Cancer Screening: One-on-One Education for Clients — Colorectal Cancer

The CPSTF finding for one-on-one education to increase screening for colorectal cancer by FOBT is based on evidence from a Community Guide systematic review published in 2008 (Baron et al., 2 studies, search period 1966-2004) combined with more recent evidence (3 studies, search period 2004-2008). The CPSTF finding for one-on-one education to increase screening for colorectal cancer by colonoscopy or flexible sigmoidoscopy is based on evidence from a Community Guide systematic review published in 2008 (Baron et al., 0 studies, search period 1966-2004) combined with more recent evidence (4 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 findings on Cancer Screening: One-On-One Education – Colorectal Cancer with Fecal Occult Blood Testing (FOBT) and Cancer Screening: One-On-One Education – Colorectal Cancer by Colonoscopy or Flexible Sigmoidoscopy.

Detailed results from the systematic review are available in the published evidence review.

Combined evidence from the original and updated reviews included 5 studies on one-on-one education to increase cancer screening by FOBT.

• Screening by fecal occult blood test (FOBT): median increase of 19.1 percentage points (interquartile interval [IQI]: 12.9 to 25.1 percentage points; 10 study arms).
• Tailored interventions showed increase ranging from 1 to 20.7 percentage points (2 studies)
• Untailored interventions showed a median increase of 20.7 percentage points (IQI: 13.8 to 25.8 percentage points; 3 studies with 8 study arms)

Combined evidence from the original and updated reviews included 4 studies on one-on-one education to increase cancer screening by colonoscopy or flexible sigmoidoscopy.

• Screening by colonoscopy: range from 0 to 11 percentage points increase (2 study arms)
• Screening by flexible sigmoidoscopy: no change reported (1 study arm)
• Screening by any test (including FOBT): range from 1 to 11 percentage point increase (2 study arms)

Detailed results from the systematic review are available in the published evidence review.

The updated search for evidence included nine studies about breast cancer (5 studies), cervical cancer (1 study), or colorectal cancer (3 studies) screening. Monetary values are presented in 2009 U.S dollars.

• Of the nine included studies, eight reported results from actual interventions and one used economic modeling.
  • The cost per additional screening ranged from $39 to $5,306, with a median of $534.
  • The most expensive intervention was the most resource intensive. Lay health advisors conducted three in-person home visits, made follow-up phone calls, and sent mailings that addressed barriers to screening.

Results from this review should apply across a range of populations, provided intervention programs to increase colorectal cancer screening by FOBT are adapted to target population and delivery context. Although no studies specifically noted inclusion of rural populations, findings are not expected to differ from those of urban and unspecified populations.

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 one-on-one education to increase breast, cervical, or colorectal cancer screening.

• What duration, dose, and intensity of one-on-one educational interventions are needed to be effective (Baron et al., 2008)?
• What characteristics of “tailoring” contribute to its effect? Are there effects of tailoring channels (personal interaction, anonymous interaction)?
• Does effectiveness of one-on-one education interventions vary according to whether or not education is delivered by a medical professional?
• What are the incremental effects of adding intervention components to other interventions?
• What influence do newer methods of communication (e.g., the Internet, e-mail, social media, automated interactive voice response, texting) have on intervention effectiveness?
• What is the influence of health system factors on intervention effectiveness?
• Are interventions effective for promoting colorectal cancer screening with methods other than FOBT?
• Are interventions to promote colorectal cancer screening equally effective when specific to one type of test as they are when addressing colorectal cancer screening more generally?

• Interventions were delivered in home and clinic settings, by phone, in person, or by medical professionals or others.
• In addition to white participants, studies included African-American, Hispanic, and Asian-American participants; participants with low socioeconomic status; and urban populations.
• All studies were conducted in the U.S., and none specified inclusion of rural populations.
• Most studies included participants 50 years and older.

Sabatino SA, Lawrence B, Elder R, et al. Effectiveness of interventions to increase screening for breast, cervical, and colorectal cancers: nine updated systematic reviews for The Guide to Community Preventive Services. American Journal of Preventive Medicine 2012;43(1):765-86.

Community Preventive Services Task Force. Updated recommendations for client- and provider-oriented interventions to increase breast, cervical, and colorectal cancer screening. American Journal of Preventive Medicine 2012;43(1):92–6.

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, Screenings by FOBT
Evidence from the previous review: Cancer Screening: One-On-One Education – Colorectal Cancer with Fecal Occult Blood Testing (FOBT)

Summary Evidence Table – Effectiveness Review, Screenings by flexible sigmoidoscopy, colonoscopy, or barium enema
Evidence from the previous review: Cancer Screening: One-On-One Education – Colorectal Cancer by Colonoscopy or Flexible Sigmoidoscopy

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).

Effectiveness Review

Screening by FOBT

Costanza ME, Luckmann R, Stoddard AM, et al. Using tailored telephone counseling to accelerate the adoption of colorectal cancer screening. Cancer Detect Prev 2007;31(3):191 8.

Myers RE, Ross EA, Wolf TA, Balshem A, Jepson C, Millner L. Behavioral interventions to increase adherence in colorectal cancer screening. Med Care 1991;29(10):1039 50.

Stokamer CL, Tenner CT, Chaudhuri J, Vazquez E, Bini EJ. Randomized controlled trial of the impact of intensive patient education on compliance with fecal occult blood testing. J Gen Intern Med 2005;20(3):278 82.

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

Tu SP, Taylor V, Yasui Y, et al. Promoting culturally appropriate colorectal cancer screening through a health educator: a randomized controlled trial. Cancer 2006;107(5):959 66.

Screening by Colonoscopy or Flexible Sigmoidoscopy

Costanza ME, Luckmann R, Stoddard AM, et al. Using tailored telephone counseling to accelerate the adoption of colorectal cancer screening. Cancer Detect Prev 2007;31(3):191 8.

Glanz K, Steffen AD, Taglialatela LA. Effects of colon cancer risk counseling for first-degree relatives. Cancer Epidemiol Biomarkers Prev 2007;16(7):1485 91.

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

Turner BJ, Weiner M, Berry SD, Lillie K, Fosnocht K, Hollenbeak CS. Overcoming poor attendance to first scheduled colonoscopy: a randomized trial of peer coach or brochure support. J Gen Intern Med 2008;23(1):58 63.

Economic Review

Andersen MR, Hager M, Su C, Urban N. Analysis of the cost-effectiveness of mammography promotion by volunteers in rural communities. Health Education & Behavior 2002;29(6):755-70.

Lynch FL, Whitlock EP, Valanis BG, Smith SK. Cost-effectiveness of a tailored intervention to increase screening in HMO women overdue for Pap test and mammography services. Preventive Medicine 2004;38:403 11.

Paskett E, Tatum C, Rushing J, Michielutte R, Bell R, Foley KL, Bittoni M, Dickinson SL, McAlearney AS, Reeves K. Randomized trial of an intervention to improve mammography utilization among a triracial rural population of women. Journal of the National Cancer Institute 2006;98(17):1226 37.

Saywell RM, Champion VL, Skinner CS, Menon U, Daggy J. A cost-effectiveness comparison of three tailored interventions to increase mammography screening. Journal of Women’s Health 2004;13(8):909-18.

Stokamer CL, Tenner CT, Chaudhuri J, Vazquez E, Bini EJ. Randomized controlled trial of the impact of intensive patient education on compliance with fecal occult blood testing. Journal of General Internal Medicine 2005;20:278 82.

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.

Thompson B, Thompson LA, Chan NL, Hislop TG, Taylor VM. Cost effectiveness of cervical cancer screening among Chinese women in North America. Asian Pacific J Cancer Prev 2007;8:287-93.

Wu JH, Fung MC, Chan W, Lairson DR. Cost-effectiveness analysis of interventions to enhance mammography compliance using computer modeling (CAN*TROL). Value in Health 2004;7(2):175-85.

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.

• Recruitment and training of educators, quality-control measures, duration of educational sessions, travel for in-person education, and professional backgrounds of educators may influence costs and feasibility of implementation.
• Interventions may require special skills or tools to develop messages, including tailored messages

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 adults who get screened for colorectal cancer — C-07