Screening for colorectal cancer
The UK colorectal cancer screening pilot group report the results
from the first round of the demonstration pilot set up by the UK health
departments in March 2000 (1). This pilot covered two geographical areas,
one in Scotland and one in England, and the main evaluation group presents
very positive findings in terms of observed population uptake, outcomes,
In July 2001, following the Race Relations (Amendment) Act 2000 which
came into force in April 2001 (2), the Department of Health extended the
feasibility study to include examination of issues of access, and progress
through the colorectal cancer screening process, by ethnic minority
groups. The new Act places a statutory duty on bodies such as the NHS to
make explicit the implications for racial equality of every new policy,
such as a cancer screening programme.
The UK colorectal cancer screening (ethnicity) pilot group worked
closely with the main pilot group, with some academic members common to
both groups. The study on ethnicity was carried out in the English pilot
site (Coventry and Warwickshire), since the Scottish site did not cover an
ethnically diverse population.
The findings from our group are far less positive than those reported
by the main pilot group. Even after controlling for the influence of
socio-economic status, a major disparity is evident in terms of observed
outcomes for this section of the population, indicating that the
programme, as piloted, may not meet emerging guidelines for culturally and
linguistically appropriate services (3). South Asian sub-groups
demonstrated a significantly (p<0.01) lower faecal occult blood test
uptake rate, ranging from 31.9% (Muslims) and 34.6% (Sikhs) to 42.6%
(Hindu-Gujeratis) and 43.7% (Hindu-Others), versus 63.7% for the non-south
Asian population in the area. Gender and age uptake patterns were also
different from those of the majority population. Multivariate analyses,
including other descriptors such as age, gender and deprivation, still
indicate that the level of successfully completed screening is half in the
South Asian population (adjusted OR 0.439 (CI 0.414 - 0.465), p<0.01);
this difference remains significant (p<0.01) at individual ethnic sub-
group level. More worryingly, colonoscopy uptake is similarly half the
level members of the for South Asian population with a positive faecal
occult blood test result (p<0.01).
Our findings indicate that, if colorectal cancer screening is
implemented in the UK, ethnic minority populations will require special
attention, including targeted interventions in order to achieve equitable
uptake rates. The implications for roll-out are likely to be particularly
significant in areas such as inner London, Leicester, Bradford and
Birmingham (with south Asian populations reaching up to 40%). Areas with
Muslim or Sikh communities, in particular, will require interventions to
improve access since these Asian sub-groups are both at higher risk, as
meat eaters, and also have been found to have the lowest uptake rates.
From the main pilot group findings, the evidence indicates that the
UK colorectal cancer screening programme as piloted should be very cost-
effective (£5,900 per life year saved). It would appear, therefore, that
there is considerable leeway in terms of NHS investment in interventions
to improve uptake for ethnic minority populations while maintaining the
overall cost-effectiveness of such a programme. However, the literature
review we have undertaken as part of our research indicates that there is
as yet limited research evidence available on effective interventions for
improving colorectal cancer screening uptake by ethnic minorities.
Professor Ala Szczepura [on behalf of UK Colorectal Cancer Screening
(Ethnicity) Pilot Group*]
Director, Centre for Health Services Studies (CHESS)
Co-Director, UK Centre for Evidence in Ethnicity, Health and diversity
1. UK Colorectal Cancer Screening Pilot Group. Results of the first
round of a demonstration pilot of screening for colorectal cancer in the
United Kingdom. BMJ 2004; 329: 133-135. (17 July)
2. Parliament. Race Relations (Amendment) Act 2000: Elizabeth II: Chapter
34. London: Stationery Office, 2000.
3. Shaw-Taylor, Y. (2002). Culturally and linguistically appropriate
health care for racial or ethnic minorities: analysis of the US Office of
Minority Health's recommended standards. Health Policy. 62(2): 211 -
* UK colorectal cancer screening (ethnicity) pilot group membership:
Professor Ala Szczepura Centre for Health Services Studies (CHESS),
University of Warwick: Project lead.
Dr Anil Gumber CHESS, University of Warwick: Analyses of uptake
Professor Mark Johnson Mary Seacole Research Centre, De Montfort
University: Focus group study.
Professor Sheina Orbell Department of Psychology, University of
Essex: Psychosocial survey.
Dr Ian O’Sullivan Department of Psychology, University of Essex:
Diane Clay CHESS, University of Warwick): Literature review searches.
Dr David Owen Centre for Research in Ethnic Relations (CRER),
University of Warwick: Geographical extrapolation of pilot findings.
Competing interests: No competing interests