Fulfilling the Potential of Cancer Prevention and Early Detection (2003) / Chapter Skim
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6. Improving Participation in Cancer Screening Programs
6. Improving Participation in Cancer Screening Programs
Pages 224-258
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From page 224... ...
individuals, to obtain recommended screening tests and pursue follow-up tests. This chapter describes the major challenges to delivering cancer screening and reviews the literature to identify interventions that are successful in improving rates of participation in screening.
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From page 225... ...
In addition, the competitive marketplace of private health insurance and the public's interest in obtaining preventive care have made coverage of cancer screening a potent marketing tool, with coverage of cancer screening heavily promoted by the managed care industry, thereby providing an infrastructure for the delivery of cancer screening services. In fact, at least some studies suggest that patients who belong to health maintenance organizations are more likely to receive cancer screening tests than those covered by indemnity plans (Phillips et al., 2000; Gordon et al., 1998; Hsia et al., 2000~.
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From page 226... ...
As of 2000,43 states and the District of Columbia mandated coverage of cancer screening, even though the provisions of the mandates were not always in compliance with evidence-based guidelines (Rathore et al., 2000~. Federal legislation establishing a national program for breast and cervical cancer screening services has had some salutary effects on screening rates (Liliquist, 2001~.
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Challenges for Clinicians Knowledge Clinicians do not promote or perform screening tests without the basic prerequisite of knowing that such screening is recommended and appropriate. Many studies have shown that simply disseminating a guideline is, for
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When primary care physicians in Colorado were surveyed about the influence of guidelines on their screening practices for prostate cancer, 89 percent rated the American Cancer Society guidelines as moderately or highly influential, whereas fewer than one-third rated the guidelines of the U.S. Preventive Services Task Force as moderately or highly influential (Moran et al., 2000~.
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Studies have shown that such changes can improve cancer screening rates, although some randomized trials have shown modest incremental benefit (Dietrich et al., 1994b, 1998; Solberg et al., 1998~. Reinforcement Even when providers are able to deliver screening tests well, reminder systems and feedback are important to identify when the need for rescreening has arisen.
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From page 230... ...
Not surprisingly, people with limited education and limited exposure to health information are less likely to have this knowledge. Knowledge about breast and cervical cancer among Hispanic women, for example, is related to age, education, income, language preference, and recent screening history (Ramirez et al., 2000a)
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A fundamental impediment is a lack of access to screening services. People who lack health insurance are less likely to receive cancer screening tests (Breen et al., 2001; Gordon et al., 1998; Hsia et al., 2000; Potosky et al., 1998)
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From page 232... ...
Patients referred to specialists to obtain screening tests or follow-up procedures may be unable to understand or navigate the increasingly onerous administrative tasks of dealing with health plans to obtain referrals to the recommended provider or facility, scheduling appointments, and being adequately prepared on arrival. Reinforcement Finally, even if patients are willing and able to be screened, remembering that screening is due or remembering to perform self-examination is often difficult simply because of forgetfulness.
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From page 233... ...
The example of the barriers to optimizing colorectal cancer screening, seen from the provider's perspective, illustrates the intermingling of the three groups (Box 6.1~. CLOSER EXAMINATION OF SPECIFIC CANCER SCREENING TESTS Using the four-part mode!
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234 CANCER PREVENTION AND EARLY DETECTION The probability of having done FOBT at home was 18.2 percent for whites, 20.3 percent for African Americans, 14.2 percent for Hispanics, and 12.3 percent for American Indians (CDC, Behavioral Risk Factor Surveillance System, 2000~. The probability of having had a flexible sigmoidoscopy or colonoscopic examination within the past 5 years was 30.4 percent for whites, 28.2 percent for African Americans, 22.4 percent for Hispanics, and 27.6 percent for American Indians (CDC, Behavioral Risk Factor Surveillance System, 2000~.
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Predictors of Screening Knowledge A likely reason for the failure of many Americans to obtain screening for colorectal cancer is unfamiliarity with the disease (Newman, 2001~. In contrast to breast cancer, most people have never heard of colorectal cancer.
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. ~ Attitude Interventions The review of the literature for this chapter found little current evidence of whether the efforts described above have been effective in shifting attitudes about the acceptability of screening tests for colorectal cancer.
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The lack of a requirement for dietary restrictions before home FOBT was shown in one randomized trial to improve adherence rates (Robinson et al., 1994~. The present review otherwise found few published studies about efforts to enhance the patient's ability to schedule, prepare, and undergo colorectal cancer screening tests, although manufacturers, public health departments, and community health centers have undertaken efforts with these aims, with a particular focus on patients with limited education and limited English-language proficiency.
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SOURCE: PhotoDisc, Inc. Size of the Gap Breast Cancer Screening In contrast to colorectal cancer screening, a relatively large proportion of women have availed themselves of screening mammography.
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In community-based screening in Albuquerque, New Mexico, only 50 percent of women aged 50 to 74 were screened each year in the study period from 1994 to 1997 (Gilliland et al., 2000~. There are important racial and ethnic disparities in breast cancer screening rates, but in contrast to other areas of health care, African Americans do not appear to be disadvantaged in terms of screening for breast cancer.
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Gaps exist not only in breast cancer screening rates but also in what happens next if the findings are abnormal. In one health maintenance organization, in 34 percent of patients, follow-up for an abnormal mass or a suspicious calcification detected on mammography was not completed within 1 month, and it was delayed beyond 2 months in an additional 35 percent of patients (Burack et al., 2000b)
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Whether a woman acquires accurate knowledge about breast cancer screening is obviously affected by language barriers, an important problem in certain ethnic minority groups. For example, proficiency with the English language is a correlate of recent mammography among Korean-American women (Tuon et al., 2000~.
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From page 242... ...
One survey conducted following the controversial 1997 NIH Consensus Development Conference on breast cancer screening for women ages 40 to 49 found 28 percent confused about the schedule on which women should have mammograms. Confusion was a significant predictor of being off schedule (Rimer et al., 1999~.
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Acculturation and the proportion of a woman's life spent in the United States are important factors among some immigrant and ethnic populations, such as Korean women Muon et al., 2000~. A study of urban Chinese-American women age 60 and older revealed that acculturation and issues surrounding modesty affected ever having had a screening mammography or a clinical breast examination, and the lack of a physician recommendation affected having it in the past year.
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Nonetheless, even after multivariate logistic regression analysis for other preventive health behaviors, education, and socioeconomic status, access to health care and insurance coverage remain independent predictors of screening (Qureshi et al., 2000~. Along with low income, they tend to have a disproportionate role as barriers to breast cancer screening among Asian Americans and Pacific Islanders (Coughlin and Uhier, 2000; Kagawa-Singer and Pourat, 2000; Tang et al., 2000~.
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From page 245... ...
Interventions aimed at reminding physicians and health care systems to advise women about the need for screening mammography, an important motivator that shapes women's attitudes about the importance of screening, also serve as reminder systems when screening is overdue and are therefore reviewed below under "Reinforcement Interventions." Other studies have engaged other health care professionals in the community in this role. For example, a before-and-after study reported that a program that was conducted by pharmacists and that incorporated risk assessment software and education and training about breast self-examination, clinical breast examination, and mammography was associated with a substantial increase in the rate of adherence to guidelines Miles et al., 2001~.
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Research suggests, for example, that African-American women's intentions to get mammograms following receipt of such messages are influenced by both the message's arguments and the degree of favorable "peripheral cues" (Kirby et al., 1998~. A randomized trial involving inner-city Spanishspeaking Hispanic women found success with a culturally sensitive, linguistically appropriate computerized education program with an interactive soap opera format, the viewers of which demonstrated increased knowIedge and altered beliefs about breast cancer compared with controls (Tibaja et al., 2000~.
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. Reinforcement Interventions Although some women who know they are due for screening proactively visit their physician or radiology facility to obtain a breast examination and mammogram, it is important that women who are unaware of this need receive timely reminders so that their screening is not delayed.
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Having the letter come from the primary care physician rather than the program director had no incremental benefit in one randomized trial, but sending a subsequent reminder postcard doubled screening mammography rates (Taplin et al., 1994~. Some work has focused on the incremental benefit of following reminder letters with telephone contacts that offer reminders or encouragement to obtain a mammogram.
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From page 249... ...
, computerized reminder systems, physician and office staff training to enhance counseling skills, patient health maintenance cards, continuing education seminars, and quality assurance feedback. These trials have generally reported promising results from such efforts, including improved rates of clinical breast examinations (Manfredi et al., 1998; Williams et al., 1998)
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From page 250... ...
For example, a primary care referral project operating within an urban emergency department improved screening rates by offering older minority women a brief motivational interview and a mammography referral and scheduling a next-day, no-cost appointment (Bernstein et al., 2000~. A randomized trial reported a tripling of mammography rates among inner-city women by offering case management by culturally sensitive community health educators (Weber and Reilly, 1997~.
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Screening for prostate cancer by testing for PSA is increasingly common in the United States. According to one survey, 87 percent of family physicians and 98 percent of urologists reported using the test for screening (McKnight et al., 1996~.
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. Randomized trials involving videotapes and pamphlet aids on the decision to undergo PSA screening have consistently demonstrated their effectiveness in improving patients' knowledge about the test (Flood et al., 1996; Schapira and VanRuiswyk, 2000; yolk et al., 1999~.
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As of 1999, 88 percent of women ages 18 to 44 and 81 percent of women ages 45 or older have received a Pap smear within the past 3 years (CDC, Behavioral Risk Factor Surveillance System, 2000~. The fact that more than 80 percent of women have had a Pap smear within the past 3 years is encouraging, but considerable progress needs to be made to achieve the goal set forth in Healthy People 2010 (US DHHS and Office of Disease Prevention and Health Promotion, 2000)
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Ability As with the other screening tests evaluated in this chapter, insurance coverage, access to care, time, money, and transportation are important determinants of Pap smear use and adequate follow-up (Lerman et al., 1992~. A lack of insurance, a low level of income, and a lack of a usual source of health care appear to play disproportionate roles as barriers to cervical cancer screening among Asian Americans and Pacific Islanders (Coughlin and Uhier, 2000; Kagawa-Singer and Pourat, 2000~.
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Another randomized trial involving low-income minority women who had received an abnormal Pap smear result reported higher rates of follow-up from telephone calls about the need for follow-up colposcopy (Miller et al., 1997~. Comprehensive office system changes such as those described above for breast cancer screening have proved effective in increasing Pap smear testing rates (Manfredi et al., 1998~.
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that could be added by optimizing screening according to this mode! were 357,554 for cervical cancer, 293,092 for colorectal cancer, and 268,780 for breast cancer.
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From page 257... ...
Women who do not receive breast cancer screening are also less likely to undergo cervical cancer screening (Cummings et al., 2000; Glasgow et al., 2000~. Screening is also less common among low-income households and those with limited education or limited or no health insurance.
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Optimization of the delivery of effective cancer screenin~ services and reductions in the numbers of inanorouriate tests that are , , performed lie in changing the behaviors of the following: · systems of care, to make cancer screening services available to eligible populations; · health care providers, to perform cancer screening as recommended, on time, and with skill when they encounter patients eligible for screening; and · individuals, to obtain recommended screening tests and to pursue follow-up. Elimination of financial and access barriers to screening improves screening rates, for example, through the use of health insurance coverage, reduced cost sharing, and the availability of free screening at public clinics.
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