Background
Colorectal cancer (CRC) is the fourth most common cancer among both men and women in the UK. Despite advancements, CRC remains a significant cause of mortality and morbidity, accounting for ∼17 000 deaths and ∼43 000 new diagnoses annually.1
The NHS Bowel Cancer Screening programme (BCSP) aims to detect CRC at early stages. Attending bowel cancer screening confers a substantial 25% reduction in CRC-related mortality.2 BCSP is supplemented by primary care efforts for CRC early detection and referral. Identifying CRC at early stages offers favourable outcomes and better potential for curative interventions.2 In England, approximately 113 individuals are diagnosed with CRC for every 100 000 individuals initially invited.3 CRCs detected through screening showed a higher likelihood to receive curative treatments compared with those detected through emergency presentations.4
The NHS sends invitations for bowel cancer screening biennially, targeting individuals aged 60–74 years, with an extended option for those older to opt in. As of April 2021, the NHS has commenced lowering the eligibility age to 50 years. Invited participants receive an invitation letter, a leaflet explaining risks and benefits, a faecal immunochemical test (FIT) kit, and accompanying instructions.5 Despite the programme achieving a commendable 70.2% participation rate across England in 2022/2023, there remains significant gaps in participation.6
Published research underlines the disparities in participation, particularly among multi-ethnic communities, socioeconomically deprived regions, and specific groups, such as individuals with serious mental health illnesses, learning difficulties, and limited health literacy.7,8 For instance, within South East London, screening coverage stands at 55% and 47% among black participants and those with serious mental illness, respectively — figures lower than the regional average rate of 62%.8,9 Additionally, NHS London internal data show that almost 10% of returned FIT samples are ineligible due to faults in sample collection and labelling.10
Text-message reminders in the context of other interventions
The importance of participation in CRC screening programmes has prompted exploration of various interventions to enhance engagement among eligible individuals. Studies show that supplementing screening invitations with a GP endorsement or additional reminder letter increases participation rates.11 Also, enhanced reminder letters featuring instructional banners targeted disparities in participation among multi-ethnic and deprived populations.11 Telephone reminders have shown promise, augmenting screening uptake by up to 8% when combined with other interventions. However, their cost and labour present challenges.11
Despite the inclusion of the FIT, an invitation letter, and instructions in the screening kit provided by the NHS in England, suboptimal participation rates persist, particularly among certain groups. The non-standardised adoption of GPs’ endorsements and enhanced reminder letters has not fully addressed these disparities. In light of these challenges, text-message reminders have emerged as a strategy, offering convenience, lower cost, less labour, and higher assurance of delivery compared with traditional postal reminders, highlighting their potential impact in the engagement of CRC screening programmes.12,13
Previous studies evaluating text-message reminders for cancer screening programmes have yielded mixed results. A 2017 systematic review concluded that, while text-messages have notably increased participation rates for cervical and breast cancer screening, their impact on CRC screening has been comparatively modest.12 A UK-based trial found that text-message reminders did yield an absolute increase among first-time invitees from 34.9% to 40.5%, but did not significantly influence overall participation in CRC screening.14
A recent systematic review and meta-analysis on mobile health interventions, including text-messages aimed at promoting CRC screening, reported a 20%–46% increase in screening uptake. However, most studies included in the review used telephone reminders and only one study implemented text-message reminders. None of the studies included in the review evaluated the performance of text-message reminders to increase uptake in a FIT-based screening programme.13
Additionally, there is limited evaluation of the content and timing of text-message reminders within the screening pathway, as well as limited assessment of the impact of text-message reminders on the participation rates among different disparate groups.12,13 This underscores the need for further research and real-world evaluation to better understand the effectiveness and implementation of text-message interventions in CRC screening programmes, particularly in addressing participation disparities.
The SMARTscreen trial
The SMARTscreen trial aimed to improve screening uptake within the Australian National Bowel Cancer Screening Program (NBCRP), which offers biennial FIT screening for individuals aged 50–74 years. In Australia, participation is suboptimal, with only 40.9% of eligible individuals engaging with the programme. Participation is even lower among those aged 50–60 years, at 33.4%.15
To address this issue, the recent SMARTscreen randomised controlled trial published in this issue of the BJGP aimed to assess the impact of text-messaging on CRC screening participation among those aged 50–60 years. The trial, including 5451 participants across 21 primary care practices, compared FIT completion rates between the intervention and control arms within a 12-month period following the text-message. The text-message and weblinks included four components: a personalised invitation, a motivational video, an instructional video, and information about CRC screening. Participants could access the videos and educational material through a weblink embedded in the text.15
Primary analysis of the trial revealed that 39% of participants who received a text-message intervention completed FIT, compared with 23% in the control arm. This indicates a significant 16.5% (P = 0.03) absolute increase in FIT completion within 12 months of follow-up. This means that for every six text-messages sent, one additional person completed CRC screening. Such a substantial increase in CRC screening participation holds the potential to reduce CRC-related mortality and decrease associated financial costs. The trial demonstrated the feasibility and effectiveness of text-messaging in increasing CRC screening participation.15
The SMARTscreen trial, conducted within a bowel cancer screening programme similar to the UK in terms of the screening test employed, pathway structure, and frequency, yields valuable insights into intervention effectiveness. However, while participation rates in the UK are 70.2%, Australia reports a lower engagement of 40.9%, thereby a potential limitation of direct applicability to the UK.6,16,17 The trial linked data on an aggregate level (practices) rather than granular level (individuals), which limited conducting subgroup analysis to investigate potential variations based on specific patient characteristics, such as age groups or ethnicity. Hence, it lacks detailed insights into intervention performance across patient groups associated with lower participation, such as ethnic minorities. Furthermore, the trial was conducted predominantly in rural areas, introducing potential limitations in participation determinants compared with more urban settings.
Future potential
Text-messaging has emerged as a promising modality for enhancing participation in CRC and other screening programmes;12 however, its full potential within the context of screening with FITs warrants further exploration.15 While growing evidence has evaluated the effect of text-messaging on overall participation, there is a need to assess efficacy in tackling disparities within CRC screening, particularly in multi-ethnic and socioeconomically deprived communities, and participants with serious mental health illnesses and learning difficulties. Text-messages offer a potential opportunity for disseminating personalised information and visual educational materials.15 While educational interventions are well established to influence content, visual illustrations and language-specific materials within text-messages remain under-researched, particularly among groups with lower participation.11 Further investigation is warranted to understand experiences and perceptions regarding text-message reminders, including for wider engagement in screening, use in consultations, and safety netting within primary care.
Notes
Provenance
Freely submitted; not externally peer reviewed.
Competing interests
For this work, Wasim Hamad and Thomas Round are funded by an NHS England Small Business Research Initiative Grant awarded to Guy’s Cancer Academy and iPlato investigating the potential to increase uptake to colorectal cancer screening using text messaging. Thomas Round is Primary Care Research and Implementation Clinical Lead for Royal Marsden Partners Cancer Alliance and is an Associate Editor at the BJGP.
- © British Journal of General Practice 2024
