ReviewHow to increase uptake in oncologic screening: A systematic review of studies comparing population-based screening programs and spontaneous access
Highlights
► Population-based programs increase test uptake compared to spontaneuos access. ► The effect was observed in different settings and in the three oncologic screening. ► The average increase in uptake was about 50%. ► Invitation letter- based and GP-based programs showed similar effectiveness.
Introduction
Cervical, breast and colorectal cancer (CRC) screenings are universally recommended public health interventions, given the relevance of the disease and the availability of screening tests, which are proven to be effective in reducing mortality as well as incidence rates for cervical cancer and CRC. In order to maximize the impact of screening programs, high test uptake and compliance to diagnostic work up are needed. Uptake represents the most important factor in determining the success of a screening programme (Barratt et al., 2002, Parkin et al., 2008). Many systematic reviews have looked at the evidence supporting various approaches to cancer screening uptake (Bonfill Cosp et al., 2001, Everett et al., 2011, Forbes et al., 2002, Jepson et al., 2000, Khalid-de Bakker et al., 2011, Palència et al., 2010, Vernon, 1997). The findings usually vary according to aspects such as type of test, cancer site and target population. However, population-based organized recruitment strategies as well as tailored invitation approaches seem to show reliable benefits over opportunistic approaches to screening. The World Health Organization and its Cancer Research Agency (IARC) recommend the implementation of population-based screening programs (International Agency for Research on Cancer. IARC, 2002, International Agency for Research on Cancer. IARC, 2005, World Health Organization. WHO, 2006).
Screening programs have been implemented in different ways in industrialized countries. The European Union (EU) currently recommends that cancer screening be offered on a population basis in organized screening programs, with quality controls at all levels (Arbyn et al., 2008, Perry et al., 2006, Segnan et al., 2011, The Council of the European Union, 2003). This recommendation derives from many observational studies that showed a higher effectiveness of organized compared to spontaneous programs. Nevertheless, the scientific community does not univocally support the implementation of population-based invitation strategies and organized screening programs.
The Italian Ministry of Health sponsored an HTA report on methods to increase participation in oncologic screening programs. The aim of this paper is to assess, through a systematic review, the effectiveness of two different types of screening programs – by letter invitation and GP-based – on screening uptake for breast, cervical and colorectal cancers compared to spontaneous testing. We also compare the effectiveness of the two population-based screening models on increasing participation.
Section snippets
Identification of studies: inclusion and exclusion criteria
The target population of cancer screening in Italy is represented by women from 50 to 69 years, (breast cancer screening), women between 25 and 64 years (cervical cancer screening) and by men and women between 50 and 70 years (colorectal cancer screening). We thus included all studies whose target population was identical to these age groups or represented a subset of these groups.
We included all studies on interventions, strategies, or programs aimed at increasing participation in these three
Results
From 5859 potentially relevant citations, titles were identified and screened, and 998 abstracts were selected. Of these, 868 studies were not useful for a quantitative analysis, and 130 were selected for a full-text revision. Thirty-two quantitative studies fulfilled inclusion criteria while 98 irrelevant quantitative studies were excluded, although some were useful for qualitative review (Fig. 1).
In brief, the main reasons for exclusion were related to: studies with patient ages different
Invitation letters vs no intervention (usual care)
Twenty-six studies compared the response to invitation letters to no intervention (usual care): 12 studies regarded cervical cancer screening, 15 mammography screening, and one colorectal cancer screening (Fig. 2). The definition of usual care did not appear to be the same for all authors; in many cases screening tests were still provided for free, and general practitioners (GPs) took part in the program. In other cases, “usual care” indicated the absence of any offer of screening test. In any
Interventions with GP's involvement
Some screening programs take into account whether it was opportune to the opportunity of actively involve GPs in different ways. This model of organizing screening programs also uses the opportunistic contacts between the GP and target people to provide the test, a mode of contact typical of the spontaneous screening model. Consequently, in some cases the distinction between spontaneous screening and organized screening, based on the collaboration between GPs and the screening coordination
Invitation letters vs GP-based organized programs
While there are different methods to utilize the GP reminder, all require coordination of screening activities for the target population. Each GP must therefore adopt the most appropriate measures to increase the participation rate. It is evident that by actively contacting patients, the model becomes an invitation-based programme and can no longer be considered an opportunistic model (Fig. 6).
Data from five interventions for cervical cancer screening were analyzed. Two studies had high-power
GP reminder and invitation letter
The second type of intervention involves reminder systems generated by the GP for non-respondents to the invitation letter sent by the screening program. This is a coordinated effort between screening program management and the GP. Four studies were identified, two on mammographic screening, one on cervical cancer screening, and one that assessed the efficacy of the intervention for both types of screening. Three studies had high power, but none was a pragmatic trial in strict terms.
For
Cost and cost-effectiveness analyses
An automated search for systematic reviews on costs and cost-effectiveness initially retrieved about 600 papers, 48 of which had the scope of an HTA report and 15 focused on comparing population-based with spontaneous screening and GP-based with invitation letter-based programs.
De Gelder and collaborators published the only cost effectiveness model comparing organized mammographic screening with spontaneous mammograms (de Gelder et al., 2009). The model is based on observational data of both
Discussion
Participation of the target population is one of the most important factors influencing the effectiveness of a cancer screening programme in reducing mortality and/or morbidity.
It is in fact necessary to get high rates of participation to make a significant impact on a population's health. This aim should be reached by encouraging “informed” participation of the individual, who should know the benefits, limitations and disadvantages of any screening programme before participating.
The aim of our
Conclusions
Population-based programs are more effective than spontaneous screening is in obtaining higher testing uptake. Both invitation letter-based and GP-based programs are effective, but the former seemed to be more consistently cost-effective.
Contributorship statement
Paolo Giorgi Rossi, Piero Borgia and Gabriella Guasticchi planned the study and defined the methods. Beatriz Jimenez and Giacomo Furnari conducted the paper selection and abstracting. Beatriz Jimenez, Paolo Giorgi Rossi and Laura Camilloni conducted the quality appraisal. Eliana Ferroni, Paolo Giorgi Rossi and Laura Camilloni planned the metanalyses and the single comparisons. Laura Camilloni made the statistical analyses. Paolo Giorgi Rossi, Eliana Ferroni and Laura Camilloni drafted the
Competing interest
None to declare.
Funding statement
This work was funded by Ministry of Health ex art. 12 and 12 bis D. Lgs.502/92.
References (67)
- et al.
Pap smear outreach: a randomized controlled trial in an HMO
Am. J. Prev. Med.
(1997) - et al.
Personal contact from friends to increase mammography usage
Am. J. Prev. Med.
(1994) - et al.
Using tailored telephone counseling to accelerate the adoption of colorectal cancer screening
Cancer Detect Prev.
(2007) - et al.
Effectiveness of a telephone outcall intervention to promote screening mammography among low-income women
Prev. Med.
(1998) - et al.
Cost-effectiveness of opportunistic versus organized mammography screening in Switzerland
Eur. J. Cancer
(2009) - et al.
Opportune intervention of family doctors in the programme of early detection of breast cancer
Aten. Primaria
(2008) - et al.
Cost-effectiveness of interventions to promote cervical screening in general practice
Aust. N. Z. J. Public Health
(1996) - et al.
A randomised trial of general practitioner-written invitations to encourage attendance at screening mammography
Community Health Stud.
(1990) - et al.
Facility-based in-reach strategies to promote annual mammograms
Am. J. Prev. Med.
(1994) - et al.
Recruitment to mammography screening: a randomised trial and meta-analysis of invitation letters and telephone calls
Aust. N. Z. J. Public Health
(2006)
Cervical screening in general practice
Aust. J. Public Health
Cost-effectiveness comparison of five interventions to increase mammography screening
Prev. Med.
Effectiveness of telephone counseling for mammography: results from five randomized trials
Prev. Med.
A randomised trial of invitations to attend for screening mammography
Aust. J. Public Health
The Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) statement: guidelines for reporting observational studies
Lancet
Cost-effectiveness analysis of interventions to enhance mammography compliance using computer modeling (CAN*TROL)
Value Health
Cervical cancer screening is effective — the Finnish experience
Improving attendance for breast screening among recent non-attenders: a randomised controlled trial of two interventions in primary care
J. Med. Screen
A randomized intervention to improve ongoing participation in mammography
Am. J. Manag. Care
Cancer screening
J. Epidemiol. Community Health
Does telephone contact with a physician's office staff improve mammogram screening rates?
Fam. Med.
Strategies for increasing the participation of women in community breast cancer screening
Cochrane Database Syst. Rev.
A randomised controlled trial of strategies to prompt attendance for a Pap smear
J. Med. Screen.
A collaborative approach to cervical cancer screening
J. Med. Screen.
A Bayesian approach to analysing the cost-effectiveness of two primary care interventions aimed at improving attendance for breast screening
Health Econ.
Effectiveness of a call/ recall system in improving compliance with cervical cancer screening: a randomized controlled trial
Can. Med. Assoc. J.
Promoting screening mammography in inner-city settings. The sustained effectiveness of computerized reminders in a randomized controlled trial
Med. Care
Promoting screening mammography in inner-city settings: a randomized controlled trial of computerized reminders as a component of a program to facilitate mammography
Med. Care
How reminders given to patients and physicians affected Pap smear use in a health maintenance organization: results of a randomized controlled trial
Cancer
Microcomputer-generated reminders. Improving the compliance of primary care physicians with mammography screening guidelines
J. Fam. Pract.
Improving physician compliance with preventive medicine guidelines
Med. Care
10 questions to help you make sense of randomised controlled trials. Tool adapted by ©Milton Keynes Primary Care Trust 2002 from Guyatt GH, Sackett DL, and Cook DJ, Users' guides to the medical literature. II. How to use an article about therapy or prevention
JAMA
Cited by (46)
Impact of postal correspondence letters on participation in cancer screening: a rapid review
2021, Preventive MedicineCitation Excerpt :None of the included reviews examined recall letters. After applying the AMSTAR 2 criteria to each review, quality ratings were critically low for five reviews (Ferroni et al., 2012; Bonfill et al., 2001; Tseng et al., 2001; Jepson et al., 2000; Wagner, 1998) and low for one review (Everett et al., 2011) (Appendix C Supplementary Table 2). Across reviews, the highest scoring items included the comprehensiveness of the search (100%) and inclusion of an explanation for observed heterogeneity (100%).
Prevalence of Abdominal Aortic Aneurysms in the General Population and in Subgroups at High Cardiovascular Risk in Italy. Results of the RoCAV Population Based Study
2018, European Journal of Vascular and Endovascular SurgeryAdherence to Cervical Cancer Screening Programs in Migrant Populations: A Systematic Review and Meta-Analysis
2023, International Journal of Environmental Research and Public HealthA Comparison of the National Cervical Cancer Policies in Six Developing Countries with the World Health Organization Recommendations: A Narrative Review
2023, Iranian Journal of Public HealthLow-Cost Interventions to Improve Cervical Cancer Screening: An Integrative Review
2023, Oncology Nursing Forum
- 1
The following are the members of the Working Group: Paolo Giorgi Rossi, AUSL Reggio Emilia; Antonio Federici, Ministero della Salute, Rome; Livia Giordano and Carlo Senore, CPO Turin; Teresa Spadea, Rete Epidemiologia Piemonte, ASL 3 Turin; Anna Iossa, and Grazia Grazzini ISPO Florence; Carla Cogo, Registro Tumori del Veneto Istituto Oncologico Veneto, Padua; Fabio Palazzo, CNR Rome; Mauro Palazzi, Azienda USL Cesena; Beatriz Jimenez, Giacomo Furnari, Laura Camilloni, Eliana Ferroni, Piero Borgia and Gabriella Guasticchi Laziosanità, Agenzia di Sanità Pubblica, Regione Lazio.