Cancer Screening: Client Reminders — Cervical Cancer

The CPSTF finding is based on evidence from a Community Guide systematic review published in 2008 (Baron et al., 11 studies, search period 1966-2004) combined with more recent evidence (6 studies, search period 2004-2008). The systematic review was conducted on behalf of the CPSTF by a team of specialists in systematic review methods, and in research, practice, and policy related to cancer prevention and control. This finding updates and replaces the 2008 CPSTF finding on Cancer Screening: Client Reminders Cervical Cancer.

Results from the 2008 Review

The original cervical cancer screening review included 11 studies.

• Pap test: median increase of 10.2 percentage points (interquartile interval [IQI]: 6.3 to 17.9 percentage points; 14 study arms).
• Enhanced and telephone reminders showed greater increase (15.5 percentage points; 6 study arms) than written reminders alone (9.8 percentage points; 8 study arms).

Results from the Updated Review

The updated review included 6 additional studies.

• Pap test: median increase in use was 2.8 percentage points (range 1.6 to 31.4; 4 studies).
• Enhanced and telephone reminders showed an increase of 1.6 to 31.4 percentage points (3 studies; 4 study arms).
• The incremental effect client reminders added to provider-directed interventions was a median increase of 3.7 percentage points (range 3.5 to 25.2; 5 study arms).

The updated search for evidence included five studies about breast cancer (1 study) or colorectal cancer (4 studies) screening. Monetary values are presented in 2009 U.S dollars.

• Of the included studies, one provided only cost information and four provided cost-effectiveness information.
  • One study found automated telephone reminders were the most effective strategy to increase mammography and also had the lowest average cost of $0.35/woman.
  • The cost-effectiveness studies found the cost per additional screening ranged from $7.89 to $1,149. The high end of the range was due to high personnel costs combined with a small intervention effect.

Tailored and untailored client reminder interventions to increase cervical cancer screening should be applicable across a range of settings and populations, provided they are adapted and targeted for a specific population and delivery context.

The CPSTF identified several areas that have limited information. Additional research and evaluation could help answer the following questions and fill remaining gaps in the evidence base. (What are evidence gaps?)

The following outlines evidence gaps for client reminders to increase breast, cervical, or colorectal cancer screening.

• How do newer methods of communication (e.g., the Internet, e-mail, text messages, or automated telephone calls) influence the effectiveness of client reminder interventions?
• To what extent does effectiveness vary for groups overdue for screening or never screened?
• Does effectiveness vary according to the source of client reminders (e.g., clinic or practice versus screening registry or program)?
• Do reminders for screenings for multiple cancer sites work as well as those for a single cancer site?
• Are interventions effective for promoting colorectal cancer screening with methods other than FOBT?
• Are interventions to promote colorectal cancer screening equally effective when addressing colorectal cancer screening more generally, as when specific to one type of test?
• What are the incremental effects of adding intervention components to other interventions?
• What is the influence of health system factors on intervention effectiveness?

Following are characteristics of included studies from the updated search period.

• Interventions included print reminders only (3 studies), telephone reminders only (1 study), and print reminders with telephone follow-up (2 studies).
• Reminders were delivered by clinical practices or organizations, or screening programs or registries.
• Outcomes were assessed by medical record review, administrative records, or screening registry records.
• Where specified, interventions were conducted in the U.S., Sweden, Belgium, and Australia.
• One study reported including nonwhite participants but did not provide more specific information, one study specified a population with low socioeconomic status, and three studies reported including urban or mixed urban/rural populations.

Effectiveness Review

Analytic Framework see Figure 1 on page 100

When starting an effectiveness review, the systematic review team develops an analytic framework. The analytic framework illustrates how the intervention approach is thought to affect public health. It guides the search for evidence and may be used to summarize the evidence collected. The analytic framework often includes intermediate outcomes, potential effect modifiers, potential harms, and potential additional benefits.

Economic Review

No content is available for this section.

Effectiveness Review

Summary Evidence Table – Effectiveness Review
Evidence from the previous review: Cancer Screening: Client Reminders Cervical Cancer

Economic Review

Summary Evidence Table – Economic Review

The number of studies and publications do not always correspond (e.g., a publication may include several studies or one study may be explained in several publications).

Effectiveness Review

Studies from the Updated Search Period

Byrnes P, McGoldrick C, Crawford M, Peers M. Cervical screening in general practice: strategies for improving participation. Aust Fam Physician 2007;36(3):183 92.

Crawford AG, Sikirica V, Goldfarb N, et al. Interactive voice response reminder effects on preventive service utilization. Am J Med Qual 2005;20(6):329 36.

de Jonge E, Cloes E, de Beeck LO, et al. A quasi-randomized trial on the effectiveness of an invitation letter to improve participation in a setting of opportunistic screening for cervical cancer. Eur J Cancer Prev 2008;17:238 42.

Eaker S, Adami H-O, Granath F, Wilander E, Sparen P. A large population-based randomized controlled trial to increase attendance at screening for cervical cancer. Cancer Epidemiol Biomarkers Prev 2004;13(3):346 54.

Morrell S, Taylor R, Zeckendorf S, Niciak A, Wain G, Ross J. How much does a reminder letter increase cervical screening among under-screened women in NSW? Aust N Z J Public Health 2005;29(1):78 84.

Ruff n MT, Gorenflo DW. Interventions fail to increase cancer screening rates in community-based primary care practices. Prev Med 2004;39(3):435 40.

Studies from the previous review

Cancer Screening: Client Reminders Cervical Cancer.

Economic Review

Church TR, Yeazel MW, Jones RM, Kochevar LK, Watt GD, Mongin SJ, Cordes JE, Engelhard D. A randomized trial of direct mailing of fecal occult blood tests to increase colorectal cancer screening. Journal of the National Cancer Institute 2004;96(10):770 80.

DeFrank JT, Rimer BK, Gierisch JM, Bowling JM, Farrell D, Skinner CS. Impact of mailed and automated telephone reminders on receipt of repeat mammograms. Am J Prev Med 2009;36(6):459 67.

Lairson DR, DiCarlo M, Myers RE, Wolf T, Cocroft J, Sifri R, Rosenthal M, Vernon SW, Wender R. Cost-effectiveness of targeted and tailored interventions on colorectal cancer screening use. Cancer 2008;112:779 88.

Lee JK, Groessl EJ, Ganiats TG, Ho SB. Cost-effectiveness of a mailed educational reminder to increase colorectal cancer screening. BMC Gastroenterology 2011;11(93). Available at URL: http://www.biomedcentral.com/1471-230X/11/93

Thompson RS, Michnich ME, Gray J, Friedlander L, Gilson B. Maximizing compliance with hemoccult screening for colon cancer in clinical practice. Medical Care 1986;24(10):904-14.

DeGroff A, Sharma K, Satsangi A, Kenney K, Joseph D, et al. Increasing colorectal cancer screening in health care systems using evidence-based interventions. Preventing Chronic Disease: Public Health Research, Practice, and Policy 2018;15:E100.

Increasing Colorectal Cancer Screening: An Action Guide for Working with Health Systems
Developed by CDC’s Division of Cancer Prevention and Control

The following outlines the search strategy used for these reviews of interventions to increase breast, cervical, and colorectal cancer screening: Client Reminders; Client Incentives; Mass Media Targeting Clients; Group Education for Clients; One-on-One Education for Clients; Reducing Structural Barriers for Clients; Reducing Client Out-of-Pocket Costs; Provider Assessment and Feedback; Provider Incentives.

Effectiveness Review

With the assistance of a CDC librarian, the following databases were searched for publications from 2004 up to 2008: Medline (Ovid), CINAHL (Ovid), PsycINFO (Ovid), Cochrane [Cochrane Reviews, Other Reviews, Methods Studies, Technology Assessments, Economic Evaluations], WoS (SSCI only), Chronic Disease Prevention – cancer prevention and control subcategory (no longer exists).

The team considered studies for inclusion if they were human studies conducted in high income economies according to the World Bank, and published in English.

Keywords

Note: discrepancies in number of results are due to limits being applied here (-) and new refs added to database (+)

PUBMED

1 AND (2 OR 3) NOT 4

1. INTERVENTIONS
(uptake*or outreach or intervention*).tw or exp intervention studies/or exp patient compliance/ or “patient acceptance of health care” or provider* or doctor* or nurse* or resident* or physician* or “allied health” or incentive* or law or laws or assessment* or feedback or checklist* or ((cancer* or neoplasm* or tumor*).tw adj4 (control* or early detection or health promotion* or reminder* or recall* or incentive* or mass media or small media or pamphlet* or brochure* or education or translation service* or reduced co-pay* or reduced cost* or women* health service* or mobile or promotor* or health advisor* or patient navigator or communit*).tw) or (access* adj5 health) or expand* hour* or longer hour* or weekend clinic* or saturday clinic* or schedul* or transporting or transportation

2. TYPES OF CANCER
exp uterine cervical neoplasms/pc or exp cervical intraepithelial neoplasia/pc or exp uterine cervical dysplasia/pc or exp breast neoplasms/pc or exp colorectal neoplasms/pc or exp colonic neoplasms/pc or exp neoplasms/pc

3. TYPES OF SCREENING (A OR B OR C)
A. Specific
exp mammography/ or exp vaginal smears/ or exp colonoscopy / or exp occult blood/ or clinical breast exam* or barium enema* or colonoscop* or endoscop* or pap* smear* or occult blood or vaginal smear*

B. Not specific
repeat screening* or diagnostic imag*

C. Other mass screening
exp mass screening/ut or exp preventive health services/ut

4. NOT
exp *skin neoplasms/ or exp *prostatic neoplasms/ or exp *bone neoplasms/ or exp *biliary tract neoplasms/ or exp *esophageal neoplasms/ or exp *cecal neoplasms/ or exp *duodenal neoplasms/ or exp *ileal neoplasms/ or exp *jejunal neoplasms/ or exp *stomach neoplasms/ or exp *liver neoplasms/ or exp *pancreatic neoplasms/ or exp *peritoneal neoplasms/ or exp *eye neoplasms/ or exp *”head and neck neoplasms”/ or exp *hematologic neoplasms/ or exp *nervous system neoplasms/ or exp *skin neoplasms/ or exp *splenic neoplasms/ or exp *thoracic neoplasms/

*** Bold terms replace “exp *gastrointestinal neoplasms/”

CINAHL

1 AND (2 OR 3) NOT 4

1. INTERVENTIONS
(uptake*or outreach or intervention*).tw or exp EARLY INTERVENTION/ or exp INTERVENTION TRIALS/ or exp PATIENT COMPLIANCE/ or “patient acceptance of health care” or provider* or doctor* or nurse* or resident* or physician* or “allied health” or incentive* or law or laws or assessment* or feedback or checklist* or ((cancer* or neoplasm* or tumor*).tw adj4 (control* or early detection or health promotion* or reminder* or recall* or incentive* or mass media or small media or pamphlet* or brochure* or education or translation service* or reduced co-pay* or reduced cost* or women* health service* or mobile or promotor* or health advisor* or patient navigator or communit*).tw) or (access* adj5 health) or expand* hour* or longer hour* or weekend clinic* or saturday clinic* or schedul* or transporting or transportation

2. TYPES OF CANCER
exp CERVIX NEOPLASMS/pc or exp UTERINE NEOPLASMS/pc or exp VAGINAL NEOPLASMS/pc or exp GENITAL NEOPLASMS, FEMALE/pc or exp BREAST NEOPLASMS/pc or exp BREAST NEOPLASMS, MALE/pc or exp DIGESTIVE SYSTEM NEOPLASMS/pc or exp INTESTINAL NEOPLASMS/pc or exp CECAL NEOPLASMS/pc or exp COLORECTAL NEOPLASMS/pc or exp COLONIC NEOPLASMS/pc or exp SIGMOID NEOPLASMS/pc or exp RECTAL NEOPLASMS/pc or exp ANUS NEOPLASMS/pc or exp NEOPLASMS/pc

3. TYPES OF SCREENING (A OR B OR C)
A. Specific
exp mammography/ or exp Cervical Smears/ or exp COLONOSCOPY/ or exp occult blood/ or clinical breast exam* or barium enema* or colonoscop* or endoscop* or pap* smear* or occult blood or vaginal smear*

B. Not specific
repeat screening* or diagnostic imag*

C. Other mass screening
exp Cancer Screening/ut or exp Preventive Health Care/ut

4. NOT
exp *prostatic neoplasms/ or exp *biliary tract neoplasms/ or exp *esophageal neoplasms/ or exp *cecal neoplasms/ or exp *duodenal neoplasms/ or exp *ileal neoplasms/ or exp *jejunal neoplasms/ or exp *stomach neoplasms/ or exp *liver tneoplasms/ or exp *pancreatic neoplasms/ or exp *peritoneal neoplasms/ or exp *hematologic neoplasms/ or exp *thoracic neoplasms/ or exp *bone neoplasms/ or exp *endocrine gland neoplasms/ or exp *eye neoplasms/ or exp *”head and neck neoplasms”/ or exp *hematologic neoplasms/ or exp *nervous system neoplasms/ or exp *skin neoplasms/ or exp *soft tissue neoplasms/ or exp *splenic neoplasms/ or exp *urogenital neoplasms/

PSYCINFO

1 AND (2 OR 3) NOT 4

1. INTERVENTIONS
(uptake*or outreach or intervention*).tw or exp intervention/or exp treatment compliance/ or “patient acceptance of health care” or provider* or doctor* or nurse* or resident* or physician* or “allied health” or incentive* or law or laws or assessment* or feedback or checklist* or ((cancer* or neoplasm* or tumor*).tw adj4 (control* or early detection or health promotion* or reminder* or recall* or incentive* or mass media or small media or pamphlet* or brochure* or education or translation service* or reduced co-pay* or reduced cost* or women* health service* or mobile or promotor* or health advisor* or patient navigator or communit*).tw) or (access* adj5 health) or expand* hour* or longer hour* or weekend clinic* or saturday clinic* or schedul* or transporting or transportation

2. TYPES OF CANCER
exp *neoplasms/ or exp breast neoplasms/

3. TYPES OF SCREENING (A OR B OR C)
A. Specific
exp mammography/ or exp cancer screening/ or exp breast cancer screening/ or clinical breast exam* or barium enema* or colonoscop* or endoscop* or pap* smear* or occult blood or vaginal smear*

B. Not specific
repeat screening* or diagnostic imag*

C. Other mass screening
mass screening or preventive health service*

4. NOT
exp *endocrine neoplasms/ or exp *leukemias/ or exp *nervous system neoplasms/ or ((skin or prostate* or bone or biliary tract or esophageal or cecal or duodenal or ileal or jejunal or stomach or liver or pancreas* or peritone* or eye or “head and neck” or splenic or spleen or thoracic) adj1 (cancer* or neoplasm*)).ti

COCHRANE

MeSH terms all done separately and exploded. Cannot copy/paste strategies this way.

1 AND (2 OR 3) NOT 4 (TOTAL )

1. INTERVENTIONS
(uptake*or outreach or intervention*):ti or “patient acceptance of health care” or provider* or doctor* or nurse* or resident* or physician* or “allied health” or incentive* or law or laws or assessment* or feedback or checklist* or ((cancer* or neoplasm* or tumor*) next/4 (control* or early detection or health promotion* or reminder* or recall* or incentive* or mass media or small media or pamphlet* or brochure* or education or translation service* or reduced co-pay* or reduced cost* or women* health service* or mobile or promotor* or health advisor* or patient navigator or communit*)):ti or (access* next/5 health) or expand* hour* or longer hour* or weekend clinic* or saturday clinic* or schedul* or transporting or transportation
MeSH done seperately: exp intervention studies or exp patient compliance

2. TYPES OF CANCER
exp uterine cervical neoplasms/pc or exp cervical intraepithelial neoplasia/pc or exp uterine cervical dysplasia/pc or exp breast neoplasms/pc or exp colorectal neoplasms/pc or exp colonic neoplasms/pc or exp neoplasms/pc

3. TYPES OF SCREENING
exp mammography/ or exp vaginal smears/ or exp colonoscopy / or exp occult blood/ or exp mass screening/ut or exp preventive health services/ut or clinical breast exam* or barium enema* or colonoscop* or endoscop* or pap* smear* or occult blood or vaginal smear* or repeat screening* or diagnostic imag*

4. NOT (cannot restrict to major topic)
exp skin neoplasms/ or exp bone neoplasms/ or exp nervous system neoplasms/ or exp biliary tract neoplasms/

WEB OF SCIENCE

1 AND 2

1. INTERVENTIONS
TI=(uptake*or outreach or intervention* or “patient acceptance of health care” or provider* or doctor* or nurse* or resident* or physician* or “allied health” or incentive* or law* or assessment* or feedback or checklist* or control* or early detection or health promotion* or reminder* or recall*)
or
TI=(incentive* or mass media or small media or pamphlet* or brochure* or education or translation service* or reduced co-pay* or reduced cost* or women* health service* or mobile or promotor* or health advisor* or patient navigator or communit*)
or
TS=((access* same health) or hour* or weekend clinic* or saturday clinic* or schedul* or transport* or intervention studies or patient compliance)

2. TYPES OF CANCER or TYPES OF SCREENING [18 terms]
TI=(((cervical or breast or colorectal or colon*) same (neoplasm* or cancer*)) or mammogra* or vaginal smear* or colonoscopy or occult blood or clinical breast exam* or barium enema* or colonoscop* or endoscop* or pap* smear* or screening* or diagnostic imag* or preventive health service*)

Economic Review

No content is available for this section.

Baron RC, Rimer BK, Breslow RA, et al. Client-directed interventions to increase community demand for breast, cervical, and colorectal cancer screening: a systematic review. Am J Prev Med 2008;35(1S): S34-55.

The following considerations are drawn from studies included in the evidence review, the broader literature, and expert opinion. The Community Guide does not conduct systematic reviews of implementation.

• Basic infrastructure, staffing, and computer support is needed to identify patients due for screening and deliver reminders efficiently.
• Funds may be required to generate and deliver reminders, though programs implemented on a large scale may cost little per person.

Evidence-Based Cancer Control Programs (EBCCP)

Find programs from the EBCCP website that align with this systematic review. (What is EBCCP?)

Healthy People 2030

Healthy People 2030 includes the following objective related to this CPSTF recommendation.

• Increase the proportion of females who get screened for cervical cancer — C-09