Cancer Screening: Patient Navigation Services to Increase Breast Cancer Screening and Advance Health Equity

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Findings and Recommendations

The Community Preventive Services Task Force (CPSTF) recommends patient navigation services to increase breast cancer screening by mammography among historically disadvantaged racial and ethnic populations and people with lower incomes.

Patient navigation services are expected to advance health equity when implemented among these populations who often have lower screening rates (Sabatino et al. 2021). With timely and appropriate follow-up care and treatment, patient navigation services may improve health for these groups.

The CPSTF finds patient navigation services to increase breast cancer screenings are cost-effective. Systematic review evidence shows estimates of cost per quality-adjusted life year (QALY) gained are below a conservative threshold of $50,000.

The full CPSTF Finding and Rationale Statement and supporting documents for Cancer Screening: Patient Navigation Services to Increase Breast, Cervical, and Colorectal Cancer Screenings and Advance Health Equity are available in The Community Guide Collection on CDC Stacks.

The CPSTF has related findings for patient navigation interventions to increase screenings for the following:

Intervention

Patient navigation services provided through healthcare systems help patients overcome barriers to accessing breast cancer screening. Services are offered to populations experiencing greater disparities in cancer screening, including people from historically disadvantaged racial and ethnic populations and people with lower incomes. Patient navigation services do one or more of the following:

  • Provide client reminders
  • Reduce structural barriers (e.g., modify administrative processes; assist with appointment scheduling, transportation, translation, or childcare; arrange alternative screening sites or hours)
  • Reduce patients’ out-of-pocket costs

Services may also provide one-on-one or group education to inform patients’ understanding of cancer and cancer screening.

Services may be delivered by community health workers (CHWs), healthcare professionals, nurses, patient navigators, social workers, or others. They are often designed to be culturally- and language-appropriate.

About The Systematic Review

The CPSTF finding is based on evidence from a systematic review that examined intervention effectiveness in increasing breast, cervical, or colorectal cancer screening. The review included 34 studies identified from an existing systematic review (Nelson et al. 2020; search period January 1996 to July 2019) and an updated search (search period through November 2021).

Of the 34 included studies, 11 evaluated intervention effects on breast cancer screening.

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.

Study Characteristics

The following characteristics describe the 34 included studies across all three cancer types.

  • All included studies were conducted in the United States.
  • Studies were conducted in clinic (22 studies) or clinic and community (12 studies) settings, and in urban (26 studies), rural (5 studies), or a mix of urban and rural areas (2 studies).
  • Study participants had a mean age of 59.5 years (25 studies), self-identified as American Indian or Alaska Native (1 study), Asian (4 studies), Black or African American (15 studies), Hispanic or Latino (11 studies), Native Hawaiian (1 study), or White (14 studies).
  • Among studies that reported on income and education, the majority of study participants had annual incomes below 150% of the federal poverty level (16 studies) and had a high school education or less (14 studies).
  • Interventions offered one to six services including assistance with appointment scheduling (20 studies) or transportation (13 studies), reductions in administrative barriers (23 studies), and one-on-one education (24 studies).
  • Services were delivered remotely (15 studies) or both remotely and face-to-face (18 studies); no services were delivered face-to-face only.
  • Services were most often delivered by CHWs or dedicated patient navigators who worked alone (CHWs, 6 studies; navigator, 14 studies) or on a team (CHWs, 3 studies; navigator, 6 studies).

Summary of Results

The systematic review included 11 studies.

  • Patient navigation interventions increased breast cancer screening by a median of 12.0 percentage points or 54.5% (11 studies)
  • Meta-analysis: risk ratio of 1.32, 95% CI 1.08 to 1.62 (10 studies)

Summary of Economic Evidence

A systematic review of economic evidence shows patient navigation services to increase breast cancer screening are cost-effective.

The economic review (search period through December 2022) included studies of screening for breast cancer (3 studies). All studies were conducted in the United States, and monetary values are reported in 2022 dollars.

  • The intervention cost per person for breast cancer screening: $109, $3,251, and $10,245 (3 studies).
  • The intervention cost per additional person screened for breast cancer: $154 and $740 (2 studies).

The systematic economic review finds patient navigation services to increase breast cancer screening are cost-effective with three studies’ estimates of cost per QALY gained falling below the conservative threshold of $50,000. Two of the three studies that evaluated breast cancer screening interventions used microsimulation models to calculate and report a cost per QALY gained of $3,852 and $39,159 with a lifetime horizon.

The third study reported a cost per life year gained (LYG) of $22,889. A LYG can be converted to QALY after multiplication by the health utility score associated with a disease. A recent meta-regression analysis estimated utility scores from patients’ responses for early and late-stage breast cancers using different utility assessment methods and found these were all above 0.5 (Gong et al. 2020). Based on this evidence, $22,889 per LYG would be below $45,778 per QALY gained.

Applicability

Based on results from the systematic review, findings are applicable to all adults and adults aged 65 years or older with different baseline screening statuses, across educational levels, employment, and insurance status.

Evidence suggests programs can be offered in urban or rural settings, include different intervention components, and be delivered by a range of providers who work alone or as part of a team.

Evidence Gaps

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. Evidence gaps were identified for breast, cervical, and colorectal cancer screenings. (What are evidence gaps?)

CPSTF identified the following questions as priorities for research and evaluation:

  • How effective are patient navigation services in increasing the following?
    • Repeat screenings (the U.S. Preventive Services Task Force recommends repeating breast, cervical, and colorectal cancer screenings at appropriate intervals [USPSTF 2016, 2018, 2021]); the included studies examined one-time screenings
    • The proportion of patients with positive screening tests who receive follow-up diagnostic tests
    • Cervical cancer screening for younger females (USPSTF recommends females start regular cervical cancer screening at age 21 years [USPSTF 2018]); the included studies recruited participants with a median age of 59.5 years.
  • What is the cost-effectiveness of patient navigation services to increase cervical cancer screening?

Remaining questions for research and evaluation identified by CPSTF:

  • How effective are patient navigation services in increasing the following?
    • Cervical cancer screening that includes HPV tests (following the 2018 update from USPSTF that recommended high risk HPV testing alone or in combination with cytology for women aged 30 to 65 years)
    • Colorectal cancer screening for adults aged 45-49 years (following the 2021 update from USPSTF that lowered the starting age for colorectal cancer screenings)
    • Colorectal cancer screening using other USPSTF-recommended tests such as the stool DNA test, flexible sigmoidoscopy, or computed tomography colonography
  • Does intervention effectiveness vary by the following?
    • Participants’ health literacy
    • Number of interactions between service deliverers and participants
  • What is the precise economic impact of patient navigation services within comprehensive health promotion interventions?

Implementation Considerations and Resources

Evidence from the systematic review suggests patient navigation services adjusted to fit local needs and resources can increase cancer screenings among people from historically disadvantaged racial or ethnic groups and people with lower incomes. Evidence suggests programs with different intervention characteristics implemented in different settings will be effective.

  • Patient navigation services examined in this review were delivered by a wide array of deliverers, including CHWs, trained lay patient or professional navigators, nurses, case managers, or clinic staff. Delivery may be enhanced when deliverers have local knowledge, provide language-appropriate and culturally competent services, have flexible working hours to better fit patients’ schedules, and work closely with healthcare providers.
  • Patient navigation services can be delivered remotely, which might help in rural areas or other settings where transportation is difficult. Programs may combine face-to-face and remote interactions based on the unique needs of the delivers and patients.
  • Patient navigation services can be provided at every step along the cancer continuum to guide patients through the healthcare system and reduce cancer mortality, and in some cases incidence.

Crosswalks

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