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Can Low-Cost Interventions Improve Cancer Screenings for Women in Remote Areas?

  • Authors: News Author: Nancy A. Melville; CME Author: Charles P. Vega, MD
  • CME / ABIM MOC / CE Released: 6/2/2023
  • Valid for credit through: 6/2/2024, 11:59 PM EST
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  • Credits Available

    Physicians - maximum of 0.25 AMA PRA Category 1 Credit(s)™

    ABIM Diplomates - maximum of 0.25 ABIM MOC points

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Target Audience and Goal Statement

This activity is intended for family medicine/primary care clinicians, hematology/oncology clinicians, nurses/nurse practitioners, physician assistants, and other clinicians who promote cancer screening among adults.

The goal of this activity is for learners to be better able to compare interventions to increase cancer screening among middle-aged women.

Upon completion of this activity, participants will:

  • Assess adherence to cancer screening recommendations in the United States
  • Compare interventions to increase cancer screening among middle-aged women
  • Outline implications for the healthcare team


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News Author

  • Nancy A. Melville

    Freelance writer, Medscape


    Nancy A. Melville has no relevant financial relationships.

CME Author

  • Charles P. Vega, MD

    Health Sciences Clinical Professor of Family Medicine
    University of California, Irvine School of Medicine


    Charles P. Vega, MD, has the following relevant financial relationships:
    Consultant or advisor for: Boehringer Ingelheim Pharmaceuticals, Inc.; GlaxoSmithKline; Johnson & Johnson Pharmaceutical Research & Development L.L.C.

Editor/Compliance Reviewer

  • Amanda Jett, PharmD, BCACP

    Associate Director, Accreditation and Compliance, Medscape, LLC


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Nurse Planner

  • Leigh Schmidt, MSN, RN, CNE, CHCP

    Associate Director, Accreditation and Compliance, Medscape, LLC


    Leigh Schmidt, MSN, RN, CNE, CHCP, has no relevant financial relationships.

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This activity has been peer reviewed and the reviewer has no relevant financial relationships.

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Can Low-Cost Interventions Improve Cancer Screenings for Women in Remote Areas?

Authors: News Author: Nancy A. Melville; CME Author: Charles P. Vega, MDFaculty and Disclosures

CME / ABIM MOC / CE Released: 6/2/2023

Valid for credit through: 6/2/2024, 11:59 PM EST


Clinical Context

The completion of cancer screening can be a challenge for patient and clinician alike, and a study by Sabatino and colleagues provided an update on rates of completion of cancer screening among US adults in 2018. The results of this research were published in the January 15, 2021, issue of Morbidity and Mortality Weekly Report.[1]

Researchers interrogated data from the 2018 National Health Interview Survey to determine the percentage of adults who were in compliance with cancer screening guidelines from the US Preventive Services Task Force (USPSTF). Among women between the ages of 50 and 74 years, 72.4% met screening guidelines for breast cancer with at least biennial mammography; however, less than 40% of women who lacked a usual source of health care were up-to-date. More than three-quarters (82.9%) of women between the ages of 21 and 65 years were up-to-date on cervical cancer screening, but women in the youngest and oldest age groups in this cohort were less likely to receive cervical cancer screening. Similarly, Asian race, lower educational attainment and income, shorter residence in the United States, no usual source of care, being gay or Lesbian, and uninsured/public health insurance status were all associated with lower rates of cervical cancer screening. More than two-thirds (66.9%) of adults between the ages of 50 and 75 years were up-to-date with colorectal cancer (CRC) screening. Age 50 to 64 years and American Indian/Alaska Native race were associated with lower rates of CRC screening.

This study did not examine living in a rural setting as a risk factor for reduced cancer screening, although the authors of the current study noted that the crude cancer mortality rate is 12 points higher in rural vs urban areas. The current study by Champion and colleagues evaluated the efficacy of 2 interventions to promote cancer screening in the rural United States.

Study Synopsis and Perspective

A low-cost intervention that involved mailing patients an educational, personally tailored DVD along with follow-up telephone counseling significantly improved rates of recommended cancer screenings among women living in rural areas, where uptake of such screenings is often suboptimal.

Women who received the DVD along with counseling from patient navigators were almost 6 times more likely to undergo guideline-recommended breast, cervical, and CRC screening in comparison with patients who received usual care.

"Our findings demonstrate that interventions delivered remotely to rural women can simultaneously improve screening rates for breast, cervical, and colorectal cancer," reported the authors of a study published on April 28 in JAMA Network Open.[2]

Rates of routine cancer screenings are lower among women in rural areas. Barriers include having worse access to care and having less knowledge about screening recommendations. Lower screening rates can lead to later-stage diagnoses and worse patient outcomes. Recent data indicate, for instance, that cancer mortality rates are higher in rural areas than in urban areas.[3]

Efforts to improve screenings often focus on one type of cancer, such as breast, cervical, or colorectal. Victoria L. Champion, PhD, RN, of the School of Nursing, Indiana University, Indianapolis, and colleagues investigated the potential benefits of an intervention to improve screening for all 3 types of cancer simultaneously.[2]

For the study, Champion and colleagues recruited 963 women from rural Indiana and Ohio who were not up-to-date on recommended cancer screenings. The women were between the ages of 50 and 74 (mean age, 58.6 ± 6.3 years); almost all (97%) were White.

Participants completed a baseline survey that assessed their beliefs, knowledge, and self-reported adherence to cervical cancer, breast cancer, and CRC screening. The authors randomly assigned participants to 1 of 3 interventions between November 2016 and July 2019.

One group was mailed an educational interactive DVD that contained messages tailored to each woman's survey responses; this group also received a telephone follow-up within 4 weeks from patient navigators. The second group received the educational DVD without telephone follow-up. The third group received only usual care, which varied by location but at best involved a reminder to schedule a cancer screening.

The interactive DVD was designed to assess patients' health beliefs and address common issues, including perceptions about the risk of developing the targeted cancers, as well as barriers, benefits, and self-efficacy in obtaining recommended screenings. The follow-up calls were provided as necessary; patients received a mean of 3 content calls (range, 1-14 calls) per woman. The patient navigators provided further counseling to help women overcome the barriers associated with screenings.

At 12-month follow-up, the unadjusted rate of screenings for all 3 types of cancer was 10% in the usual-care group, 15% in the DVD group, and 30% in the DVD-plus-patient navigation group (omnibus P < .001). The unadjusted 12-month rate of being up-to-date with screening for any of the 3 types of cancer was 25% for usual care, 29% for DVD alone, and 49% for both interventions (omnibus P < .001).

After multivariate adjustment, women who received the DVD/patient navigator intervention were nearly 6 times more likely to obtain all needed screenings compared with women who received only usual care (odds ratio [OR] 5.69; P < .001).

Women who received only the DVD were almost 2 times more likely to undergo the recommended cancer screenings (OR 1.84; P = .048). Women in the double intervention group were 3 times more likely to obtain all needed screenings compared with women in the DVD group (OR 3.09; P < .001).

The authors also found that participants who were aged 65 years or older were only half as likely to be up to date on screenings for all cancers (OR 0.53; P = .03).

With previous studies showing similar results, the current study adds to a growing body of evidence of the benefits of such interventions; however, with DVD technology becoming obsolete, the authors noted the need to translate the DVD intervention to an online tool.

Overall, "this study supports the one-stop-shop approach as advocated by other researchers who also found that a screening intervention could simultaneously improve the uptake of more than 1 cancer screening test," the authors said. "The potential for increasing multiple screening behaviors at one time is especially relevant for rural communities where health care may be hampered by remote living conditions that limit access to preventive services."

Plus, with the general costs of cancer treatment in the United States running an average of about $150,000 per patient, the relatively low cost of this intervention, even with patient navigators, could yield significant savings.

"The additional costs required for the addition of patient navigators to improve screening may result in cost savings by avoiding cancer deaths or treatment at more advanced stages," Champion and colleagues wrote.

The study was supported by grants from the National Cancer Institute and the National Institute of Nursing Research.

Study Highlights

  • For the study, investigators recruited women between the ages of 50 and 74 years from 98 rural counties in Ohio and Indiana between 2016 and 2019. The study excluded patients with a history of previous cancer diagnosis.
  • All participants spoke English and were not up-to-date with ≥ 1 cancer screening recommendation from the USPSTF.
  • Researchers randomly assigned women to receive a DVD with an interactive, personalized program to promote appropriate cancer screening; the DVD with telephone follow-up (≤ 3 calls) by a trained patient navigator within 4 weeks; or usual care.
  • The main study outcome was completion of screening studies for cervical cancer, breast cancer, and CRC at 12 months after randomization. This outcome was determined by participant self-report and verified in the health record.
  • The study analysis was adjusted to account for demographic variables, smoking status, cancer screening knowledge and enthusiasm, and other health beliefs.
  • 963 women had data for analysis. The mean age of participants was 58.6 ± 6.3 years. 46% of women completed college or postgraduate education. 97% of the cohort was White, and 5% reported not having health insurance.
  • 19% of women were not up-to-date for breast cancer, cervical cancer, or CRC screening at baseline. Baseline adherence was highest for breast cancer screening, followed by cervical cancer and CRC screening.
  • Rates of being up-to-date for all 3 cancer screenings at 12 months were 10%, 15%, and 30% in the usual care, DVD-only, and DVD-plus-navigator groups, respectively. The respective rates of being up-to-date for any one of the cancer screenings were 25%, 29%, and 49%.
  • Compared with the usual care group, the OR for having all cancer screening complete at 12 months was 1.84 (95% CI: 1.02, 3.43) for the DVD group. The respective OR for the DVD-plus-navigator group was 5.69 (95% CI: 3.24, 10.5).
  • The OR for receiving all cancer screening in comparing the DVD-plus-navigator cohort with the DVD group was 3.09 (95% CI: 2.05, 4.68).
  • Higher self-efficacy scores and planning to get screening done in the next 6 months were associated with getting all cancer screening done, as was living in wealthier areas.
  • Only the DVD-plus-navigator intervention was significantly better than usual care at improving the rate of completing any 1 cancer screening by 12 months (OR 4.01 [95% CI: 2.6, 6.28]). The DVD intervention alone was not.
  • Variables associated with a higher rate of completing any cancer screening at 12 months included full time employment, wealthier place of residence, greater self-efficacy, planning to get screening in the next 6 months, and greater knowledge regarding cancer screening.
  • Interestingly, higher perceived barriers to cancer screening at baseline were also associated with higher rates of completing ≥ 1 cancer screening. Although there was no significant interaction between this variable and study intervention, the work of patient navigators may have influenced this unexpected outcome.
  • The estimated total costs for the DVD-alone and DVD-plus-navigator interventions were $326,012 and $344,829, respectively. The cost-effectiveness per up-to-date participant were $14,462 for the DVD-only intervention and $10,638 for the DVD-plus-navigator intervention.

Implications for the healthcare team

  • In a previous study by Sabatino and colleagues, the rates of adherence to routine cancer screening among US adults in 2018 were 72.4% for breast cancer screening, 82.9% for cervical cancer screening, and 66.9% for colorectal cancer screening.
  • The current study by Champion et al found that adding phone-based counseling from a patient navigator to an educational DVD increases the rate of cancer screening completion among women compared with a DVD-only intervention and usual care. The cost-effectiveness of the DVD-plus-navigator intervention was slightly more than $10,000 per woman made up-to-date for screening.
  • The healthcare team should consider cancer screening education plus the use of a patient navigator to improve cancer screening rates among women.


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