Cancer Screening: Client Reminders — Cervical Cancer
Findings and Recommendations
The Community Preventive Services Task Force (CPSTF) recommends the use of client reminders to increase screening for cervical cancers on the basis of strong evidence of effectiveness.
The full CPSTF Finding and Rationale Statement and supporting documents for Increasing Cancer Screening: Client Reminders [for Breast, Cervical, and Colorectal Cancers] are available in The Community Guide Collection on CDC Stacks.
Intervention
Client reminders are written (letter, postcard, email) or telephone messages (including automated messages) advising people that they are due for screening. Client reminders may be enhanced by one or more of the following:
- Follow-up printed or telephone reminders
- Additional text or discussion with information about indications for, benefits of, and ways to overcome barriers to screening
- Assistance in scheduling appointments
These interventions can be untailored to address the overall target population or tailored with the intent to reach one specific person, based on characteristics unique to that person, related to the outcome of interest, and derived from an individual assessment.
About The Systematic Review
The CPSTF finding is based on evidence from a Community Guide systematic review published in 2008 (Baron et al., 11 studies, search period 1966-2004) combined with more recent evidence (6 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.
Study Characteristics
Following are characteristics of included studies from the updated search period.
- Interventions included print reminders only (3 studies), telephone reminders only (1 study), and print reminders with telephone follow-up (2 studies).
- Reminders were delivered by clinical practices or organizations, or screening programs or registries.
- Outcomes were assessed by medical record review, administrative records, or screening registry records.
- Where specified, interventions were conducted in the U.S., Sweden, Belgium, and Australia.
- One study reported including nonwhite participants but did not provide more specific information, one study specified a population with low socioeconomic status, and three studies reported including urban or mixed urban/rural populations.
Summary of Results
Results from the 2008 Review
The original cervical cancer screening review included 11 studies.
- Pap test: median increase of 10.2 percentage points (interquartile interval [IQI]: 6.3 to 17.9 percentage points; 14 study arms).
- Enhanced and telephone reminders showed greater increase (15.5 percentage points; 6 study arms) than written reminders alone (9.8 percentage points; 8 study arms).
Results from the Updated Review
The updated review included 6 additional studies.
- Pap test: median increase in use was 2.8 percentage points (range 1.6 to 31.4; 4 studies).
- Enhanced and telephone reminders showed an increase of 1.6 to 31.4 percentage points (3 studies; 4 study arms).
- The incremental effect client reminders added to provider-directed interventions was a median increase of 3.7 percentage points (range 3.5 to 25.2; 5 study arms).
Summary of Economic Evidence
The updated search for evidence included five studies about breast cancer (1 study) or colorectal cancer (4 studies) screening. Monetary values are presented in 2009 U.S dollars.
- Of the included studies, one provided only cost information and four provided cost-effectiveness information.
- One study found automated telephone reminders were the most effective strategy to increase mammography and also had the lowest average cost of $0.35/woman.
- The cost-effectiveness studies found the cost per additional screening ranged from $7.89 to $1,149. The high end of the range was due to high personnel costs combined with a small intervention effect.
Applicability
Tailored and untailored client reminder interventions to increase cervical cancer screening should be applicable across a range of settings and populations, provided they are adapted and targeted for a specific 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?)The following outlines evidence gaps for client reminders to increase breast, cervical, or colorectal cancer screening.
- How do newer methods of communication (e.g., the Internet, e-mail, text messages, or automated telephone calls) influence the effectiveness of client reminder interventions?
- To what extent does effectiveness vary for groups overdue for screening or never screened?
- Does effectiveness vary according to the source of client reminders (e.g., clinic or practice versus screening registry or program)?
- Do reminders for screenings for multiple cancer sites work as well as those for a single cancer site?
- 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 is the influence of health system factors on intervention effectiveness?
Implementation Considerations and Resources
- Basic infrastructure, staffing, and computer support is needed to identify patients due for screening and deliver reminders efficiently.
- Funds may be required to generate and deliver reminders, though programs implemented on a large scale may cost little per person.
Crosswalks
Find programs from the Evidence-Based Cancer Control Programs EBCCP website that align with this systematic review. (What is EBCCP?)
Healthy People 2030 includes the following objective related to this CPSTF recommendation.