Cancer Screening: Reducing Structural Barriers for Clients — Colorectal Cancer

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Findings and Recommendations

The Community Preventive Services Task Force (CPSTF) recommends interventions to reduce structural barriers to increase screening for colorectal cancers by fecal occult blood testing (FOBT) on the basis of strong evidence of effectiveness.

The CPSTF finds insufficient evidence 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 was identified.

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

Intervention

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, or measures to reduce out-of-pocket costs to the client.

About The Systematic Review

The CPSTF finding for reducing structural barriers to increase screening for colorectal cancer by FOBT is based on evidence from a Community Guide systematic review published in 2008 (Baron et al., 7 studies, search period 1966-2004) combined with more recent evidence (5 studies, search period 2004-2008).

The CPSTF finding for reducing structural barriers to increase screening for colorectal cancer by colonoscopy or flexible sigmoidoscopy is based on evidence from a Community Guide systematic review published in 2008 (Baron et al., 0 studies, search period 1966-2004) combined with more recent evidence (5 studies, search period 2004-2008).

Study Characteristics

Following are characteristics of included FOBT studies from the updated search period.

  • Most evidence focused on approaches to reduce time and distance to completing screening (e.g., mailing FOBT cards to clients).
  • Studies were conducted in the U.S. and France and in medical care and community settings.
  • All studies enrolled men and women aged 50 years.
  • Specified racial/ethnic groups included whites, Hispanics/Latinos, African Americans, and Native Hawaiians.
  • Included populations also varied, from residents of urban communities to residents of a remote Hawaiian Island.
  • Outcomes were assessed by proportion of returned kits, self-report, and medical record review.

Summary of Results

Results of the Previous Review

The original reviews included 7 studies on reducing structural barriers to increase cancer screening by FOBT.

  • Screening by FOBT: median increase of 16.1 percentage points (IQI: 12.1 to 22.9 percentage points; 11 study arms)

Results of the Updated Review

Of the five additional studies that qualified for the review, 2 reported on screening by FOBT, 1 reported on the mean number of colonoscopies per month, 1 looked at screening by colonoscopy or FOBT, and 1 reported on any of three testing modalities (FOBT, colonoscopy, or sigmoidoscopy).

  • Colorectal cancer screening by any test: median increase of 36.9 percentage points (range: 16.3 to 41.1 percentage points; 4 study arms)
  • One study reported a 9.5% relative increase in the mean number of colonoscopies per month

Summary of Economic Evidence

Three studies qualified for the review of evidence for colorectal cancer screening by FOBT. 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

Applicability

  • The original review findings were applicable across a range of settings where target populations may have limited physical access to FOBT.
  • Evidence from the updated search period about reducing structural barriers to increase screening by FOBT expands applicability to include diverse populations as the additional studies included some from another high-income economy and some samples included other populations (e.g., Native Hawaiians, Hispanics).

Evidence Gaps

The following outlines evidence gaps for interventions to reduce structural barriers to increase breast, cervical, or colorectal cancer screening.

  • 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 influence do newer methods of communication (e.g., the Internet, e-mail, social media, automated interactive voice response, texting) have on intervention effectiveness?
  • What is the influence of health system factors on intervention effectiveness?

Implementation Considerations and Resources

  • Alternative screening sites need to be identified
  • Adequate staffing is required for alternate sites or extended hours
  • When test results are abnormal, follow-up must be provided to clients lacking access to regular care

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