The document summarizes a Health Technology Assessment report on interventions to increase participation in organized cancer screening programs. It found that mail and phone recalls, as well as having a general practitioner's signature on the invitation letter, consistently increased participation. Fixed appointments also increased participation compared to open invitations. Self-sampling for HPV testing increased participation in non-responders relative to standard recall letters. The report evaluated interventions' efficacy, cost-effectiveness, organizational impact, and social/ethical issues.

1. HTAi 2012- Bilbao
Health Technology Assessment (HTA)
Report: Interventions to increase
participation to organised cancer
screening programs
Ministry of Health Grant for Applied Research
Giorgi Rossi P, Camilloni L, Ferroni E,
Jimenez B, Furnari G, Guasticchi G, Borgia
P.
Laziosanità – Agenzia di Sanità Pubblica
della Regione Lazio

2. Background
• The most important barrier reducing the
effectiveness of oncological screening program is
low participation of the target population.
• High participation rates are necessary to obtain a
significant impact on population health.
• Compliance to invitation should be achieved by
encouraging “informed” participation by individuals
who are aware of the benefits, limitations and
disadvantages of the screening program.

3. Objective
To synthesize the scientific evidence
produced by International research on
the efficacy of interventions to increase
participation in screening programs.

4. Methods: the HTA process
• Identification of a multi-discipliner working group
including all the principal investigators who
conducted studies with public funding on screening
participation in Italy
• Scope definition
• Stakeholder consultation
• Assessment and draft of the report
• Stakeholder consultation
• Final report

5. Methods: PICOS
Population: breast 49-69; cervix 25-64;
colorectal 50-74
Intervention: any type of intervention or strategy aimed at
increasing participation
Comparison: standard invitation letter (with or without recall)
Outcome: participation to screening program;
Study: RCT, cRCT, controlled non-randomised, before/after
studies.
We updated the systematic review by Jepson et al 2000.

6. Methods: assessment domains
1.Efficacy
2.Cost-effectiveness
3.Organizational impact
4.Social (inequalities), ethic
(informed participation) and legal
(privacy) issues

7. Study selection Flow chart
Potentially relevant
citations (titles) identified
and screened (n=5879) Excluded
irrelevant citations
(n=4821)
Potentially relevant
abstracts identified and
screened (n=958) Excluded QT irrelevant
abstracts but useful for
QL Review (n=813)
Retrieve full text for
critical appraisal (n=145) Excluded irrelevant QT
studies but useful for
QT Studies full field QL Review (n=93)
inclusion criteria (n=52)
Studies from Jepson
Final set (n=122) Review (n=70)

8. Classification of the interventions, according to the
target
•To the target population:
•the individual: invitations, reminders, etc.
•the population: health education, information campaigns
by the mass-media.
•Screening tests: new tests or new procedures; self-
administered tests; etc.
•Health professionals: training; stimuli for physicians, audit
and feedback, etc.
•Health service organization: removing financial or
economic barriers, involving more providers, fixed or open
appointments, etc.

9. Interventions targeted to individuals
•There is strong evidence of a positive effect of mail recall

10. Interventions targeted to individuals
•And phone recall

11. Interventions targeted to individuals
•Heterogenous results for face to face recall

12. Interventions targeted to individuals
•Thre is
consistent
evidence of a
modest positive
effect of the GP’s
sign on the
invitation letter

13. Interventions targeted to individuals
•Informational matherial mailed with the letter has
no effect on participation

14. Interventions targeted to the population
Few studies evaluated the effect of mass media campaigns and
there are several methodological problems
Other studies evaluating multi-facetted interventions, including
mass media campaigns, showed non consistent results

15. Interventions that make screening tests easier
or more acceptable
•Diet restrictions have a negative effect on FOBT compliance
•Higher number of evacuations have a negative effect on Guaiac
FOBT compliance

16. Interventions that make screening tests
easier or more acceptable
Self-sampling for HPV increases participation in non-
responders compared to recall letter
self-sampling direct mail standard recall Risk Ratio Risk Ratio
Study or Subgroup Events Total Events Total Weight M-H, Fixed, 95% CI M-H, Fixed, 95% CI
Giorgi Rossi 2010 121 616 86 619 48.5% 1.41 [1.10, 1.82]
Gok 2010 7404 26920 46 277 51.5% 1.66 [1.27, 2.16]
Total (95% CI) 27536 896 100.0% 1.54 [1.28, 1.85]
Total events 7525 132
Heterogeneity: Chi² = 0.73, df = 1 (P = 0.39); I² = 0%
0.1 0.2 0.5 1 2 5 10
Test for overall effect: Z = 4.59 (P < 0.00001) standard self sampling

17. Interevtions targeted to health service organization
Fixed appointment has higher participation than open invitation

18. Interevtions targeted to health service organization
Remainder addressed to the GP flagging not screened people
have a a modest consistent positive effect

19. Interevtions targeted to health service organization
Direct mailing of the FOBT vs piking up at the clinc showed
heterogenous mostly positve results
Direct mailing has better results than on demand mailing

20. Cost-effectiveness
Given the low cost per QALY of the three cancer
screening, we might spend up to 40€ to gain an
unscreened woman to Pap test, 130€ for
mammography, 80€ an individual to FOBT and 800€
for sygmoidoscopy.
We found economic evaluations only for few
interventions and results are often context dependent:
•Recall letters are consistently cost effective
•Results for reminders to GPs are more
heterogeneous

21. Social issues
•Some interventions have effects on inequalities:
•Longer and more detailed letters increase differneces
in access.
•GP involvement is effective in increasing participation
specifically of more disadvantaged people.
•Phone recalls are more effective in women with low
educational level.

22. Conclusions
Many interventions have been implemented to increase
patrticipation to screening, but only few of them have been
evaluated
Effectiveness of these interventions may be context
dependent.
Some interventions showed consistent positive results in
many context and can be implemented with few resources:
•Mail recall
•GP’s sign
•Fixed appointment

23. Thank you!
HTA report available at:
Epiprev.it