title: Resilience of a FIT screening programme against screening fatigue: a modelling study.
abstract: BACKGROUND
  Repeated participation is important in faecal immunochemical testing (FIT) screening for colorectal cancer (CRC). However, a large number of screening invitations over time may lead to screening fatigue and consequently, decreased participation rates. We evaluated the impact of screening fatigue on overall screening programme effectiveness.
  
  
  METHODS
  Using the ASCCA model, we simulated the Dutch CRC screening programme consisting of biennial FIT screening in individuals aged 55-75. We studied the resilience of the programme against heterogeneity in screening attendance and decrease in participation rate due to screening fatigue. Outcomes were reductions in CRC incidence and mortality compared to no screening.
  
  
  RESULTS
  Assuming a homogenous 63 % participation, i.e., each round each individual was equally likely to attend screening, 30 years of screening reduced CRC incidence and mortality by 39 and 53 %, respectively, compared to no screening. When assuming clustered participation, i.e., three subgroups of individuals with a high (95 %), moderate (65 %) and low (5 %) participation rate, screening was less effective; reductions were 33 % for CRC incidence and 43 % for CRC mortality. Screening fatigue considerably reduced screening effectiveness; if individuals refrained from screening after three negative screens, model-predicted incidence reductions decreased to 25 and 18 % under homogenous and clustered participation, respectively. Figures were 34 and 25 % for mortality reduction.
  
  
  CONCLUSIONS
  Screening will substantially decrease CRC incidence and mortality. However, screening effectiveness can be seriously compromised if screening fatigue occurs. This warrants careful monitoring of individual screening behaviour and consideration of targeted invitation systems in individuals who have (repeatedly) missed screening rounds.
authors.affiliation: Department of Epidemiology and Biostatistics, VU University Medical Center, PO Box 7057, MF F-wing, 1007 MB, Amsterdam, The Netherlands. mj.greuter@vumc.nl.
authors.forename: Marjolein J E
authors.initials: MJ
authors.lastname: Greuter
authors.affiliation: Department of Epidemiology and Biostatistics, VU University Medical Center, PO Box 7057, MF F-wing, 1007 MB, Amsterdam, The Netherlands.
authors.forename: Johannes
authors.initials: J
authors.lastname: Berkhof
authors.affiliation: Cancer Research Division, Cancer Council NSW, Sydney, NSW, Australia.|School of Public Health, Sydney Medical School, The University of Sydney, Sydney, NSW, Australia.
authors.forename: Karen
authors.initials: K
authors.lastname: Canfell
authors.affiliation: Cancer Research Division, Cancer Council NSW, Sydney, NSW, Australia.|Prince of Wales Clinical School, Faculty of Medicine, The University of New South Wales, Sydney, NSW, Australia.
authors.forename: Jie-Bin
authors.initials: JB
authors.lastname: Lew
authors.affiliation: Department of Gastroenterology and Hepatology, Academic Medical Centre, Amsterdam, The Netherlands.
authors.forename: Evelien
authors.initials: E
authors.lastname: Dekker
authors.affiliation: Department of Epidemiology and Biostatistics, VU University Medical Center, PO Box 7057, MF F-wing, 1007 MB, Amsterdam, The Netherlands.
authors.forename: Veerle M H
authors.initials: VM
authors.lastname: Coupé
keywords: Colorectal cancer; Participation; Screening