Cancer Screening: Multicomponent Interventions — Colorectal Cancer

The CPSTF finding is based on evidence from a systematic review of 88 studies (search period January 2004 – November 2013) that evaluated intervention effects on breast (33 studies), cervical (20 studies) or colorectal cancer (56 studies) screening use services recommended by the U.S. Preventive Services Task Force (2016a, 2018, 2016b, respectively).

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.

Detailed results from the systematic review are available in the CPSTF Finding and Rationale Statement.

• Compared with no intervention, multicomponent interventions changed colorectal cancer screening using the following tests:
  • Any test (colonoscopy, FOBT, or flexible sigmoidoscopy): median increase of 15.4 percentage points (39 study arms).
  • Colonoscopy: median increase of 10.2 percentage points (9 study arms)
  • FOBT: median increase of 7.7 percentage points (21 study arms)
  • Flexible sigmoidoscopy: median decrease of 0.5 percentage points (5 study arms)
• Multicomponent interventions vary in the number and type of approaches or strategies used. The review team conducted stratified analyses to understand the influence of these factors on cancer screening use.
  • Studies of interventions to increase breast, cervical, and colorectal cancer screening were considered for these analyses.
  • Intervention approaches are categorized into three strategies: increasing community demand, increasing community access, or increasing provider delivery of screening.
    • Multicomponent interventions that used all three strategies increased cancer screening by a median of 24.2 percentage points (5 study arms).
    • Multicomponent interventions that used strategies to increase community demand and access increased cancer screening by a median of 11.2 percentage points (48 study arms).
• Multicomponent interventions that used two or more approaches increased cancer screening.
  • Interventions that used five or more approaches showed a larger increase than interventions with fewer approaches.
  • Cancer screening increased independent of which approaches were used.
• Multicomponent interventions that included approaches to reduce structural barriers increased cancer screening rates.
  • Providing language translation services led to the largest increase (median increase of 62.7 percentage points, 4 studies).
  • Addressing transportation needs led to the next largest increase (median increase of 18.4 percentage points, 11 studies).
  • None of the included studies evaluated interventions that provided child care.

Detailed results from the systematic review are available in the CPSTF Finding and Rationale Statement.

The CPSTF finds that multicomponent interventions to increase screening for colorectal cancer are cost-effective. Results also showed the interventions led to cost savings from averted treatment costs that exceed intervention costs.

A systematic search for economic evidence (search period January 2004 January 2018) identified 53 studies, 33 of which focused on colorectal cancer screening. Two studies focused on both breast and colorectal cancer screening. Studies evaluated interventions that used FOBT (26 studies), colonoscopy (8 studies), and flexible sigmoidoscopy (1 study).

The majority of these studies were conducted in the United States with 9 studies conducted in other high-income countries. All monetary values are reported in 2016 U.S. dollars.

• Overall, the median cost per participant was $36.63 (42 study arms).
  • The median cost per participant for interventions that increased community demand was $44.07 (3 study arms).
  • The mean cost per participant for interventions that increased provider delivery was $366.51 (2 study arms).
  • The median cost per participant for interventions that increased both community demand and access was $30.82 (33 study arms).
• Across all studies, the median incremental cost per additional person screened was $582.44 (15 study arms).
  • The median incremental cost per additional person screened for interventions that increased both community demand and community access was $582.44 (11 study arms).
  • There was no consistent relationship between the baseline-screening rate (median: 44%; 9 estimates) and the incremental cost per additional person screened.
• Two good quality, modeled studies with societal perspectives calculated incremental cost per quality-adjusted life year (QALY) gained. Both reported declines in the incremental cost per QALY gained, indicating these interventions are cost-effective.
  • The incremental cost per QALY gained declined $3,817 and $1,651 (2 studies).
  • QALYs gained from screening were associated with treatment cost savings that outweighed the intervention costs.

Based on results for interventions to increase breast, cervical, or colorectal cancer screening, findings should be applicable to the following:

• U.S. or non-U.S. populations
• Urban or rural settings
• Healthcare systems, communities, or both
• Different racial or ethnic groups
• Age groups recommended for regular cancer screening (specified in USPSTF recommendations)
• People who are, or are not, up-to-date with recommended cancer screenings
• People with average risk for developing breast, cervical, or colorectal cancers

Based on results for interventions that had a range of characteristics, findings should be applicable to interventions that used the following:

• Intervention approaches to increase community demand, alone or in combination with approaches from other strategies
• Community health workers, patient navigators, or clinical providers to deliver interventions

Based on the limited evidence available, findings are likely applicable to people with different levels of income or health coverage.

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?)

• What are intervention effects on repeat cancer screening rates?
• How effective are interventions that only include strategies to increase community access and provider delivery?
• What is the magnitude of effect for multicomponent interventions that provide language translation services, and does it vary across population subgroups?
• What are the effects of specific combinations of intervention approaches?
• How well do interventions work among people who have low health literacy?
• How cost-effective are these interventions?

More consistent terminology and reporting of study details would improve future assessments of intervention effectiveness.

• What specific activities were used as part of an intervention approach?
• How were structural barriers reduced?
• Who delivered the intervention approaches?
• Who were the study participants (e.g., demographic characteristics including income and health insurance status)?

The following characteristics were summarized from all included studies.

• Intervention settings
  • The United States (76 studies), Canada (5 studies), Australia (2 studies), the United Kingdom (1 study), Italy (1 study), Taiwan (1 study), Singapore (1 study), and Israel (1 study)
  • Primarily urban (43 studies) or mixed settings (15 studies)
• Study population characteristics
  • Mean age of 58.2 years (51 studies reporting)
  • African American (median of 27%, 35 studies reporting), Hispanic (median of 11%, 25 studies reporting), Asian American (median of 5%, 15 studies reporting), White (median of 51%, 39 studies reporting)
  • Majority low-income study participants (38 studies)
  • High school education or less (median of 43%, 39 studies reporting)

Effectiveness Review

Analytic Framework

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
Contains evidence from reviews of multicomponent interventions to increase screening for breast, cervical, or colorectal cancer.

Economic Review

No content is available for this section.

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).

The following list of included studies is for multicomponent interventions to increase breast, cervical, or colorectal cancer screening.

Effectiveness Review

Ahmed N, Haber G, Semenya K, Hargreaves M. Randomized controlled trial of mammography intervention in insured very low-income women. Cancer Epidemiol Biomarkers Prev 2010;19(7):1790-8.

Allen B, Bazargan Hejazi S. Evaluating a tailored intervention to increase screening mammography in an urban area. J Natl Med Assoc 2005;97(10):1350-60.

Aragones A, Schwartz M, Shah N, Gany F. A randomized controlled trial of a multilevel intervention to increase colorectal cancer screening among Latino immigrants in a primary care facility. J Gen Intern Med 2010;25(6):564-7.

Armelao F, Orlandi PG, Tasini E, et al. High uptake of colonoscopy in first-degree relatives of patients with colorectal cancer in a healthcare region: a population-based, prospective study. Endoscopy 2010;42(1):15-21.

Biswas M, Whalley H, Foster J, Friedman E, Deacon R. Women with learning disability and uptake of screening: audit of screening uptake before and after one to one counselling. J Public Health 2005;27(4):344-7.

Blumenthal D, Fort J, Ahmed N, et al. Impact of a two-city community cancer prevention intervention on African Americans. J Natl Med Assoc 2005;97(11):1479-88.

Blumenthal D, Smith S, Majett C, Alema Mensah E. A trial of three interventions to promote colorectal cancer screening in African Americans. Cancer 2010;116(4):922-9.

Bowen D, Powers D. Effects of a mail and telephone intervention on breast health behaviors. Health Educ Behav 2010;37(4):479-89.

Braun K, Fong M, Kaanoi M, Kamaka M, Gotay C. Testing a culturally appropriate, theory-based intervention to improve colorectal cancer screening among Native Hawaiians. Prev Med 2005;40(6):619-27.

Byrnes P, McGoldrick C, Crawford M, Peers M. Cervical screening in general practice strategies for improving participation. Aust Fam Physician 2007;36(3):183-4, 92.

Cardarelli K, Jackson R, Martin M, et al. Community-based participatory approach to reduce breast cancer disparities in south Dallas. Prog Community Health Partnersh 2011;5(4):375-85.

Charters T, Strumpf E, Sewitch M. Effectiveness of an organized colorectal cancer screening program on increasing adherence in asymptomatic average-risk Canadians. BMC Health Serv Res 2013;13:449.

Chaudhry R, Scheitel S, McMurtry E, et al. Web-based proactive system to improve breast cancer screening: a randomized controlled trial. Arch Intern Med 2007;167(6):606-11.

Christie J, Itzkowitz S, Lihau Nkanza I, Castillo A, Redd W, Jandorf L. A randomized controlled trial using patient navigation to increase colonoscopy screening among low-income minorities. J Natl Med Assoc 2008;100(3):278-84.

Coronado GD, Golovaty I, Longton G, Levy L, Jimenez R. Effectiveness of a clinic-based colorectal cancer screening promotion program for underserved Hispanics. Cancer 2011;117(8):1745-54.

Danigelis N, Worden J, Flynn B, Skelly J, Vacek P. Increasing mammography screening among low-income African American women with limited access to health information. Prev Med 2005;40(6):880-7.

Decker KM, Turner D, Demers AA, Martens PJ, Lambert P, Chateau D. Evaluating the effectiveness of cervical cancer screening invitation letters. J Women’s Health (Larchmt) 2013;22(8):687-93.

Dietrich A, Tobin J, Cassells A, et al. Telephone care management to improve cancer screening among low-income women: a randomized, controlled trial. Ann Intern Med 2006;144(8):563-71.

Dietrich AJ, Tobin JN, Cassells A, et al. Translation of an efficacious cancer-screening intervention to women enrolled in a Medicaid managed care organization. Ann Fam Med 2007;5(4):320-7.

Dietrich AJ, Tobin JN, Robinson CM, et al. Telephone outreach to increase colon cancer screening in Medicaid managed care organizations: a randomized controlled trial. Ann Fam Med 2013;11(4):335-43.

Elkin E, Shapiro E, Snow J, Zauber A, Krauskopf M. The economic impact of a patient navigator program to increase screening colonoscopy. Cancer 2012;118(23):5982-8.

Fang CY, Ma GX, Tan Y, Chi N. A multifaceted intervention to increase cervical cancer screening among underserved Korean women. Cancer Epidemiol Biomarkers Prev 2007;16(6):1298-302.

Fern ndez M, Gonzales A, Tortolero Luna G, et al. Effectiveness of Cultivando la Salud: a breast and cervical cancer screening promotion program for low-income Hispanic women. Am J Public Health 2009;99(5):936-43.

Ferreira MR, Dolan N, Fitzgibbon M, et al. Health care provider-directed intervention to increase colorectal cancer screening among veterans: results of a randomized controlled trial. J Clin Oncol 2005;23(7):1548-54.

Fiscella K, Humiston S, Hendren S, et al. A multimodal intervention to promote mammography and colorectal cancer screening in a safety-net practice. J Natl Med Assoc 2011;103(8):762-8.

Flight I, Wilson C, Zajac I, Hart E, McGillivray J. Decision support and the effectiveness of web-based delivery and information tailoring for bowel cancer screening: an exploratory study. JMIR Research Protocols 2012;1(2):e12.

Ford ME, Havstad S, Vernon SW, et al. Enhancing adherence among older African American men enrolled in a longitudinal cancer screening trial. Gerontologist 2006;46(4):545-50.

Fouad M, Partridge E, Dignan M, et al. Targeted intervention strategies to increase and maintain mammography utilization among African American women. Am J Public Health 2010;100(12):2526-31.

Gellert K, Braun K, Morris R, Starkey V. The ‘Ohana Day Project: a community approach to increasing cancer screening. Prev Chronic Dis 2006;3(3):A99.

Green BB, Wang CY, Anderson ML, et al. An automated intervention with stepped increases in support to increase uptake of colorectal cancer screening: a randomized trial. Ann Intern Med 2013;158(5 Pt 1):301-11.

Greiner KA, James A, Born W, et al. Predictors of fecal occult blood test (FOBT) completion among low-income adults. Prev Med 2005;41(2):676-84.

Hannon PA, Vu T, Ogdon S, et al. Implementation and process evaluation of a workplace colorectal cancer screening program in eastern Washington. Health Promot Pract 2013;14(2):220-7.

Heyding R, Cheung A, Mocarski EJM, Moineddin R, Hwang S. A community-based intervention to increase screening mammography among disadvantaged women at an inner-city drop-in center. Women & Health 2005;41(1):21-31.

Holland D. Sending men the message about preventive care: an evaluation of communication strategies. International Journal of Men’s Health 2005;4(2):97-114.

Holt CL, Shipp M, Eloubeidi M, Fouad MN, Britt K, Norena M. Your body is the temple: impact of a spiritually based colorectal cancer educational intervention delivered through community health advisors. Health Promotion and Practices 2011;12(4):577-88.

Honein-AbouHaidar GN, Baxter NN, Moineddin R, Urbach DR, Rabeneck L, Bierman AS. Trends and inequities in colorectal cancer screening participation in Ontario, Canada, 2005-2011. Cancer Epidemiology 2013;37(6):946-56.

Honeycutt S, Green R, Ballard D, et al. Evaluation of a patient navigation program to promote colorectal cancer screening in rural Georgia, USA. Cancer 2013;119(16):3059-66.

Hou SI. Stage of adoption and impact of direct-mail communications with and without phone intervention on Chinese women’s cervical smear screening behavior. Prev Med 2005;41(3-4):749-56.

Husaini BA, Emerson JS, Hull PC, Sherkat DE, Levine RS, Cain VA. Rural-urban differences in breast cancer screening among African American women. J Health Care Poor Underserved 2005;16(4 Suppl A):1-10.

Jandorf L, Gutierrez Y, Lopez J, Christie J, Itzkowitz S. Use of a patient navigator to increase colorectal cancer screening in an urban neighborhood health clinic. J Urban Health 2005;82(2):216-24.

Jean-Jacques M, Kaleba EO, Gatta JL, Gracia G, Ryan ER, Choucair BN. Program to improve colorectal cancer screening in a low-income, racially diverse population: a randomized controlled trial. Ann Fam Med 2012;10(5):412-7.

Kaczorowski J, Hearps SJ, Lohfeld L, et al. Effect of provider and patient reminders, deployment of nurse practitioners, and financial incentives on cervical and breast cancer screening rates. Can Fam Physician 2013;59(6):e282-9.

Katz ML, Tatum C, Dickinson SL, et al. Improving colorectal cancer screening by using community volunteers: results of the Carolinas cancer education and screening (CARES) project. Cancer 2007;110(7):1602-10.

Kempe KL, Shetterly SM, France EK, Levin TR. Automated phone and mail population outreach to promote colorectal cancer screening. Am J Manag Care 2012;18(7):370-8.

Khankari K, Eder M, Osborn CY, et al. Improving colorectal cancer screening among the medically underserved: a pilot study within a federally qualified health center. J Gen Intern Med 2007;22(10):1410-4.

Kim Y, Sarna L. An intervention to increase mammography use by Korean American women. Oncology Nursing Forum 2004;31(1):105-10.

Krist AH, Woolf SH, Rothemich SF, et al. Interactive preventive health record to enhance delivery of recommended care: a randomized trial. Ann Fam Med 2012;10(4):312-9.

Lasser KE, Murillo J, Lisboa S, et al. Colorectal cancer screening among ethnically diverse, low-income patients: a randomized controlled trial. Arch Intern Med 2011;171(10):906-12.

Lebwohl B, Neugut AI, Stavsky E, et al. Effect of a patient navigator program on the volume and quality of colonoscopy. J Clin Gastroenterol 2011;45(5):e47-53.

Leffler DA, Neeman N, Rabb JM, et al. An alerting system improves adherence to follow-up recommendations from colonoscopy examinations. Gastroenterology 2011;140(4):1166-73.e1-3.

Leone LA, Reuland DS, Lewis CL, et al. Reach, usage, and effectiveness of a Medicaid patient navigator intervention to increase colorectal cancer screening, Cape Fear, North Carolina, 2011. Prev Chronic Dis 2013;10:E82.

Levy BT, Xu Y, Daly JM, Ely JW. A randomized controlled trial to improve colon cancer screening in rural family medicine: an Iowa Research Network (IRENE) study. J Am Board Fam Med 2013;26(5):486-97.

Lewis CL, Brenner AT, Griffith JM, Moore CG, Pignone MP. Two controlled trials to determine the effectiveness of a mailed intervention to increase colon cancer screening. N C Med J 2012;73(2):93-8.

Livaudais JC, Coronado GD, Espinoza N, Islas I, Ibarra G, Thompson B. Educating Hispanic women about breast cancer prevention: evaluation of a home-based promotora-led intervention. J Women’s Health (Larchmt) 2010;19(11):2049-56.

Ma GX, Shive S, Tan Y, et al. Community-based colorectal cancer intervention in underserved Korean Americans. Cancer Epidemiol 2009;33(5):381-6.

Manne SL, Coups EJ, Markowitz A, et al. A randomized trial of generic versus tailored interventions to increase colorectal cancer screening among intermediate risk siblings. Ann Behav Med 2009;37(2):207-17.

Maxwell A, Bastani R, Danao L, Antonio C, Garcia G, Crespi C. Results of a community-based randomized trial to increase colorectal cancer screening among Filipino Americans. Am J Public Health 2010;100(11):2228-34.

Michielutte R, Sharp PC, Foley KL, et al. Intervention to increase screening mammography among women 65 and older. Health Educ Res 2005;20(2):149-62.

Mosen DM, Feldstein AC, Perrin N, et al. Automated telephone calls improved completion of fecal occult blood testing. Med Care 2010;48(7):604-10.

Moskowitz JM, Kazinets G, Wong JM, Tager IB. “Health is strength”: a community health education program to improve breast and cervical cancer screening among Korean American Women in Alameda County, California. Cancer Detect Prev 2007;31(2):173-83.

Myers R, Sifri R, Hyslop T, et al. A randomized controlled trial of the impact of targeted and tailored interventions on colorectal cancer screening. Cancer 2007;110(9):2083-91.

Myers RE, Bittner-Fagan H, Daskalakis C, et al. A randomized controlled trial of a tailored navigation and a standard intervention in colorectal cancer screening. Cancer Epidemiol Biomarkers Prev 2013;22(1):109-17.

Nguyen BH, McPhee SJ, Stewart SL, Doan HT. Effectiveness of a controlled trial to promote colorectal cancer screening in Vietnamese Americans. Am J Public Health 2010;100(5):870-6.

Nguyen TT, Le G, Nguyen T, et al. Breast cancer screening among Vietnamese Americans: a randomized controlled trial of lay health worker outreach. Am J Prev Med 2009;37(4):306-13.

Nguyen TT, McPhee SJ, Gildengorin G, et al. Papanicolaou testing among Vietnamese Americans: results of a multifaceted intervention. Am J Prev Med 2006;31(1):1-9.

Otero-Sabogal R, Owens D, Canchola J, Tabnak F. Improving rescreening in community clinics: does a system approach work? J Community Health 2006;31(6):497-519.

Percac-Lima S, Grant RW, Green AR, et al. A culturally tailored navigator program for colorectal cancer screening in a community health center: a randomized, controlled trial. J Gen Intern Med 2009;24(2):211-7.

Percac-Lima S, Ashburner JM, Bond B, Oo SA, Atlas SJ. Decreasing disparities in breast cancer screening in refugee women using culturally tailored patient navigation. J Gen Intern Med 2013;28(11):1463-8.

Persell SD, Friesema EM, Dolan NC, Thompson JA, Kaiser D, Baker DW. Effects of standardized outreach for patients refusing preventive services: a quasiexperimental quality improvement study. Am J Manag Care 2011;17(7):e249-54.

Phillips CE, Rothstein JD, Beaver K, Sherman BJ, Freund KM, Battaglia TA. Patient navigation to increase mammography screening among inner city women. J Gen Intern Med 2011;26(2):123-9.

Pignone M, Winquist A, Schild LA, et al. Effectiveness of a patient and practice-level colorectal cancer screening intervention in health plan members: the CHOICE trial. Cancer 2011;117(15):3352-62.

Potter MB, Namvargolian Y, Hwang J, Walsh JM. Improving colorectal cancer screening: a partnership between primary care practices and the American Cancer Society. J Cancer Educ 2009;24(1):22-7.

Potter M, Somkin C, Ackerson L, et al. The FLU-FIT program: an effective colorectal cancer screening program for high volume flu shot clinics. Am J Manag Care 2011;17(8):577-83.

Powe BD, Ntekop E, Barron M. An intervention study to increase colorectal cancer knowledge and screening among community elders. Public Health Nurs 2004;21(5):435-42.

Richards CA, Kerker BD, Thorpe L, et al. Increased screening colonoscopy rates and reduced racial disparities in the New York Citywide campaign: an urban model. Am J Gastroenterol 2011;106(11):1880-6.

Roetzheim R, Christman L, Jacobsen P, Schroeder J, Abdulla R, Hunter S. Long-term results from a randomized controlled trial to increase cancer screening among attendees of community health centers. Ann Fam Med 2005;3(2):109-14.

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

Sauaia A, Min SJ, Lack D, et al. Church-based breast cancer screening education: impact of two approaches on Latinas enrolled in public and private health insurance plans. Prev Chronic Dis 2007;4(4):A99.

Sequist TD, Zaslavsky AM, Marshall R, Fletcher RH, Ayanian JZ. Patient and physician reminders to promote colorectal cancer screening: a randomized controlled trial. Arch Intern Med 2009;169(4):364-71.

Sequist TD, Zaslavsky AM, Colditz GA, Ayanian JZ. Electronic patient messages to promote colorectal cancer screening: a randomized controlled trial. Arch Intern Med 2011;171(7):636-41.

Slater JS, Henly GA, Ha CN, et al. Effect of direct mail as a population-based strategy to increase mammography use among low-income underinsured women ages 40 to 64 years. Cancer Epidemiol Biomarkers Prev 2005;14(10):2346-52.

Studts CR, Tarasenko YN, Schoenberg NE, Shelton BJ, Hatcher-Keller J, Dignan MB. A community-based randomized trial of a faith-placed intervention to reduce cervical cancer burden in Appalachia. Prev Med 2012;54(6):408-14.

Tanjasiri SP, Sablan-Santos L, Merrill V, Quitugua LF, Kuratani DG. Promoting breast cancer screening among Chamorro women in Southern California. J Cancer Educ 2008;23(1):10-7.

Thompson B, Coronado G, Chen L, Islas I. Celebremos la salud! a community randomized trial of cancer prevention (United States). Cancer Causes & Control 2006;17(5):733-46.

Walsh JM, Salazar R, Nguyen TT, et al. Healthy colon, healthy life: a novel colorectal cancer screening intervention. Am J Prev Med 2010;39(1):1-14.

Wang X, Fang C, Tan Y, Liu A, Ma GX. Evidence-based intervention to reduce access barriers to cervical cancer screening among underserved Chinese American women. J Women’s Health (Larchmt) 2010;19(3):463-9.

Wee L, Koh G, Chin R, Yeo W, Seow B, Chua D. Socioeconomic factors affecting colorectal, breast and cervical cancer screening in an Asian urban low-income setting at baseline and post-intervention. Prev Med 2012;55(1):61-7.

Wilf-Miron R, Galai N, Gabali A, et al. Organisational efforts to improve quality while reducing healthcare disparities: the case of breast cancer screening among Arab women in Israel. Qual Saf Health Care 2010;19(5):e36.

Economic Review

No content is available for this section.

Action Guide

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

Webinar

• Tools of the Trade: Multicomponent Interventions to Increase Cancer Screening (July 18, 2017)
  Developed by the National Cancer Institute in collaboration with The Community Guide

The following outlines the search strategy for multicomponent interventions to increase breast, cervical, or colorectal cancer screening.

Effectiveness Review

The CPSTF findings are based on evidence from a systematic review with 88 included studies (search period from January 2004 through November 2013). The team conduced two searches to identify qualified studies. Both search strategies are described below.

• The first search (from January 2004 to October 2008) was a broad search for all papers potentially relevant to cancer screening interventions, both single and multicomponent interventions. This search was used to identify single component interventions in order to update several Community Guide reviews on single component interventions to increase cancer screening. Papers evaluating multicomponent interventions were then screened for independently by two abstractors. Papers from 2004 that were included in our previous multicomponent review were excluded. Details on this search can be found here: Sabatino SA, Lawrence B, Elder R, et al. Effectiveness of Interventions to Increase Screening for Breast, Cervical, and Colorectal Cancers. AJPM. 2012;43(1):97-118.
• We modified the terms for the second search (search period from 2009 through November 2013) to (i) focus the search on papers evaluating multicomponent interventions and (ii) and to include new technology terms, given an increase in interventions using newer technologies in recent years.

The following databases were used in the updated search strategy to identify English-language papers that evaluated the impact of multicomponent interventions on breast, cervical, or colorectal cancer screening in high-income countries:

• PubMED
• Medline
• PsycINFO
• Embase
• CINAHL
• Cochrane
• Chronic Disease Prevention
• Web of Science

Search strategies were adjusted to each database, based on controlled and uncontrolled vocabularies and search software. Following are the search strategies used in Medline.

Databases: Medline

1. mass screening/ or multiphasic screening/ or (screen or screened or screening).ti,ab. or “early detection of cancer”/
2. (neoplasms/ or breast neoplasms/ or colorectal neoplasms/ or uterine cervical neoplasms/ or carcinoma, ductal, breast/ or “hereditary breast and ovarian cancer syndrome”/ or inflammatory breast neoplasms/ or colonic neoplasms/ or rectal neoplasms/) and (di or pc).fs.
3. ((adenoma* or neoplasia or cancer* or neoplasm* or tumo?r* or carcinoma* or adenocarcinoma*) and (breast or cervical or cervix or colon or colorectal or crc)).ti,ab.
4. 2 or 3
5. 1 and 4
6. colonography, computed tomographic/ or colonoscopy/ or endoscopy, gastrointestinal/ or sigmoidoscopy/ or ((occult blood.ti,ab. or occult blood/) and (feces/ or (faeces or fecal or faecal or colorectal).ti,ab.)) or (enema/ and barium sulfate/)
7. mammography/ or mammogra*.ti,ab.
8. (colonography or colonoscop* or fobt or sigmoidoscop*).ti,ab.
9. vaginal smears/ or (pap or papanicolaou).ti,ab.
10. 6 or 7 or 8 or 9
11. 5 or 10
12. health knowledge, attitudes, practice/ or “patient acceptance of health care”/ or patient compliance/ or patient participation/
13. health promotion/ or healthy people programs/ or health education/ or patient education as topic/ or persuasive communication/
14. (accept or acceptance or adherence or adhere* or compliance or compliant or health promotion or education or persuad* or persuasive or rescreen*).ti,ab.
15. reminder systems/ or “appointments and schedules”/
16. (prompt* or reminder*).ti,ab.
17. insurance/ or “cost sharing”/ or Financing, Personal/ or insurance benefits/ or insurance coverage/ or insurance, health/ or health benefit plans, employee/ or insurance, major medical/ or managed care programs/ or health maintenance organizations/ or medicare/ or Medicaid/
18. (cost or costs or costing or compensated or complimentary or copay* or co-pay* or cost assistance or coupon* or cover* or discount* or fee reduction* or financial assist* or free or indigen* or out-of-pocket or reduc* fee* or shared cost* or sharing cost* or subsidies or subsidis* or subsidiz* or subsidy or uncompensated or voucher* or employer-provided or low income).ti,ab.
19. (reduc* adj2 fee*).ti,ab.
20. “delivery of health care”/ or after-hours care/ or “delivery of health care, integrated”/ or health services accessibility/
21. (((Health care or healthcare or health services) adj3 access*) or onsite or “on-site” or after hours or (contract or contracted or contracts)).ti,ab. or contract services/
22. (insured or insurance or uninsured).ti,ab.
23. (health reform* or healthcare reform* or health care reform* or health policy or health policies or healthcare policy or healthcare policies or health care policy or health care policies).ti,ab. or Health Care Reform/ or Health Policy/
24. Quality Asurance, Health Care/ or clinical audit/ or medical audit/ or (public-health-improvement or continuous-quality-improvement).mp.
25. ((audit* adj2 (physician* or record or clinic*)) or quality assurance or incentive* or clinical audit).ti,ab. or Guideline Adherence/ or (incentive* or medical audit*).ti,ab. or Practice Guidelines as Topic/ or Predictive Value of Tests/ or (Quality or quality assurance).ti,ab. or quality assurance,healthcare/ or (quality audit or quality control or Quality Indicator*).ti,ab. or quality indicators, health care/ or Health Care/ or quality of health care/ or standards.hw. or quality improvement/ or (clinical quality or quality improvement).ti,ab.
26. Organizational Policy/ or ((organization* or institution*) adj2 (directive* or policies or policy or commitment)).ti,ab.
27. communications media/ or mass media/ or radio/ or television/ or internet/ or blogging/ or social media/ or video recording/ or telecommunications/ or electronic mail/ or blogging/ or text messaging/ or *computers/ or microcomputers/ or computers, handheld/ or computer-assisted instruction/
28. (television or radio or mass media or microcomputer*or cyberspace or “health 2.0” or avatar or wikipedia or weblog* or microblog* or “web 2.0” or listserv* or wiki* or “short message service” or sms or “mobile app” or iphone or ipad or ipod or “tablet computer” or xbox or x-box or nintendo or instagram or orkut or flickr or foursquare or video game* or computer game* or wii or ddr or advergam* or mobile phone* or cell phone* or handheld* or hand-held or web-based learning).ti,ab.
29. (internet or social media or world wide web or small media or advertis* or apps or app or automated voice or billboard* or blog or blogged or blogging or chat room* or commercial* or dvd or dvds or “dvd’s” or educational entertainment).ti,ab.
30. (email* or facebook or Googleplus or “google+” or Google plus or instagram or LinkedIn or myspace or toolkit* or edutainment or (“virtual reality” and (gaming or game*))).ti,ab.
31. (online or pinterest or pod cast* or podcast* or psa or psas or “psa’s” or public service announcement* or push* content or radio or Reddit or smart phone* or smartphone* or social network* or telephon* or television* or text messag* or instant messag* or social web or social website* or texting or texts or tumblr or tweet* or twitter or video* or vine or vlog* or video log or video blog or web page* or web site* or webinar* or website* or you tube or youtube).ti,ab.
32. (friending or wireless or “new media” or “new technolog*” or conversation* or messag* or video*).ti.
33. exp Community Health Workers/ or Patient Navigation/ or Community Health Centers/
34. (community health worker* or lay health worker* or consejera* or embajador* or group educat* or health advocat* or health educator* or link worker* or outreach worker* or outreach health or promotora* or patient navigat*).ti,ab.
35. ((Indigenous health* adj2 worker*) or link worker* or Peer-based health care team* or Peer-based healthcare team* or Allied health worker or community health center* or Community-based health worker or Lay health advisor* or Skilled health attendant* or wraparound or wrap around).ti,ab.
36. (access* adj5 health*).ti,ab. or beauty culture/ or occupational health services/ or (assessment* or beauty parlor or beauty salon or checklist* or cosmetologist or employee health clinic or expand* hour* or feedback or hair dressers or hair salon or incremental or interven* or law or laws or longer hour* or mobile or multicomponent or multilevel or multiphas* or occupational health clinic or occupational health service* or outreach or provider* or doctor* or nurse* or resident* or physician* or allied health or salon or saturday clinic* or schedul* or transportation or transported or transporting or week end clinic* or weekend clinic* or work place or work site or workplace or worksite).ti,ab.
37. or/12-36
38. 11 and 37
39. limit 38 to (english language and yr=”2009 -Current”)
40. limit 39 to humans
41. animals/
42. 39 not 41
43. 40 or 42

Economic Review

No content is available for this section.

The following considerations are drawn from studies included in the evidence review, the broader literature, and expert opinion.

• This review included a large number of interventions with many combinations. When designing and implementing multicomponent interventions, consider the following:
  • Local population, needs, and context
  • Cost and resource requirements, particularly for intensive or large-scale interventions
• Cancer screening use increased when interventions used two or more individual approaches.
  • Interventions that used two, three, or four individual approaches had similar effects.
  • Interventions with five or more intervention approaches showed a larger median increase. This was particularly true for interventions aimed at increasing colorectal cancer screening.
  • Combinations of approaches from all three strategies showed the greatest effect, and combinations from strategies to increase community demand and access showed the second greatest effect.
• Multicomponent interventions to increase cancer screening can be modified for specific populations.
  • People with lower incomes and people who do not have health insurance are less likely to be current with recommended cancer screenings.
  • It may be especially effective to reduce structural barriers by
    • Providing language translation services to largely non-English speaking populations, or
    • Offering transportation services to populations without ready access to healthcare services.
• Multicomponent interventions may use technology.
  • Technological advances may improve efficiency of certain approaches, such as web-based education programs or apps for client reminders.
  • Additional costs and resources may be needed to set up technology-dependent services.
  • Population groups might not have equal understanding, access, or use of new technologies.

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 objectives related to this CPSTF recommendation.

• Reduce the colorectal cancer death rate — C-06
• Increase the proportion of adults who get screened for colorectal cancer — C-07