title: Impact of general practice endorsement on the social gradient in uptake in bowel cancer screening.
abstract: BACKGROUND
  There is a socioeconomic gradient in the uptake of screening in the English NHS Bowel Cancer Screening Programme (BCSP), potentially leading to inequalities in outcomes. We tested whether endorsement of bowel cancer screening by an individual's general practice (GP endorsement; GPE) reduced this gradient.
  
  
  METHODS
  A cluster-randomised controlled trial. Over 20 days, individuals eligible for screening in England from 6480 participating general practices were randomly allocated to receive a GP-endorsed or the standard invitation letter. The primary outcome was the proportion of people adequately screened and its variation by quintile of Index of Multiple Deprivation.
  
  
  RESULTS
  We enrolled 265,434 individuals. Uptake was 58.2% in the intervention arm and 57.5% in the control arm. After adjusting for age, sex, hub and screening episode, GPE increased the overall odds of uptake (OR=1.07, 95% CI 1.04-1.10), but did not affect its socioeconomic gradient. We estimated that implementing GPE could result in up to 165 more people with high or intermediate risk colorectal adenomas and 61 cancers detected, and a small one-off cost to modify the standard invitation (£78,000).
  
  
  CONCLUSIONS
  Although GPE did not improve its socioeconomic gradient, it offers a low-cost approach to enhancing overall screening uptake within the NHS BCSP.
authors.affiliation: Department of Applied Health Research, University College London, London WC1E 6BT, UK.
authors.forename: Rosalind
authors.initials: R
authors.lastname: Raine
authors.affiliation: Centre for Cancer Prevention, Wolfson Institute of Preventive Medicine, Queen Mary University of London, London EC1M 6BQ, UK.
authors.forename: Stephen W
authors.initials: SW
authors.lastname: Duffy
authors.affiliation: Department of Epidemiology and Public Health, University College London, London WC1E 6BT, UK.
authors.forename: Jane
authors.initials: J
authors.lastname: Wardle
authors.affiliation: Department of Applied Health Research, University College London, London WC1E 6BT, UK.
authors.forename: Francesca
authors.initials: F
authors.lastname: Solmi
authors.affiliation: Department of Applied Health Research, University College London, London WC1E 6BT, UK.
authors.forename: Stephen
authors.initials: S
authors.lastname: Morris
authors.affiliation: Department of Surgery and Cancer, Imperial College London, London W2 1PG, UK.
authors.forename: Rosemary
authors.initials: R
authors.lastname: Howe
authors.affiliation: Department of Biostatistics, King's Clinical Trials Unit, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London SE5 8AF, UK.
authors.forename: Ines
authors.initials: I
authors.lastname: Kralj-Hans
authors.affiliation: NHS Bowel Cancer Screening Programme Southern Hub, Royal Surrey County Hospital NHS Foundation Trust, Guildford GU2 7YS, UK.
authors.forename: Julia
authors.initials: J
authors.lastname: Snowball
authors.affiliation: Cancer Research UK and University College London Cancer Trials Centre, London WC1E 6BT, UK.
authors.forename: Nicholas
authors.initials: N
authors.lastname: Counsell
authors.affiliation: Centre for Cancer Prevention, Wolfson Institute of Preventive Medicine, Queen Mary University of London, London EC1M 6BQ, UK.
authors.forename: Sue
authors.initials: S
authors.lastname: Moss
authors.affiliation: Cancer Research UK and University College London Cancer Trials Centre, London WC1E 6BT, UK.
authors.forename: Allan
authors.initials: A
authors.lastname: Hackshaw
authors.affiliation: Department of Epidemiology and Public Health, University College London, London WC1E 6BT, UK.
authors.forename: Christian
authors.initials: C
authors.lastname: von Wagner
authors.affiliation: Department of Epidemiology and Public Health, University College London, London WC1E 6BT, UK.
authors.forename: Gemma
authors.initials: G
authors.lastname: Vart
authors.affiliation: Department of Epidemiology and Public Health, University College London, London WC1E 6BT, UK.
authors.forename: Lesley M
authors.initials: LM
authors.lastname: McGregor
authors.affiliation: Centre for Cancer Prevention, Wolfson Institute of Preventive Medicine, Queen Mary University of London, London EC1M 6BQ, UK.|Department of Epidemiology and Public Health, University College London, London WC1E 6BT, UK.
authors.forename: Samuel G
authors.initials: SG
authors.lastname: Smith
authors.affiliation: NHS Bowel Cancer Screening Programme Southern Hub, Royal Surrey County Hospital NHS Foundation Trust, Guildford GU2 7YS, UK.|Department of Biochemistry and Physiology, University of Surrey, Guildford GU2 7XH, UK.
authors.forename: Stephen
authors.initials: S
authors.lastname: Halloran
authors.affiliation: NHS Bowel Cancer Screening Programme North East Hub, Gateshead Health NHS Foundation Trust, Queen Elizabeth Hospital, Gateshead NE9 6SX, UK.
authors.forename: Graham
authors.initials: G
authors.lastname: Handley
authors.affiliation: NHS Bowel Cancer Screening Programme Eastern Hub, Nottingham University Hospitals, Nottingham NG7 2UH, UK.
authors.forename: Richard F
authors.initials: RF
authors.lastname: Logan
authors.affiliation: NHS Bowel Cancer Screening Programme London Hub, Northwick Park and St Mark's Hospitals NHS Trust, Middlesex HA1 3UJ, UK.
authors.forename: Sandra
authors.initials: S
authors.lastname: Rainbow
authors.affiliation: NHS Bowel Cancer Screening Programme Midlands and North West Hub, University Hospitals Coventry and Warwickshire NHS Trust, Hospital of St Cross, Rugby CV22 5PX, UK.
authors.forename: Steve
authors.initials: S
authors.lastname: Smith
authors.affiliation: Department of Applied Health Research, University College London, London WC1E 6BT, UK.
authors.forename: Mary C
authors.initials: MC
authors.lastname: Thomas
authors.affiliation: Department of Surgery and Cancer, Imperial College London, London W2 1PG, UK.
authors.forename: Wendy
authors.initials: W
authors.lastname: Atkin
mesh_terms: D000236:Adenoma / Q000175:diagnosis*; D000368:Aged; D001291:Attitude of Health Personnel; D002277:Carcinoma / Q000175:diagnosis*; D003113:Colonoscopy / Q000706:statistics & numerical data; D015179:Colorectal Neoplasms / Q000175:diagnosis*; D003142:Communication; D055088:Early Detection of Cancer / Q000706:statistics & numerical data*; D004739:England; D005260:Female; D058006:General Practice / Q000706:statistics & numerical data*; D054625:Healthcare Disparities; D006801:Humans; D008297:Male; D008875:Middle Aged; D009780:Occult Blood; D010349:Patient Compliance; D010817:Physician-Patient Relations; D012923:Social Class; D012959:Socioeconomic Factors; D013222:State Medicine