Evid Based Nurs doi:10.1136/ebn1139
  • Adult nursing
  • Cohort study

Repeat invitations to non-attenders increase uptake of colorectal cancer screening; incidence screening continues to detect important cancers

  1. Beverly Greenwald
  1. Angelo State University, San Angelo, Texas, USA
  1. Correspondence to Beverly Greenwald
    PO Box 10155, Fargo, ND 58106-0155, USA; beverly.greenwald{at}

Commentary on:

Colorectal cancer: preventable and treatable

Colorectal cancer (CRC) is the third leading cause of cancer deaths in men and women. CRC is preventable by polypectomy, and, with proper screening, it can be found in early stages when the disease is most treatable, minimising morbidity and mortality. The American Cancer Society recommends screening for average-risk adults to start at age 50, but about half of the people who should be screened are not screened. The faecal occult blood test (FOBT) is an inexpensive and convenient CRC screening option. A positive FOBT should be followed with a diagnostic colonoscopy.1

Effects of repeated invitations for screening

Steele and associates extended 645 362 invitations for CRC screening to Scottish adults, aged 50–69 years. Each participant received three invitations for screening with guaiac FOBT (Hema-Screen; Immunostics, Ocean, New Jersey, USA) in each of three biennial rounds between 2000 and 2007. Responses to the initial invitation were recorded, and a repeat invitation was extended for each of the remaining two rounds. Patients responding to the invitation to screening on the first round were 169 508 (27.1%), and the second and third rounds were 38 283 (6.1%) and 41 207 (6.6%), respectively. Responses to follow-up invitations to previously screened patients were also recorded, and 126 618 (19.6%) were also screened on the second round, while 135 374 (21.0%) were screened on the third round.

This is the first known study to monitor individual results over time and allow scrutiny on the effect of repeated invitations to screening. The findings of the study included that the FOBT positivity was 1.9%, 1.7% and 1.1% for each of the three rounds of invitations, respectively. The uptake of the offer to have colonoscopy when the FOBT was positive increased with each subsequent invitation (87% initially and then 90% and 94.5%).

Repeat invitations were found to increase the participation in colonoscopies and finding adenomas and cancers. Adenoma(s) were found at colonoscopy in 35.5%, 29.4% and 26.7% of screened patients for each of the three invitations, respectively, whereas cancer was found in 11.0%, 6.5% and 7.5%, respectively. The cancers were staged at diagnosis, and the numbers of stage I (Duke's A) and stage IV (Duke's D) decreased for each of the three rounds of invitations (46.5%, 41% and 35% for stage I and 6%, 2% and 0% for stage IV). Repeated FOBT screening allowed CRC to be detected at the earlier, more treatable stages.

Improved faecal occult testing

The researchers acknowledge that the newer, faecal immune test (FIT) for CRC screening has advantages over the older, guaiac FOBT which was used in this study. The chief advantage is the FIT's specificity for human haemoglobin, making it a more sensitive test. The FIT is also more user friendly, as dietary and medication restrictions are not necessary.

The role of nurses in CRC screening

The lab results were forwarded to a nurse who contacted the patients with positive FOBT and arranged for colonoscopies. The role of the nurse is patient education of the need for a follow-up colonoscopy. This study demonstrates the importance of repeated invitations to participate in CRC screening as each invitation is an opportunity for patient education that may lead to CRC screening. This study provides data to support a policy of continued offering of CRC screening to patients who have failed to participate. Perseverance by the nurse is in order and may benefit the patients. Patients need to realise the importance of screening for this prevalent cause of cancer morbidity and mortality. The FOBT can be a low-cost but valuable screening tool for patients who do not have insurance or cannot afford more expensive CRC screening. Patients who do choose the annual FOBT as a CRC screening should have a diagnostic colonoscopy following any positive test.1

Future work for nurses

Nurses need to develop studies to determine what factors contribute to compliance with completion of the FOBT. Determination of the best means to ensure that patients with a positive FOBT comply with a follow-up diagnostic colonoscopy to identify adenomas or cancer is another important area of study.


  • Competing interests None.


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