title: A national cluster-randomised controlled trial to examine the effect of enhanced reminders on the socioeconomic gradient in uptake in bowel cancer screening.
abstract: BACKGROUND
  The NHS Bowel Cancer Screening Programme in England offers biennial guaiac faecal occult blood testing (gFOBt). There is a socioeconomic gradient in participation and socioeconomically disadvantaged groups have worse colorectal cancer survival than more advantaged groups. We compared the effectiveness and cost of an enhanced reminder letter with the usual reminder letter on overall uptake of gFOBt and the socioeconomic gradient in uptake.
  
  
  METHODS
  We enhanced the usual reminder by including a heading 'A reminder to you' and a short paragraph restating the offer of screening in simple language. We undertook a cluster-randomised trial of all 168 480 individuals who were due to receive a reminder over 20 days in 2013. Randomisation was based on the day of invitation. Blinding of individuals was not possible, but the possibility of bias was minimal owing to the lack of direct contact with participants. The enhanced reminder was sent to 78 067 individuals and 90 413 received the usual reminder. The primary outcome was the proportion of people adequately screened and its variation by quintile of Index of Multiple Deprivation. Data were analysed by logistic regression with conservative variance estimates to take account of cluster randomisation.
  
  
  RESULTS
  There was a small but statistically significant (P=0.001) increase in participation with the enhanced reminder (25.8% vs 25.1%). There was significant (P=0.005) heterogeneity of the effect by socioeconomic status with an 11% increase in the odds of participation in the most deprived quintile (from 13.3 to 14.1%) and no increase in the least deprived. We estimated that implementing the enhanced reminder nationally could result in up to 80 more people with high or intermediate risk colorectal adenomas and up to 30 more cancers detected each year if it were implemented nationally. The intervention incurred a small one-off cost of £78 000 to modify the reminder letter.
  
  
  CONCLUSIONS
  The enhanced reminder increases overall uptake and reduces the socioeconomic gradient in bowel cancer screening participation at little additional cost.
authors.affiliation: Department of Applied Health Research, University College London, London, WC1E 7HB, UK.
authors.forename: Rosalind
authors.initials: R
authors.lastname: Raine
authors.affiliation: Wolfson Institute of Preventive Medicine, Queen Mary University of London, London EC1M6BQ, UK.
authors.forename: Sue M
authors.initials: SM
authors.lastname: Moss
authors.affiliation: Cancer Research UK Health Behaviour Research Centre, Department of Epidemiology and Public Health, University College London, London, WC1E 7HB, UK.
authors.forename: Christian
authors.initials: C
authors.lastname: von Wagner
authors.affiliation: Cancer Screening and Prevention Group, Faculty of Medicine, Department of Surgery & Cancer, Imperial College London, London, SW7 2AZ UK.
authors.forename: Wendy
authors.initials: W
authors.lastname: Atkin
authors.affiliation: Department of Biostatistics, King's Clinical Trials Unit, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK.
authors.forename: Ines Kralj
authors.initials: IK
authors.lastname: Hans
authors.affiliation: Department of Surgery and Cancer, Imperial College London, London, UK.
authors.forename: Rosemary
authors.initials: R
authors.lastname: Howe
authors.affiliation: UCL Division of Psychiatry, 6th Floor, Wing B, Maple House, 149 Tottenham Court Road, London W1T 7NF, UK.
authors.forename: Francesca
authors.initials: F
authors.lastname: Solmi
authors.affiliation: Department of Applied Health Research, University College London, London, WC1E 7HB, UK.
authors.forename: Stephen
authors.initials: S
authors.lastname: Morris
authors.affiliation: Cancer Research UK & UCL Cancer Trials Centre, Cancer Institute, University College London, 90 Tottenham Court Road, London, W1T 4TJ, UK.
authors.forename: Nicholas
authors.initials: N
authors.lastname: Counsell
authors.affiliation: Cancer Research UK & UCL Cancer Trials Centre, Cancer Institute, University College London, 90 Tottenham Court Road, London, W1T 4TJ, UK.
authors.forename: Allan
authors.initials: A
authors.lastname: Hackshaw
authors.affiliation: Faculty of Health and Medical Sciences, University of Surrey, Guildford, Surrey GU2 7XH, UK.
authors.forename: Stephen
authors.initials: S
authors.lastname: Halloran
authors.affiliation: North East Bowel Cancer Screening Programme Hub, Biochemistry Department, Gateshead Health NHS Foundation Trust, Queen Elizabeth Hospital, Gateshead NE9 6SX, UK.
authors.forename: Graham
authors.initials: G
authors.lastname: Handley
authors.affiliation: Eastern Bowel Cancer Screening Programme Hub, Nottingham University Hospitals, Nottingham NG7 2UH, UK.
authors.forename: Richard F
authors.initials: RF
authors.lastname: Logan
authors.affiliation: London Bowel Cancer Screening Programme Hub, The Northwest London Hospitals NHS Trust, Northwick Park & St Mark's Hospitals, Watford Road, Harrow, Middlesex HA1 3UJ, UK.
authors.forename: Sandra
authors.initials: S
authors.lastname: Rainbow
authors.affiliation: Midlands and North West Bowel Cancer Screening Programme Hub, Hospital of St Cross, Barby Road, Rugby CV22 5PX, UK.
authors.forename: Steve
authors.initials: S
authors.lastname: Smith
authors.affiliation: Southern Bowel Cancer Screening Programme Hub, Surrey Research Park, 20 Priestly Road, Guildford Road, Surrey GU2 7YS, UK.
authors.forename: Julia
authors.initials: J
authors.lastname: Snowball
authors.affiliation: Southern Bowel Cancer Screening Programme Hub, Surrey Research Park, 20 Priestly Road, Guildford Road, Surrey GU2 7YS, UK.
authors.forename: Helen
authors.initials: H
authors.lastname: Seaman
authors.affiliation: NIHR CLAHRC North Thames, Department of Applied Health Research, University College London, London, WC1E 7HB, UK.
authors.forename: Mary
authors.initials: M
authors.lastname: Thomas
authors.affiliation: Centre for Cancer Prevention, Wolfson Institute of Preventive Medicine, Queen Mary University of London, London EC1M 6BQ, UK.|Cancer Research UK Health Behaviour Research Centre, Department of Epidemiology and Public Health, University College London, London, WC1E 7HB, UK.
authors.forename: Samuel G
authors.initials: SG
authors.lastname: Smith
authors.affiliation: Cancer Research UK Health Behaviour Research Centre, Department of Epidemiology and Public Health, University College London, London, WC1E 7HB, UK.
authors.forename: Lesley M
authors.initials: LM
authors.lastname: McGregor
authors.affiliation: Research Office, University of Roehampton, London SW15 5PU UK.
authors.forename: Gemma
authors.initials: G
authors.lastname: Vart
authors.affiliation: Department of Epidemiology and Public Health, Cancer Research UK Health Behaviour Research Centre, University College London, London, WC1E 7HB, UK.
authors.forename: Jane
authors.initials: J
authors.lastname: Wardle
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
mesh_terms: D000368:Aged; D016000:Cluster Analysis; D015179:Colorectal Neoplasms / Q000175:diagnosis*; D005260:Female; D006801:Humans; D008297:Male; D017010:Reminder Systems; D012959:Socioeconomic Factors