Social vulnerability and medical skepticism top factors limiting adherence to cancer screening: an online survey [ESMO 2018 Press Release]

Results from the EDIFICE 6 survey identified major social and behavioural indicators for reluctance to undergo cancer screening tests in the French population

MUNICH, Germany – Immunotherapy has been a major breakthrough in oncology, with registered drugs now approved for use in an increasing number of tumour types – but little is known about its safety for HIV-positive cancer patients. A study (1) to be presented at the in Munich has now provided data to suggest that treatment with PD-1/PD-L-1 immune checkpoint inhibitors, which target the very system affected by the HIV virus, is feasible in this patient population for whom cancer is currently one of the principal cause of mortality.

MUNICH, Germany - Social vulnerability showed to be a major limitation to participation in cancer screening for four tumors types – breast, cervical, colorectal and lung – according to the French nationwide observational survey, EDIFICE 6. Also, a disbelief in cancer test efficacy among target populations was highlighted as new indicator of the non-uptake of screening, according to results to be presented at the ESMO 2018 Congress (1, 2, 3, 4)

The EDIFICE programme has been conducted every three years since 2005 with the aim to provide a better understanding of population adherence to cancer screening in France. The latest round of the survey was conducted from 26 June to 28 July 2017 by using an online questionnaire (rather than phone calls as in previous editions) and involved a representative sample of 12,046 individuals between 18 and 69 years old.

Analysing results on breast cancer, Professor Jean-Francois Morere of Hopital Paul Brousse of Villejeuif said: “Participation rates for breast cancer screening, which is freely accessible to all women aged 50-74 in France, are generally higher than for other types of cancer. In our survey, only 6% of participants declared they had never had a mammogram.” He continued: “On the last two rounds we started to observe an impact of social vulnerability on screening reluctance. We can only suppose that for persons with low social conditions prevention is not a priority”. 

Higher reluctance was reported for colorectal cancer (CRC) screening, with 38% of individuals involved in the analysis who had never undergone a fecal immunochemical test (FIT) in their lifetime. Professor François Eisinger of Institute Paoli-Calmettes of Marseille, France, said: “They were more likely to be younger, current smokers or socially vulnerable. Fear of the examination or of results was a barrier for 29% of survey participants. We cannot make a reliable comparison with past surveys due to a change in methodology, but ten years ago very few persons declared this motivation.” He continued: “Attendance rates in both breast and CRC cancer screening have now reached a plateau in the country and new strategies are needed to move beyond it. What is not clear is why the plateau is only 50-60% for colorectal cancer. We have to understand if it is due to CRC screening test in itself, organisation of screening or poor risk or benefit perception.”

Targeting who is out of reach of cancer screening is still a major issue for long-standing practices like cervical cancer (CC) screening, according to Dr Thibault De La Motte Rouge of the Centre Eugène Marquis in Rennes, France. He reminded that incidence of cervical cancer is higher among socially marginalised women who are generally more exposed to HPV infections, due to several factors, including early age at first sexual practice, poor diet, tobacco and alcohol consumption. “However, our survey showed that major items associated with reluctance to undergo tests are, living alone or socio-economic deprivation,” he said. “We are now trying to implement a screening programme at a national level in France, and identifying social patterns can help us improving the organisation of the programme.”

Researchers agree that one key question is to understand why some unscreened groups do not trust preventive measures offered by healthcare systems. Morere said: “A sort of negative attitude towards the efficacy of how cancer care is organised emerged. We reported disbelief in progress of clinical research and efficacy of protection given by screening programmes as relevant items of poor adherence to breast and colorectal cancer screenings. It is the first time that we have tried to address medical skepticism; the investigation approach is still not accurate enough but we will refine this type of questions for the next round.”

Commenting for ESMO, Professor Martin-Moreno of the Medical School and Clinical Hospital of the University of Valencia, Spain, stated that addressing inequalities in uptake must remain a priority for screening programmes and a combined approach is required. He said: “Stratifying screening through correlation with anamnestic, clinical, radiological and genomic data has proved to be useful in other studies. Furthermore, exploiting new information and communication technologies such as smartphone applications or personalised text messages should also be increasingly used. Strategies to improve uptake typically produce only incremental increases: we need to be consistent and resilient if we are to succeed in achieving coverage rates that are high enough for screening programmes to be truly effective.”

Differently from programmes for other types of cancer, implementation of lung cancer screening is still under debate in Europe. “In France it is not routinely proposed to individuals, although it has the potential to early detect lung cancer, which is typically diagnosed when it is has spread (stage IIIb or IV)”, said Professor Sebastien Couraud of Hospices Civils de Lyon, Lyon. He continued: “In our survey, current smoking was associated with intention of being screened, which is good news: we want to screen smokers. We also found that 15% of samples had already been tested although we did not investigate which type of exam was or whether the proper exam was ordered by the physician.”

Martin-Moreno commented that despite smokers’ attitude towards lung cancer tests, low-dose CT screening is a major cause for hesitation due to false-positive rates and the possibility of complications from invasive follow-up. “We need to build evidence-based prevention which is trustworthy and worthwhile for the people to whom it is offered. One drawback of screening is that some smokers may think that it does not matter to continue smoking as long as there is a test on hand that tells them if something is wrong with their lungs in time”.  

He said: “Screening can provide an educational opportunity to reach the target population and promote preventive measures, but evidence is still poor. At the moment, I believe that it is best to focus priority efforts from the very beginning on quitting smoking”.

Despite the many challenges in the implementation of cancer screening programmes in Europe, detection of pre-cancer conditions or early disease has been recognised to play a key role in cancer management. The ESMO Clinical Practice Guidelines (5,6,7,8) recommend screening for breast cancer in all women aged 50-69 years with regular mammography after discussion of the benefits and risks with expert oncologists. Also, primary prevention of cervical cancer is recommended via immunisation with highly efficacious HPV vaccines; and HPD DNA testing or Pap test has proven to be effective for screening female population. For early detection of colorectal cancer, ESMO dedicated guidelines encourage the use of faecal occult blood test for regularly screening of average-risk populations aged 50-74 years. While important questions on who to screen for lung cancer, how often and for how long, are still under evaluation, recent recommendations support that screening with low dose CT scan can reduce lung cancer-related mortality provided it is offered within a dedicated programme with quality control in current or former heavy smokers aged 55-74 years. 

Martin-Moreno concluded: “It is clear that oncology has shifted from being merely reactive to being proactive and cancer screening is fully in line with this idea. (9) It has the potential to make a major contribution to effective early diagnosis, if wide coverage, informed choice and equitable distribution of screening services are ensured.”

Notes to Editors

Please make sure to use the official name of the meeting in your reports: ESMO 2018 Congress

Official Congress hashtag: #ESMO18

References

  1. Abstract 1350PD_PR “Social and behavioral indicators of undergoing a screening test for lung cancer” will be presented by Jean-
  2. François Morere during Poster Discussion Session on Sunday, 21 October 2018, 14.45 to 16.00 CEST in Room 1 – ICM. Annals of Oncology, Volume 29 Supplement 8 October 2018
  3. Abstract 962P_PR “Indicators of non-participation in cervical cancer screening: results from the EDIFICE 6 survey” will be presented by Thibault de La Motte Rouge during Poster Display Session on Saturday, 20 October 2018, 12.30 to 13.30 CEST in Poster Area Networking Hub - Hall A3. Annals of Oncology, Volume 29 Supplement 8 October 2018
  4. Abstract 1594P_PR “Indicators of non-uptake of breast cancer screening: results from the EDIFICE 6 survey” will be presented by Jean-François Morere during Poster Display Session on Saturday, 20 October 2018, 12.45 to 13.45 CEST in Poster Area Networking Hub - Hall A3. Annals of Oncology, Volume 29 Supplement 8 October 2018
  5.  Abstract 525P_PR “Profile of individuals who never undergo colorectal cancer screening” will be presented by Jerome Viguier during Poster Display Session on Sunday 21 October 2018, 12.45 to 13.45 CEST in Poster Area Networking Hub - Hall A3. Annals of Oncology, Volume 29 Supplement 8 October 2018
  6. ESMO Clinical Practice Guidelines - Early-stage and locally advanced (non-metastatic) non-small-cell lung cancer
  7. ESMO Clinical Practice Guidelines - Early colon cancer
  8. ESMO Clinical Practice Guidelines - Primary breast cancer
  9. ESMO Clinical Practice Guidelines - Cervical cancer
  10. Pillar 3 of the ESMO 2020 Vision

About the European Society for Medical Oncology (ESMO)

ESMO is the leading professional organisation for medical oncology. With 18,000 members representing oncology professionals from over 150 countries worldwide, ESMO is the society of reference for oncology education and information. ESMO is committed to offer the best care to people with cancer, through fostering integrated cancer care, supporting oncologists in their professional development, and advocating for sustainable cancer care worldwide.

525P_PR - Profile of individuals who never undergo colorectal cancer screening

J. Viguier1, J.F. Morère2, S. Couraud3, M. Roupret4, C. Touboul5, C. Lhomel6, L. Greillier7, T. de La Motte Rouge8, F. Eisinger9
1CCDC 37, Hôpital Bretonneau, Tours, France, 2Medical Oncology Department, AP-HP, Hôpital Paul Brousse, Villejuif, France, 3Department of Respiratory Diseases and Thoracic Oncology, Centre Hospitalier Lyon Sud, Pierre Bénite, France, 4Medical Oncology, Hôpital Universitaire Pitié-Salpêtrière, Paris, France, 5Statistics, Kantar Health, Paris, France, 6Medical, Roche, Boulogne-Billancourt, France, 7Department of Multidisciplinary Oncology and Therapeutic Innovations, Hopital St. Marguerite Assistance Publique Hopitaux de Marseille, Marseille, France, 8Département d'Oncologie Médicale, Centre Eugene - Marquis, Rennes, France, 9Département d'Anticipation et de Suivi du Cancer DASC, Institute Paoli Calmettes, Marseille, France

Background: Colorectal cancer (CRC) screening has been part of a nationally organized program in France since 2009. In 2015, a fecal immunochemical test (FIT) replaced the previously used guaiac test. Nevertheless, the target participation rate has still not been reached. In this context, it is important to have a clear insight into the characteristics of individuals who remain refractory to screening.

Methods: The French nationwide observational survey EDIFICE 6 was conducted online from 26 June to 28 July 2017 on 12 046 individuals (age, 18-69 years). Representativeness was ensured by quota sampling on age, gender, profession, and stratification by geographical area and type of urban district. Multivariate stepwise logistic regression analysis was conducted to identify factors likely to explain non-uptake of CRC screening. The present analysis focused on the 4300 individuals (age, 50-69 years) with no history of cancer.

Results: Of those who were in the target population for CRC screening, 38% (N = 1625) had never taken part in the CRC screening program. Compared to individuals who had undergone at least one screening test in their life time, those who had never been screened were more likely to be younger (58±6 yrs vs 60±6 yrs, P<0.05), current smokers (30% vs 21%, P<0.05) or socially vulnerable (47% vs 36%, P<0.05). In multivariate analysis, items associated with not undergoing screening included belonging to the socio-professional category of skilled manual workers and supervisory or clerical workers (OR=1.83, 95% CI [1.24 – 2.70]), considering that prevention does not provide effective protection from CRC (OR=1.76 [1.48–2.08]), being a current smoker (OR=1.45 [1.25–1.69]) and being socially vulnerable (OR=1.29, [1.13-1.47]). The most frequently cited reasons for not being screened were "I don't feel concerned" (37%), “individual negligence/not a priority” (32%), fear of the examination/results (29%), and a reason related to the physician (i.e., he didn't suggest screening) (23%).

Conclusions: Medical skepticism for CRC prevention efficiency and vulnerability are social indicators of non-participation in a CRC screening program. Likewise, current smoking—which is already acknowledged as a behavioral risk factor for CRC—is also an indicator of non-uptake of CRC screening.

Editorial Acknowledgement: Medical writing assistance was provided by Potentiel d’Action (France).
Legal entity responsible for the study: Kantar Health.
Funding: Roche.

Disclosure: J.F. Morère, S. Couraud, M. Roupret, L. Greillier, T. de La Motte Rouge, F. Eisinger: Honorarium fees from Roche. C. Lhomel: Employee of Roche. All other authors have declared no conflicts of interest.

962P_PR - Indicators of non-participation in cervical cancer screening: Results from the EDIFICE 6 survey

T. de La Motte Rouge1, S. Couraud2, F. Eisinger3, M. Roupret4, L. Brignoli-Guibaudet5, C. Lhomel6, L. Greillier7, J. Viguier8, J.F. Morère9
1Medical Oncology, Centre Eugene - Marquis, Rennes, France, 2Department of Respiratory Diseases and Thoracic Oncology, Centre Hospitalier Lyon Sud, Pierre Bénite, France, 3Département d'Anticipation et de Suivi du Cancer DASC, Institute Paoli Calmettes, Marseille, France, 4Medical Oncology, Hôpital Universitaire Pitié-Salpêtrière, Paris, France, 5Statistics, Kantar Health, Paris, France, 6Medical, Roche, Boulogne-Billancourt, France, 7Department of Multidisciplinary Oncology and Therapeutic Innovations, Hopital St. Marguerite Assistance Publique Hopitaux de Marseille, Marseille, France, 8CCDC 37, Hôpital Bretonneau, Tours, France, 9Medical Oncology Department, AP-HP, Hôpital Paul Brousse, Villejuif, France

Background: Cervical cancer (CC) screening is a long-standing practice in France. Since the 1980s, individual screening has led to a substantial reduction in the frequency of these tumors and the associated mortality. However the process is not optimal and an organized program is about to be implemented at a national level in France. In this context, it is important to have a clear insight into the characteristics of women who are resistant to CC screening.

Methods: The French nationwide observational survey, EDIFICE 6, was conducted online from 26 June-28 to July 2017 on a core sample of 12 046 individuals (age, 18-69 years). Representativeness was ensured by quota sampling on age, gender, profession, and stratification by geographical area and type of urban district. Multivariate stepwise logistic regression analysis was conducted to identify factors likely to explain non-uptake of CC screening. The present analysis included 4499 women (age, 25-65 years) with no history of cancer.

Results: Of those who had never taken part in a screening program, 12% (N = 539) were in the target population for CC screening. Compared to women who had at least one screening test in their life time, the population of never-screened women was characterized by a lower mean age (38±11 yrs vs 44±12 yrs, P<0.05) and higher proportions of single women (48% vs 20%, P<0.05), socially vulnerable individuals (59% vs 38%, P<0.05), and never-smokers (69% vs 49%, P<0.05). In multivariate analysis, items significantly (P<0.05) associated with not undergoing CC screening included living alone (OR=2.26, 95% CI [1.85-2.75]), social vulnerability (OR=1.95 [1.59-2.40]), belonging to the socio-professional categories of unskilled workers (OR=1.89 [1.17-2.94]), skilled manual workers and supervisory or clerical workers (OR=1.80 [1.02-3.05]), and higher managerial and professional occupations (OR=1.74 [1.32-2.28]). The most frequently cited reasons for not undergoing screening were "I don't feel concerned" (40%) and “individual negligence/not a priority” (31%).

Conclusions: Economically active women but also socially vulnerable women, particularly those who are younger, are reluctant to undergo CC screening. These findings are important, notably for vulnerable women who are more at risk of CC.

Editorial Acknowledgement: Medical writing assistance was provided by Potentiel d’Action (France).
Legal entity responsible for the study: Kantar Health.
Funding: Roche.

Disclosure: T. de La Motte Rouge S. Couraud, F. Eisinger, M. Roupret, L. Greillier, J.F. Morère: Honorarium fees from Roche. C. Lhomel: Employee of Roche. All other authors have declared no conflicts of interest.

1350PD_PR - Social and behavioral indicators of undergoing a screening test for lung cancer

S. Couraud1, J.F. Morère2, J. Viguier3, M. Roupret4, L. Brignoli-Guibaudet5, C. Lhomel6, T. de La Motte Rouge7, F. Eisinger8, L. Greillier9
1Department of Respiratory Diseases and Thoracic Oncology, Centre Hospitalier Lyon Sud, Pierre Bénite, France, 2Medical Oncology Department, AP-HP, Hôpital Paul Brousse, Villejuif, France, 3CCDC 37, Hôpital Bretonneau, Tours, France, 4Medical Oncology, Hôpital Universitaire Pitié-Salpêtrière, Paris, France, 5Statistics, Kantar Health, Paris, France, 6Medical, Roche, Boulogne-Billancourt, France, 7Medical Oncology, Centre Eugene - Marquis, Rennes, France, 8Département d'Anticipation et de Suivi du Cancer DASC, Institute Paoli Calmettes, Marseille, France, 9Department of Multidisciplinary Oncology and Therapeutic Innovations, Hopital St. Marguerite Assistance Publique Hopitaux de Marseille, Marseille, France

Background: The French health authorities are not in favor of systematic lung cancer (LC) screening and instead advocate boosting measures aimed at prohibiting smoking and controlling the use of tobacco. In this context, it appeared important to have a clear insight into the characteristics of individuals who have already undergone a screening test for LC.

Methods: The French nationwide observational survey, EDIFICE 6, was conducted online from 26 June-28 to July 2017 on a core sample of 12 046 individuals (age, 18-69 years). Representativeness was ensured by quota sampling on age, gender, profession, and stratification by geographical area and type of urban district. Multivariate stepwise logistic regression analysis was conducted to identify the characteristics of individuals likely to undergo LC screening. The present analysis included 3114 individuals (age, 55-69 years) with no history of cancer.

Results: Fifteen percent of the study population declared having already undergone a screening test for LC. Compared to individuals who had never been screened for LC, these 15% were characterized by a higher proportion of men (64% vs 54%, P<0.05), of retired individuals (59% vs 54%, P<0.05), and of current and former smokers (34% vs 21%, P<0.05, and 47% vs 38%, P<0.05, respectively). Mean age and social vulnerability did not differ significantly between the screened/unscreened populations. In multivariate analysis, items associated with undergoing screening included current smoking (OR=1.92, 95% CI=1.54-2.38), low body mass index (OR=1.92, 95% CI=0.97-3.57), male gender (OR=1.61, 95% CI=1.31-1.99), and higher education (OR=1.29, 95% CI=1.06-1.58). In contrast, belonging to the socioprofessional category of unskilled workers was associated with the likelihood of non-uptake of a LC screening exam (OR=0.38, 95% CI=0.16 – 0.78).

Conclusions: Individuals with a history of smoking or who currently smoke are the most likely to undergo screening for LC. The social criteria most frequently related to either uptake of or resistance to LC screening were higher education and belonging to lower socioprofessional categories, respectively.

Editorial Acknowledgement: Medical writing assistance was provided by Isabelle Lawrence, Potentiel d’Action (France)
Legal entity responsible for the study: Kantar Health.
Funding: Roche.

Disclosure: S. Couraud, J.F. Morère, M. Roupret, T. de La Motte Rouge, F. Eisinger, L. Greillier: Honorarium fees from Roche. C. Lhomel: Employee of Roche. All other authors have declared no conflicts of interest.

1594P_PR - Indicators of non-uptake of breast cancer screening: Results from the EDIFICE 6 survey

J-F. Morere1, J. Viguier2, L. Greillier3, M. Roupret4, C. Touboul5, C. Lhomel6, S. Couraud7, T. de La Motte Rouge8, F. Eisinger9
1Oncology, Hôpital Paul Brousse, Villejuif, France, 2Hôpital Bretonneau, Tours, France, 3Department of Multidisciplinary Oncology and Therapeutic Innovations, Hopital St. Marguerite Assistance Publique Hopitaux de Marseille, Marseille, France, 4Medical Oncology, Hôpital Universitaire Pitié-Salpêtrière, Paris, France, 5Statistics, Kantar Health, Paris, France, 6Medical, Roche, Boulogne-Billancourt, France, 7Department of Respiratory Diseases and Thoracic Oncology, Centre Hospitalier Lyon Sud, Pierre Bénite, France, 8Medical Oncology, Centre Eugene - Marquis, Rennes, France, 9Département d'Anticipation et de Suivi du Cancer DASC, Institute Paoli Calmettes, Marseille, France

Background: Breast cancer (BC) screening has been part of a nationally organized program in France since 2004. Women aged 50-74 years are invited for a mammography every two years. After an initial rise in participation, the uptake rate remained stable over 2008-2014 and since has shown a slight decrease. In this context, it is important to have clear insight into the characteristics of individuals who are reluctant to undergo BC screening.

Methods: The French nationwide observational survey EDIFICE 6 was conducted online from 26 June to 28 July 2017 on 12 046 individuals (age, 18-69 years). Representativeness was ensured by quota sampling on age, gender, profession, and stratification by geographical area and type of urban district. Multivariate stepwise logistic regression analysis was conducted to identify factors likely to explain non-uptake of BC screening. The present analysis included 1954 individuals (50-69 years) with no history of cancer.

Results: Of those who were in the target age range for BC screening, 6% (N=108) had never had a mammogram. Compared to individuals who had at least one test in their life time, the population of never-screened women was characterized by a lower mean age (56±6 yrs vs 59±6 yrs, P<0.05), and higher proportions of unmarried women (23% vs 13%, P<0.05), low socioprofessional categories (38% vs 27%, P<0.05), socially vulnerable individuals (67% vs 42%, P<0.05), and smokers (35% vs 23%, P<0.05). In multivariate analysis, items associated with not undergoing screening included: considering that progress made possible thanks to clinical research is not important (OR=2.14, 95% CI [1.16 – 3.82]), social vulnerability (OR=2.09 [CI=1.36 – 3.25]), and considering that protection provided by a prevention program is ineffective (OR=1.60 [1.01 - 2.51]). The most frequently cited reasons for not undergoing screening were "I don't feel concerned" (42%), fear of the examination/results (36%), “individual negligence/not a priority” (27%), and self-examination (22%).

Conclusions: Social vulnerability and medical skepticism are indicators of non-participation in BC screening. Not feeling concerned and individual negligence are the main reasons for this reluctance. These findings highlight the need for targeted communication for this population.

Editorial Acknowledgement: Medical writing assistance was provided by Potentiel d’Action (France).
Legal entity responsible for the study: Kantar Health.
Funding: Roche.

Disclosure: J-F. Morere, L. Greillier, M. Roupret, S. Couraud, T. de La Motte Rouge, F. Eisinger: Honorarium fees from Roche. C. Lhomel: Employee of Roche. All other authors have declared no conflicts of interest.

This press release contains information provided by the authors of the highlighted abstracts and reflects the content of those abstracts. It does not necessarily reflect the views or opinions of ESMO who cannot be held responsible for the accuracy of the data. Commentators quoted in the press release are required to comply with the ESMO Declaration of Interests policy and the ESMO Code of Conduct.