Results from the first three rounds of the Scottish demonstration pilot of FOBT screening for colorectal cancer.

OBJECTIVES: To assess the effects of the first three rounds of a pilot colorectal screening programme based on guaiac faecal occult blood testing (gFOBT) and their implications for a national population-based programme. METHODS: A demonstration pilot programme was conducted in three Scottish NHS Boards. Residents aged between 50 and 69 years registered on the Community Health Index were included in the study. RESULTS: In the first round, the uptake was 55.0%, the positivity rate was 2.07% and the cancer detection rate was 2.1/1000 screened. In the second round, these were 53.0%, 1.90% and 1.2/1000, respectively, and in the third round, 55.3%, 1.16% and 0.7/1000, respectively. In the first round, the positive predictive value of the gFOBT was 12.0% for cancer and 36.5% for adenoma; these fell to 7.0% and 30.3% in the second round and were maintained at 7.5% and 29.1% in the third round. The percentage of screen-detected cancers diagnosed at Dukes' stage A was 49.2% in the first round, 40.1% in the second round and 36.3% in the third round. CONCLUSIONS: These results are compatible with those of previous randomised trials done in research settings, demonstrating that population-based colorectal cancer screening is feasible in Scotland and should lead to a comparable reduction in disease-specific mortality.

Cervical screening: the optimum visit plan for contacting users and non-users in Scotland.

OBJECTIVE: To investigate the numbers of visits required to obtain interviews with users and non-users of cervical screening, and to determine the workload involved to enable an optimum visit plan to be developed. DESIGN: Case-control study of users and non-users of cervical screening using a flexible visit plan that involved up to eight attempts at contact. Visits were made in mornings, afternoons, and evenings, the visit pattern being determined by information gained from local sources. PATIENTS: Altogether 660 non-users of cervical screening (cases), aged 20-64 and registered with 23 randomly selected general practitioners (GPs), were identified from the Tayside computerised register of cervical smears. These women were selected from the computerised lists of 18 GPs in Dundee and five in Perth. A total of 417 women recorded as having a smear within the previous three years (controls), matched by age and GP, were also identified from the computerised register. RESULTS: Altogether 1834 attempts were made to contact the cases, of whom 339 were interviewed, giving a workload of 18 interviews per 100 attempts. For the controls 1359 attempts were made at contact to yield 339 interviews, a workload of 25 interviews per 100 attempts. Refusals (19%) and incorrect addresses (23%) were the two major reasons for failing to achieve interview. Only for four (0.6%) of the cases and one (0.2%) of the controls was no information gained. The proportion of attempts which led to interview remained constant with increasing numbers of call-backs (up to six for the cases and eight for the controls). CONCLUSIONS: A flexible approach to visit scheduling that takes account of local knowledge can lead to interviews with 66% of non-users of health screening, when incorrect addresses are removed. It is preferable to plan for many (up to six) visits to achieve interview. This will minimise non-response bias without increasing the workload per successful interview.

Assessing the effectiveness of a screening campaign: who is missed by 80% cervical screening coverage?

A case-control study was conducted to assess the effectiveness of a regional call programme in reaching women at risk of cervical cancer. Home interviews were conducted with a random sample of 614 women aged 20-64 who were identified from a computerized register as either having had a smear test within the previous 3 years or not having an up-to-date smear history. Unscreened women fell principally into two age cohorts: under 35 years and over 50 years. A small social class differential was found to persist following the campaign. Overall, unscreened women were not at epidemiologically higher risk than the screened population. Thirty-five per cent of unscreened women reported never having had sexual intercourse compared to 3% of screened women: 17% of the unscreened and 38% of screened women reported two or more lifetime sexual partners. No difference was observed between screened and unscreened women in the frequency of current cigarette smoking (37% unscreened, 38% screened). Cigarette smoking was, however, associated with social class (31% classes 1 or 2 compared with 50% classes 4 and 5). Level of practical difficulties did not differentiate those who attended from those who did not, suggesting that recent changes to delivery or screening services have been effective in ensuring equity of access. Non-attenders and lower class women held more negative attitudes towards the test procedure and were less likely to believe that they were at risk of cervical cancer. Perceived personal risk was not associated with cigarette smoking, suggesting that further attention might be given to this factor in educational campaigns.

Women's experiences at cervical screening.

Concerns about attendance for cervical screening has focussed on determining the reasons why some women never attend. Less attention has been paid to whether women continue to attend for further smears, although this is essential for further screening. This study investigated women's experiences of cervical screening and their views on subsequent attendance. Three hundred and thirty nine women aged 20-64 were identified from a computerised register of cervical smears as having had a smear test within the previous three years. They were interviewed at home about their most recent experience of screening. Just over half of the women (53%) recalled being anxious before the test, and about one fifth reported embarrassment (19%) or pain (20%) during it. The frequencies of discomfort were higher amongst those who were anxious about the test, although 24% of those who were embarrassed and 28% who had pain reported being unconcerned beforehand. The frequencies of pain and embarrassment were only slightly higher when the smear taker was male. Many women (22%) reported being concerned about the test result although only 10% of those who were concerned were recalled for further assessment. Although a number of women had unpleasant experiences, almost all (95%) who were under 60 years of age said they were likely to attend for a subsequent smear. Taking cervical smears is often an unpleasant experience for women, although some of the distressing events could easily have been avoided. Attention to technique and to the concerns of individual patients, especially ensuring privacy, could reduce the extent of the problem. The uptake of subsequent smears should be monitored to ensure that women are not being discouraged from attendance.

Experience with a wipe guaiac-based faecal occult blood test as an alternative test in a bowel screening programme.

The format of the traditional guaiac faecal occult blood test (gFOBT), particularly the collection technique, might cause difficulties for some. A multistage evaluation of alternative tests was performed. Firstly, four tests with different faecal collection approaches were assessed: a focus group recommended further investigation of a wipe gFOBT. Secondly, 100 faecal samples were analysed using two wipe tests and the routine gFOBT: no differences were found. Thirdly, a wipe gFOBT was introduced. Over 21 months, 400 requests were made and 311 wipe kit sets were submitted for analysis: 153 (49.2%) were negative, 21 (6.8%) positive (all 3 kits positive), 96 (30.9%) weak positive (1 or 2 positive) and 41 (13.2%) un-testable. Forty-three participants were referred for colonoscopy. Outcome data were provided on 39 participants: nine declined colonoscopy, two were judged unsuitable, two did not attend, two were already in follow-up, 13 had normal colonoscopy and two normal barium enema, two had diverticular disease, two had a metaplastic polyp, four had a low-risk adenoma and one had a high-risk adenoma. No participant had cancer. Detection of significant neoplasia was small. The use of the wipe gFOBT was ceased: it cannot be recommended as a screening test for bowel cancer.

Unemployment, socioenvironmental factors, and coronary heart disease in Scotland.

Scotland, which has one of the highest death rates in the world from coronary heart disease, also has considerable regional variation in mortality from this cause. The relation between standardised mortality ratios for coronary deaths (1979-83) for 56 local government districts and a range of socioeconomic factors from the 1981 Census as well as climatic factors and water hardness were investigated. Strong associations were seen with several measures of social disadvantage, the strongest being with percentage of male unemployment. A fitted multiple regression model with mortality from coronary heart disease in men found independent effects of two social variables (percentage male unemployment and percentage social class III-V) and one climatic factor (rainfall). The model explained much (73%) of the geographical variation in mortality from coronary heart disease, but part of the geographical pattern, in particular some of the east-west gradient in mortality, remained unexplained by it. Explanations for the geographical variation and the association with economic factors are currently being sought in terms of individual risk factors in a large screening study, the Scottish Heart Health Study.

Prevalence of coronary heart disease in Scotland: Scottish Heart Health Study.

Data from 10,359 men and women aged 40-59 years from 22 districts in the Scottish Heart Health Study were used to describe the prevalence rates of coronary heart disease in Scotland in 1984-1986 and their relation to the geographical variation in mortality in these districts. Prevalence was measured by previous history, Rose chest pain questionnaire, and the Minnesota code of a 12 lead resting electrocardiogram. The prevalence of coronary heart disease in Scotland was high compared with studies from other countries that used the same standardised methods. A history of angina was more common in men (5.5%) than in women (3.9%), though in response to the Rose questionnaire 8.5% of women and 6.3% of men reported chest pain. A history of myocardial infarction was three times more common in men than women, as was a Q/QS pattern on the electrocardiogram. There were significant correlations between the different measures of coronary prevalence. District measures of angina correlated well with mortality from coronary heart disease, and these correlations tended to be stronger in women than in men. There was no significant correlation between mortality from coronary heart disease and measures of myocardial infarction. The study provides data on the prevalence of coronary heart disease in men and women that are valuable for the planning of cardiological services.

Development of coronary prevention strategies by health authorities in the United Kingdom.

The United Kingdom has one of the highest coronary heart disease mortality rates in the world. However, over the last decade there has been a growing impetus in coronary prevention. In 1988 the Faculty of Community Medicine carried out a survey of all health authorities in the UK to assess the progress and problems with coronary prevention. This survey received a 92 per cent response rate and shows some interesting findings. The picture at present reveals a growing momentum in the last couple of years with half the health authorities at present claiming to have a programme. The main hindrances reported are lack of funding rather than lack of interest. The development and difficulties with nutrition and smoking policies, and with blood pressure screening are also described. The regional pattern of development of these programmes and policies is complex. Many authorities favour a general health promotion approach rather than a negative, disease oriented one; this conflict in approach requires further debate.