining participation in the Lung-SEARCH screening trial was conducted. Two questions were addressed: Are the screening methods offered acceptable to patients? Why do some people take part and others decline?MethodsThe qualitative study used semi-structured interviews with 60 respondents from three groups: (a) trial participants providing an annual sputum sample; (b) trial participants with a sputum sample showing abnormal cytology and thus undergoing annual CT scanning and bronchoscopy; and (c) those declining trial participation.ResultsMost respondents (48/60, 80%) viewed sputum provision, CT scanning and bronchoscopy as largely acceptable. Those declining trial participation described fear of bronchoscopy, inconvenience of travelling to hospitals for screening investigations and perceived themselves as having low susceptibility to lung cancer or being too old to benefit. Patients declining participation discounted their risk from smoking and considered negative family histories and good health to be protective. Four typological behaviours emerged within those declining: ‘too old to be bothered’, ‘worriers’, ‘fatalists’ and ‘avoiders’.ConclusionSputum provision, CT scanning and bronchoscopy are largely acceptable to those participating in a screening trial. However, the decision to participate or decline reflects a complex balance of factors including acceptability and convenience of screening methods, risk perception, altruism and self-interest. Improving practical and changing cognitive aspects of participation will be key to improving uptake of lung cancer screening.

BackgroundThe Affordable Care Act (ACA) eliminated cost-sharing for evidence-based preventive services in an effort to encourage use.ObjectiveTo evaluate use of colorectal cancer (CRC) screening in a national population-based sample before and after implementation of the ACA.DesignRepeated cross-sectional analysis of the Medical Expenditure Panel Survey (MEPS) between 2009 and 2012 comparing CRC screening rates before and after implementation of the ACA.ParticipantsAdults 50–64 with private health insurance and adults 65–75 with Medicare.Main MeasuresSelf-reported receipt of screening colonoscopy, sigmoidoscopy, or fecal occult blood test (FOBT) within the past year among those eligible for screening.Key ResultsOur study included 8617 adults aged 50–64 and 3761 adults aged 65–75. MEPS response rates ranged from 58 to 63%. Among adults aged 50–64, 18.9–20.9% received a colonoscopy in the survey year, 0.59–2.1% received a sigmoidoscopy, and 7.9–10.4% received an FOBT. For adults aged 65–75, 23.6–27.7% received a colonoscopy, 1.3–3.2% a sigmoidoscopy, and 13.5–16.4% an FOBT. In adjusted analyses, among participants aged 50–64, there was no increase in yearly rates of colonoscopy (−0.28 percentage points, 95% CI −2.3 to 1.7, p = 0.78), sigmoidoscopy (−1.1%, 95% CI −1.7 to −0.46, p = <0.001), or FOBT (−1.6%, 95% CI −3.2 to −0.03, p = 0.046) post-ACA. For those aged 65–75, rates of colonoscopy (+2.3%, 95% CI −1.4 to 6.0, p = 0.22), sigmoidoscopy (+0.34%, 95% CI 0.88 to 1.6, p = 0.58) and FOBT (−0.65, 95% CI −4.1 to 2.8, p = 0.72) did not increase. Among those aged 65–75 with Medicare and no additional insurance, the use of colonoscopy rose by 12.0% (95% CI 3.3 to 20.8, p = 0.007). Among participants with Medicare living in poverty, colonoscopy use also increased (+5.7%, 95% CI 0.18 to 11.3, p = 0.043).ConclusionsEliminating cost-sharing for CRC screening has not resulted in changes in the use of CRC screening services for many Americans, although use may have increased in the post-ACA period among some Medicare beneficiaries.

ABSTRACT Background In recent years, there has been a growing interest in reducing the overuse of healthcare services. However, little is known about how patients conceptualize the benefits and harms of overused screening tests or how patients make decisions regarding these tests. Objective To determine how patients think about the harms and benefits of overused screening tests and how they consider these and other factors when making decisions. Design Semi-structured, qualitative interviews. Participants The study comprised 50 patients, ages 50–84, who had previously received or not received any of four overused screening services: 1) prostate cancer screening (men ages 50–69), 2) colon cancer screening (men and women ages 76–85), 3) osteoporosis screening (low-risk women ages 50–64), or 4) cardiovascular disease screening (low-risk men and women ages 50–85). Approach We conducted a thematic analysis, using a hybrid inductive-deductive approach. Two independent coders analyzed interview transcriptions to identify themes and exemplifying quotes. Key Results Many patients could not name a harm of screening. When they did name harms, patients often focused on only the harms of the screening test itself and rarely mentioned harms further along the screening cascade (e.g., from follow-up testing and treatment). In contrast, patients could easily name benefits of screening, although many seemed to misunderstand or overestimate the magnitude of the benefits. Furthermore, patients described many additional factors they considered when making screening decisions, including their clinicians’ recommendations, their age, family or friends’ experiences with disease, and insurance coverage. Conclusions This study highlights the need to help adults recognize and understand the benefits and harms of screening and make appropriate decisions about overused screening tests.

•Mean prevalence of HPV infection in 8610 women with normal cytology is 12.6%.•HPV DNA was found in 86.6% of cervical cancers.•The prevalence of HPV16/18 among HPV-positive cervical cancers was 87.5%.•Seven countries have organized and 9 countries opportunistic cervical screening.•Only 6 countries integrated HPV vaccination into national immunization programmes. We present a review of current cervical cancer screening practices, the implementation status of vaccination against human papillomaviruses (HPV) and available data concerning the burden of HPV infection and HPV type-specific distribution in 16 Central and Eastern European countries: Albania, Bosnia and Herzegovina, Bulgaria, Croatia, Czech Republic, Estonia, Hungary, Latvia, Lithuania, Montenegro, Poland, Romania, Serbia, Slovakia, Slovenia and the Former Yugoslav Republic (FYR) of Macedonia. Since published data were relatively scarce, two detailed surveys were conducted during August–October 2011 and in January 2013 to obtain relevant and updated information. The mean prevalence of HPV infection in 8610 women with normal cervical cytology from the region was 12.6%, with HPV16 being the most frequent HPV type. The overall HPV DNA prevalence in women with high-grade cervical lesions was 78.1%. HPV DNA was found in 86.6% of cervical cancers; the combined prevalence of HPV16/18 among HPV positive cases was 87.5%. The overall HPV DNA prevalence in genital warts and laryngeal papillomas was 94.8% and 95.2%, respectively, with HPV6 and HPV11 being the most frequent types. Opportunistic and organized cervical screening, mainly based on conventional cytology, is performed in nine and seven countries in the region, respectively, with the proposed age of the start of screening ranging from 20 to 30 years and the estimated coverage ranging from a few percent to over 70%. At least one of the current HPV prophylactic vaccines is registered in all Central and Eastern European countries except Montenegro. Only Bulgaria, Czech Republic, FYR Macedonia, Latvia, Romania and Slovenia have actually integrated HPV vaccination into their national immunization programme and currently provide routine vaccination free of charge to the primary target population. The key reasons for lack of implementation of HPV vaccination into the national immunization programme are high vaccine cost and negative public perception. This article forms part of a regional report entitled “Comprehensive Control of HPV Infections and Related Diseases in the Central and Eastern Europe and Central Asia Region” Vaccine Volume 31, Supplement 7, 2013. Updates of the progress in the field are presented in a separate monograph entitled “Comprehensive Control of HPV Infections and Related Diseases” Vaccine Volume 30, Supplement 5, 2012.