Increasing Cancer Screening: Reducing Structural Barriers for Clients

Task Force Finding and Rationale Statement

Definition

Structural barriers are non-economic burdens or obstacles that impede access to 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); and 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), or measures to reduce out-of-pocket costs to the client. Interventions principally designed to reduce client costs are considered to be a separate class of approaches.

Task Force Finding

The Community Preventive Services Task Force recommends interventions to reduce structural barriers to increase screening for breast and colorectal cancers (by mammography and FOBT, respectively) on the basis of strong evidence of effectiveness. Evidence is insufficient, however, 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 were identified. Evidence is also insufficient to determine the effectiveness of the intervention in increasing screening for cervical cancer because only three relevant studies were identified, and these had some methodological limitations.

Rationale

The Task Force finding is based on an update of a previous review. Based on this update, the Task Force made no change to its original conclusions regarding the effectiveness of interventions to reduce structural barriers to screening for breast, cervical, and colorectal cancers.

The original breast cancer review included eight studies that found a median 17.7 percentage point increase in mammography screening (IQI: 11.5 to 30.5 percentage points). The single additional study identified in the update review was consistent with the overall findings, with an 18 percentage point increase.

The original colorectal cancer screening review included seven studies that found a median 16.1 percentage point increase (IQI: 12.1 to 22.9 percentage points) in screening by FOBT. The update review included four studies with a median increase of 38 percentage points (Range: 16.1 to 41.1 percentage points). The apparently larger intervention effect in the more recent review may be at least partially attributable to differences in target populations, baseline rates of screening, and study designs.

The findings for cervical cancer screening remain unchanged. Only one additional study of least suitable design was identified, resulting in a total of three qualifying studies. Although the effects from all of these studies were in the favorable direction, there were too few qualifying studies of adequate methodological quality to assess the effectiveness of reducing structural barriers to cervical cancer screening.

No other benefits and no harms of reducing structural barriers were identified.

There are various approaches to implementing interventions to reduce structural barriers to cancer screening. Questions remain about whether certain of these approaches are more or less effective or appropriate for use within specific settings or with specific populations—such as with people who have never been screened or who may be hard to reach for screening. In the absence of such research, specific intervention approaches should be selected and implemented only after careful consideration of the specific characteristics of the target population and of the most important barriers to their being screened.