Should screening be an offer that is difficult to refuse? A systematic review of decision support interventions for individuals considering bowel cancer screening

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Anna Llupia
Joan Gene Badia
Antoni Trilla
Kirsten J. McCaffery
Glyn Elwyn


Objective: To assess the effect on uptake of interventions designed to support individuals making decisions about screening tests for colorectal cancer.Evidence acquisition: We searched for patient decision support interventions, designed to help individuals consider screening tests for colorectal cancer. We identified those that had been evaluated by randomized trials controlled against usual care and conducted a systematic review.Evidence synthesis: Fourteen trials were identified and 7 were excluded. We observed 2 categories of interventions – those that invited participants to choose ‘one from many’ potential screening tests and those that were explicit that not taking the screening test was also an option. These two categories led to different effects in actual uptake: for those interventions that offered the option of not taking part in screening there was either no difference among groups or the patient decision support interventions favoured control. Where the interventions offered the choice of ‘one from many screening tests’, patient decision support interventions favoured uptake.Conclusions: Decision support interventions that offer a menu of screening tests, that is, ‘pick one from many’ lead to different screening test uptake compared to interventions that are explicit about the option of not taking part in screening. Screening programmes for colorectal cancer and other similar programmes, need to consider whether to ‘nudge’ individuals towards participation or to accept that, in some situations, when given information about benefits and potential harms, less individuals decide to take screening tests.

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Ferlay, J., Autier, P., Boniol, M., Heanue, M., Colombet, M. & Boyle, P. (2007). Estimates of the cancer incidence and mortality in Europe in 2006. Annals of Oncology 18 (3) 581-592.

Campbell, N., Elliott, A., Sharp, L., Ritchie, L., Cassidy, J. & Little, J. (2001). Rural and urban differences in stage at diagnosis of colorectal and lung cancers. British Journal of Cancer 84 (7) 910-914.

Boyle, P., Vainio, H., Smit, R., Benamouzig, R., Lee, W. & Segnan, N. (2005). Workgroup I: criteria for screening. UICC International Workshop on Facilitating Screening for Colorectal Cancer, Oslo, Norway (29 and 30 June 2002). Annals of Oncology 16 (1) 25-30.

Hewitson, P., Glasziou, P., Watson, E., Towler, B. & Irwig, L. (2008). Cochrane systematic review of colorectal cancer screening using the fecal occult blood test (hemoccult): an update. American Journal of Gastroenterology 103 (6) 1541-1549.

Bresalier, R.S. (2009). Early detection of and screening for colorectal neoplasia. Gut and Liver 3 (2):69-80.

Gutiérrez-Ibarluzea, I., Asua, J. & Latorre, K. (2008). Policies of screening for colorectal cancer in European countries. International Journal of Technology Assessment in Health Care 24 (3) 270-276.

Weller, D., Coleman, D., Robertson, R., Butler, P., Melia, J., Campbell, C., Parker, R., Patnick, J. & Moss, S. The UK colorectal cancer screening pilot: results of the second round of screening in England. British Journal of Cancer 97 (12) 1601-1605.

Chapple, A., Ziebland, S., Hewitson, P. & McPherson, A. (2008). What affects the uptake of screening for bowel cancer using a faecal occult blood test (FOBt): a qualitative study. Social Science & Medicine 66 (12) 2425-2435.

Raffle, A. (2001). Information about screening: is it to achieve high uptake or to ensure informed choice? Health Expectations 4 (2) 92-98.

Jorgensen, K. & Gotzsche, P. (2006). Content of invitations for publicly funded screening mammography. British Medical Journal 332 (7540) 538-541.

Jørgensen, K., Klahn, A. & Gotzsche, P. (2007). Are benefits and harms in mammography screening given equal attention in scientific articles? A cross-sectional study. BMC Medicine 5, 12.

Woodrow, C., Watson, E., Rozmovits, L., Parker, R. & Austoker, J. (2008). Public perceptions of communicating information about bowel cancer screening. Health Expectations 11 (1)16-25.

Barratt, A., Trevena, L., Davey, H. & McCaffery, K. (2004). Use of decision aids to support informed choices about screening. British Medical Journal 329, 507-510.

O’Connor, A., Bennett, C., Stacey, D., Barry, M., Col, N., Eden, K. et al. (2009). Decision aids for people facing health treatment or screening decisions. Cochrane Database of Systematic Reviews. 2009; Citation: (3): CD001431. DOI: 10.1002/14651858.CD001431.

Redelmeier, D., Koehle, D., Liberman, V. & Tversky, A. (1995). Probability Judgment in Medicine: discounting unspecified possibilities. Medical Decision Making 15, 227-230.

Elwyn, G., OʼConnor, A., Stacey, D., Volk, R., Edwards, A., Coulter, A., Thomson, R., Barratt, A., Barry, M., Berstein, S., Butow, P., Clarke, A., Entwistle, V., Feldman-Stewart, D., Holmes-Rovner, M., Llewellyn-Thomas, H., Moumjid, N., Mulley, A., Ruland, C., Sepucha, K., Sykes, A., Whelan, T. & International Patient Decision Aids Standards (IPDAS) Collaboration. (2006). Developing a quality criteria framework for patient decision aids: online international Delphi consensus process. British Medical Journal 333 (7565) 417.

Altman, D., Schulz, K., Moher, D., Egger, M., Davidoff, M., Elbourne, D., Gøtzsche, P.C., Lang, T. & CONSORT GROUP (Consolidated Standards of Reporting Trials). (2001). The revised CONSORT statement for reporting randomized trials: explanation and elaboration. Annals of Internal Medicine 134 (8) 663-694.

Centre for Reviews and Dissemination. (2009). Systematic Review: CRDʼs Guidance for undertaking reviews in health care. York: University of York.

Higgins, J. & Altman, D. (2008). Assessing risk of bias in included studies. In: Higgins, J. & Green, S.eds. Cochrane Handbook for Systematic Reviews of Interventions: The Cochrane Collaboration.

Wakefield, C., Meiser, B., Homewood, J., Peate, M., Kirk, J., Warner, B., Lobb, E., Gaff, C. & Tucker, K. (2007). Development and pilot testing of two decision aids for individuals considering genetic testing for cancer risk. Journal of Genetic Counseling 16 (3) 325-339.

Myers R.E., Weinberg, D.S., Manne, S.L., Sifri, R., Cocroft, J., Kash, K. & Wilfond, B. (2007). Genetic and environmental risk assessment for colorectal cancer risk in primary care practice settings: a pilot study. Genetics in Medicine 9 (6) 378-384.

Manne, S., Meropol, N., Weinberg, D., Vig, Z., Catts, A., Manning, C., Ross, E., Shannon, K. & Chung, D.C. (2010). Facilitating Informed Decisions Regarding Microsatellite Instability Testing Among High-Risk Individuals Diagnosed With Colorectal Cancer. Journal of Clinical Oncology 28 (8) 1366-1372.

Braun, K., Fong, M., Kaanoi, M. & Kamaka, M. (2005). Testing a culturally appropriate, theory-based intervention to improve colorectal cancer screening among Native Hawaiians. Preventive Medicine 40 , 619-627.

Hart, A.R., Barone, T.L., Gay, S.P., Inglis, A., Griffin, L., Tallon, C.A. & Mayberry, J.F. (1997). The effect on compliance of a health education leaflet in colorectal cancer screening in general practice in central England. Journal of Epidemiology and Community Health 51 (2) 187-191.

Centers for Disease Control and Prevention. Centers for Disease Control and Prevention (CDC). Colorectal (Colon) Cancer. (2009). Available at: Accessed June 5, 2009.

American Gastroenterological Association. Patient Center: Colorectal Cancer Prevention and Detection. Patient Center. Available at: Cancer Screening Tests.

Miller, D.P., Kimberly, J.R., Case, L.D. & Wofford, J.L. (2005). Using a computer to teach patients about fecal occult blood screening. A randomized trial. Journal of General Internal Medicine 20 (11) 984-988.

Siteman Cancer Center. (2007). Siteman Cancer Center at Barnes-Jewish Hospital and Washington. Your Disease Risk-Cancer, Colon. Available at:;. Accessed June 05, 2009.

Stokamer, C.L., Tenner, C.T., Chaudhuri, J., Vazquez, E. & Bini, E.J. (2005). Randomized controlled trial of the impact of intensive patient education on compliance with fecal occult blood testing. Journal of General Internal Medicine 20 (3) 278-282.

US Department for Health and Human Services. (2009). Get tested for colorectal cancer. Available at: Accessed June 05, 2009.

Zapka, J., Lemon, S., Puleo, E., Estabrook, B., Luckmann, R. & Erban, S. (2004). Patient education for colon cancer screening: a randomized trial of a video mailed before a physical examination. Annals of Internal Medicine 141, 683-692.

US Departament for Health and Human Services. Colorectal Cancer Awareness. Available at: Accessed June 08, 2009. 2008 ;

Gimeno-García, A.Z., Quintero, E., Nicolás-Pérez, D., Parra-Blanco, A. & Jiménez-Sosa, A. (2009). Impact of an educational video-based strategy on the behavior process associated with colorectal cancer screening: a randomized controlled study. Cancer Epidemiology 33 (3-4) 216-222.

Kim, J., Whitney, A., Hayter, S., Lewis, C., Campbell, M., Sutherland, L., Fowler, B., Googe, S., McCoy, R. & Pignone, M. (2005). Development and initial testing of a computer-based patient decision aid to promote colorectal cancer screening for primary care practice. BMC Medical Informatics and Decision Making 5, 36.

Lewis, C.L., Brenner, A.T., Griffith, J.M. & Pignone, M.P. (2008). The uptake and effect of a mailed multi-modal colon cancer screening intervention: a pilot controlled trial. Implementation Science 3, 32.

Lewis, C.L., Golin, C.E., DeLeon, C., Griffith, J.M., Ivey, J., Trevena, L. & Pignone, M. (2010). A targeted decision aid for the elderly to decide whether to undergo colorectal cancer screening: development and results of an uncontrolled trial. BMC Medical Informatics and Decision Making 10, 54.

Lewis, C., Pignone, M., Schild, L., Scott, T., Winquist, A., Rimer, B. & Glanz, K. (2010). Effectiveness of a patient and practice level colorectal cancer screening intervention in health plan members: design and baseline findings of the CHOICE trial. Cancer 116 (7) 1664-1673.

Wilson, C., Flight, I., Zajac, I., Turnbull, D., Young, G., Cole, S. & Gregory, T. (2010). Protocol for population testing of an Internet-based Personalised Decision Support system for colorectal cancer screening. BMC Medical Informatics and Decision Making 10, 50.

Griffith, J., Fichter, M., Fowler, F., Lewis, C. & Pignone, M. (2008). Should a colon cancer screening decision aid include the option of no testing? A comparative trial of two decision aids. BMC Medical Informatics and Decision Making 8,10.

Griffith, J., Lewis, C., Brenner, A. & Pignone, M. (2008). The effect of offering different numbers of colorectal cancer screening test options in a decision aid: a pilot randomized trial. BMC Medical Informatics and Decision Making 8, 4.

Donner-Banzhoff, N., Sönnichsen, A. & Baum, E. (2004). “Frau Doktor, soll ich mich auf Darmkrebs untersuchen lassen?” Eine evidenzbasierte Entscheidungshilfe “Doctor, Should I Take Part in this Bowel Cancer Screening?“ An Evidence Based Decision Support. Zeitschrift für Allegemeinmedizin 80, 460-462.

Young, G.P. (2009). Population-based screening for colorectal cancer: Australian research and implementation. Journal of Gastroenterology and Hepatology ;24 (Supplement 3) S33-42.

Wolf, A. & Schorling, J. (2000). Does Informed Consent Alter Elderly Patientsʼ Preferences for Colorectal Cancer Screening? Journal of General Internal Medicine 15, 24-30.

Health Dialog / Foundation for Informed Medical Decision Making. (2009). Health Dialog. Normal 0 21 Colon Cancer Screening: Deciding Whatʼs Right For You. Available at: Accessed June 4, 2009.

University of Sydney. Sydney Health Decision Group and Screening and Test Evaluation Program. Should I have a screening test for bowel cancer? Available at: Accessed August 5, 2010.

University of Sydney. (2008). Sydney Health Decision Group and Screening and Test Evaluation Program. Should you have a test to screen for bowel cancer? Published by the School of Public Health of the University of Sydney. Sydney, Australia.

Schroy, P., Emmons, K., Peters, E., Glick, J., Robinson, P., Lydotes, M., Mylvanaman, S., Evans, S., Chaisson, C., Pignone, M., Prout, M., Davidson, P. & Heeren, T.C. (2011). The Impact of a Novel Computer-Based Decision Aid on Shared Decision Making for Colorectal Cancer Screening. Medical Decision Making 31 (1) 93-107.

Dolan, P. (1999). Effect of deliberation on the publicʼs views of prority setting in health care: focus group study. British Medical Journal 318, 916-919.

University of North Carolina. Center for Decision Making Research. Colon Cancer Screening. What you need to know. Available at: Accessed August 5, 2010.

Healthwise. Healthwise Inc. (2008). Which test should I have to screen for colorectal cancer? Available at: Accessed June 5, 2009.

Mayo Clinic. (2009). Colon Cancer. Available at: Accessed June 4, 2009.

University of Michigan. University of Michigan Health System. Colorectal Web. Available at: Accessed August 5, 2010.

Dolan, J. & Frisina, S. (2002). Randomized controlled trial of a patient decision aid for colorectal cancer screening. Medical Decision Making 22, 125-139.

Pignone, M., Harris, R. & Kinsinger, L. (2000). Videotape-based decision aid for colon cancer screening. Annals of Internal Medicine 133, 761-769.

Ruffin, M., Fetters, M. & Jimbo, M. (2007). Preference-based electronic decision aid to promote colorectal cancer screening: results of a randomized controlled trial. Preventive Medicine 45, 267-273.

Trevena, L.J. (2008). Randomized trial of a self-administered decision aid for colorectal cancer screening. Journal of Medical Screening 15, 76-82.

Smith, S., Trevena, L., Simpson, J., Barratt, A., Nutbeam, D. & McCaffery, K. (2010). A decision aid to support informed choices about bowel cancer screening among adults with low education: randomised controlled trial. British Medical Journal 341, c5370.

Mathieu, E., Barratt, A.L., McGeechan, K., Davey, H.M., Howard, K. & Houssami, N. (2010). Helping women make choices about mammography screening: an online randomized trial of a decision aid for 40-year-old women. Patient Education and Counseling 81 (1) 63-72.

Mathieu, E., Barratt, A., Davey, H.M., McGeechan, K., Howard, K. & Houssami, N. (2007). Informed choice in mammography screening: a randomized trial of a decision aid for 70-year-old women. Archives of Internal Medicine 167 (19) 2039-2046.

Bekker, H. (2010). Decision aids and uptake of screening. British Medical Journal 341, c5407.

Scholefield, J., Moss, S., Sufi, F., Mangham, C. & Hardcastle, J. (2002). Effect of faecal occult blood screening on mortality from colorectal cancer: results from a randomised controlled trial. Gut 50 (6) 840-844.

Entwistle, V.A., Carter, S.M., Trevena, L., Flitcroft, K., Irwig, L., McCaffery, K. & Salkeld, G. (2008). Communicating about screening. British Medical Journal 337, a1591.

Entwistle, V.A., Carter, S.M., Cribb, A. & McCaffery, K. (2010). Supporting patient autonomy: the importance of clinician-patient relationships. Journal of General Internal Medicine 25 (7) 741-745.