Guide to Community Preventive Services
Intervention to Increase Recommendation and Delivery of Screening for Breast, Cervical, and Colorectal Cancers by Healthcare Providers: A Systematic Review of Provider Reminders

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Abstract

Most major medical organizations recommend routine screening for breast, cervical, and colorectal cancers. Screening can lead to early detection of these cancers, resulting in reduced mortality. Yet, not all people who should be screened are screened regularly or, in some cases, ever. This report presents results of systematic reviews of effectiveness, applicability, economic efficiency, barriers to implementation, and other harms or benefits of provider reminder/recall interventions to increase screening for breast, cervical, and colorectal cancers. These interventions involve using systems to inform healthcare providers when individual clients are due (reminder) or overdue (recall) for specific cancer screening tests. Evidence in this review of studies published from 1986 through 2004 indicates that reminder/recall systems can effectively increase screening with mammography, Pap, fecal occult blood tests, and flexible sigmoidoscopy. Additional research is needed to determine if provider reminder/recall systems are effective in increasing colorectal cancer screening by colonoscopy. Specific areas for further research are also suggested.

Introduction

Cancer is the second leading cause of death in the U.S.,1 and breast and colorectal cancers are among the leading causes of cancer deaths.2 For breast, colorectal, and cervical cancers, effective screening tests can reduce cancer-related mortality.3, 4, 5, 6 Furthermore, some screening tests (e.g., Pap, flexible sigmoidoscopy, colonoscopy) may lead to a reduction in incidence via detection of pre-neoplastic lesions, which can be removed or treated.3 The U.S. Preventive Services Task Force (USPSTF) recommends breast cancer screening with mammography,4 cervical cancer screening with Pap,5 and colorectal cancer screening with fecal occult blood tests (FOBTs), flexible sigmoidoscopy, or colonoscopy.6

Each year, an estimated 4475 deaths from breast cancer, 3644 deaths from cervical cancer, and 9632 deaths from colorectal cancer could be prevented if all eligible Americans received appropriate cancer screening services.7 Yet, the 2005 National Health Interview Survey of U.S. adults8 showed that only 67% of women aged ≥40 years reported mammograms within the previous 2 years, and only 78% of women aged ≥18 years reported having a Pap within the previous 3 years. Among adults aged ≥50 years, only 50% reported ever having colorectal screening endoscopy, and only 17% reported an FOBT within the previous 2 years. Lower rates were observed among American Indians and Alaska Natives; people of Asian, Latino, or Hispanic ethnicity; African Americans (endoscopy only); and among people who are poorer or less educated. Efforts to maximize control of breast, cervical, and colorectal cancers face the additional challenge of ensuring that cancer screening, once initiated, is repeated at recommended intervals.9, 10 Increasing use of these screening tests at recommended intervals and reducing social inequalities in their use are important steps toward reducing cancer and mortality.2

The systematic review reported in this article focused on interventions to increase cancer screening, not on subsequent follow-up for abnormal screening results. Despite the fact that not everyone with a positive screening test is adequately followed, diagnosed, and treated, there is independent evidence (from the USPSTF among others)4, 5, 6 establishing the effectiveness of screening for reducing morbidity and mortality.

The Guide to Community Preventive Services (Community Guide), developed by the independent, nonfederal Task Force on Community Preventive Services (Task Force), has conducted systematic reviews on the effectiveness, applicability, economic efficiency, barriers to implementation, and other harms or benefits of community- and systems-based interventions to increase screening for breast, cervical, and colorectal cancers.11

An array of such interventions are available to programs and planners for use in promoting cancer screening.11, 12 They can be conceptualized as falling under three primary strategies: increasing community demand for cancer screening services; reducing barriers to access; and reducing missed opportunities by healthcare providers to discuss, recommend, or deliver cancer screening services. The first two strategies encompass client-directed approaches intended to influence client knowledge, motivation, access, and decision to be screened. The third strategy includes provider-directed approaches to reduce missed opportunities during the provider–client interaction to recommend, order, or deliver cancer screening services. Evidence from these systematic reviews provides the basis for Task Force recommendations on interventions in each of these strategic areas as well as for identifying additional research needs.

Discussion between healthcare providers and their clients regarding the options for and importance of cancer screening is an important determinant of adherence to cancer screening recommendations.13, 14, 15 Missed opportunities to engage in such provider–client interactions and lack of adherence to offered or ordered screening tests can limit the ability to achieve higher screening rates and associated reductions in cancer-related mortality.13, 14, 16 The effectiveness of one provider-directed intervention intended to facilitate such interactions, provider reminder and recall systems (provider reminders), is the subject of this systematic review. Reviews of two other provider-directed approaches, provider assessment and feedback and provider incentives,17 along with those of client-directed approaches to increase community demand18, 19 have been published.

Provider reminder and recall systems inform those who deliver health services that individual clients are due (reminder) or overdue (recall) for specific cancer screening tests. Reminders may be generated electronically or manually, and they may be delivered in client charts or by computer, mail, or other means. They can vary in format (notation, flow chart, electronic message, or checklist) and content. These reminders convey information to providers, before, during, or after a scheduled visit, regarding the client's cancer screening status. Similar interventions have been demonstrated to improve adherence to vaccine recommendations and to control tobacco use.20, 21, 22

Section snippets

Methods

General methods for conducting systematic reviews for the Community Guide have been described in detail elsewhere.23, 24 Specific methods for conducting reviews of interventions to increase breast, cervical, and colorectal cancer screening, for assessing applicability, economic efficiency, other positive or negative effects, and barriers to implementation are also described in detail elsewhere.12 That description includes the overall literature search of primary scientific publications from

Effectiveness

The search for evidence identified 38 studies26, 27, 28, 29, 30, 31, 32, 33, 34, 35, 36, 37, 38, 39, 40, 41, 42, 43, 44, 45, 46, 47, 48, 49, 50, 51, 52, 53, 54, 55, 56, 57, 58, 59, 60, 61, 62, 63 that reported on using provider reminders to increase recommended screening for breast, cervical, and colorectal cancers. Of these, six26, 27, 28, 29, 30, 31 were excluded because of their low quality of execution and six more32, 33, 34, 35, 36, 37 were excluded because of the lack of a concurrent

Conclusions About Provider Reminders

According to Community Guide rules of evidence,23 based on consistently favorable results, there is strong evidence that provider reminder and recall systems are effective in increasing breast, cervical, and colorectal cancer screening by mammography, Pap, and FOBT, respectively. In addition, there is sufficient evidence that provider reminders are effective in increasing colorectal cancer screening by flexible sigmoidoscopy, based on a single well-executed study. These findings apply across a

Discussion

This review has summarized evidence supporting the Task Force recommendation65 for use of provider reminder and recall systems to increase recommended screening for breast, cervical, and colorectal cancers. This intervention can be effective in a variety of clinical settings in which improvement in recommendation and delivery of breast, cervical, and colorectal cancer screening services is indicated.

The great majority of intervention studies to increase colorectal cancer screening focus on

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