Cancer Screening: Reducing Structural Barriers for Clients Colorectal Cancer

Summary of CPSTF Finding

The Community Preventive Services Task Force (CPSTF) recommends interventions to reduce structural barriers to increase screening for colorectal cancers by fecal occult blood testing (FOBT) on the basis of strong evidence of effectiveness.

The CPSTF finds insufficient evidence to determine whether reducing structural barriers is effective in increasing colorectal cancer screening by flexible sigmoidoscopy or colonoscopy because only one study using these screening procedures was identified.

The CPSTF has related findings for reducing structural barriers specific to the following:

Intervention

Structural barriers are non-economic burdens or obstacles that make it difficult for people to access cancer screening. Interventions designed to reduce these barriers may facilitate access to cancer screening services by:
  • Reducing time or distance between service delivery settings and target populations
  • Modifying hours of service to meet client needs
  • Offering services in alternative or non-clinical settings (e.g., mobile mammography vans at worksites or in residential communities)
  • Eliminating or simplifying administrative procedures and other obstacles (e.g., scheduling assistance, patient navigators, transportation, dependent care, translation services, limiting the number of clinic visits)

Such interventions often include one or more secondary supporting measures, such as:

  • Printed or telephone reminders
  • Education about cancer screening
  • Information about screening availability (e.g., group education, pamphlets, or brochures)
  • Measures to reduce out-of-pocket costs to the client (though interventions principally designed to reduce client costs are considered to be a separate class of approaches)

CPSTF Finding and Rationale Statement

Read the full CPSTF Finding and Rationale Statement for details including implementation issues, possible added benefits, potential harms, and evidence gaps.

About The Systematic Review

The CPSTF finding for reducing structural barriers to increase screening for colorectal cancer by FOBT is based on evidence from a Community Guide systematic review published in 2008 (Baron et al., 7 studies, search period 1966-2004) combined with more recent evidence (5 studies, search period 2004-2008).

The CPSTF finding for reducing structural barriers 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 (5 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: Reducing Structural Barriers Colorectal Cancer by Fecal Occult Blood Testing and Cancer Screening: Reducing Structural Barriers Colorectal Cancer by Colonoscopy or Flexible Sigmoidoscopy.

Summary of Results

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

Results of the Previous Review

The original reviews included 7 studies on reducing structural barriers to increase cancer screening by FOBT.

  • Screening by fecal occult blood test (FOBT): median increase of 16.1 percentage points (IQI: 12.1 to 22.9 percentage points; 11 study arms)

Results of the Updated Review

Of the five additional studies that qualified for the review, 2 reported on screening by FOBT, 1 reported on the mean number of colonoscopies per month, 1 looked at screening by colonoscopy or FOBT, and 1 reported on any of three testing modalities (FOBT, colonoscopy, or sigmoidoscopy).

  • Colorectal cancer screening by any test: median increase of 36.9 percentage points (range: 16.3 to 41.1 percentage points; 4 study arms)
  • One study reported a 9.5% relative increase in the mean number of colonoscopies per month.

Summary of Economic Evidence

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

Three studies qualified for the review of evidence for colorectal cancer screening by FOBT. Monetary values are presented in 2009 U.S dollars.

  • Two studies measured the cost per additional screen by FOBT to be $63.20 and $424.67.
  • One study estimated a cost-effectiveness ratio of $3000 to $4000 per year of life saved.

Applicability

  • The original review findings were applicable across a range of settings where target populations may have limited physical access to FOBT.
  • Evidence from the updated search period about reducing structural barriers to increase screening by FOBT expands applicability to include diverse populations as the additional studies included some from another high-income economy and some samples included other populations (e.g., Native Hawaiians, Hispanics).

Evidence Gaps

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 interventions to reduce structural barriers to increase breast, cervical, or colorectal cancer screening.

  • 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 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?

Study Characteristics

Following are characteristics of included FOBT studies from the updated search period.
  • Most evidence focused on approaches to reduce time and distance to completing screening (e.g., mailing FOBT cards to clients).
  • Studies were conducted in the U.S. and France and in medical care and community settings.
  • All studies enrolled men and women aged 50 years.
  • Specified racial/ethnic groups included whites, Hispanics/Latinos, African Americans, and Native Hawaiians.
  • Included populations also varied, from residents of urban communities to residents of a remote Hawaiian Island.
  • Outcomes were assessed by proportion of returned kits, self-report, and medical record review.

Analytic Framework

Effectiveness Review

Analytic Framework see Figure 2 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.

Included Studies

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 Updated Search Period

Denis B, Reutsch M, Strentz P, et al. Short term outcomes of the first round of a pilot colorectal cancer screening programme with guaiac based faecal occult blood test. Gut 2007;56(11):1579 84.

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

Goldberg D, Schiff GD, McNutt R, Furumoto-Dawson A, Hammerman M, Hoffman A. Mailings timed to patients’ appointments: a controlled trial of fecal occult blood test cards. Am J Prev Med 2004;26(5):431 5.

Myers R, Hyslop T, Sifri R, et al. Tailored navigation in colorectal cancer screening. Med Care 2008;9(S1):S123 31.

Nash DB, Azeez S, Vlahov D, Schori M. Evaluation of an intervention to increase screening colonoscopy in an urban public hospital setting. J Urban Health 2006;83(2):231 43.

Studies from the previous review

Cancer Screening: Reducing Structural Barriers Colorectal Cancer by Fecal Occult Blood Testing

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.

Goldberg D, Schiff GD, McNutt R, Furumoto-Dawson A, Hammerman M, Hoffman A. Mailings timed to patients’ appointments: a controlled trial of fecal occult blood test cards. Am J Prev Med 2004;26(5):431 5.

Rossi PG, Grazzini G, Anti M, Baiocchi D, Barca A, Bellardini P, Brezzi S, Camilloni L, Falini P, Maccallini V, Mantellini P, Romeo D, Rubeca T, Venditti MA. Direct mailing of faecal occult blood tests for colorectal cancer screening: a randomized population study from Central Italy. J Med Screen 2011;18:121 7.

Sequist TD, Franz C, Ayanian JZ. Cost-effectiveness of patient mailings to promote colorectal cancer screening. Medical Care 2010;48(6):553 7.

Tifratene K, Eisinger F, Rinald Y, Didelot R, Seitz J. Colorectal cancer screening program: cost effectiveness of systematic recall letters. Gastroenterol Clin Biol 2007;31:929-33.

Additional Materials

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 and Promoting Screening Quality: An Action Guide for Engaging Employers and Professional Medical Organizations
Developed by CDC’s Division of Cancer Prevention and Control

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

Search Strategies

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.

Review References

Considerations for Implementation

The following considerations are drawn from studies included in the evidence review, the broader literature, and expert opinion.
  • Alternative screening sites need to be identified.
  • Adequate staffing is required for alternate sites or extended hours.
  • When test results are abnormal, follow-up must be provided to clients lacking access to regular care.

Crosswalks

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