{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,9,30]],"date-time":"2026-09-30T06:56:20Z","timestamp":1790751380616,"version":"4.1.0"},"reference-count":38,"publisher":"Frontiers Media SA","license":[{"start":{"date-parts":[[2026,9,30]],"date-time":"2026-09-30T00:00:00Z","timestamp":1790726400000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"content-domain":{"domain":["frontiersin.org"],"crossmark-restriction":true},"short-container-title":["Front. Public Health"],"abstract":"<jats:p>Organised colorectal cancer (CRC) screening reduces mortality, yet participation routinely falls short of policy targets, a gap most acute in structurally disadvantaged, insular, and rapidly ageing populations. The Azores, an outermost European Union archipelago, exemplifies this challenge: CRC accounts for 10% of regional cancer diagnoses and is the second leading oncological cause of potential years of life lost, with 2024 mortality (24.9 per 100,000) exceeding mainland Portugal. Despite a mature organised screening programme (ROCCRA), archipelago-wide participation stands at just 30.3%, with roughly one in five residents who consent and receive a home test kit never returning it. This perspective article argues that conversational artificial intelligence based on large language models (LLMs), the current generation of natural language processing (NLP) technology, capable of understanding and responding to patient concerns in real time, represents a promising approach for bridging this gap. Because the barriers identified in the literature are well, inherently dialogic, an interactive, multi-channel conversational cascade is better suited to address cognitive and operational friction than static reminders. Specifically, this paper synthesises presumed drivers of non-adherence, inferred from the literature and considered likely to apply to the Azorean context, reviews the evidence supporting conversational and voice-enabled outreach in cancer screening, and uses regional data to model the potential impact of a well-targeted voice AI deployment. Beyond the Azores, this framework illustrates how NLP-enabled conversational AI could support more responsive, equitable, and scalable public health screening programmes in geographically dispersed and underserved populations.<\/jats:p>","DOI":"10.3389\/fpubh.2026.1968297","type":"journal-article","created":{"date-parts":[[2026,9,30]],"date-time":"2026-09-30T06:06:17Z","timestamp":1790748377000},"update-policy":"https:\/\/doi.org\/10.3389\/crossmark-policy","source":"Crossref","is-referenced-by-count":0,"title":["Harnessing conversational generative artificial intelligence and natural language processing to address the colorectal cancer screening adherence gap: the Azores endeavour"],"prefix":"10.3389","volume":"14","author":[{"given":"Francisco","family":"Goiana-da-Silva","sequence":"first","affiliation":[{"name":"Centre for Health Policy, Institute of Global Health Innovation, Imperial College London","place":["London, United Kingdom"]},{"name":"NOVA Medical School, Universidade NOVA de Lisboa","place":["Lisbon, Portugal"]},{"name":"Faculdade de Ci\u00eancias da Sa\u00fade, Universidade da Beira Interior","place":["Covilh\u00e3, Portugal"]},{"name":"Sword Health, Inc","place":["Draper, UT, United States"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Duarte","family":"Tude-Gra\u00e7a","sequence":"additional","affiliation":[{"name":"Sword Health, Inc","place":["Draper, UT, United States"]},{"name":"Faculdade de Medicina, Universidade de Lisboa","place":["Lisbon, Portugal"]},{"name":"Centre for Public Administration and Public Policies, Institute of Social and Political Sciences, University of Lisbon","place":["Lisbon, Portugal"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Filipa Patr\u00edcia Gon\u00e7alves","family":"Correia","sequence":"additional","affiliation":[{"name":"Azores Oncology Centre","place":["Angra do Hero\u00edsmo, Azores, Portugal"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Rik","family":"Renard","sequence":"additional","affiliation":[{"name":"Sword Health, Inc","place":["Draper, UT, United States"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Jo\u00e3o","family":"Pereira","sequence":"additional","affiliation":[{"name":"Sword Health, Inc","place":["Draper, UT, United States"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Tom\u00e1s","family":"Portas","sequence":"additional","affiliation":[{"name":"Sword Health, Inc","place":["Draper, UT, United States"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Jo\u00e3o Perestrelo","family":"Borba","sequence":"additional","affiliation":[{"name":"Azores Oncology Centre","place":["Angra do Hero\u00edsmo, Azores, Portugal"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Hutan","family":"Ashrafian","sequence":"additional","affiliation":[{"name":"Centre for Health Policy, Institute of Global Health Innovation, Imperial College London","place":["London, United Kingdom"]},{"name":"Department of Surgery and Cancer, Faculty of Medicine, Imperial College London","place":["London, United Kingdom"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Jo\u00e3o Carlos Cruz Barbosa","family":"de Macedo","sequence":"additional","affiliation":[{"name":"Azores Oncology Centre","place":["Angra do Hero\u00edsmo, Azores, Portugal"]}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"1965","published-online":{"date-parts":[[2026,9,30]]},"reference":[{"key":"ref1","doi-asserted-by":"publisher","first-page":"1978","DOI":"10.1001\/jama.2021.4417","article-title":"Screening for colorectal cancer: updated evidence report and systematic review for the US preventive services task force","volume":"325","author":"Lin","year":"2021","journal-title":"JAMA"},{"key":"ref2","volume-title":"Registo Oncol\u00f3gico Nacional de Todos os Tumores na Popula\u00e7\u00e3o Residente em Portugal, em 2022","year":"2025"},{"key":"ref3","doi-asserted-by":"publisher","first-page":"1232","DOI":"10.1136\/gutjnl-2018-317293","article-title":"Performance of colorectal cancer screening in the European Union member states: data from the second European screening report","volume":"68","author":"Senore","year":"2019","journal-title":"Gut"},{"key":"ref4","doi-asserted-by":"publisher","first-page":"1002","DOI":"10.1016\/S1470-2045(21)00199-6","article-title":"Colorectal cancer incidence, mortality, and stage distribution in European countries in the colorectal cancer screening era: an international population-based study","volume":"22","author":"Cardoso","year":"2021","journal-title":"Lancet Oncol"},{"key":"ref5","volume-title":"Preparing for Demographic Change in the Azores, Portugal","year":"2025"},{"key":"ref6","doi-asserted-by":"publisher","first-page":"712","DOI":"10.1093\/ije\/dyr008","article-title":"Inequalities in participation in an organized national colorectal cancer screening programme: results from the first 2.6 million invitations in England","volume":"40","author":"Von Wagner","year":"2011","journal-title":"Int J Epidemiol"},{"key":"ref7","doi-asserted-by":"publisher","first-page":"e0264067","DOI":"10.1371\/journal.pone.0264067","article-title":"Socioeconomic differences in participation and diagnostic yield within the Dutch national colorectal cancer screening programme with faecal immunochemical testing","volume":"17","author":"Van Der Meulen","year":"2022","journal-title":"PLoS One"},{"key":"ref8","doi-asserted-by":"publisher","first-page":"e20346","DOI":"10.2196\/20346","article-title":"The effectiveness of artificial intelligence conversational agents in health care: systematic review","volume":"22","author":"Milne-Ives","year":"2020","journal-title":"J Med Internet Res"},{"key":"ref9","author":"Sehgal","year":"2025"},{"key":"ref10","doi-asserted-by":"publisher","first-page":"e103857","DOI":"10.1136\/bmjopen-2025-103857","article-title":"Theory-based chatbot for promoting colorectal cancer screening in a community setting in Hong Kong: study protocol of a randomised controlled trial","volume":"15","author":"Hu","year":"2025","journal-title":"BMJ Open"},{"key":"ref11","year":"2026"},{"key":"ref12","volume-title":"Registo Oncol\u00f3gico nos A\u00e7ores: 20 Anos","year":"2018"},{"key":"ref13","year":"2025"},{"key":"ref14","doi-asserted-by":"publisher","first-page":"101810","DOI":"10.1016\/j.canep.2020.101810","article-title":"Measuring progress against cancer in the Azores, Portugal: incidence, survival, and mortality trends and projections to 2025","volume":"69","author":"Forjaz","year":"2020","journal-title":"Cancer Epidemiol"},{"key":"ref15","first-page":"51","article-title":"European guidelines for quality assurance in colorectal cancer screening and diagnosis: overview and introduction to the full supplement publication","volume-title":"Endoscopy","author":"von Karsa","year":"2012"},{"key":"ref16","doi-asserted-by":"publisher","first-page":"21501319251397205","DOI":"10.1177\/21501319251397205","article-title":"Assessing the feasibility and acceptability of a colorectal cancer risk prediction tool in primary care to increase screening uptake in Singapore: a multi-methods pilot study","volume":"16","author":"Fok","year":"2025","journal-title":"J Prim Care Community Health"},{"key":"ref17","doi-asserted-by":"publisher","first-page":"1073","DOI":"10.1007\/s11606-021-06922-2","article-title":"A centralized program with stepped support increases adherence to colorectal cancer screening over 9 years: a randomized trial","volume":"37","author":"Green","year":"2022","journal-title":"J Gen Intern Med"},{"key":"ref18","doi-asserted-by":"publisher","first-page":"e35760","DOI":"10.1002\/cncr.35760","article-title":"Interventions to increase uptake in a fecal-immunochemical test population-based colorectal cancer screening program: a quasi-experimental study of first-time invitees","volume":"131","author":"Clarke","year":"2025","journal-title":"Cancer"},{"key":"ref19","doi-asserted-by":"publisher","first-page":"1235","DOI":"10.1001\/jamainternmed.2014.2352","article-title":"Comparative effectiveness of a multifaceted intervention to improve adherence to annual colorectal cancer screening in community health centers: a randomized clinical trial","volume":"174","author":"Baker","year":"2014","journal-title":"JAMA Intern Med"},{"key":"ref20","doi-asserted-by":"publisher","first-page":"96","DOI":"10.1186\/s13012-020-01045-4","article-title":"Implementing a multilevel intervention to accelerate colorectal cancer screening and follow-up in federally qualified health centers using a stepped wedge design: a study protocol","volume":"15","author":"Kim","year":"2020","journal-title":"Implementation Sci"},{"key":"ref21","doi-asserted-by":"publisher","first-page":"72","DOI":"10.1007\/s11606-017-4184-x","article-title":"Effect of reminding patients to complete Fecal immunochemical testing: a comparative effectiveness study of automated and live approaches","volume":"33","author":"Coronado","year":"2018","journal-title":"J Gen Intern Med"},{"key":"ref22","doi-asserted-by":"publisher","first-page":"1081","DOI":"10.1016\/S0140-6736(24)02813-7","article-title":"Behavioural interventions to increase uptake of FIT colorectal screening in Scotland (TEMPO): a nationwide, eight-arm, factorial, randomised controlled trial","volume":"405","author":"Robb","year":"2025","journal-title":"Lancet"},{"key":"ref23","doi-asserted-by":"publisher","first-page":"503","DOI":"10.1111\/spc3.12265","article-title":"The intention-behavior gap","volume":"10","author":"Sheeran","year":"2016","journal-title":"Soc Personal Psychol Compass"},{"key":"ref24","doi-asserted-by":"publisher","first-page":"1158","DOI":"10.1136\/gutjnl-2014-308081","article-title":"Optimising colorectal cancer screening acceptance: a review","volume":"64","author":"Senore","year":"2015","journal-title":"Gut"},{"key":"ref25","doi-asserted-by":"publisher","first-page":"15","DOI":"10.1186\/1471-2296-9-15","article-title":"Barriers to colorectal cancer screening in community health centers: a qualitative study","volume":"9","author":"Lasser","year":"2008","journal-title":"BMC Fam Pract"},{"key":"ref26","doi-asserted-by":"publisher","first-page":"1","DOI":"10.1155\/2015\/165074","article-title":"Social cognitive mediators of sociodemographic differences in colorectal cancer screening uptake","volume":"2015","author":"Lo","year":"2015","journal-title":"Biomed Res Int"},{"key":"ref27","doi-asserted-by":"publisher","first-page":"907","DOI":"10.1158\/1055-9965.EPI-15-0990","article-title":"Systematic review and meta-study synthesis of qualitative studies evaluating facilitators and barriers to participation in colorectal cancer screening","volume":"25","author":"Honein-AbouHaidar","year":"2016","journal-title":"Cancer Epidemiol Biomarkers Prev"},{"key":"ref28","doi-asserted-by":"publisher","first-page":"454","DOI":"10.1097\/00002820-200312000-00005","article-title":"Cancer fatalism: the state of the science","volume":"26","author":"Powe","year":"2003","journal-title":"Cancer Nurs"},{"key":"ref29","doi-asserted-by":"publisher","first-page":"e296","DOI":"10.2196\/jmir.7893","article-title":"Text messaging interventions on cancer screening rates: a systematic review","volume":"19","author":"Uy","year":"2017","journal-title":"J Med Internet Res"},{"key":"ref30","doi-asserted-by":"publisher","first-page":"e57959","DOI":"10.2196\/57959","article-title":"Effectiveness and acceptability of targeted text message reminders in colorectal cancer screening: randomized controlled trial (M-TICS study)","volume":"10","author":"Vives","year":"2024","journal-title":"JMIR Public Health Surveill"},{"key":"ref31","doi-asserted-by":"publisher","first-page":"e64243","DOI":"10.2196\/64243","article-title":"Text messaging versus postal reminders to improve participation in a colorectal cancer screening program: randomized controlled trial","volume":"13","author":"Vives","year":"2025","journal-title":"JMIR Mhealth Uhealth"},{"key":"ref32","doi-asserted-by":"publisher","first-page":"496","DOI":"10.1097\/MLR.0000000000000116","article-title":"Use of interactive voice response to improve colorectal cancer screening","volume":"52","author":"Cohen-Cline","year":"2014","journal-title":"Med Care"},{"key":"ref33","first-page":"199","article-title":"Improving endoscopy completion: effectiveness of an interactive voice response system","volume":"17","author":"Griffin","year":"2011","journal-title":"Am J Manag Care"},{"key":"ref34","doi-asserted-by":"publisher","first-page":"353","DOI":"10.1038\/s41746-025-01776-y","article-title":"How generative AI voice agents will transform medicine","volume":"8","author":"Adams","year":"2025","journal-title":"NPJ Digit Med"},{"key":"ref35","doi-asserted-by":"publisher","first-page":"301","DOI":"10.7326\/0003-4819-158-5-201303050-00002","article-title":"An automated intervention with stepped increases in support to increase uptake of colorectal cancer screening: a randomized trial","volume":"158","author":"Green","year":"2013","journal-title":"Ann Intern Med"},{"key":"ref36","doi-asserted-by":"publisher","first-page":"1120","DOI":"10.1111\/codi.14707","article-title":"Effectiveness of a brief phone intervention to increase participation in a population-based colorectal cancer screening programme: a randomized controlled trial","volume":"21","author":"Selva","year":"2019","journal-title":"Color Dis"},{"key":"ref37","doi-asserted-by":"publisher","first-page":"1073","DOI":"10.3390\/cancers14041073","article-title":"A global evaluation of the performance indicators of colorectal cancer screening with fecal immunochemical tests and colonoscopy: a systematic review and meta-analysis","volume":"14","author":"Ding","year":"2022","journal-title":"Cancer"},{"key":"ref38","first-page":"102","article-title":"Results of faecal immunochemical test for colorectal cancer screening, in average risk population, in a cohort of 1389 subjects","volume":"86","author":"Miu\u0163escu","year":"2013","journal-title":"Clujul Med"}],"container-title":["Frontiers in Public Health"],"original-title":[],"link":[{"URL":"https:\/\/www.frontiersin.org\/articles\/10.3389\/fpubh.2026.1968297\/full","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2026,9,30]],"date-time":"2026-09-30T06:06:19Z","timestamp":1790748379000},"score":1,"resource":{"primary":{"URL":"https:\/\/www.frontiersin.org\/articles\/10.3389\/fpubh.2026.1968297\/full"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2026,9,30]]},"references-count":38,"alternative-id":["10.3389\/fpubh.2026.1968297"],"URL":"https:\/\/doi.org\/10.3389\/fpubh.2026.1968297","relation":{},"ISSN":["2296-2565"],"issn-type":[{"value":"2296-2565","type":"electronic"}],"subject":[],"published":{"date-parts":[[2026,9,30]]},"article-number":"1968297"}}