Cancer Screening: Multicomponent Interventions — Colorectal Cancer

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Findings and Recommendations

The Community Preventive Services Task Force (CPSTF) recommends multicomponent interventions to increase screening for colorectal cancer. Interventions are effective in increasing screening with colonoscopy or fecal occult blood test (FOBT).

Evidence suggests multicomponent interventions lead to greater effects when they combine strategies to increase community demand for, and access to, cancer screening. The greatest effects come, however, when these two strategies are used together with the strategy to increase provider delivery of services.

Multicomponent interventions can be used to increase screening use among underserved populations. If interventions provide access to appropriate follow-up care and treatment, they may improve health for these groups.

The Community Preventive Services Task Force finds that multicomponent interventions to increase screening for colorectal cancers are cost-effective.

The full CPSTF Finding and Rationale Statement and supporting documents for Cancer Screening: Multicomponent Interventions — Colorectal Cancer are available in The Community Guide Collection on CDC Stacks.

Intervention

Multicomponent interventions combine two or more intervention approaches reviewed by the CPSTF, or two or more interventions to reduce structural barriers.

Interventions to increase community demand: client reminders, client incentives, small media, mass media, group education, and one-on-one education

Interventions to increase community access: reducing structural barriers and reducing client out-of-pocket costs

Interventions to increase provider delivery: provider assessment and feedback, provider incentives, and provider reminders

Reducing structural barriers includes: reducing administrative barriers, assisting with appointment scheduling, setting up alternative screening sites, adding screening hours, addressing transportation barriers, providing language translation services, offering child care

About The Systematic Review

The CPSTF finding is based on evidence from 88 studies (search period January 2004 – November 2013) evaluating intervention effects on breast (33 studies), cervical (20 studies), or colorectal (56 studies) cancer screening recommended by the U.S. Preventive Services Task Force.

Study Characteristics

The following characteristics were summarized from all included studies.

  • Intervention settings
    • The United States (76 studies), Canada (5 studies), Australia (2 studies), the United Kingdom (1 study), Italy (1 study), Taiwan (1 study), Singapore (1 study), and Israel (1 study)
    • Primarily urban (43 studies) or mixed settings (15 studies)
  • Study population characteristics
    • Mean age of 58.2 years (51 studies reporting)
    • African American (median of 27%, 35 studies reporting), Hispanic (median of 11%, 25 studies reporting), Asian American (median of 5%, 15 studies reporting), White (median of 51%, 39 studies reporting)
    • Majority low-income study participants (38 studies)
    • High school education or less (median of 43%, 39 studies reporting)

Summary of Results

Compared with no intervention, multicomponent interventions changed colorectal cancer screening using the following tests:

  • Any test (colonoscopy, FOBT, or flexible sigmoidoscopy): median increase of 15.4 percentage points (39 study arms)
  • Colonoscopy: median increase of 10.2 percentage points (9 study arms)
  • FOBT: median increase of 7.7 percentage points (21 study arms)
  • Flexible sigmoidoscopy: median decrease of 0.5 percentage points (5 study arms)
  • Interventions using all three strategies increased cancer screening by a median of 24.2 percentage points (5 study arms)
  • Interventions using strategies to increase community demand and access increased cancer screening by a median of 11.2 percentage points (48 study arms)
  • Providing language translation services led to largest increase (median 62.7 percentage points, 4 studies)
  • Addressing transportation needs led to next largest increase (median 18.4 percentage points, 11 studies)

Summary of Economic Evidence

A systematic search (search period January 2004 – January 2018) identified 53 studies, 33 of which focused on colorectal cancer screening. All monetary values reported in 2016 U.S. dollars.

  • Median cost per participant: $36.63 (42 study arms)
  • Median incremental cost per additional person screened: $582.44 (15 study arms)
  • Two good quality, modeled studies reported declines in incremental cost per QALY gained, indicating cost-effectiveness
  • Incremental cost per QALY gained declined $3,817 and $1,651 (2 studies)
  • QALYs gained from screening were associated with treatment cost savings that outweighed intervention costs

Applicability

Based on results for interventions to increase breast, cervical, or colorectal cancer screening, findings should be applicable to the following:

  • U.S. or non-U.S. populations
  • Urban or rural settings
  • Healthcare systems, communities, or both
  • Different racial or ethnic groups
  • Age groups recommended for regular cancer screening (specified in USPSTF recommendations)
  • People who are, or are not, up-to-date with recommended cancer screenings
  • People with average risk for developing breast, cervical, or colorectal cancers

Based on results for interventions that had a range of characteristics, findings should be applicable to interventions that used the following:

  • Intervention approaches to increase community demand, alone or in combination with approaches from other strategies
  • Community health workers, patient navigators, or clinical providers to deliver interventions

Based on the limited evidence available, findings are likely applicable to people with different levels of income or health coverage.

Evidence Gaps

  • What are intervention effects on repeat cancer screening rates?
  • How effective are interventions that only include strategies to increase community access and provider delivery?
  • What is the magnitude of effect for multicomponent interventions that provide language translation services, and does it vary across population subgroups?
  • What are the effects of specific combinations of intervention approaches?
  • How well do interventions work among people who have low health literacy?
  • How cost-effective are these interventions?
  • What specific activities were used as part of an intervention approach?
  • How were structural barriers reduced?
  • Who delivered the intervention approaches?
  • Who were the study participants (e.g., demographic characteristics including income and health insurance status)?

Implementation Considerations and Resources

When designing and implementing multicomponent interventions, consider:

  • Local population, needs, and context
  • Cost and resource requirements, particularly for intensive or large-scale interventions
  • Combining approaches from all three strategies shows greatest effect
  • Interventions with five or more approaches show larger median increases, particularly for colorectal cancer screening
  • Language translation services for largely non-English speaking populations
  • Transportation services to populations without ready access to healthcare

Crosswalks

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