Cancer Screening: Small Media Targeting Clients — Breast Cancer

Summary of CPSTF Finding

The Community Preventive Services Task Force (CPSTF) recommends interventions that use small media based on strong evidence of their effectiveness in increasing breast cancer screening by mammography.

The CPSTF has related findings for small media specific to the following:


Small media include videos and printed materials such as letters, brochures, and newsletters. These materials can be used to inform and motivate people to be screened for cancer. They can provide information tailored to specific individuals or targeted to general audiences.

CPSTF Finding and Rationale Statement

Read the CPSTF finding.

About The Systematic Review

The CPSTF finding is based on evidence from a systematic review of 19 studies (search period 1966 – 2004). The 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.

Summary of Results

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

Nineteen studies qualified for the systematic review.

  • Mammography screening: median increase of 7.0 percentage points (interquartile interval [IQI]: 0.3 to 13.2 percentage points; 21 study arms)
  • Interventions were effective when tailored: 7.0 percentage point median increase (IQI: 4.5 to 11.2 percentage points; 7 study arms)
  • Interventions also were effective when untailored: 4.7 percentage point median increase (IQI: 0.5 to 13.4 percentage points; 14 study arms)

Summary of Economic Evidence

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

Five studies qualified for the review and reported a wide range of cost effectiveness estimates based on different metrics and assumptions.


Findings should apply to both tailored and untailored interventions across a range of populations and settings, provided the intervention is appropriately adapted to the target population and delivery context.

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?)
  • Does effectiveness of small media differ by choice of medium (e.g., letter, video, brochure, or Internet-delivered application), information source (e.g., personal physician, educator), or intensity or frequency of delivery?
  • What is the relative cost effectiveness of tailored versus untailored messages?
  • How does the effectiveness of interventions to increase community demand for screening vary with the health literacy of a target population or subpopulation?
  • How can newer methods of communication including automated telephone calls and Internet-delivered applications be used to improve delivery, acceptance, and effectiveness of these interventions?
  • How effective are these interventions in increasing screening by colorectal endoscopy or by double contrast barium enema (for which no qualifying studies were identified)?
  • What is required to disseminate and implement effective interventions in community settings across the United States?
  • How can or should these approaches be applied to assure that screening, once initiated, is maintained at recommended intervals?
  • With respect to interventions that may be tailored to individuals, how are effective tailoring programs adapted, disseminated, and implemented in community-based settings across the United States?

Study Characteristics

  • Tailored interventions used booklets, personalized letters, or other printed materials.
  • Untailored interventions used personal checklists or record-keeping booklets, printed information distributed at medical facilities, informational or motivational posters and videos in patient waiting or other areas, letters, or a video with brochures.
  • Reviewed studies were conducted in both rural and urban communities and among different racial, ethnic, and socioeconomic groups.

Analytic Framework

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.

Summary Evidence Table

Effectiveness Review

Summary Evidence Table – Effectiveness Review
Contains evidence from reviews of interventions to increase breast, cervical, and colorectal cancer screening

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

Bankhead C, Richards SH, Peters TJ, et al. Improving attendance for breast screening among recent non-attenders: a randomised controlled trial of two interventions in primary care. J Med Screen 2001;8(2):99-105.

Bastani R, Marcus A, Maxwell A, et al. Evaluation of an intervention to increase mammography screening in Los Angeles. Prev Med 1994;23:83-90.

Bastani R, Maxwell AE, Bradford C, et al. Tailored risk notification for women with a family history of breast cancer. Prev Med 1999;29(5):355-64.

Champion V, Maraj M, Hui S, et al. Comparison of tailored interventions to increase mammography screening in nonadherent older women. Prev Med 2003;36(2):150-8.

Champion VL, Skinner CS, Menon U, et al. Comparisons of tailored mammography interventions at two months postintervention. Ann Behav Med 2002;24(3):211-8.

Davis T, Berkel H, Arnold C, et al. Intervention to increase mammography utilization in a public hospital. J Gen Intern Med 1998;13(4):230-3.

Dickey L, Petitti D. A patient-held minirecord to promote adult preventive care. J Fam Pract 1992;34(4):457-63.

Dietrich AJ, Duhamel M. Improving geriatric preventive care through a patient-held checklist.Fam Med 1989;21(3):195-8.

Falvo DR, Tippy PK. Comparison of interventions to increase asymptomatic women’s use of mammography screening. Health Values 1993;17(1):12-7.

Fox SA, Stein JA, Sockloskie RJ, Ory MG. Targeted mailed materials and the Medicare beneficiary: increasing mammogram screening among the elderly. Am J Public Health 2001;91(1):55-61.

Herman C, Speroff T, Cebul R. Improving compliance with breast cancer screening in older women: results of a randomized controlled trial. Arch Intern Med 1995;155:717-22.

Jibaja-Weiss ML, Volk RJ, Kingery P, et al. Tailored messages for breast and cervical cancer screening of low-income and minority women using medical records data. Patient Educ Couns 2003;50(2):123-32.

Lipkus I, Rimer B, Halabi S, Strigo T. Can tailored interventions increase mammography use among HMO women? Am J Gastroenterol 2000;18(1):1-10.

McCaul KD, Wold KS. The effects of mailed reminders and tailored messages on mammography screening. J Community Health 2002;27(3):181-90.

Mead V, Rhyne R, Wiese W, et al. Impact of environmental patient education on preventive medicine practices. J Fam Pract 1995;40(4):363-9.

Rakowski W, Ehrich B, Goldstein M, et al. Increasing mammography among women aged 40-74 by use of a stage-matched, tailored intervention. Prev Med 1998;27:748-56.

Richards SH, Bankhead C, Peters TJ, et al. Cluster randomised controlled trial comparing the effectiveness and cost-effectiveness of two primary care interventions aimed at improving attendance for breast screening. J Med Screen 2001;8(2):91-8.

Rimer BK, Halabi S, Sugg SC, et al. Effects of a mammography decision-making intervention at 12 and 24 months. Am J Prev Med 2002;22(4):247-57.

Rothman A. Attributions of responsibility and persuasion: Increasing mammography utilization among women over 40 with an internally oriented message. Health Psychol 1993;12:29-47.

Seow A, Straughan P, Ng E, et al. Factors determining acceptability of mammography in an Asian population: a study among women in Singapore. Cancer Causes Control 1997;8:771-9.

Skinner C, Strecher V, Hospers H. Physicians’ recommendations for mammography: do tailored messages make a difference? Am J Public Health 1994;84(1):43-9.

Economic Review

Armstrong GN, Lairson DR. Cost-effectiveness of alternate contact protocols and costs of mammography promotion interventions for women veterans. Evaluation and Program Planning 2006;29:120 9.

Brown J, Welton NJ, Bankhead C, Richards SH, Roberts L, Tydeman, Peters TJ. A Bayesian approach to analysing the cost-effectiveness of two primary care interventions aimed at improving attendance for breast screening. Health Economics 2006;15:435-45.

Lairson DR, Newmark GR, Rakowski W, Tiro JA, Vernon SW. Development costs of a computer-generated tailored intervention. Evaluation and Program Planning 2004;27:161 9.

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.

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.

Additional Materials

Search Strategies

The following outlines the search strategy used for these reviews of interventions to increase breast, cervical, and colorectal cancer screening: Client Reminders (archived); Client Incentives (archived); Mass Media Targeting Clients (archived); Small Media Targeting Clients; Group Education for Clients (archived); One-on-One Education for Clients (archived); Reducing Structural Barriers for Clients (archived); Reducing Client Out-of-Pocket Costs (archived); Provider Assessment and Feedback (archived); Provider Incentives (archived).

>h4>Effectiveness Review

To establish the evidence base the team searched five computerized databases from the earliest entries in each through November 2004: MEDLINE, database of the National Library of Medicine (from 1966); the Cumulative Index to Nursing and Allied Health database (CINAHL, from 1982); the Chronic Disease Prevention database (CDP, Cancer Prevention and Control subfield, from 1988); PsycINFO (from 1967); and the Cochrane Library databases. Medical subject headings (MeSH) searched (including all subheadings) are shown below. The team also scanned bibliographies from key articles and solicited other citations from other team members and subject-matter experts. Conference abstracts were not included because, according to Community Guide criteria, they generally do not provide enough information to assess study validity and to address the research questions.

The search identified over 9000 citations whose titles and abstracts were screened for potential relevance to interventions and outcomes of interest; of these, 580 articles were retrieved for full-text review.

Search terms used in five electronic databases to find studies for inclusion in the systematic reviews of cancer screening. Searches were conducted to find all studies of cancer screening including those specific to screening for breast, cervical, or colorectal cancer.


Neoplasms combined with any of the following headings:

  • Early detection
  • Mass screening
  • Multiphasic screening
  • Preventive health services
  • Screening
Breast cancer
  • Breast neoplasms
  • Mammography
Cervical cancer
  • Cervical intraepithelial neoplasia
  • (Uterine) cervical neoplasms
  • Cervix dysplasia
  • Vaginal smears
Colorectal cancer
  • Colonic neoplasms
  • Colorectal neoplasms
  • Occult blood
  • Sigmoid neoplasms
  • Sigmoidoscopy

Economic Review

No content is available for this section.

Considerations for Implementation

The following considerations are drawn from studies included in the evidence review, the broader literature, and expert opinion.
  • Primary barriers to implementing a small media intervention include limited resources and infrastructure.
  • Access to effective marketing strategies, educational messages, and instructional materials (particularly for specific subgroups) may be limited by cost and special skills required to develop and test these messages.
  • Materials libraries (such as those available at National Cancer Institute’s Evidence-Based Cancer Control Programs) are a potential source of high quality, topic- and population-specific messages developed as components of evidence-based programs.
  • Production and dissemination of tailored messages may be more costly and resource intensive than untailored programs because tailoring generally requires new data collection (although electronic or other medical records could be used for some simple tailoring algorithms), development of extensive message libraries with graphics, and computer programming support to ensure appropriate individualization.
    • Cost effectiveness may improve through economies of scale.
    • Web-based tailored intervention programs may provide a good solution to both the cost and complexity of developing and delivering tailored interventions to promote cancer screening.
  • Recruitment, training, and support of community health workers and other interventionists to deliver educational messages may pose substantial barriers in smaller community or free-standing clinical settings.
    • Regional or other aggregations of populations and services might be considered as strategies to overcome this problem.


Evidence-Based Cancer Control Programs (EBCCP)

EBCCP logo 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 objective related to this CPSTF recommendation.