Bowel cancer screening campaign: England

Bowel cancer is the fourth most common cancer and the second most common cause of cancer death in the UK[1], and trials show that bowel cancer screening can reduce deaths from the disease by 15% in the target population (60-74 year olds).[2]

However, there is low uptake of bowel cancer screening across England (58% in 2014). In some areas, particularly the North West, uptake is as low as 40%.[3]

These are some of the reasons why the North West was chosen as the pilot site for this campaign:

• The North West was carefully selected based on a number of criteria including current uptake, incidence and mortality of bowel cancer, deprivation, population size of 60 – 74 year olds and local support for the campaign aims
• The North West holds a high density of 60-74 year olds and uptake is among the poorest in England in some parts of the region. By focussing marketing activity in this area, it is targeted to those in greatest need.

Evidence indicates that fear of the test outcome, being asymptomatic, having a low perceived risk of bowel cancer and concerns about the practicalities and cleanliness of the screening test can act as barriers to participation.[4]

1. Cancer Research UK, UK, http://main.int.cruk.org/health-professional/cancer-statistics/statistics-by-cancer-type/bowel-cancer, Accessed August 2016.
2. Hewitson P et al. (2007). Screening for colorectal cancer using the faecal occult blood test Hemmoccult. Cochrane Database System Review. Accessed August 2016.
3. Cancer Research UK, Local cancer statistics. Accessed August 2016.
4. Cancer Research UK, http://main.int.cruk.org/health-professional/early-diagnosis-activities/bowel-screening-projects-and-resources/evidence-on-increasing-bowel-screening-uptake. Accessed August 2016.

The key message for the public was:

 ‘This little kit could save your life’.

Other key messages included:

• If you’re aged 60-74 you’ll be sent a free NHS bowel screening kit in the post every two years.
• It’s meant for people with no symptoms.
• It can detect bowel cancer early, when it is easier to treat successfully
• Don’t ignore it, take the test.
• Be Clear on Cancer

An advertising campaign including TV, posters at bus stops, adverts in newspapers and on Facebook ran for 12 weeks. Advertising ran for the full campaign period, whilst direct mail ran alongside advertising from 20th February to 2nd April only. Direct mail consisted of two versions:

• Version one: A personalised CRUK endorsement letter, sent to First Timers only (i.e. those being invited to bowel screening for the first time).
• Version two: A personalised CRUK endorsement letter and a pack containing 3 pairs of latex-free gloves, sent to Non-Responders only (i.e. those who have been invited previously but have never responded).

The mailings arrived two-three days following an NHS bowel screening test kit. Previously screened invitees will not be targeted with the CRUK direct mailing.

Advertising and direct mail ran across the North West of England (Granada TV region). This included Lancashire, South Cumbria, Greater Manchester, Merseyside and Cheshire, however some CCG areas acted as control areas for direct mail, and therefore didn't receive the activity. This will enable us to compare the impact of advertising on its own and advertising plus direct mail. Previously screened invitees were not targeted with the CRUK direct mailing. 

The campaign was aimed at 55-74 year olds from lower socioeconomic groups, with a skew towards men. This targeting allowed the campaign to reach both those currently eligible and soon to be eligible for screening, and to focus advertising on those least likely to participate.[1]

The advertising focussed on targeting lower socioeconomic groups, particularly men, since we know that deprived men are least likely to participate in bowel cancer screening.

1. England bowel screening data for FY 2014/15, persons aged 60-74, “Percentage of people adequately screened out of those invited for FOBt screening” were provided by PHE Screening on request April 2016.

While Be Clear on Cancer campaigns had run in England since 2010, this was the first time activity was used to support one of the national cancer screening programmes. Previous Be Clear on Cancer symptom-focused campaigns had shown positive changes in attitudes and behaviours related to recognising and acting on the signs of cancer, including increasing awareness of bowel cancer symptoms.

The activities for this campaign were based on the results from pilot campaigns on bowel cancer screening which were carried out by CRUK:

Wales pilot (Feb – Mar 2015)

A personalised CRUK endorsement letter was found to:

• increase uptake by 9.1 percentage points among ‘First Timers’

A letter including a pack (containing latex-free gloves) was found to:

• increase uptake by 3.2 percentage points among more deprived ‘Non-Responders’

London pilot (Feb – Mar 2014)

A pack (containing gloves and poo catchers) and endorsement flyer achieved a greater impact when supported with advertising:

• increased uptake by 6.1 percentage points among 60-69 year olds
• increased uptake by 7.3 percentage points among 70-74 year olds

The impact of the campaign on bowel cancer screening uptake was analysed across a range of metrics, including:

• by screening history, age, gender and deprivation in target areas
• vomparison of those invited pre-campaign vs comparison areas not exposed to advertising

The campaign’s impact on services was also analysed:

• by number and waiting times for Specialist Screening Practitioner (SPP) appointments and colonoscopies
• by 62 day wait from NHS screening programme urgent referrals, and all suspected bowel cancer urgent referrals, to first treatment
• by collecting data and reporting from Screening Centres on increases in demand pre/during/post campaign
• via questionnaire for patients attending SSP appointment and/or colonoscopy
• via GP attendance data

Some cancer outcomes data was also analysed:

• Number of pre-cancerous adenomas/polyps and cancer detected through screening
• Overall number of bowel cancers diagnosed