Cancer Screening: Small Media Targeting Clients — Colorectal Cancer

Summary of CPSTF Finding

The Community Preventive Services Task Force (CPSTF) recommends interventions that use small media based on strong evidence of their effectiveness in increasing colorectal cancer screening by fecal occult blood test (FOBT). The CPSTF finds insufficient evidence to determine the effectiveness of using small media to increase colorectal cancer screening by flexible sigmoidoscopy, colonoscopy, or double contrast barium enema because no studies evaluating these screening procedures were identified.

The CPSTF has related findings for small media specific to the following:

Intervention

Small media include videos and printed materials such as letters, brochures, and newsletters. These materials can be used to inform and motivate people to be screened for cancer. They can provide information tailored to specific individuals or targeted to general audiences.

CPSTF Finding and Rationale Statement

Read the CPSTF finding.

About The Systematic Review

The CPSTF finding for small media to increase colorectal cancer screening by FOBT is based on evidence from a systematic review of 7 studies (search period 1966 – 2004). No studies were included for interventions to increase colorectal cancer screening by flexible sigmoidoscopy, colonoscopy, or double contrast barium enema.

The 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.

Summary of Results

Detailed results from the systematic review are available in the published evidence review.

Seven studies on interventions to increase colorectal cancer screening by FOBT were included in the systematic review.

  • Proportion of study participants completing screening by FOBT: median increase of 12.7 percentage points (Interquartile interval: 0 to 26.4 percentage points; 8 study arms)

No studies were included for interventions to increase colorectal cancer screening by flexible sigmoidoscopy, colonoscopy, or double contrast barium enema.

Summary of Economic Evidence

Detailed results from the systematic review are available in the published evidence review.

Two studies qualified for the review of interventions to increase colorectal cancer screening by FOBT. Monetary values are presented in 2009 U.S dollars.

  • One study reported the average intervention cost was $150 per person screened.
  • One study found the cost per additional person screened was $44.49.

Applicability

Findings should apply to a range of populations and settings, provided the intervention is appropriately adapted to the target 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?)
  • Does effectiveness of small media differ by choice of medium (e.g., letter, video, brochure, or Internet-delivered application), information source (e.g., personal physician, educator), or intensity or frequency of delivery?
  • What is the relative cost effectiveness of tailored versus untailored messages?
  • How does the effectiveness of interventions to increase community demand for screening vary with the health literacy of a target population or subpopulation?
  • How can newer methods of communication including automated telephone calls and Internet-delivered applications be used to improve delivery, acceptance, and effectiveness of these interventions?
  • How effective are these interventions in increasing screening by colorectal endoscopy or by double contrast barium enema (for which no qualifying studies were identified)?
  • What is required to disseminate and implement effective interventions in community settings across the United States?
  • How can or should these approaches be applied to assure that screening, once initiated, is maintained at recommended intervals?
  • With respect to interventions that may be tailored to individuals, how are effective tailoring programs adapted, disseminated, and implemented in community-based settings across the United States?

Study Characteristics

  • Evaluated interventions used a personal record booklet; leaflets or pamphlets; videos, newsletters, or other printed materials; or a sequence of two letters.
  • Studies were conducted in urban and rural populations and included study participants from both clinical and community settings.
  • Of the 7 included studies, only one evaluated a tailored intervention.

Publications

Baron RC, Rimer BK, Breslow RA, et al. Client-directed interventions to increase community demand for breast, cervical, and colorectal cancer screening: a systematic review. American Journal of Preventive Medicine. 2008;35(1S):34-55.

Task Force on Community Services. Recommendations for client- and provider-directed interventions to increase breast, cervical, and colorectal cancer screening. American Journal of Preventive Medicine. 2008;35(1S):21-5.

Baron RC, Rimer BK, Coates RJ, et al. Methods for conducting systematic reviews of evidence on effectiveness and economic efficiency of interventions to increase screening for breast, cervical, and colorectal cancers. American Journal of Preventive Medicine. 2008;35(1S):26-33.

Breslow RA, Rimer BK, Baron RC, et al. Introducing the Community Guide’s reviews of evidence on interventions to increase screening for breast, cervical, and colorectal cancers. American Journal of Preventive Medicine. 2008;35(1S):14-20.

Hannon PA, Harris JR. Interventions to improve cancer screening: opportunities in the workplace. American Journal of Preventive Medicine. 2008;35(1S):10-3.

Shepherd WL, Moore A. Task Force recommendations: application in the “real world” of community intervention. American Journal of Preventive Medicine. 2008;35(1S):1-2.

Yabroff KR. Interventions to improve cancer screening: commentary from a health services research perspective. American Journal of Preventive Medicine. 2008;35(1S):6-9.

Glanz K, Melvin C. How not to get lost in translation: implementing the recommendations and identifying evidence gaps. American Journal of Preventive Medicine. 2008;35(1S):3-5.

Analytic Framework

Effectiveness Review

Analytic Framework

When starting an effectiveness review, the systematic review team develops an analytic framework. The analytic framework illustrates how the intervention approach is thought to affect public health. It guides the search for evidence and may be used to summarize the evidence collected. The analytic framework often includes intermediate outcomes, potential effect modifiers, potential harms, and potential additional benefits.

Economic Review

No content is available for this section.

Summary Evidence Table

Effectiveness Review

Summary Evidence Table – Effectiveness Review
Contains evidence from reviews of interventions to increase breast, cervical, and colorectal cancer screening

Economic Review

Summary Evidence Table – Economic Review.

Included Studies

The number of studies and publications do not always correspond (e.g., a publication may include several studies or one study may be explained in several publications).

Effectiveness Review

Dickey L, Petitti D. A patient-held minirecord to promote adult preventive care. J Fam Pract 1992;34(4):457-63.

Harris MA, Byles JE, Cockburn J, D’Este C. A general practice-based recruitment strategy for colorectal cancer screening. Aust N Z J Public Health 2000;24(4):441-3.

Hart A, Barone T, Gay S, et al. The effect on compliance of a health education leaflet in colorectal cancer screening in general practice in central England. J Epidemiol Community Health 1997;51:187-91.

Kramish Campbell M, James A, Hudson MA, et al. Improving multiple behaviors for colorectal cancer prevention among African American church members. Health Psychol 2004;23(5):492-502.

Lee C. A randomised controlled trial to motivate worksite fecal occult blood testing. Yonsei Med J 1991;32(2):131-8.

Powe BD. Promoting fecal occult blood testing in rural African American women. Cancer Pract 2002;10(3):139-46.

Pye G, Christie M, Chamberlain J, et al. A comparison of methods for increasing compliance within a general pracititioner based screening project for colorectal cancer and the effect on practitioner workload. J Epidemiol Community Health 1988;42:66-71.

Economic Review

Lairson DR, DiCarlo M, Myers RE, Wolf T, Cocroft J, Sifri R, Rosenthal M, Vernon SW, Wender R. Cost-effectiveness of targeted and tailored interventions on colorectal cancer screening use. Cancer 2008;112:779 88.

Shankaran V, McKoy JM, Dandade N, Nonzee N, Tigue CA, Bennett CL, Denberg TD. Costs and cost-effectiveness of a low-intensity patient-directed intervention to promote colorectal cancer screening. Journal of Clinical Oncology 2007;25(33):5248-53.

Additional Materials

Search Strategies

The following outlines the search strategy used for these reviews of interventions to increase breast, cervical, and colorectal cancer screening: Client Reminders (archived); Client Incentives (archived); Mass Media Targeting Clients (archived); Small Media Targeting Clients; Group Education for Clients (archived); One-on-One Education for Clients (archived); Reducing Structural Barriers for Clients (archived); Reducing Client Out-of-Pocket Costs (archived); Provider Assessment and Feedback (archived); Provider Incentives (archived).

>h4>Effectiveness Review

To establish the evidence base the team searched five computerized databases from the earliest entries in each through November 2004: MEDLINE, database of the National Library of Medicine (from 1966); the Cumulative Index to Nursing and Allied Health database (CINAHL, from 1982); the Chronic Disease Prevention database (CDP, Cancer Prevention and Control subfield, from 1988); PsycINFO (from 1967); and the Cochrane Library databases. Medical subject headings (MeSH) searched (including all subheadings) are shown below. The team also scanned bibliographies from key articles and solicited other citations from other team members and subject-matter experts. Conference abstracts were not included because, according to Community Guide criteria, they generally do not provide enough information to assess study validity and to address the research questions.

The search identified over 9000 citations whose titles and abstracts were screened for potential relevance to interventions and outcomes of interest; of these, 580 articles were retrieved for full-text review.

Search terms used in five electronic databases to find studies for inclusion in the systematic reviews of cancer screening. Searches were conducted to find all studies of cancer screening including those specific to screening for breast, cervical, or colorectal cancer.

General

Neoplasms combined with any of the following headings:

  • Early detection
  • Mass screening
  • Multiphasic screening
  • Preventive health services
  • Screening
Breast cancer
  • Breast neoplasms
  • Mammography
Cervical cancer
  • Cervical intraepithelial neoplasia
  • (Uterine) cervical neoplasms
  • Cervix dysplasia
  • Vaginal smears
Colorectal cancer
  • Colonic neoplasms
  • Colorectal neoplasms
  • Occult blood
  • Sigmoid neoplasms
  • Sigmoidoscopy

Economic Review

No content is available for this section.

Considerations for Implementation

The following considerations are drawn from studies included in the evidence review, the broader literature, and expert opinion.
  • Primary barriers to implementing a small media intervention include limited resources and infrastructure.
  • Access to effective marketing strategies, educational messages, and instructional materials (particularly for specific subgroups) may be limited by cost and special skills required to develop and test these messages.
  • Materials libraries (such as those available at National Cancer Institute’s Evidence-Based Cancer Control Programs) are a potential source of high quality, topic- and population-specific messages developed as components of evidence-based programs.
  • Production and dissemination of tailored messages may be more costly and resource intensive than untailored programs because tailoring generally requires new data collection (although electronic or other medical records could be used for some simple tailoring algorithms), development of extensive message libraries with graphics, and computer programming support to ensure appropriate individualization.
    • Cost effectiveness may improve through economies of scale.
    • Web-based tailored intervention programs may provide a good solution to both the cost and complexity of developing and delivering tailored interventions to promote cancer screening.
  • Recruitment, training, and support of community health workers and other interventionists to deliver educational messages may pose substantial barriers in smaller community or free-standing clinical settings.
    • Regional or other aggregations of populations and services might be considered as strategies to overcome this problem.

Crosswalks

Evidence-Based Cancer Control Programs (EBCCP)

EBCCP logo Find programs from the EBCCP website that align with this systematic review. (What is EBCCP?)

Healthy People 2030

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