Randomized controlled trial: Flexible sigmoidoscopy as an adjunct to faecal occult blood testing in population screening.

OBJECTIVES: Flexible sigmoidoscopy screening at around age 60 can reduce colorectal cancer incidence. Insufficient evidence exists on flexible sigmoidoscopy at age 60 in a population being offered biennial faecal occult blood test screening from age 50. This randomized controlled trial assessed if flexible sigmoidoscopy would be an effective adjunct to faecal occult blood test. METHODS: In the Scottish Bowel Screening Programme between June 2014 and December 2015, 51,769 individuals were randomized to be offered flexible sigmoidoscopy instead of faecal occult blood test at age 60 or to continue faecal occult blood test. Those not accepting flexible sigmoidoscopy and those with normal flexible sigmoidoscopy were offered faecal occult blood test. All with flexible sigmoidoscopy-detected neoplasia or a positive faecal occult blood test result were offered colonoscopy. RESULTS: Overall flexible sigmoidoscopy uptake was 17.8%, higher in men than women, and decreased with increasing deprivation (25.7% in the least to 9.2% in the most deprived quintile). In those who underwent flexible sigmoidoscopy, detection rate for colorectal cancer was 0.13%, for adenoma 7.27%, and for total neoplasia 7.40%. In those who underwent colonoscopy after a positive flexible sigmoidoscopy, detection rate for colorectal cancer was 0.28%, adenoma 8.66%, and total neoplasia 8.83%. On an intention to screen basis, there was no difference in colorectal cancer detection rate between the study and control groups. Adenoma and total neoplasia detection rate were significantly higher in the study group, with odds ratios of 5.95 (95%CI: 4.69-7.56) and 5.10 (95%CI: 4.09-6.35), respectively. CONCLUSIONS: In a single screening round at age 60, there was low uptake and neoplasia detection rate. Flexible sigmoidoscopy detected significantly more neoplasia than faecal occult blood test alone.

Pre-notification increases uptake of colorectal cancer screening in all demographic groups: a randomized controlled trial.

OBJECTIVES: To assess whether pre-notification is effective in increasing uptake of colorectal cancer screening for all demographic groups. SETTING: Scottish national colorectal cancer screening programme. METHODS: Males and females aged 50-74 years received a faecal occult blood test by post to complete at home. They were randomized to receive in addition: the pre-notification letter, the pre-notification letter + information booklet, or the usual invitation. Overall, 59,953 subjects were included in the trial between 13/04/09 and 29/05/09 and followed to 27/11/09. Pre-notification letters were posted two weeks ahead of the screening test kit. Uptake was defined as the return of a screening test and chi-squared tests compared uptake between the trial arms. Logistic regression assessed the impact of the letter and letter + booklet on uptake independently of gender, age, deprivation and screening round. RESULTS: Uptake was higher with both the letter (59.0%) and the letter + booklet (58.5%) compared with the usual invitation (53.9%, p < 0.0001). This increased uptake was seen for males, females, all age groups and all deprivation categories including least deprived females (letter 69.9%, usual invitation 66.6%) and most deprived males (42.6% vs. 36.1%), the groups with the highest and lowest levels of uptake respectively in the pilot screening rounds conducted prior to the roll out of the programme. Uptake with the pre-notification letter compared with the usual invitation was higher both unadjusted and adjusted for demographic factors (odds ratio 1.24, 95% CI 1.193-1.294). CONCLUSIONS: Pre-notification is an effective method of increasing uptake in colorectal cancer screening for both genders and all age and deprivation groups.