Family history

People with a positive family history for CRC are sometimes considered for exclusion from screening programmes targeting average-risk people.

Implementing this option requires the adoption of procedures for identifying people with a positive family history and accurately collecting the information that is relevant to assess an individual’s level of risk. It is also necessary to ensure that an alternative organised programme is in place for this group of people.

Specific surveillance protocols based on colonoscopy at shorter intervals and starting at a younger age have been shown to be effective and are recommended for members of families with hereditary syndromes. However, it is still not clear if more intensive surveillance for people at moderate risk can achieve a favourable cost-benefit ratio (Sondergaard, Bulow & Lynge 1991; Benhamiche-Bouvier et al. 2000; Nakama et al. 2000; Johns & Houlston 2001; Church 2005; Baglietto et al. 2006; Butterworth, Higgins & Pharoah 2006; Menges et al. 2006; Cottet et al. 2007)

If an alternative option (i.e. access to a specific surveillance protocol) is not available, people with positive family history should not be excluded from a population-based screening programme as screening offers the opportunity of access to an intervention that may ensure protection for people who would not be otherwise be covered.

Furthermore, family history, in the absence of hereditary syndromes, does not represent an indication for changing standard surveillance protocols (see Ch. 9, Sect. 9.2.3.2, Rec. 9.13). In a recent study, the characteristics of the neoplasm rather than individual’s family history were found to be associated with the risk of recurrence among subjects not fulfilling the Amsterdam criteria. This suggests that these people could be considered at moderate risk of developing CRC and that surveillance intervals of more than five years may be appropriate in these cases (Dove-Edwin et al. 2005). Therefore, family history should not represent a criterion for exclusion from the screening programme, even for patients identified at the time of assessment. 

Barriers  

Several factors influencing participation have been identified related to individual’s characteristics, the setting and the organisation of the intervention and the knowledge, attitudes and practice of the provider (Vernon 1997; Jepson et al. 2000). The findings concerning the relative weight of these factors are not consistent across studies assessing determinants and barriers to participation. However, the variability of the reported findings is probably related to the different conditions under which the examined screening interventions have been implemented.

The organisation of screening within health services appears, in most countries, to be a major determinant of participation rate. Lack of insurance coverage and cost of the test have been identified as the main negative influences on participation for all screening interventions and tests. Also, lack of resources is the most likely explanation for the negative association of lower socio-economic status with completion of CRC screening tests

Knowledge and perceived benefits of screening, perceived risk of CRC and health motivation were associated with higher participation in most of the studies assessing the influence of these determinants. Worry about pain, discomfort, or embarrassment associated with the test, or fear of test results were also consistently associated with a lower attendance 

Gender and age differences in participation to CRC screening have also been reported; most studies have shown a trend to decreased participation among older people, although these findings have not been confirmed by all investigators. It has been reported that participation may be higher among women for FOBT screening and among men for endoscopy screening 

Support from a partner probably explains the positive association of marriage with screening uptake. This is more prominent in males. One reason for these findings could be that women have prior experience of screening (breast, cervix) and may therefore need less support to participate