ReviewHow equitable are colorectal cancer screening programs which include FOBTs? A review of qualitative and quantitative studies
Introduction
Globally, colorectal cancer (CRC) ranks as the third most common cancer and the fourth leading cause of death from cancer (WHO, 2008). Rates of CRC are highest in Australia, New Zealand, North America, and Western Europe (Max Parkin et al., 2005). In Australia, CRC is the second most common diagnosed cancer and cause of death from malignant disease (AIHW and AACR, 2008). Similar rates for incidence and death apply for the USA (American Cancer Society, 2008) and UK (Westlake and Cooper, 2008). The crude CRC incidence is increasing in Australia and is predicted to rise by about 30% between 2001 and 2011 (McDermid, 2005).
Evidence from experimental studies has demonstrated that screening for CRC using a guaiac-based faecal occult blood test (g-FOBT) decreased mortality from CRC by 15–33% due to the early detection of colorectal adenomas, the precursor lesions for most CRC (Kronborg et al., 1996, Hardcastle et al., 1996, Mandel et al., 2000). This is consistent with data from South Australia that demonstrates the 5-year survival rate for CRC declines significantly from 88% if detected in stage A, when the cancer is limited within the bowel wall to 7% in stage D, when the cancer becomes surgically incurable or has spread to other areas of body (The Cancer Council Australia, 2007).
Identification and delivery of effective population-based CRC screening therefore provides an opportunity to reduce the number of new cancer cases and to increase survival rates for CRC. However, while some of the screening tests are relatively simple, such as g-FOBT, for there to be benefit the test must first be done, positive results followed up by diagnostic evaluation, and high quality treatment implemented where necessary. In other words, access to all phases of the screening process is required for benefit.
Section snippets
CRC screening
Because of the overwhelming evidence of the benefit, CRC screening guidelines have been developed in many countries, some of which are establishing structured screening programs. In some countries, e.g., USA, organisation of and communication about screening is left largely to the responsibility of individuals and primary health care providers. The 2008 updated guideline for population-based intervention for the USA for people aged 50 or older at average risk includes either an annual Faecal
Aims and conceptual framework
Although a number of reviews have already been undertaken on CRC screening participation amongst different population groups, few studies could be identified that placed an emphasis on the concept of equity in access or utilisation.
It has been well established that more egalitarian societies have both better overall levels of health and reduced inequities in morbidity and mortality (Wilkinson and Pickett, 2007, Wilkinson and Pickett, 2006, CSDH, 2008). In addition, the concept of equity in
Methods and data analysis
The overarching methodology for this paper is a realist review (Pawson, 2006, Pawson et al., 2005), which applies the systematic searching stage from systematic reviews, but then allows for the use of a broad range of literature (including both qualitative and quantitative papers) rather than solely limiting itself to particular types of evidence. In this way, a realist review is still ‘systematic’ although less restrictive than a traditional systematic review and can begin to address the ‘why’
Number, type and location of studies
Sixty-three articles were identified that met the inclusion criteria. The majority of studies (37 out of 63) were based on work undertaken in the USA, followed by studies conducted in UK, Canada, Australia, and Italy.
Twenty-two articles examined predictors of CRC screening participation. Age, gender, socioeconomic status (measured via income, education, postcode or employment) and ethnicity were variables used to determine disparities in access to and utilisation.
Twenty-seven papers focused on
Discussion
In this review we were primarily interested in the first domain of equity of health care described earlier in this paper – equal access for people in equal need. By ‘access’ we mean not just the fact that people receive an FOBT kit via mail, but that this is done in a socially and culturally appropriate manner. Ward (2009a) argues that access to health services is more than geographical access and includes cultural, social and economic accessibility to health services in order to achieve equity
Conclusion
It is clear from this review that there is currently inequitable access to CRC screening, at least in relation to socioeconomic status and ethnicity. As is common in public health, we have considerable evidence about the extent of this problem, but limited understanding of the mechanism by which it is sustained, and few evidence-based solutions. Although the pursuit of health equity is a founding principle in public health, taught to students and recounted in rhetoric, its achievement is
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