Increasing Cancer Screening: Reducing Structural Barriers for Clients
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)
Summary of Task Force Recommendations and Findings
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.
Results from the Systematic Reviews
The Task Force findings are based on evidence from a previously completed review (search period 1966-2004) and an updated review (search period 2004-2008). Updates of reviews are conducted to incorporate more recent evidence.
Results of the Original Review
The original breast cancer screening review included seven studies.
- Mammography screening: median increase of 17.7 percentage points (interquartile interval [IQI]: 11.5 to 30.5 percentage points).
Results of the Updated ReviewOne additional study qualified for the updated review.
- Mammography screening: increase of 18 percentage points
- Clinical breast examinations: increase of 34 percentage points
The Task Force recommendation should apply across a range of populations and settings, provided that the program is adapted to the target population and delivery context.
Three studies qualified for the review.
- Pap screening: median increase of 13.6 percentage points (range: 5.9-17.8)
- While these results were in the favorable direction, the studies had some methodological limitations.
Results of the Original Review
The original colorectal cancer screening review included seven studies.
- Screening by fecal occult blood test (FOBT): median increase of 16.1 percentage points (IQI: 12.1 to 22.9 percentage points)
Results of the Updated Review
Five additional studies qualified for the updated review.
- Colorectal cancer screening: median increase of 36.9 percentage points (range: 16.3 to 41.1 percentage points; 4 study arms)
- The larger intervention effect during the update period imay be at least partially due to differences in target populations, baseline rates of screening, and study designs.
These findings were based on a systematic review of all available studies, conducted on behalf of the Task Force by a team of specialists in systematic review methods, and in research, practice and policy related to cancer prevention and control.
Six studies qualified for the review. Monetary values are presented in 2009 U.S dollars.
- Cost per woman screened from a mobile mammography program ranged from $63.09 to $150.50, depending on the number of women screened and the year of program operation (4 studies). Due to one-time, fixed costs associated with program implementation, the first year of program operation is generally more expensive.
- One study found the benefits of mobile screening outweighed the costs when distances traveled were greater than 15 miles.
- Another study reported the cost per additional screening was $208 for mobile film mammography and $267 for mobile digital mammography.
An economic review of this intervention was not conducted because the Task Force found insufficient evidence to determine its effectiveness.
Colorectal Cancer (FOBT)
Three studies qualified for the review. 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.
- Analytic Framework – see Figure 2 on page 100 [PDF - 230 kB]
- Evidence Gaps
- Summary Evidence Tables - Effectiveness Review
- Summary Evidence Tables - Economic Review
- Included Studies - Economic Review
- Search Strategy
Sabatino SA, Lawrence B, Elder R, Mercer SL, Wilson KM, DeVinney B, Melillo S, Carvalho M, Taplin S, Bastani R, Rimer BK, Vernon SW, Melvin CL, Taylor V, Fernandez M, Glanz K, Community Preventive Services Task Force. Effectiveness of interventions to increase screening for breast, cervical, and colorectal cancers: nine updated systematic reviews for The Guide to Community Preventive Services. [PDF - 235 kB] Am J Prev Med 2012;43(1):765-86.
Community Preventive Services Task Force. Updated recommendations for client- and provider-oriented interventions to increase breast, cervical, and colorectal cancer screening. [PDF - 90 kB]. Am J Prev Med 2012;43(1):760-4.
Read other Community Guide publications about Cancer Prevention and Control in our library.
The findings and conclusions on this page are those of the Community Preventive Services Task Force and do not necessarily represent those of CDC. Task Force evidence-based recommendations are not mandates for compliance or spending. Instead, they provide information and options for decision makers and stakeholders to consider when determining which programs, services, and policies best meet the needs, preferences, available resources, and constraints of their constituents.
The content of publications of the Guide to Community Preventive Services is in the public domain. Citation as to source, however, is appreciated. Sample citation:
Guide to Community Preventive Services. Increasing cancer screening: reducing structural barriers for clients. www.thecommunityguide.org/cancer/screening/client-oriented/ReducingStructuralBarriers.html. Last updated: MM/DD/YYYY.
Review completed: March 2010
- Page last reviewed: April 19, 2016
- Page last updated: April 19, 2016
- Content source: The Guide to Community Preventive Services