Cancer Screening: Patient Navigation Services to Increase Colorectal 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 colorectal cancer screening by colonoscopy, fecal occult blood test (FOBT) or fecal immunochemical test (FIT), 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 colorectal 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. In addition, the CPSTF finds that the return on investment is favorable for patient navigation services to increase colorectal cancer screening by colonoscopy, as estimated values for colonoscopy reimbursement exceed the cost of the intervention.

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

Intervention

Patient navigation services provided through healthcare systems help patients overcome barriers to accessing colorectal 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, 27 evaluated intervention effects on colorectal 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 27 studies. Patient navigation interventions increased colorectal cancer screening for all types of screening.

  • Received colorectal cancer screening using any colorectal cancer screening test recommended by USPSTF
    • Colorectal cancer screening increased by a median of 13.6 percentage points or 76.2% (26 studies)
    • Meta-analysis: risk ratio of 1.82, 95% CI 1.50 to 2.21 (26 studies)
  • Received colorectal cancer screening using colonoscopy
    • Colorectal cancer screening increased by a median of 13.9 percentage points or 109.9% (12 studies)
    • Meta-analysis: risk ratio of 1.97, 95% CI 1.34 to 2.89 (11 studies)
  • Received colorectal cancer screening using FOBT or FIT
    • Colorectal cancer screening increased by a median of 12.4 percentage points or 57.3% (12 studies)
    • Meta-analysis: risk ratio of 1.65, 95% CI 1.38 to 1.99 (12 studies)

Summary of Economic Evidence

A systematic review of economic evidence shows patient navigation services to increase colorectal cancer screening are cost-effective. In addition, the CPSTF finds that the return on investment is favorable for patient navigation services to increase colorectal cancer screening by colonoscopy as estimated values for colonoscopy reimbursement exceed the cost of the intervention.

The economic review (search period through December 2022) included studies of screening for colorectal cancer (17 studies). All but one study was conducted in the United States, and monetary values are reported in 2022 dollars.

Intervention Cost

  • The median intervention cost per person for colorectal cancer screening: $150 (Interquartile Interval (IQI): $66, $338; 16 studies).
  • The median intervention cost per additional person screened for colorectal cancer: $663 (IQI: $202, $1711; 17 studies).

Economic Benefit

An increase in colorectal cancer screenings is expected to raise healthcare costs initially due to an associated increase in diagnostic tests and follow up treatment costs. Over time, however, earlier detection of cancer is expected to lower treatment costs that lead to economic benefits.

Three colorectal cancer screening studies modeled long-term treatment cost net of intervention cost.

  • Net savings per person for colorectal cancer screening intervention: $173 and $1,442 (2 studies)
  • Net cost per person for colorectal cancer screening intervention: $42 (1 study)

Cost-effectiveness

The systematic economic review finds patient navigation services to increase colorectal cancer screening are cost-effective with three studies’ estimates of cost per QALY gained falling below the conservative threshold of $50,000. Two studies showed that when using patient navigation services, cost declined, and quality-adjusted life year (QALY) increased for colorectal cancer screening. One study showed the cost per life year gained when using patient navigation services with colorectal cancer screening was $3,231, and when converted to QALY, this estimate was below $50,000 per QALY gained.

Rate of Return on Investment (ROI)

  • The median ROI: 2.3% (IQI: 1.7%, 6.9%; 5 estimates, 2 studies).

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.

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