Damian Sendler: An important part of reducing cancer mortality at the population level is early detection through organized screening. It is critical that those who have been invited to participate in screening programs do so. As a result, uptake rates are below average across screening programs, indicating that patient factors must be clarified in order to develop strategies that are based on evidence. Behavioral interventions have been shown to be effective in increasing cancer screening uptake, according to this review of individual-level (sociodemographic and psychosocial) factors. The authors discuss current trends and future directions in behavioral cancer screening research in order to overcome challenges and address unmet needs in cancer mortality reduction.
Damian Jacob Sendler: As the world’s population ages, so does the cancer burden it carries. Estimates suggest that, by 2040, there will be 28.4 million new cases of cancer worldwide, up from an estimated 19.3 million in 2020 and a staggering 10 million deaths from the disease [1]. Early detection of cancer is critical to lowering the death toll from the disease. Many countries have set goals to improve cancer detection and treatment. When it comes to cancer diagnosis, the National Health Service in England has set a goal of increasing the percentage of people diagnosed at an early stage from about 50–75 percent by 2028.
Dr. Sendler: A key component of any national cancer strategy is the early detection of cancer and precancer through screening of asymptomatic people. High-quality randomized trials show that organized screenings are effective in reducing cancer mortality [3–6]. Therefore, many countries have established national screening programs for breast, cervical, and colorectal cancer. Lung cancer screening is currently being expanded internationally, and prostate cancer screening is available but not recommended as an organized program. There are many countries where cancer screening has been implemented in high- and middle-income countries such as Europe and North America, but it is less common in low and middle-income countries.
Using evidence known to the authors as well as evidence gathered through ad hoc’scoping’ searches, this review examines the role of patient factors in cancer screening uptake. The authors use the original research authors’ interpretations to highlight the most significant developments. According to the authors, evidence of prostate cancer screening uptake is relevant for other cancer screening programs, such as colorectal and lung cancer screenings.
Evidence from the United Kingdom and the United States is the primary focus of the authors, supplemented by evidence from other countries that have implemented cancer screening programs in the past. Patient factors in cancer screening have been largely studied in the UK and US, indicating that current knowledge may not be universally applicable to screening uptake globally and the need for additional research in various cultures and health systems. However, while country-specific nuances of screening programs and their organization can make it difficult to transfer lessons learned in one country to another, evidence from both countries provides insight into patient factors in cancer screening in two contrasting healthcare systems. This study Cancer screening in the United Kingdom is free at the point of delivery, supported by the UK National Screening Committee, and includes a systematic call and recall of eligible patients based on their registration with a primary care physician. Patients in the United States, on the other hand, can self-refer and discuss screening with their doctor through health insurance or government-run health programs, as there is no centrally organized cancer screening program in the country. Cancer screening recommendations from the US Preventive Services Task Force and the UK National Screening Committee are currently in place.
An adequate screen (a definitive test result) can be defined as the percentage of those invited who receive it within a specified time after their test. Uptake has been cited as the most critical determinant of the success of a screening program for cancer [17]. There are a slew of good reasons for everyone to get screened for cancer. There must be a sufficient number of cancers detected early enough to make the program cost-effective, and high uptake ensures this. A lack of screening could lead to a widening disparity in cancer survival because of disparities in uptake among different sociodemographic groups. For example, those who are most likely to develop cancer may not be screened because of the ‘inverse care law,’ a potential problem for screening.
A cancer screening program’s benefits should outweigh its drawbacks. A reduction in cancer-specific mortality, lower health care costs, increased awareness of the disease and its symptoms, and emotional reassurance are among the possible benefits of telemedicine. Potential harms include overdiagnosis, false-positive results, and unnecessary treatment leading to greater costs, the associated risks and complications of diagnostic procedures, and emotional distress to the patient.. Screening participation is not just about increasing the number of people who participate; it’s about making informed decisions that take into account the potential costs and benefits of participating [19]. In order to make an informed and autonomous decision that is consistent with one’s own values and beliefs, one must have access to information about the possible consequences [20]. Cancer screening participation should therefore be up to the individual and not dictated by an authoritative figure.
According to data from the National Health Interview Survey in the United States, uptake of cancer screening varies by cancer type: 81.3 percent for cervical screening, 71.7 percent for breast screening, and 63.4 percent for colorectal screening [21]. In England, 72.2 percent of National Health Service cancer screening programs are used for cervical screening, 69.1 percent for breast screening, and 579 percent for colorectal screening. Different cancer screening methods and ‘at-risk’ populations are shown to have different uptake rates, highlighting the difficulty of identifying barriers to screening that may differ between screening programs (Table 1).
Colorectal screening methods can change from country to country; for example, a simple fecal immunochemical test (FIT) has replaced the guaiac fecal occult blood test (FOBT) for colorectal cancer screening in many countries, while more invasive flexible sigmoidoscopy and colonoscopy methods are still used in some countries. In addition, the screening guidelines for the National Health Service are reviewed on a regular basis [25], for example, a proposed age extension to the service’s breast cancer screening program. Although new developments have been made, much of the prior research on patient factors and the various influences on screening behavior is still relevant to current screening methods and techniques.
To reduce cancer mortality, it is necessary to understand patient factors associated with cancer screening uptake (including sociodemographic characteristics such as age and psychosocial factors such as perceived risk of cancer) and to use behavioral science to inform interventions to promote greater participation in screening programs. Patient factors are recognized as only one part of the multilevel influences on screening behavior [26], but they are crucial for increasing cancer screening uptake.
It is the goal of this review to provide a narrative summary of the evidence relating patient factors to cancer screening participation, to describe advances in behavioral strategies to promote uptake and to examine current and future challenges in the field of cancer screening behavior. Various sociodemographic and psychosocial factors, such as an individual’s ability, motivation, and opportunity to participate in cancer screening, are examined by the authors. A variety of behavioral mechanisms are also considered by the authors as interventions that operate at the individual level. In the future, cancer screening developments could have a significant impact on patient involvement. Cancer screening uptake has been linked to a variety of patient factors, and these factors have been evaluated for their ability to increase screening uptake. These associations and effects are discussed in the overview, but no quantitative data are presented in a systematic manner, which makes it difficult to identify knowledge gaps and future research directions that need to be addressed through the collection of additional data.
Compared to men, women are consistently more likely to participate in colorectal cancer screening in the UK [24,28,29] and in the United States [21]. [30] Colorectal cancer screenings are less common among men than women in Australia. A number of factors, including the screening method and setting, can influence the association between gender and the uptake of colorectal cancer screening. It was found that men were more likely to use the FIT test than women in a pilot study in England, which reduced the absolute difference from 5.7% to 3.6% [32].
It’s possible that women are less likely than men to have their lungs screened for cancer, but this evidence comes from clinical trials, not the general population who is screen-eligible [33]. When it comes to lung cancer screening in the United States, where uptake has been extremely low (less than 18 percent since it was recommended), there are no gender differences in uptake or return for a second annual screening. It is unlikely that sexism has any significant impact on cancer screening uptake, as differences between genders are small.
Age is a significant factor in both the UK and the US when it comes to breast cancer screening. There was a 68.2 percent uptake of breast cancer screening in women ages 50–52 and 73.2 percent in those ages 65–70 in England in the 2018–2019 period [23]. [23] Data from the age extension trial, which only included women aged 45–49 years, backs up this trend. Only 66.5 percent of those women participated. Compared to the United Kingdom, the age gap in breast cancer screening participation is smaller in the United States. [37] Women 65–74 years old have a slightly higher participation rate than those 50–64 years old (72.2 vs 71.3 percent). It has also been found that older men are more likely to undergo colorectal cancer screening than younger men [38].
Because of the broader age range targeted, there is a more complicated relationship between age and cervical screening. Increases in England’s coverage (the percentage of eligible population who have been tested and are in good health) are seen in younger age groups, but then declines in older age groups [22]. Uptake in the US reaches its pinnacle among people aged 30 to 39 years old [39]. The 60–74-year-old age group is more likely to adhere to lung cancer screening than younger and older age groups, according to research [36]. Two studies found no age-related differences in screening uptake, while one found a higher percentage of 65–80-year-olds screened than those 55–64-year-olds screened (16.5 vs. 12.4 percent) [34,40]. Age does not appear to have an effect on the uptake of lung cancer screening in pilot programs in the UK [41].
Screening for cancer has a well-established socioeconomic gradient. When it comes to breast, cervical, and colorectal cancer screenings, women who live in lower socioeconomic areas are less likely to go [43,44] and are also less likely to have been screened for any of these three diseases at all [45]. In a study of women in Scotland, greater deprivation was associated with lower uptake of breast and colorectal screening than cervical screening [44]. Even though the gradient is less apparent for income and cervical screening in the United States [21], higher education and income are associated with greater likelihood of recent breast and colorectal cancer screening in the United States. In other countries, such as Italy and South Korea, lower colorectal screening uptake has been observed in more disadvantaged groups [48]. Participation in lung cancer screening in the United States is higher among those who have a high school education compared to those who do not [47]. In contrast to other types of cancer screening, those who have completed at least a high school education are also less likely to have been screened, and only time will tell if this association persists as lung screening becomes more widely used.
Nonwhite ethnic groups have a consistently lower rate of cancer screening uptake. All three major cancer screening programs in the United Kingdom are less popular in ethnically diverse areas, particularly among South Asians [50–53]. More than 70% of non-Hispanic African American women have undergone a mammogram in the United States, while only 69% of Hispanic women have had the procedure, according to a study published in the Journal of the American Medical Association. [37] Data from countries other than the United Kingdom were insufficient to draw conclusions about ethnic group participation in FOBT colorectal cancer screening programs [48]. According to US statistics, African American/Black women are more likely (74.6 percent) than white or Hispanic/Latina women (68.4 percent) to get a cervical screening (68.6 percent ) [54]. In Australia, Aboriginal and Torres Strait Islander people are less likely than non-Indigenous people to undergo cancer screening (e.g., 34% vs. 56%) [55,56]. White participants in a meta-analysis were found to be more likely to participate in lung cancer screening than nonwhite participants. [36] Factors associated with minority status, such as language and cultural barriers, may play a role in ethnic disparities. Immigrants in Norway had a 53.1 percent screening rate for breast cancer compared to 76.1 percent for nonimmigrants. The data from Norway showed that the gap narrowed as the length of time spent in the country increased, suggesting that barriers to assimilation are linked to acculturation.
Damian Jacob Markiewicz Sendler: To participate in cancer screening, people need to know more about the disease and how it’s detected. A high level of public knowledge about cancer screening programs has been found, particularly in the case of more established programs [59–61]. As a result of these misconceptions, cancer screening may not be necessary if there are no cancer symptoms present [63,64]. Nonetheless In a nationally representative US sample, those who avoided learning about cancer risk had lower rates of colorectal cancer screening [65]. Minority ethnic groups in England had lower levels of knowledge than whites, and this may be due to language barriers [66, 67]. Breast and FOBT screenings, but not cervical or flexible sigmoidoscopy screening, were found to be less well understood by ethnic minorities and lower socioeconomic status groups in England, a population-based survey found [63]. It is critical for screening participants to be educated about the advantages and disadvantages of screening, but screening invitations may lack the information necessary to promote this knowledge and informed choice [68,69].
Those who have a learning disability are less likely to participate in cancer screenings than the general population. [44] A study of women with learning disabilities found that they participated less in all three cancer screening programs in Scotland. Colorectal and breast cancer screening participation was lower among women with depression or greater multimorbidity in the same study. The uptake of cancer screening is particularly low in people with psychosis or more severe mental health problems [71–73]. Colorectal cancer screening participation in England was linked to better self-rated health and mediated the relationship between socioeconomic status and uptake significantly [74]. If a patient is already receiving cancer treatment or has a medical condition that prevents them from participating in a screening, they may not be able to participate.
There is a link between low health literacy and lower cancer screening rates [76,77]. Low health literacy and numeracy may also be significant barriers to informed cancer screening, according to studies that show better health literacy is associated with greater screening knowledge, lower cancer fatalism (the belief that death from cancer is inevitable), and a more positive attitude toward screening [78].
Negative emotions like anxiety and fear play a larger role in theories explaining health-protective behavior than do positive emotions like joy and happiness. Anxiety about breast, cervical, and colorectal cancer is a motivator for screening, but moderate anxiety appears to be more motivating than low or high anxiety [79–81]. Fear has been shown to have a complex relationship with uptake, acting as both a barrier and a facilitator in cancer screening in general [82]. Groups that are least likely to participate in cancer screening [83,84] are more likely to experience feelings of fear, worry, and disgust, whereas in the absence of screening, people’s fear of cancer can motivate them to attend [85]. In addition to screening invitations, screening methods, and the possibility of abnormal test results, other sources of fear can act as a barrier. Screening for breast, cervical, and colorectal cancers is hindered by a fear of embarrassment, discomfort, or pain [81,87–90]. Disgust at handling stool samples is a predictor of avoiding routine colorectal cancer screenings [91]. Different aspects of emotion can influence decision-making and action-taking processes, according to the evidence..
A wide range of studies have consistently found that the best predictor of future behavior is the person’s past behavior. As a result, past screening participation is the most important predictor of future screening participation [92], and people who have participated in one cancer screening program are much more likely to participate in additional screening programs [44]. Because of the different levels of uptake observed, this suggests that screening programs face common and unique barriers to participation [93]. Increasing the number of first-time participants may be a key factor in increasing the number of people who attend.
As a result of the possible risks, most people are enthusiastic about cancer screening. It’s not clear how much information about screening’s benefits and drawbacks affects attitudes. For example, even when people are informed about the dangers of cancer screening, they still have a favorable attitude toward it [69]. True-positive mammogram results were more acceptable to women who had previously received a false-positive result [96]. People who have been misdiagnosed and overtreated as a result of screening are more likely to believe that they owe their health to screening, which is called the ‘Popularity paradox’ [97]. There is evidence to suggest that people’s attitudes are resistant to information about screening’s risks, and that people don’t necessarily make deliberative decisions about screening attendance by weighing the risks and benefits.
A lack of interest in routine screenings for breast, cervical, and colorectal cancers is linked to cancer fatalism in both the United Kingdom and the United States [74,98]. Concerns about practicality and cleanliness of the screening method appear to be a greater barrier to colorectal cancer screening than for breast or cervical screening [45]. According to some reports, people go to cancer screenings for altruistic reasons, such as the belief that screenings are an efficient use of health-care resources [64,99] and a form of medical research that can advance science [100].
Damien Sendler: There was a correlation between higher efficacy beliefs about cancer screening and greater uptake of colorectal cancer screening in a sample of English adults aged 60–69 [74]. Overestimation of mammography’s effectiveness was found in women in the United States, United Kingdom, Italy, and Switzerland, with a higher number of accurate estimates negatively associated with having undergone screening in the preceding two years [101]. A UK study [102] found a link between lower health literacy and a person’s self-efficacy in regards to colorectal cancer screening. South Asian ethnicity and lower uptake in England and Scotland were linked through self-efficacy [103].
Risk perceptions are known to play an important role in health behavior, but they are difficult to measure, limiting our understanding of the link between screening uptake and risk perceptions. Cancer screening participation is associated with increased cancer risk perception, but individuals may be overly optimistic about their own chances of developing the disease [105]. Screening decision-making is influenced by benchmarks or ‘candidates,’ which have been discovered through qualitative research [106-107]. Affective risk perception (also known as ‘affective risk perception’) can be triggered by a person’s beliefs about the severity of a disease, such as cancer, and by known risk factors like a family history of cancer or tobacco use [108]. Objective cancer risk factors may only be weakly associated with people’s risk perceptions. Through further research, it is necessary to gain a better understanding of the nature and impact of risk perceptions
In the United States, screening intentions for breast, colorectal, and prostate cancer are predicted by perceived norms [111]. Among men and those from ethnic minorities, a study in England found that cancer stigma was more prevalent among those who participated irregularly or not at all in any of the three national screening programs [112]. Cultural taboos such as the prohibition on exposing one’s body to strangers or the association between cervical cancer and promiscuity [86] may make cervical screening an even more taboo subject for some ethnic groups. Lung cancer screening has been hampered by the stigma of cancer as a self-inflicted disease [113]. As a result, smokers in the United States are less likely to participate in lung cancer screening compared to nonsmokers [114], while smokers in the United Kingdom are less likely to participate in colorectal screening [80].
Cancer screening uptake can be influenced by an individual’s environment and resources. When compared to the United States, people who live in urban areas may be less likely to attend church services in the UK [47,115]. Rural areas in the United States may have a greater distance barrier than urban areas, which may account for this disparity. Making an appointment and relying on others to carry out daily activities are two other possible practical barriers to cancer screening [81,92]. Nonattendance is linked to a lack of social support, as well as being unmarried [31,88]. It is common for colorectal cancer screening to be offered as a home test kit, which can be perceived as a barrier to participation [93,99]. The invitation may not have reached some screening nonattendees [117], perhaps because they have relocated.
There is some evidence that psychosocial factors can explain the influence of well-established sociodemographic factors on cancer screening uptake. Screening uptake is influenced by socioeconomic factors such as lower health literacy and knowledge, greater cancer cynicism, higher perceived cancer stigma in more deprived groups [74,84]. Sociodemographic factors may also play a role in the intention–behavior gap by predicting screening intention more accurately than behavior. As a result of this information, behavioral interventions to encourage cancer screening uptake have been developed and targeted.
Screening invitation reminders are a good way to increase the number of people who accept the invitation. Post, phone, or text message are all effective methods of distributing them. First-time invitees were more likely to show up for their screening appointment if they received a text message reminder 48 hours before their scheduled appointment, compared to the control group. For women who did not respond to the first invitation, a postal reminder increased cervical screening uptake by 9% in absolute terms compared to no reminder. In those who had not yet responded, a follow-up phone call boosted uptake by 31% more than it would have been without it [122]. In England, text message reminders didn’t have an overall impact on colorectal screening uptake, but they had a significant impact on first-time invitees (40.5 vs. 34.9 percent). A small effect on colorectal cancer screening was found in a systematic review, which found that text messaging interventions had a modest effect on breast and cervical cancer screening uptake [124]. Colorectal cancer screening kit return rates can be improved with advance notification letters [125], but the UK has found that they are ineffective at encouraging the return of cervical screening self-sampling kits [126]. A systematic review of international studies found that reminders increased adherence to lung cancer screening. The effectiveness of personalized reminders has also been studied. It was found that sending a follow-up letter that reiterated the original invitation to undergo colorectal cancer screening increased uptake overall and was more effective in the most deprived areas [127]. Electronic physician and primary care provider prompts to recommend screening for nonattenders in ambulatory settings increased breast and colorectal cancer screening, but not cervical screening, in a meta-analysis [128]. Patients who receive reminders are more likely to show up because they are less likely to forget. They are also more likely to plan ahead of time. Cancer screening inequalities may be reduced through the use of reminders, which appear to be particularly effective in first-time invitees and areas of greater deprivation [129].
To make things as simple for themselves as possible, people often choose to act in a way that is different from what they would normally do. With the help of default options, screening programs have found that providing a fixed appointment time on invitations has boosted the number of women who participate in breast and cervical screening [92,130]. Using a second timed appointment to send reminders to people who missed their first breast cancer screening appointment has also been found to be effective [131]. To avoid inefficiency and waste due to missed appointments, this strategy lessens the burden on the invitee in terms of preparation. FIT and HPV self-sampling kits need to incorporate goal-setting and planning techniques in order to avoid the ‘easier’ option of delaying and not responding to a test.. By allowing patients to change their office hours for a breast cancer screening, a 2.8% increase in uptake was observed, with 7% opting for an evening or weekend appointment instead of an office appointment [132].
There is a link between mass media campaigns and increased cancer screening uptake in areas where organized screening is readily available [136]. Campaigns of this type can aim to disseminate information about screening, challenge preconceived notions, alleviate anxieties, and set an example for others to follow. In Australia, for example, a television ad campaign resulted in an 18 percent increase in cervical screening and an 11 percent increase in colorectal cancer screening kit return, with a greater impact on those who had never participated before. Increases in cancer screening may also be linked to media coverage of high-profile deaths from the disease [139].
Screening for colorectal cancer was found to have a 3.6 percent higher attendance rate when materials addressed known barriers were used compared to standard materials [141]. Participation in colorectal cancer screening increased by 6% as a result of an improved procedural leaflet [142]. There were no significant differences in uptake between low-literacy or low-numeracy groups when supplemented with simplified summaries of key information and a narrative leaflet containing personal screening stories designed to improve comprehension by people with low literacy or numeracy [127]. Redesigning written information, especially in low-literacy areas, may have little effect on uptake. In a study conducted in the United States, a clinic-based research assistant evaluated a sample of low-literate people and found that 11.4 percent returned all three subsequent annual FOBT kits, compared to 4.7 percent who did not receive the education [143]. The education included a demonstration of how to complete the kit. More intensive support from a clinic nurse, such as phone contact and problem solving, resulted in a greater uptake in another group of participants (13.6 percent ). Even though uptake is still low and such support requires significantly more resources, this shows the potential for personal support to promote uptake without relying on written materials The use of illustrations and social media techniques should be explored as evidence-based health communication methods [144,145].
Damian Sendler
Framing screening messages by comparing them to descriptive social norms (highlighting what is commonly done) rather than injunctive norms (highlighting what other people approve of) may have a greater impact. Descriptive norms run the risk of “reactance” and unintended consequences. Injunctive norms, on the other hand, can prevent these. African Americans are more likely to get screened for prostate cancer if they have a stronger sense of racial identity than those who don’t, according to the effects of subjective norms on prostate cancer screening participation [152]. When people are encouraged to think about the negative consequences of not getting screened for breast cancer, loss-framed messages appear to be slightly more effective than gain-framed messages at increasing the likelihood of getting screened. Studies on colorectal cancer screening found similar results [154]. An accompanying ‘affective booster’ (for example, the opportunity to anticipate and feel relief at receiving a negative test) increased the message’s persuasiveness in the gain-framed condition, according to the authors of this study. Colorectal cancer screening participation was not affected by a theory-based intervention that was delivered with prenotification letters that included a questionnaire about anticipated regret. However, those with low intention to participate were more likely to participate. Cervical screening was found to be more popular among those who received the regret messages in a similar intervention [156]. There are some questions about whether these approaches are able to facilitate autonomous and informed decisions because they are focused on automatic and affective decision-making rather than rational and reflective cognitive decision-making. The impact of information design strategies on information comprehension and values-aligned decisions, as well as their effect on uptake, must be evaluated.
Helping people make specific plans about screening participation is one way to close the gap between their intentions and their actions. This is what they’re aiming for, and they’re doing it by making goals and taking action (e.g., making if-then plans, or implementation intentions). According to one study, a colorectal cancer screening information leaflet with three pre-formulated implementation intentions was not effective at increasing uptake of screenings. There were no statistically significant differences in the number of women attending breast cancer screenings between those who completed three implementation intentions and those who did not [158]. User participation in the design and development of planning interventions is critical to their success [159]. Existing motivation to participate in screening and engagement with the support tool are among the factors that may determine their effectiveness. In contrast to mailing in a test kit, attending a screening appointment requires a different type of action. The former requires time, travel, and a social context, whereas the latter allows for greater personal control over where and when screening occurs. Other health behaviors [160] have demonstrated the effectiveness of planning support tools, indicating a need to investigate their applicability in cancer screening programs as well.
Evidence of individual-level behavioral interventions that aim to restructure the individual’s environment, modify information design, and support planning has been summarized by the authors in this review. Reminders, simplified information, and easy-to-understand tests are all likely to improve the effectiveness of interventions [161]. [161] Improved understanding of how and why interventions work can help improve cancer screening uptake, and interventions at multiple levels (such as provider and patient level) may be more effective [162].
Sociodemographic and psychosocial variables have been shown to influence cancer screening uptake. Other variables appear to be associated with the overall uptake of cancer screenings, whereas others are specific to individual screening programs. Such information enables the development and evaluation of intervention strategies based on solid evidence. Cancer mortality can be reduced through increased screening uptake with behavioral support, but it is critical that intervention development builds on existing research and theory. Screening should be simplified, the amount of time it takes to participate reduced, and people should be supported in planning participation and responding to barriers. screening providers should implement interventions that have been proven to be effective, many of which can be implemented at a low cost.
Individual differences in cancer risk and the potential benefits of cancer screening are gaining attention as a way to improve cancer screening programs’ efficiency and reduce the harms they cause. There has been an increase in the use of a risk-stratified screening approach, which focuses on those at higher risk of cancer and those at low risk of cancer. Breast cancer screening programs across the country are already incorporating risk stratification. [163] According to the findings of a 2019 independent review of screening in England, a single advisory body should oversee both targeted screening and population screening. It is also being studied to improve the criteria for selecting patients for lung cancer screening using multivariate models rather than just age and smoking history, as is the current recommendation in the United States. Risk communication can benefit from the insights of behavioral science. Screening information tailored to the individual’s beliefs and concerns, as well as a tailored risk approach, may be more effective in promoting participation. In order to avoid exacerbating already-existing inequalities in screening uptake, risk-stratified screening should take into account public attitudes, beliefs, risk perceptions, and emotions.
Damian Jacob Sendler
Generic tests or simple biomarker tests have been used to stratify cancer risk in recent years due to advances in genomics and cell biology. [165] Stool, urine, blood, and exhaled breath are all examples of biomarker tests that can be used to screen for multiple types of cancer in a single sample. It is possible that these tests could be more effective and less harmful at detecting early cancer than existing tests because they are faster and more cost-effective to perform. New screening methods may be able to detect cancers that can be treated at an early stage, such as ovarian, liver, and pancreatic cancers, more effectively than current screening methods. As a result of these developments, questions arise about the role of patients in cancer screening. For example, how will a blood test to detect lung cancer be received and perceived? There are an increasing number of screening tests available, each with their own unique characteristics and potential benefits and drawbacks. Behavioral science may be able to help answer these questions and develop interventions based on scientific evidence to help spread awareness and encourage participation in a cancer screening program using a new test.
More people may be at risk of overdiagnosis due to the development of new tests and an increase in cancer screening in many countries. Overdiagnosis must be better understood by the public, and the “popularity paradox” must be avoided. Informed decision-making about cancer screening participation requires this, but it may be difficult to achieve and requires evidence-based health communication methods. Screening uptake does not have to drop if people are made more aware of the risks of screening and the fact that the program is effective in reducing cancer burden when everyone participates. Behavioral interventions that prioritize patient autonomy are needed in the pursuit of greater uptake and informed uptake. As a result, there may be a shift to behavioral techniques that educate rather than manipulate and support people in acting in accordance with their values and intentions. Screening decisions that reflect a patient’s values, priorities, and attitudes toward risk can be supported by the use of decision aids. While screening for breast and colorectal cancer, the use of decision aids was found to reduce participation [166,167]. Because of the uncertainty about the balance of benefits and risks for an individual, a risk-based approach may necessitate accepting that better information may lead to lower overall uptake.
The ‘at-risk’ population, primarily those with a long history of smoking, will necessitate special consideration when the lung cancer screening program is implemented. There is a high level of public awareness of the cancer risk associated with smoking, which may lead to an increase in cancer screening participation among those who are eligible. High levels of cancer fear, according to behavioral theory, may lead to screening avoidance rather than attendance in the absence of high levels of self-efficacy for screening [168]. The American Thoracic Society recommends the use of patient navigators as outreach workers to help the most vulnerable overcome barriers, shared decision-making tools that are suitable for low literacy and numeracy levels and for different cultural backgrounds, and the use of telehealth and mobile screening units to overcome geographic barriers [169]. For those who are more likely to live in areas of high deprivation, the use of media such as letters and leaflets has been shown to increase uptake by 53%. False assurance from negative screening results can also have an unintended effect on smokers’ motivation to quit smoking, a potential unintended harm of lung cancer screening. Patients’ factors should be carefully monitored and appropriate behavioral interventions, such as smoking cessation support tailored to individual screening experiences, developed as lung cancer screening becomes more common.
As a result of efforts to reduce inequalities, there has been a significant reduction in breast cancer screening uptake disparities between the most and least deprived groups in England [172]. Improved service design is still needed to break down cultural and linguistic barriers and improve uptake among underserved populations. It’s important to address the unique barriers faced by groups such as those with a learning disability or mental illness because there is currently a lack of evidence about appropriate behavioral support [173]. In order to ensure informed decision-making, screening information should clearly explain the possible benefits and harms, but this assumes that people make rational decisions, when the evidence in this review suggests that automatic motivation (like emotions or habits) is an important determinant of screening participation. Research on nonresponders to screening invitations is often limited to sociodemographic factors rather than psychosocial ones. To better understand the link between screening participation and various patient characteristics in underserved populations, more resources will be needed to conduct research methods that can effectively engage nonresponders.