Preventive Medicine 175 (2023) 107706 Contents lists available at ScienceDirect Preventive Medicine journal homepage: www.elsevier.com/locate/ypmed Review Article Participants’ satisfaction with colorectal cancer screening programs: A systematic review Anna Selva a, b, *, Giansanto Mosconi d, Stefano Cacitti e, Anna Odone d, Liisa Pylkkanen f, Ivan Solà c, g, h, Núria Torà i, Sara Russo d, Ennio Cadum e, Silvia Deandrea e a Department of Paediatrics, Obstetrics and Gynaecology and Preventive Medicine and Public Health, Universitat Autònoma de Barcelona, Barcelona, Spain b Clinical Epidemiology and Cancer Screening, Parc Taulí Hospital Universitari. Institut i Innovació Parc Taulí (I3PT_CERCA). Univesitat Autònoma de Barcelona., Sabadell, Spain c CIBER Epidemiología y Salud Pública, Instituto de Salud Carlos III, Madrid, Spain d Department of Public Health, Experimental and Forensic Medicine, University of Pavia, Pavia, Italy e Health Protection Agency of Pavia, Pavia, Italy f Department of Oncology, University of Turku, Turku, Finland g Iberoamerican Cochrane Centre. Hospital de la Santa Creu i Sant Pau. Institute of Biomedical Research, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain h Universitat Autònoma de Barcelona, Spain i Cancer Screening Programs, Althaia Xarxa Assistencial Universitària de Manresa, Manresa, Catalonia, Spain A R T I C L E I N F O A B S T R A C T Keywords: Introduction: Since satisfaction with cancer screening experience can increase adherence to programs and Colorectal neoplasms contribute to reduce morbidity and mortality, its assessment is crucial for programs´effectiveness. Our aim was to Early detection of cancer conduct a systematic review about satisfaction of participants with organized colorectal cancer screening. cancer screening Methods: We searched relevant scientific databases (MEDLINE, EMBASE, PsycINFO, and CINAHL) from inception Patient satisfaction Patient experience to May 2022. We selected cross-sectional studies and clinical trials reporting a quantitative survey-based measure Systematic review of satisfaction towards CRC screening. Results: A total of 15 studies were included, being published from 1992 to 2019 for an overall number of 21 surveys. Of those, 16 (76%) investigated satisfaction with screening tests (fecal occult blood test, fecal immu­ nochemical test, sigmoidoscopy, colonoscopy, computed tomographic colonography), 4 (19%) with colonoscopy as assessment test after suspicious findings, and 2 (10%) with both the screening and assessment phase. None of the included surveys used a validated questionnaire. Most surveys reported a high level of satisfaction for both screening and further assessment phases. Temporary pain, discomfort, embarrassment, and anxiety while waiting for results were the commonest negative aspects perceived, with some variability across studies and considered procedures. Conclusions: Satisfaction with the information and communication about screening was generally good, but some authors reported participants’ sub-optimal understanding of informative material. Satisfaction with CRC screening is generally high, but its evaluation is performed using non-validated instruments, which limits the interpretation of results and prevents comparability of the current body of evidence. 1. Introduction CRC screening is aimed at lowering the risk of mortality from the disease by its early detection, as well as the rate of complications asso­ Colorectal cancer (CRC) is the third most common cancer by prev­ ciated with cancer diagnosis at a later stage (Lauby-Secretan et al., alence and the second by incidence worldwide, accounting for 10% of 2018). By identifying and removing premalignant lesions, CRC the new diagnosed malignancies in 2020 (Wild et al., 2020). With almost screening is also aiming to reduce the incidence of CRC (Lauby-Secretan 900,000 deaths annually, it is the second major cause of cancer mor­ et al., 2018). Furthermore, early diagnosis can also spare many patients tality (Keum and Giovannucci, 2019). from adjuvant treatment and can hence have a great impact on health * Corresponding author at: Clinical Epidemiology and Cancer Screening, Parc Taulí Hospital Universitari, Sabadell, Parc Taulí, 1, 08208 Sabadell, Spain. E-mail address: aselva@tauli.cat (A. Selva). https://doi.org/10.1016/j.ypmed.2023.107706 Received 13 June 2023; Received in revised form 12 September 2023; Accepted 15 September 2023 Available online 16 September 2023 0091-7435/© 2023 The Authors. Published by Elsevier Inc. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by- nc-nd/4.0/). A. Selva et al. Preventive Medicine 175 (2023) 107706 care costs and the patients´ quality of life. According to the literature, interviews are the most commonly used instruments (Travaglia and different screening procedures show different impacts on the CRC inci­ Debono, 2009b). Although there are different methods to assess patient dence and especially mortality rates. Declines in mortality rates among satisfaction, the most used by far are self-reported questionnaires screening program participants range between 18% and 32% for Fecal (Travaglia and Debono, 2009b). Occult Blood Test (FOBT) (Zauber, 2015), while reduced mortality rates This systematic review summarizes satisfaction of screening partic­ of about 41% for Fecal Immunochemical Test (FIT) (Gini et al., 2020), or ipants with their experience with different kinds of organized CRC even higher (50–70%) for more invasive tests like Flexible Sigmoidos­ screening programs in order to understand the key determinants of good copy (FS) or optical colonoscopy (OC) have been reported (Brenner screening experience and satisfaction. A better experience with et al., 2014). Evidence on the effect of CT colonography (CTC) screening screening programs could lead to greater participation and hence on CRC mortality rates is limited (Lauby-Secretan et al., 2018); ac­ improved effectiveness of the screening programs. cording to estimates by the U.S. Preventive Services Task Force, this test could prevent 26 deaths per 1000 people screened if performed at 5-year 2. Methods intervals starting at age 45–50 (Lin et al., 2021). In general, approxi­ mately 50 % of the reduction in CRC incidence and mortality between We conducted a systematic review to address the question of how 1975 and 2010 on the population level is considered attributable to the satisfied people are with organized colorectal cancer screening pro­ increases in CRC screening rates and the use of more effective tests grams. We registered the review protocol in PROSPERO (http://www. (Zauber, 2015). crd.york.ac.uk/PROSPERO) [registration number CRD42021225343]. Despite their confirmed effectiveness, CRC screening procedures also This systematic review followed the standard Cochrane Collaboration bring along some undesirable effects that vary by test and should be methodology (Higgins et al., 2019) and adhered to the PRISMA state­ considered carefully. The most common undesirable effects related to ment for reporting of systematic reviews (Moher et al., 2015). FOBT and FIT are embarrassment, difficulties with the stool collection We adapted a search strategy from a systematic review on patient process, anxiety, false-negative results leading to interval cancers, and reported experience measures (Selva et al., 2021). It combined false-positive results, leading to fear of cancer and unnecessary further controlled vocabulary from each database and text words related to the examination (Lin et al., 2021). In a minority of cases, people undergoing review topics (e.g., satisfaction and colorectal cancer screening). We endoscopic examinations may experience discomfort, nausea, vomiting, conducted the search in MEDLINE (PubMed), EMBASE (Ovid), Psy­ moderate to severe pain during or after the procedure, bleeding, and cINFO (EBSCOHost) and CINAHL (EBSCOHost) without language or problems related to sedation (Jodal et al., 2019). Severe adverse events date restrictions from inception to May 2022. The detailed search stra­ are rare: perforation risk is 3.1/10,000 for colonoscopy and 0.2/10,000 tegies are available in Supplementary File I. for FS, while major bleeding risk is 14.6/10,000 for colonoscopy and We included quantitative cross-sectional studies (i.e., surveys) and 0.5/10,000 for FS (Lin et al., 2021). The risk of major adverse events controlled clinical trials that measure the participants´ satisfaction or following a screening CT-colonography is low to nonexistent, according experience with organized colorectal cancer screening programs that to the available data; however, exposure to ionizing radiation and used FOBT, FIT, FS, colonoscopy, or computed assisted colonography frequent detection of extra-colonic findings represent significant draw­ (CT-colonography) as screening test. Systematic reviews were consid­ backs of this technique (Lin et al., 2021). Finally, in older subjects or ered to locate the primary studies included. We limited the inclusion to those with concomitant diseases, bowel preparation for endoscopic studies published in English, Spanish or Italian. We excluded qualitative exams can potentially result in electrolyte imbalances or dehydration studies, studies on non-organized screening programs, studies on (Lin et al., 2021). screening programs based on bowel capsule, magnetic resonance im­ To achieve the desired population level impact of organized aging, or peripheral blood biomarkers, studies not assessing partici­ screening programs, it is critical to reach high participation rates but pants’ satisfaction or experience as the main outcome, and studies only also high adherence rates among participants (von Karsa et al., 2013). assessing discomfort with the test without any other aspect of the pro­ Adherence to screening programs is influenced by different factors, vision of services considered. Two authors independently assessed the including the participants’ experience and satisfaction (Selva et al., titles and abstracts of retrieved references, and then made a final deci­ 2021). The level of satisfaction with a previous stool test screening, for sion based on the full text of the references deemed eligible. Disagree­ example, has been found to be a powerful behavioral predictor of ments were resolved with the help of a third reviewer. adherence to future screening rounds (Duncan et al., 2012; Duncan We developed and pilot-tested a case report form (CRF) using Google et al., 2014; Osborne et al., 2017). Furthermore, patient satisfaction can Forms. The CRF is available from the authors on request. Two authors affect health outcomes (Crow et al., 2002; Fitzpatrick, 1991), and its independently extracted data from the surveys contained in the included evaluation can provide useful elements to improve clinical strategies studies and disagreements were resolved with the help of a third (Travaglia and Debono, 2009a). The measurement of participants’ reviewer. Surveys were considered to be distinct when they: i) contained satisfaction with screening programs can be invaluable in evaluating different questions depending on the respondent’s subgroup ii) investi­ and monitoring the quality of healthcare services and identifying areas gated different aspects of participants’ experience AND were adminis­ for improvement (Beattie et al., 2015; Doyle et al., 2013), so it has been tered at separate times. We extracted the following data: 1. General proposed as a quality indicator (Jover et al., 2012; Lee et al., 2012; von characteristics of the study (country, year of publication, study design); Karsa et al., 2010). As a result, assessing participants´satisfaction is an 2. Characteristics of the colorectal cancer screening protocol (screening important aspect of evaluating the screening services quality and it is test, stage of the program assessed, screening round); 3. Population also a way to improve adherence to screening programs. characteristics (age, sex, sample size); 4. Data collection procedure However, there is no widely accepted definition for satisfaction in (measurement tool and evidence of instrument validation); 5. Response the literature. Satisfaction is a Patient-Reported Outcome Measure rate; 6. Outcomes assessed; 7. Satisfaction domains assessed, based on (PROM) (Kingsley et al., 2023) and reflects a personal assessment of the definitions provided in previous research (Deandrea et al., 2018; quality of care in relation to a subjective standard (Pascoe, 1983); a Pagliarin et al., 2021) (Accessibility; Staff’s interpersonal skills; Staff’s working definition may be the extent to which health care practitioners technical skills; Information transfer/communication; Physical sur­ and/or services meet the participants´intended expectations, objectives, roundings; Discomfort, physical/physical experience; Discomfort, psy­ and/or preferences (Travaglia and Debono, 2009b). When attempting to chological/psychological experience; General satisfaction); 8. measure participants’ satisfaction, different issues can occur, and it is Satisfaction according screening result (positive vs negative). Our main not possible to rely on a single assessment method. According to liter­ outcome was general satisfaction with the screening program at any ature, surveys, critical incident techniques, questionnaires, and stage. When studies collected satisfaction concerning both the screening 2 A. Selva et al. Preventive Medicine 175 (2023) 107706 phase and the assessment phase, we extracted those independent sur­ absolute frequencies and proportions for categorical variables and veys as individual records. means (or medians) and standard deviations or percentiles for contin­ We assessed the methodological quality of cross-sectional studies uous variables. We planned to quantitatively pool the results reported by using the NICE Critical Appraisal Checklist for surveys performed by different studies, but we were not able to do so as studies were too means of questionnaires (Excellence, N.I.f.H.a.C, 2012). This checklist heterogeneous in the outcomes assessed and scales used. Therefore, we consists of 17 items exploring eight domains (1. Validity and reliability; reported review findings as a narrative synthesis distinguishing 2. Format; 3. Piloting; 4. Sampling; 5. Distribution, administration, and screening and assessment phases and in tabulated summaries. response; 6. Coding and analysis; 7. Results; 8. Conclusions and dis­ cussion). This checklist does not provide guidance on assessment 2.1. Ethical approval and consent to participate criteria, so we defined some criteria for each item in order to be objec­ tive and transparent when assessing the studies. The assessment criteria No ethical approval was required as this study is a systematic review. defined can be found in Supplementary File II. Final scores were ob­ tained by summing the scores of individual items and reported as final 3. Results score out of the maximum score. We planned to apply the Cochrane risk of bias tool to assess the methodological quality of controlled trials 3.1. Study selection (Boutron et al., 2019). Two reviewers independently assessed the risk of bias for each study. Differences were solved by consensus or by A total of 4420 individual citations were retrieved, 3970 references consulting a third reviewer. were reviewed by title and abstract, 164 articles were read in full text. We used descriptive statistics to synthesize findings, calculating Among full texts assessed for eligibility, 149 were excluded mainly Fig. 1. Flow-chart of study selection process according to PRISMA statement. *Reasons for exclusion: Not measures satisfaction with colorectal cancer screening as main outcome (n = 53); Not uses a questionnaire (n = 13); Narrative review (n = 6); Measures satisfaction with the decision to participate in a study (n = 3); Not about organized colorectal cancer screening (n = 41); Study protocol (n = 1); Language (n = 3), Duplicate (n = 4), Measures satisfaction in relation to a small part of the process or an specific technique n = 25). 3 A. Selva et al. Preventive Medicine 175 (2023) 107706 because not measured satisfaction with CRC screening as a main of execution (20/21, 95%); 2) general satisfaction (17/21, 81%), and 3) outcome (n = 53), were not about CRC organized screening programs (n psychological experience, including psychological discomfort and state = 41) or measured satisfaction in relation to a small part of the screening of mind while waiting for results (11/21, 52%) (Fig. 2). Table 3 de­ process or a specific technique (n = 25). We finally included 15 studies. scribes the eight dimensions of satisfaction assessed by all surveys and A PRISMA flow diagram describing the records identification, the se­ the questions used to explore them. lection process and all reasons for exclusion is reported in Fig. 1. 3.5. General satisfaction 3.2. Characteristics of included studies General satisfaction was conceptualized, measured and expressed in Table 1 shows the characteristics of the included studies. The different ways across surveys. This heterogeneity precluded pooling of included studies were mainly conducted in European countries, and the results. Supplementary File IV summarizes how general satisfaction were predominantly published after 2000. Almost all included studies was measured across surveys and their results. followed a cross-sectional design (7/15, 47%) (Arveux et al., 1992; Regarding the screening phase (16 surveys), the overall satisfaction Bevan et al., 2015; Burón et al., 2017; Ghanouni et al., 2016; Hambleton was high regardless of the type of test used (Arveux et al., 1992; Bevan and Jones, 2017; Plumb et al., 2017; Shin et al., 2018) or were cross- et al., 2015; Blom et al., 2004; Bretthauer et al., 2002; Burón et al., 2017; sectional substudies nested in either a clinical trial (6/15, 40%) (Blom Hambleton and Jones, 2017; Hol et al., 2010; Kinner et al., 2007; Robb et al., 2004; Bretthauer et al., 2002; Denters et al., 2013; Hol et al., 2010; et al., 2012; Sali et al., 2019; Shin et al., 2018). Respondents were mostly Kinner et al., 2007; Sali et al., 2019) or in a case-controlled study (Sarkar willing to repeat the test (Arveux et al., 1992; Bevan et al., 2015; Blom et al., 2012), except for one study, which had a longitudinal design et al., 2004; Hol et al., 2010; Sali et al., 2019; Sarkar et al., 2012; Shin (Robb et al., 2012). The selected studies contained 24 satisfaction sur­ et al., 2018) or recommend it to friends or relatives (Arveux et al., 1992; veys, of which 21 were suitable for inclusion in the systematic review Bevan et al., 2015; Blom et al., 2004; Bretthauer et al., 2002; Hol et al., (Table 2) and investigated satisfaction with screening tests (16/21, 2010; Robb et al., 2012; Sali et al., 2019). Hol et al. (Hol et al., 2010) 76%), further assessment tests (4/21, 19%) or both screening and compared satisfaction with FOBT, FIT, and FS, and found that, although assessment tests (1/21, 10%). Overall, 144,223 subjects were invited in the percentage of participants willing to repeat the test and to recom­ participating the included surveys, 114,155 responses were collected mend it to others was generally high, it was lower in those who un­ (average response rate 79%), and the final analyzed samples involved a derwent FS. The “pharmacy strategy”, which involves pharmacies in the total of 113,258 participants (although both the Sali et al. and Robb distribution and collection of FITs and FOBTs, received good feedback in et al. studies contained two surveys whose participants were partially terms of general satisfaction (Burón et al., 2017). Among the factors overlapping). All the surveys used non-validated questionnaires (mostly affecting satisfaction with FIT there were sex, age and income, since written and self-administered) developed for the purpose of the study. satisfaction was higher among women, those under 65 years old, and Despite Kinner et al. (2007) stated that they used a written, self- individuals with greater income (Shin et al., 2018); on the other hand, administered validated questionnaire, they did not provide further in­ general satisfaction was not affected by the result of the FS (Hambleton formation about the development nor validation of the questionnaire. and Jones, 2017). Robb et al. pointed out that the attitude and behavior We tried to contact authors to obtain information about the question­ of staff may be key factors for general satisfaction (Robb et al., 2012). naire development and/or validation studies without success. Overall satisfaction with the assessment tests was high in both The screening protocols differed in organization and type of tests included surveys that evaluated this domain (Denters et al., 2013; Sarkar used. Seven studies (Arveux et al., 1992; Burón et al., 2017; Denters et al., 2012). Denters et al. (2013) did not find differences in the level of et al., 2013; Ghanouni et al., 2016; Plumb et al., 2017; Sarkar et al., overall satisfaction (mean: 7.9/10) according to sex, age or test results. 2012; Shin et al., 2018) referred to programs in which FIT or FOBT were Results from the study conducted by Sarkar et al. (2012) showed that the performed at the beginning and, if positive, were followed by a colo­ satisfaction of subjects undergoing colonoscopy within the British na­ noscopy or a CT-colonography, seven referred to protocols in which tional Bowel Cancer Screening Programme was similar to that of the colonoscopy or flexible sigmoidoscopy or CT-colonography (Bevan ones receiving colonoscopy outside a screening program. et al., 2015; Blom et al., 2004; Bretthauer et al., 2002; Hambleton and Also in the case of the surveys that assessed participants’ experience Jones, 2017; Kinner et al., 2007; Robb et al., 2012; Sali et al., 2019) was with both the screening and assessment phases, overall satisfaction with the first screening test, while three surveys from the same study (Hol the programs as a whole was high (Burón et al., 2017). et al., 2010) assessed satisfaction with FOBT, FIT, and FS as primary tests respectively. 3.6. Physical discomfort and physical experience 3.3. Methodological quality of included studies Results show high variability, even in accordance with the screening protocol phase and procedures considered in the different surveys. With regard to the methodological quality of included studies, final The execution of FOBT was considered simple by >95% of re­ scores ranged from 7.5 to 14 out of a maximum of 17. All included sponders (Arveux et al., 1992; Burón et al., 2017), and both FOBT and studies scored badly for the validity and reliability domain because there FIT were found to be only slightly troublesome (Hol et al., 2010). The was no evidence that questionnaires measured what they set out to surveys evaluating the FS as a screening test found it was usually well measure or that their responses were stable over time. Many studies also tolerated (Bevan et al., 2015; Blom et al., 2004; Bretthauer et al., 2002; lack information on questionnaire piloting (only three reported some Hambleton and Jones, 2017) or less painful than expected (Robb et al., sort of pilot testing) and include small and non-representative samples 2012). However, the percentage of participants reporting severe (only five studies include a sufficiently large and representative sample). discomfort during the test execution varied widely, ranging from 0% Supplementary material (Supplementary File III) contains further (Bretthauer et al., 2002) to 17.4% (Hol et al., 2010). Two surveys information. investigated symptoms after FS examination (Hol et al., 2010; Robb et al., 2012), with abdominal pain, and flatulence as the most reported 3.4. Satisfaction dimensions investigated side effects. Furthermore, Hol et al. (2010) reported women were more likely to experience discomfort during FS, which was also rated as more The most frequently assessed dimensions in the included surveys burdensome than both FOBT and FIT. were: 1) the physical experience, including physical discomfort and ease Both in the study by Ghanouni et al. (2016) and Plumb et al. (2017), 4 A. Selva et al. Preventive Medicine 175 (2023) 107706 Table 1 Characteristics of included studies (N = 17). Study Urveys Country Study design Population Phase of Test Sample Dimensions of Risk of screening size# satisfaction bias process score* Arveux et al. 1 France Cross-sectional General population Screening FOBT 705 Accessibility/ waiting 8/17 (1992) (45–74 y) time Information transfer/ communication Discomfort, physical/ physical experience Discomfort, psychological/ psychological experience General satisfaction Bevan et al. 1 United Cross-sectional General population (>55 Screening FS 528 General satisfaction 8/17 (2015) Kingdom y) Blom et al. 1 Sweden Cross-sectional General population Screening FS 468 Information transfer/ 10.5/18 (2004) nested in a clinical (59–61 y) communication trial Physical surroundings Discomfort, physical/ physical experience Discomfort, psychological/ psychological experience General satisfaction Bretthauer 1 Norway Cross-sectional General population Screening FS 185 Discomfort, physical/ 9.5/17 et al. nested in a clinical (50–64 y) physical experience (2002) trial General satisfaction Burón et al. 2 Spain Cross-sectional General population Screening and FOBT + 473 Accessibility/ waiting 14/17 (2017) (50–69 y) assessment OC time Information transfer/ communication Discomfort, physical/ physical experience Discomfort, psychological / psychological experience General satisfaction Others Denters et al. 1 Netherlands Cross-sectional General population Assessment OC 273 Discomfort, physical/ 13.5/17 (2013) nested in a clinical (50–75 y) physical experience trial Discomfort, psychological/ psychological experience General satisfaction Others Ghanouni 1 United Cross-sectional General population with Assessment FOBT 50,858 Staffs’ interpersonal 10.5/18 et al. Kingdom abnormal FOBT (≥60 y) skills (2016) Staff’s technical skills Information transfer/ communication Physical surroundings Discomfort, physical/ physical experience Hambleton 1 United Cross-sectional Adults aged 55 years from Screening FS 110 General satisfaction 9/17 (2017) Kingdom the general population Others Hol et al. 3 Netherlands Cross-sectional General population Screening FOBT, 1784 Discomfort, physical/ 10/17 (2010) nested in a clinical (50–74 y) FIT, FS physical experience trial Discomfort, psychological / psychological experience General satisfaction Kinner et al. 1 Germany Cross-sectional Insurants of a national Screening OC 284 Discomfort, physical/ 11/17 (2007) nested in a clinical health company (≥50 y) physical experience trial General satisfaction Others (continued on next page) 5 A. Selva et al. Preventive Medicine 175 (2023) 107706 Table 1 (continued ) Study Urveys Country Study design Population Phase of Test Sample Dimensions of Risk of screening size# satisfaction bias process score* Plumb et al. 1 United Cross-sectional General population Assessment OC + 52,945 Accessibility/ waiting 10.5/17 (2017) Kingdom (60–74 y) CTC time Staffs’ interpersonal skills Information transfer/ communication Physical surroundings Discomfort, physical/ physical experience Others Robb et al. 2 United Longitudinal General population Screening FS 1587 Staffs’ interpersonal 11.5/18 (2012) Kingdom (58–59 y) skills Information transfer/ communication Physical surroundings Discomfort, physical/ physical experience General satisfaction Sali et al. 2 Italy Cross-sectional General population never Screening CTC 1866 Discomfort, physical/ 12/18 (2019) nested in a clinical screened (54-65y) physical experience trial Discomfort, psychological/ psychological experience General satisfaction Sarkar et al. 1 United Cross-sectional Subjects in the general Screening OC 131 Discomfort, physical/ 11.5/17 (2012) Kingdom nested in a case- population (≥18 years physical experience control study old) undergoing day-case General satisfaction colonoscopy Shin et al. 2 Korea Cross-sectional General population Screening FIT 1657 Discomfort, physical/ 13.5/17 (2018) (50–74) physical experience General satisfaction OC: optical colonoscopy; CTC: computed tomographic colonography; FIT: fecal immunochemical test, FOBT: fecal occult blood test; FS: Flexible sigmoidoscopy. # Some of the surveys in the included studies did not contain relevant information for the purpose of this systematic review and were therefore excluded. For this reason, the sum of the sample sizes of the included studies does not coincide with the sum of the sample sizes of the included surveys. * Denominator varies because sometimes the judgment criteria are not applicable. about 21% of the participants declared having experienced more pain 3.8. Physical surroundings and privacy than expected during colonoscopy. Subjects in the Sarkar et al. (2012) study rated pain during colonoscopy as low (median: 1 on a 0–5 likert Respondents expressed high levels of satisfaction with the environ­ scale) but Denters et al. (2013) reported 85% of participants referred ment of the screening facilities, including respect for privacy (Blom some degree of pain. et al., 2004; Robb et al., 2012), and almost all participants felt that their The bowel cleansing procedure was reported as more unpleasant privacy was maintained during the visit in the assessment phase (Gha­ than the insertion of the endoscope (Burón et al., 2017; Kinner et al., nouni et al., 2016; Plumb et al., 2017). 2007), particularly among younger subjects (Kinner et al., 2007). Sali et al. (2019) found reduced cathartic bowel preparation was signifi­ 3.9. Information transfer and communication cantly more tolerable than full cathartic preparation without affecting significantly physical discomfort during CTC (participants rating the The satisfaction level for information transfer and communication procedure as painful: 16% in the reduced preparation group vs 13% in was generally high in the included surveys. However, Buron et al. the full preparation group, p = 0.14). (Burón et al., 2017) found that about a third of participants reported incomplete understanding of information material regarding the FOBT 3.7. Psychological discomfort and psychological experience and 16% of participants did so regarding the colonoscopy. Authors found that both the understanding of the instructions and the sample Regarding the screening phase, although most respondents did not collection process was more difficult for participants with positive FOBT report that the procedure made them feel embarrassed, mixed results results (7.0%) than for participants with negative FOBT results (1.5%) emerged in regard to anxiety while waiting for the test result. Arveux and stated that this difference could be explained by a memory bias. et al. (1992) found people with positive FOBT results were more often Ghanouni et al. (2016) found the level of satisfaction was not affected by upset by the result than those with negative FOBT. Robb et al. (2012) deprivation, sex, or age. found no significant change in the anxiety symptoms of participants between the pre-FS period and the following three months, while Blom 3.10. Accessibility and waiting time et al. (2004) observed that anxiety before FS was associated with pain, showing that reassurance might be an efficient way to reduce discom­ One study found high satisfaction related to return time, which was fort. CTC was reported to be more embarrassing than optical colonos­ considered rapid or quick enough by 98.8% of responders (Arveux et al., copy (Sali et al., 2019). 1992). Another study (Burón et al., 2017) found that pharmacy care, its In assessment phase, the mean level of satisfaction was good, accessibility and its role as a test collection and drop-off centre were although more than a third of respondents (38%) reported some degree particularly noteworthy (score above 9.3/10.0 on average), as was the of embarrassment with the colonoscopy (Denters et al., 2013). waiting time to be seen at the pharmacy and the waiting time to receive 6 A. Selva et al. Preventive Medicine 175 (2023) 107706 Table 2 General characteristics of included surveys (N = 21). Characteristics Screening Assessment Screening þ assessment Total number (n ¼ 16, 76%) (n ¼ 4, 19%) (n ¼ 1, 10%) n (%) Geographical area Europe 14 4 1 19 (90.5%) Asia 2 0 0 2 (9.52%) Survey year 1980–1989 1 0 0 1 (4.76%) 1990–1999 1 0 1 2 (9.52%) 2000–2009 7 2 1 9 (42.86%) 2010–2019 7 2 1 9 (42.86%) Sample size ≤500 7 2 1 10 (47.62%) 501–1000 8 0 0 8 (38.10%) >1000 1 2 0 3 (14.29%) Response rate <50% 0 0 0 0 (0.00%) 50–74% 4 2 0 6 (28.57%) ≥75% 12 2 1 15 (71.43%) Assessed test Fecal occult blood test (FOBT) 3 0 0 3 (14.29%) Fecal immunochemical test (FIT) 3 0 0 3 (14.29%) Flexible sigmoidoscopy 7 0 0 7 (33.33%) Colonoscopy 1 3 0 4 (19.05%) CT-colonography 2 1 0 3 (14.29%) FOBT followed by colonoscopy 0 0 1 1 (4.76%) Screening round First 11 0 0 11 (52.38%) Second 0 1 0 1 (4.76%) Mixed 5 2 1 8 (38.10%) Unclear 0 1 0 1 (4.76%) Data collection Self-administered questionnaire 15 3 0 18 (85.71%) Telephone interview 1 1 1 3 (14.29%) Validated questionnaire Yes 1 0 0 1 (4.76%)** No 15 4 1 20 (95.24%) Time of administration of the questionnaire Same day of the exam or the day after 9 0 0 9 (42.86%) After two days – Within the first week 3 0 0 3 (14.29%) After a week – Within a month past the exam 1 2 0 3 (14.29%) After one month 3 1 1 5 (23.81%) Not reported 0 1 0 1 (4.76%) * Authors were contacted without exit to ask for the questionnaire development and/or validation studies. the FOBT result. On the other hand, participants reported issues with 3.12. The staff’s technical skills telephone assistance concerning difficulties in contacting the program staff (27.1%) and incomplete call resolutions (18.8%). None of the surveys investigated this domain. Satisfaction according to screening results. 3.11. Staff’s interpersonal skills Four surveys reported satisfaction according to screening results: there were no differences in general satisfaction according to screening Regarding screening phase, results from one survey on FS (Robb results in FS and OC protocols (Denters et al., 2013; Hambleton and et al., 2012) showed that 99.4% of participants were ‘satisfied’ or ‘very Jones, 2017). Regarding FOBT protocols, participants with positive re­ satisfied’. Authors suggested that this dimension may be a fundamental sults reported higher psychological discomfort (Arveux et al., 1992) and factor in determining overall satisfaction with the screening procedure. more difficulty in the sample collection process (Burón et al., 2017), Regarding assessment phase (two surveys), almost all participants felt although authors state that this last result could be explained by a treated with respect by hospital staff in the conduction of colonoscopy memory bias. (Ghanouni et al., 2016; Plumb et al., 2017). 7 A. Selva et al. Preventive Medicine 175 (2023) 107706 Fig. 2. Satisfaction domains assessed in included surveys. Table 3 Description of dimensions of satisfaction. Dimension Questions explored Screening test Assessment tests Screening þ surveys (N = 16) surveys assessment surveys (N = 4) (N = 1) General Willingness to participate again in the future; willingness to recommend test 14 (87.5%) 2 (50.0%) 1 (100.0%) Satisfaction to relatives/friends; overall rating of procedure; satisfaction with the experience; how participants found the procedure; acceptability of the procedure; other generic questions about general satisfaction Discomfort, physical/ Easiness of test execution; pain experienced during procedure and its 15 (93.8%) 4 (100.0%) 1 (100.0%) Physical experience different parts; burden experienced during procedure; necessity to use of sedation or to stop the procedure; pain and symptoms after the procedure; unpleasantness of the bowel preparation; procedure more or less painful than expected; difficulty collecting the FOBT sample; level of discomfort; sensation of distension; Discomfort, Embarrassment related to touching fecal material; embarrassment with 9 (56.3%) 1 (25.0%) 1 (100.0%) psychological/ effects of bowel prep, with introduction of colonoscope or colonoscopy itself; Psychological state of mind while waiting for results; anxiety prior to examination; fear of experience finding a tumor; apprehension of long examination time Physical surroundings Privacy was maintained as much as possible; satisfaction with facilities at the 2 (12.5%) 2 (50.0%) 0 (0.0%) (privacy included) center; participants felt exposed Information transfer/ Staff gave clear and reassuring or repulsive and complicated explanations; 4 (25.0%) 2 (50.0%) 1 (100.0%) Communication participants were informed of risks and benefits of the procedure and about how to take the bowel prep medicine; users were satisfied with information they were given before the test or would like to have known more about the procedure before they arrived at the Centre; users were satisfied about the way the results were explained; the staff explained the procedure in terms users could understand; users understood invitation letter and information brochure; information at the pharmacy was clear and useful Accessibility (waiting Satisfaction with return time of the test; satisfaction with easiness of 2 (12.5%) 1 (25.0%) 1 (100.0%) time included) telephone contact with the program and resolution of the reason for calling, waiting time to be seen at the pharmacy, assessment of accessibility at the pharmacy Staff’s interpersonal skills Staff was courteous; staff treated participant with respect; staff made to feel 1 (6.25%) 2 (50.0%) 0 (0.0%) at ease during appointments; staff had a good attitude Staff’s technical skills 0 (0.0%) 0 (0.0%) 0 (0.0%) 4. Discussion a pilot test phase and to the inclusion of small and non-representative samples. This systematic review has identified 15 studies that assessed par­ General satisfaction with organized CRC was high both for screening ticipants’ satisfaction with organized CRC screening through 21 and assessment phases and for different tests used. Only one study different surveys. All studies used questionnaires designed for the con­ compared satisfaction using different tests and found higher satisfaction duction of each study and none had been evaluated regarding their for FIT and FOBT than for FS (Hol et al., 2010). The satisfaction domain measurement properties (validation). Methodological quality of most frequently assessed was physical discomfort and physical experi­ included studies was limited mainly due to the lack of evidence on ence, showing high heterogeneity according to the test used: in general, validity and reliability of questionnaires used, but also to the absence of physical discomfort was similar for OC, CTC, and FS, and was specially 8 A. Selva et al. Preventive Medicine 175 (2023) 107706 related to bowel preparation, and it was much lower for fecal tests. did not identify any validated questionnaire for assessing participants’ Psychological discomfort was frequently assessed, showing low levels of satisfaction with CRC screening programs using stool tests (Selva et al., embarrassment while conducting the screening process but some extent 2021). Our systematic review has identified four studies that have of anxiety while waiting for the screening test result. Other satisfaction already developed questionnaires to assess this aspect, and that should domains were less assessed, for example, participants were not asked for be validated in the future. perceived staff’s technical skills in any study. To our knowledge, this is the first systematic review to assess satis­ 4.1. Strengths faction with organized CRC screening programs. As far as we know, the only systematic review summarizing the results of studies investigating This study has several strengths. To our knowledge, it is the first the experience of participants in organized cancer screening programs systematic review assessing satisfaction with organized CRC screening was focused on breast cancer screening (Pagliarin et al., 2021). Even programs. Moreover, we conducted systematic searches in four different though the studies included in that review mainly relied on non- databases and both the selection and data extraction processes were validated questionnaires, as happens in the present work, satisfaction conducted in duplicate to minimize selection bias and possible errors. with breast cancer screening programs resulted in being generally high. The average response rate of included surveys is quite high (79%), This finding, although referring to different populations and settings, similar to that found in a similar systematic review on satisfaction with contributes - in line with our study - to suggest that participation in breast cancer screening (76%), mitigating the risk of potential non- organized cancer screening programs is experienced positively by par­ response bias(Compton et al., 2019; Pagliarin et al., 2021). In addi­ ticipants. Effective communication, good staff interpersonal skills and tion, a significant portion of the surveys were administered close to the prompt delivery of test results emerged as key elements in determining phenomenon being measured, minimizing the risk of potential recall participants´satisfaction with breast cancer screening. The results of the bias. current systematic review indicate a good level of satisfaction with these dimensions also for CRC screening, although only a minority of the 4.2. Study limitations included studies focused on their evaluation. In fact, the specific char­ acteristics of CRC screening protocols (laboratory test for FIT, invasive As we only included studies published in English, Spanish or Italian procedure for FS and colonoscopy) caused a shift of research focus to­ and we did not search for grey literature, we cannot exclude a possible wards participants’ embarrassment and pain/discomfort, at the expense selection bias. As we did not limit searches for language and excluded of operator communication and staff’s technical skills. High satisfaction only three studies due to language in the eligibility phase, we can as­ scores are common in surveys of satisfaction with health and preventive sume that the language restriction has had a limited impact. The major services (Pagliarin et al., 2021; Perneger et al., 2020). This can reflect a limitation is that our literature search did not find any original studies true association between patient satisfaction with health services and using validated questionnaires, which highlights the need for further adherence to preventive care. However, it’s essential to acknowledge research in this field. Additionally, due to heterogeneity in question­ the potential for an upward bias in satisfaction scores, which can arise naires used and the way results were reported across surveys, we could from an overrepresentation of satisfied individuals among survey re­ not pool the data and hence we could only provide a narrative summary spondents. This notion is supported by a study on 717 hospital surveys of results. which shows a positive correlation between higher satisfaction scores Even though we only could provide a narrative summary of this and survey response rate, suggesting that the most satisfied patients are topic, we are confident that we were able to identify the most commonly those more likely to participate and return satisfaction questionnaires used domains and items in this context. These data could be used as a (Jerant et al., 2014; Perneger et al., 2005; Perneger et al., 2020). starting point for the development of structured tools to measure satis­ None of the included studies used a validated questionnaire and none faction and experience of CRC screening participants in relation to as­ of the self-developed questionnaires has been tested for their validity pects for which a validated questionnaire does not exist, for example, for and reliability. A recent systematic review on validated patient reported assessing satisfaction with stool test-based screening programs. Also the outcome measures (PROMs) (Selva et al., 2021) found some validated themes and results from another systematic review in breast cancer questionnaires for measuring patient satisfaction with screening colo­ screening (Pagliarin et al., 2021) could be considered in this context. noscopy(Brotons et al., 2019) and sigmoidoscopy (Schoen et al., 2000). To be able to develop a generally acceptable methodology, wide The Colonoscopy Satisfaction and Safety Questionnaire-CSSQP (Brotons collaborative efforts among health care organizations responsible for et al., 2019) was developed and validated in the Spanish population and screening, researchers in the fields, health care professional societies, has sufficient content validity and internal consistency but indetermi­ and patient organizations, are required. This is needed to ensure that all nate structural and construct validity (Selva et al., 2021). However, this aspects concerning this multifaceted topic would be heard and taken questionnaire has been available only since 2019, and this could explain into account to guarantee applicability and acceptability of the devel­ why none of the studies included in this systematic review (that were all oped methods. In the meantime, screening programs should anyway conducted before 2019) used it. On the other hand, the Screening take into consideration the collection of their users’ feedback, consid­ Flexible Sigmoidoscopy Assessment Questionnaire, developed in USA ering the inclusion in their tools the themes highlighted in this study, and available from 2000 (Schoen et al., 2000), has sufficient internal and in particular those mostly impacting on satisfaction. consistency, responsiveness and reliability, but inconsistent content validity, that is the most important measurement property, and inde­ 5. Conclusions terminate structural validity and measurement error (Selva et al., 2021). All studies assessing FS included in our systematic review were pub­ This systematic review showed that satisfaction with CRC screening lished from year 2002 onwards but none used or mentioned this already was generally high, but its evaluation is performed using non-validated available and validated questionnaire. It has been a lost opportunity to instruments, which limits the interpretation of the results and prevents have not further validated this existing questionnaire, translating it to comparability of the current body of evidence. The few surveys available different languages and assessing its measurement properties in comparing tests showed higher satisfaction scores for FIT and FOBT than different populations. The use of non-validated questionnaires limits for FS. trustworthiness of results and precludes the comparison across different studies. Furthermore, the development of new questionnaires when Author contributions there are validated ones available supposes an unnecessary waste of time and resources. On the other hand, the systematic review of PROMs Conceptualization, S.D., A.S., I.S., L.P.; methodology, A.S., I.S., N.T.; 9 A. Selva et al. Preventive Medicine 175 (2023) 107706 data curation, G.M., S.C., S.R.; writing—original draft preparation, G. Duncan, A., Turnbull, D., Gregory, T., Cole, S.R., Young, G.P., Flight, I., Wilson, C., 2012. Using the Transtheoretical model of behaviour change to describe readiness to M., S.C., L.P., A.S., N.T.; writing—review and editing, G.M., S.C., L.P., A. rescreen for colorectal cancer with faecal occult blood testing. Health Promotion J. S., N.T., S.D.; supervision, E.C., A.O., S.D. All authors have read and Australia Off. J. Australian Assoc. Health Promot. Prof. 23, 122–128. agreed to the published version of the manuscript. Duncan, A., Turnbull, D., Wilson, C., Osborne, J.M., Cole, S.R., Flight, I., Young, G.P., 2014. Behavioural and demographic predictors of adherence to three consecutive faecal occult blood test screening opportunities: a population study. BMC Public Funding Health 14, 1–13. Excellence, N.I.f.H.a.C, 2012. Methods for the Development of NICE Public Health Guidance. This research did not receive any specific grant from funding Fitzpatrick, R., 1991. Surveys of patients satisfaction: I–Important general agencies in the public, commercial, or non-for-profit sectors. considerations. BMJ 302, 887–889. Ghanouni, A., Plumb, A., Hewitson, P., Nickerson, C., Rees, C.J., von Wagner, C., 2016. Patients’ experience of colonoscopy in the English Bowel Cancer Screening Institutional review board statement Programme. Endoscopy 48, 232–240. Gini, A., Jansen, E.E.L., Zielonke, N., Meester, R.G.S., Senore, C., Anttila, A., Segnan, N., Not applicable. Mlakar, D.N., de Koning, H.J., et al., 2020. Impact of colorectal cancer screening on cancer-specific mortality in Europe: a systematic review. Eur. J. Cancer 127, 224–235. Informed consent statement Hambleton, S., Jones, C., 2017. Participant satisfaction with NHS bowel scope screening: a cross-sectional survey. Gastrointest. Nurs. 15, 41–48. Higgins, J.P., Thomas, J., Chandler, J., Cumpston, M., Li, T., Page, M.J., Welch, V.A., Not applicable. 2019. Cochrane Handbook for Systematic Reviews of Interventions. John Wiley & Sons. Hol, L., de Jonge, V., van Leerdam, M.E., van Ballegooijen, M., Looman, C.W., van Declaration of Competing Interest Vuuren, A.J., Reijerink, J.C., Habbema, J.D., Essink-Bot, M.L., et al., 2010. Screening for colorectal cancer: comparison of perceived test burden of guaiac-based faecal occult blood test, faecal immunochemical test and flexible sigmoidoscopy. Eur. J. The authors declare no conflict of interest. Cancer 46, 2059–2066. Jerant, A., Fenton, J.J., Bertakis, K.D., Franks, P., 2014. Satisfaction with health care Data availability providers and preventive care adherence: a national study. Med. Care 52. Jodal, H.C., Helsingen, L.M., Anderson, J.C., Lytvyn, L., Vandvik, P.O., Emilsson, L., 2019. Colorectal cancer screening with faecal testing, sigmoidoscopy or Data will be made available on request. colonoscopy: a systematic review and network meta-analysis. BMJ Open 9, e032773. Jover, R., Herráiz, M., Alarcón, O., Brullet, E., Bujanda, L., Bustamante, M., Campo, R., Carreño, R., Castells, A., et al., 2012. Clinical practice guidelines: quality of Appendix A. Supplementary data colonoscopy in colorectal cancer screening. Endoscopy 44. Keum, N., Giovannucci, E., 2019. Global burden of colorectal cancer: emerging trends, Supplementary data to this article can be found online at https://doi. risk factors and prevention strategies. Nat. Rev. Gastroenterol. Hepatol. 16, 713–732. org/10.1016/j.ypmed.2023.107706. Kingsley, C., ST7 Anaesthetist, R.F.L.N.F.T., Pond Street, London NW3 2QG, UK, Patel, S, Consultant Anaesthetist, U.C.L.H.N.T., 235 Euston Rd, Fitzrovia, London NW1 2BU, References 2023. Patient-reported outcome measures and patient-reported experience measures. BJA Educ. 17, 137–144. Kinner, S., Kuehle, C.A., Langhorst, J., Ladd, S.C., Nuefer, M., Zoepf, T., Barkhausen, J., Arveux, P., Durand, G., Milan, C., Bedenne, L., Lévy, D., Doan, B.D., Faivre, J., 1992. Gerken, G., Lauenstein, T.C., 2007. MR colonography vs. optical colonoscopy: Views of a general population on mass screening for colorectal cancer: the Burgundy comparison of patients’ acceptance in a screening population. Eur. Radiol. 17, Study. Prev. Med. 21, 574–581. 2286–2293. Beattie, M., Murphy, D.J., Atherton, I., Lauder, W., 2015. Instruments to measure patient Lauby-Secretan, B., Vilahur, N., Bianchini, F., Guha, N., Straif, K., 2018. The IARC experience of healthcare quality in hospitals: a systematic review. Syst. Rev. 4. perspective on colorectal cancer screening. N. Engl. J. Med. 378, 1734–1740. Bevan, R., Rubin, G., Sofianopoulou, E., Patnick, J., Rees, C.J., 2015. Implementing a Lee, T.J., Rutter, M.D., Blanks, R.G., Moss, S.M., Goddard, A.F., Chilton, A., national flexible sigmoidoscopy screening program: results of the English early pilot. Nickerson, C., McNally, R.J.Q., Patnick, J., et al., 2012. Colonoscopy quality Endoscopy 47, 225–231. measures: experience from the NHS bowel cancer screening programme. Gut 61. Blom, J., Lidén, A., Nilsson, J., Påhlman, L., Nyrén, O., Holmberg, L., 2004. Colorectal Lin, J.S., Perdue, L.A., Henrikson, N.B., Bean, S.I., Blasi, P.R., 2021. Screening for cancer screening with flexible sigmoidoscopy-participants’ experiences and colorectal cancer: updated evidence report and systematic review for the US technical feasibility. Eur. J. Surg. Oncol. 30, 362–369. preventive services task force. JAMA 325, 1978–1998. Boutron, I., Page, M.J., Higgins, J.P., Altman, D.G., Lundh, A., Hróbjartsson, A., Moher, D., Shamseer, L., Clarke, M., Ghersi, D., Liberati, A., Petticrew, M., Shekelle, P., Group, C.B.M., 2019. Considering bias and conflicts of interest among the included Stewart, L.A., Group, P.-P., 2015. Preferred reporting items for systematic review studies. Cochrane handbook for systematic reviews of interventions, pp. 177–204. and meta-analysis protocols (PRISMA-P) 2015 statement. Syst. Rev. 4, 1. Brenner, H., Stock, C., Hoffmeister, M., 2014. Effect of screening sigmoidoscopy and Osborne, J.M., Wilson, C., Duncan, A., Cole, S.R., Flight, I., Turnbull, D., Hughes, D.L., screening colonoscopy on colorectal cancer incidence and mortality: systematic Young, G.P., 2017. Patterns of participation over four rounds of annual fecal review and meta-analysis of randomised controlled trials and observational studies. immunochemical test-based screening for colorectal cancer: what predicts BMJ 348, g2467. rescreening? BMC Public Health 18, 81. Bretthauer, M., Hoff, G., Thiis-Evensen, E., Grotmol, T., Larsen, I.K., Kjellevold, Ø., Pagliarin, F., Pylkkanen, L., Salakari, M., Deandrea, S., 2021. Are women satisfied with Skovlund, E., 2002. Use of a disposable sheath system for flexible sigmoidoscopy in their experience with breast cancer screening? Systematic review of the literature. decentralized colorectal cancer screening. Endoscopy 34, 814–818. Eur. J. Pub. Health 31, 206–214. Brotons, A., Guilabert, M., Lacueva, F.J., Mira, J.J., Lumbreras, B., Picó, M.D., Vitaller, J., Pascoe, G.C., 1983. Patient satisfaction in primary health care: a literature review and García-Sepulcre, M.F., Belda, G., et al., 2019. The colonoscopy satisfaction and safety analysis. Eval. Program Plann. 6. questionnaire (CSSQP) for colorectal cancer screening: a development and validation Perneger, T., Chamot, E., Bovier, P., 2005. Nonresponse bias in a survey of patient study. Int. J. Environ. Res. Public Health 16. perceptions of hospital care. Med. Care 43. Burón, A., Posso, M., Sivilla, J., Grau, J., Guayta, R., Castells, X., Castells, A., Macià, F., Perneger, T., Peytremann-Bridevaux, I., Combescure, C., 2020. Patient satisfaction and Procolon, e.n.d.G, 2017. Analysis of participant satisfaction in the Barcelona survey response in 717 hospital surveys in Switzerland: a cross-sectional study. BMC colorectal cancer screening programme: positive evaluation of the community Health Serv. Res. 20. pharmacy. Gastroenterol. Hepatol. 40, 265–275. Plumb, A.A., Ghanouni, A., Rees, C.J., Hewitson, P., Nickerson, C., Wright, S., Taylor, S. Compton, J., Glass, N., Fowler, T., 2019. Evidence of selection bias and non-response bias A., Halligan, S., von Wagner, C., 2017. Patient experience of CT colonography and in patient satisfaction surveys. Iowa Orthop. J. 39. colonoscopy after fecal occult blood test in a national screening programme. Eur. Crow, R., Gage, H., Hampson, S., Hart, J., Kimber, A., Storey, L., Thomas, H., 2002. The Radiol. 27, 1052–1063. measurement of satisfaction with healthcare: implications for practice from a Robb, K.A., Lo, S.H., Power, E., Kralj-Hans, I., Edwards, R., Vance, M., von Wagner, C., systematic review of the literature. Health Technol. Assess. 6, 1–244. Atkin, W., Wardle, J., 2012. Patient-reported outcomes following flexible Deandrea, S., Salakari, M., Neamţiu, L., Ulutürk, A., Lerda, D., Pylkkänen, L., 2018. sigmoidoscopy screening for colorectal cancer in a demonstration screening Validated tools measuring women’s satisfaction in breast cancer screening programme in the UK. J. Med. Screen. 19, 171–176. programmes: a systematic review. Breast 39, 33–38. Sali, L., Ventura, L., Grazzini, G., Borgheresi, A., Delsanto, S., Falchini, M., Mallardi, B., Denters, M.J., Deutekom, M., Bossuyt, P.M., Fockens, P., Dekker, E., 2013. Patient Mantellini, P., Milani, S., et al., 2019. Patients’ experience of screening CT burden of colonoscopy after positive fecal immunochemical testing for colorectal colonography with reduced and full bowel preparation in a randomised trial. Eur. cancer screening. Endoscopy 45, 342–349. Radiol. 29. Doyle, C., Lennox, L., Bell, D., 2013. A systematic review of evidence on the links between patient experience and clinical safety and effectiveness. BMJ Open 3. 10 A. Selva et al. Preventive Medicine 175 (2023) 107706 Sarkar, S., Athwal, V., Sturgess, R.P., Lythgoe, D., Bodger, K., 2012. The effect of high Travaglia, J.F., Debono, D.S., 2009b. Complaints and Patient Satisfaction: A quality assurance measures in bowel cancer screening on patient satisfaction of Comprehensive Review of the Literature. Centre for Clinical Governance Research in colonoscopy. J. Gastrointestin. Liver Dis. 21, 251–258. Health, Faculty of Medicine, University of New South Wales, Sydney, Australia, Schoen, R.E., Weissfeld, J.L., Bowen, N.J., Switzer, G., Baum, A., 2000. Patient Sydney, Australia. satisfaction with screening flexible sigmoidoscopy. Arch. Intern. Med. 160, von Karsa, L., Patnick, J., Segnan, N., 2010. European Guidelines for Quality Assurance 1790–1796. in Colorectal cancer Screening and Diagnosis. Publications Office of the European Selva, A., Selva, C., Álvarez-Pérez, Y., Torà, N., López, P., Terraza-Núñez, R., Union. Rodríguez, V., Solà, I., Group, C, 2021. Satisfaction and experience with colorectal von Karsa, L., Patnick, J., Segnan, N., Atkin, W., Halloran, S., Lansdorp-Vogelaar, I., cancer screening: a systematic review of validated patient reported outcome Malila, N., Minozzi, S., Moss, S., et al., 2013. European guidelines for quality measures. BMC Med. Res. Methodol. 21, 230. assurance in colorectal cancer screening and diagnosis: overview and introduction to Shin, H.Y., Suh, M., Choi, K.S., Hwang, S.H., Jun, J.K., Han, D.S., Lee, Y.K., Oh, J.H., the full supplement publication. Endoscopy 45, 51–59. Lee, C.W., et al., 2018. Higher satisfaction with an alternative collection device for Wild, C., Weiderpass, E., Stewart, B.W., 2020. World cancer Report: cancer Research for stool sampling in colorectal cancer screening with fecal immunochemical test: a cancer Prevention. International Agency for Research on Cancer. cross-sectional study. BMC Cancer 18, 365. Zauber, A.G., 2015. The impact of screening on colorectal cancer mortality and Travaglia, J., Debono, D., 2009a. Peer Review in Medicine: A Comprehensive Review of incidence: has it really made a difference? Dig. Dis. Sci. 60, 681–691. the Literature. Centre for Clinical Governance Research. University of New South Wales, Sydney, Australia, Sydney. 11