Optimizing Screening Uptake

Monitoring screening uptake rates is vital to ensure that tests are cost-effective and are reaching the majority of the eligible population. In countries with organized screening (e.g., the UK), objective uptake rates can be calculated, but in countries that do not have these systems in place, uptake is usually determined from population-based surveys of self-reported participation. These surveys offer the best available estimates, although self-selection bias in survey participation and biases in self-reported screening are likely to mean these figures are overestimates.

In most developed countries, uptake of cervical screening is good. The most recent figures in the UK show that 79% of women aged 25-64 years have been screened within the last 5 years (2008-2009 figures: NHSCSP, 2009), and in Australia the equivalent figure for women aged 20-69 years is 86% [2006-2007 figures: Australian Institute of Health and Welfare (AIHW), 2009b]. Across Europe, uptake of cervical screening at the recommended intervals ranges from 30 to 93% and is greater than 75% for six countries: Finland, Sweden, UK, Denmark, Iceland, and the Netherlands (Anttila et al, 2004). In the US National Health Interview Survey, 83% of American women aged 18 or older reported having had a Pap test in the preceding 3 years (2000 data: Solomon et al, 2007). Similarly in the Canadian National Population Health Survey, 79% of women aged 20-69 said they had had a Pap test within the previous 3 years (data from 1998-1999).

Mammography coverage is similar to cervical screening, with most studies suggesting high uptake. In population surveys in Canada, 72% of women aged 50-69 reported having had a mammogram in the past 2 years (Shields and Wilkins, 2009) and data from the 2006 Behavioral Risk Factor Surveillance System in the USA found 76% self-reported mammogra-phy in women over 40 years within the preceding 2 years (Ryerson et al, 2008). Similar levels are recorded in the UK screening program (74% for women aged 50-64 years having a mammogram within 3 years: 2007-2008 figures), with records in Australia showing slightly lower uptake: 57% of women aged 50-69 years have had a mammo-gram in the past 2 years (AIHW, 2009a).

The figures presented above suggest that the majority of eligible women participate in breast and cervical screening whether in organized or opportunistic contexts. Colorectal cancer screening has not achieved such high uptake rates, with figures ranging from 20 to 71% (Power et al, 2009). Self-reported uptake in the USA showed that in 2005 only 50% of adults over 50 years had had either an FOB test within the last year or endoscopy (colonoscopy or sig-moidoscopy) in the last 10 years (Shapiro et al, 2008). This is similar to uptake rates for FOB testing from the pilot centers for the UK national program (Steele et al, 2009; Weller et al, 2007).

Prostate cancer screening using PSA testing is only offered opportunistically. The most recent estimates from the US suggest that around half of 50-79 year olds have had a PSA test in the past 2 years (Ross et al, 2008; Weller et al, 2007). UK estimates based on a survey of general practitioners suggest that the rate of PSA testing in asymptomatic men is only 2% (Melia et al, 2004).

Most cancer screening programs target gender-specific cancers, but gender differences are of interest in colorectal cancer screening. Evidence for gender differences is mixed and seems to depend on the test that is used. An international review of participation in endoscopy concluded that men are more likely to be screened than women (Stock et al, 2010), although data from a small trial in England with female nurse endo-scopists found the reverse effect (Brotherstone et al, 2007). In contrast, there is evidence that women are more likely to complete FOB tests than men (Seeff et al, 2004; Steele et al, 2009; Weller et al, 2007). Across all procedures, men in the USA are more likely to be screened than women, but the difference is small at around 3% (Seeff et al, 2004; Shapiro et al, 2008).

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