1. Updated Recommendations for Client- and Provider-Oriented Interventions to Increase Breast, Cervical, and Colorectal Cancer Screening Community Preventive Services Task Force Summary: The Community Preventive Services Task Force (Task Force) recommends increasing screening for breast cancer through use of group education, one-on-one education, client reminders, reducing client out-of-pocket costs, and provider assessment and feedback; increasing screening for cervical cancer through use of one-on-one education, client reminders, and provider assessment and feedback; and increasing screening for colorectal cancer through use of one-on-one education, client reminders, reducing structural barriers to screening, and provider assessment and feedback. The Task Force found insuffcient evidence to determine the effectiveness of increasing screening for breast cancer through use of client incentives, mass media, or provider incentives; for cervical cancer screening through use of group education, client incentives, mass media, reducing client out-of pocket costs, reducing structural barriers, or provider incentives; and for colorectal cancer screening through use of group education, client incentives, mass media, reducing client out-of-pocket costs, or provider incentives. Details of these fndings, and some considerations for use, are provided in this article. (Am J Prev Med 2012;43(1):9296) 2012 Published by Elsevier Inc. on behalf of American Journal of Preventive MedicineIntroduction access to screening services) and provider-oriented inter ventions. Seven client-oriented intervention reviewsI n 2008, the Community Preventive Services Task were updated: group education, one-on-one education, Force (Task Force) published recommendations for client incentives, client reminders, mass media, reducing ten interventions to increase screening for breast, out-of-pocket costs, and reducing structural barriers.cervical, and colorectal cancer.1 Interventions were in Two intervention reviews to increase provider delivery ofthree primary strategic objective areas2: increasing community demand for cancer screening services, increasing cancer screening services were updated: provider assesscommunity access to screening services, and increasing ment and feedback, and provider incentives.screening service delivery by healthcare providers. The Overall, the new data changed fndings for three interTask Force recently updated its recommendations in this ventions: group education to increase breast cancercritical area, based on an expanded review of the litera screening is now recommended on the basis of suffcientture (through October 2008) and systematic reviews of all evidence of effectiveness (previously, insuffcient evievidence. dence to determine effectiveness had been found); one- These updated recommendations cover nine inter on-one education to increase colorectal cancer screeningventions to increase screening for breast, cervical, and is now recommended on the basis of suffcient evidencecolorectal cancer. These fall into two strategic areas: client- of effectiveness (previously, insuffcient evidence to deoriented interventions (combining increasing commu termine effectiveness had been found); and client renity demand for screening and increasing community minders to increase colorectal cancer screening are now recommended on the basis of strong evidence of effec tiveness (previously, this intervention was recommendedNames and affliations of the Task Force members can be found at on the basis of suffcient evidence of effectiveness). Findwww.thecommunityguide.org/about/task-force-members.html. Address correspondence to: Susan A. Sabatino, MD, MPH, Division ings, by intervention and cancer site, are presented below,of Cancer Prevention and Control, CDC, 4770 Buford Highway (K-55), and the evidence on which these fndings are based isAtlanta GA 30341. E-mail: SSabatino@cdc.gov. 0749-3797/$36.00 provided in the accompanying article in this issue of the http://dx.doi.org/10.1016/j.amepre.2012.04.008 American Journal of Preventive Medicine.392 Am J Prev Med 2012;43(1):9296 2012 Published by Elsevier Inc. on behalf of American Journal of Preventive Medicine

2. Community Preventive Services Task Force / Am J Prev Med 2012;43(1):9296 93 An updated review for small media interventions is vical, and colorectal cancer screening services and to inunderway. An initial review of provider reminders re crease provider referral for and delivery of cancercently was published.4 The current updated recommen screening. Effectiveness of client-oriented interventionsdations represent the work of the independent, nonfed was studied separately for increasing breast cancereral Community Preventive Services Task Force (Task screening by mammography, cervical cancer screeningForce). The Task Force is developing the Guide to Com by Pap test, and colorectal cancer screening by fecal ocmunity Preventive Services (the Community Guide) with cult blood test (FOBT), flexible sigmoidoscopy, orthe support of DHHS in collaboration with public and colonoscopy; effectiveness of provider-oriented interprivate partners. The CDC provides staff support to the ventions was studied across all three cancer sites.Task Force for development of the Community Guide, butthe opinions and recommendations resulting from the Client-Oriented Interventionsreviews are those of the Task Force. General methods forconducting Community Guide evidence reviews, and spe Group education. Group education conveys informacifc methods for conducting cancer screening reviews, tion on indications for, benefts of, and ways to overcomehave been published elsewhere.5,6 barriers to screening with the goal of informing, encour The selected community and healthcare system inter aging, and motivating participants to seek recommendedventions on which this report is based were developed, in screening. Group education usually is conducted bypart, to help meet goals of lowering cancer mortality set health professionals or by trained lay people who useby Healthy People 2020 (www.healthypeople.gov/2020/ presentations or other teaching aids in a lecture or intertopicsobjectives2020/overview.aspx?topicid=5). The active format, and often incorporate role-modeling orcancer objectives for Healthy People 2020 reflect the im other methods. Group education can be given to a varietyportance of increasing screening for breast, cervical, and of groups, in various settings, and by various types ofcolorectal cancer by measuring use of effective screening educators with various backgrounds and styles.tests identifed in the U.S. Preventive Services Task Force The Task Force recommends group education (www.(USPSTF) recommendations (see below). thecommunityguide.org/cancer/screening/client-oriented/ RRgroupeducation_a.html) on the basis of suffcient evi dence that these interventions are effective in increasingInformation from Other Advisory Groups screening for breast cancer. There was insuffcient eviThe U.S. Preventive Services Task Force issues recom dence, however, to determine the effectiveness of groupmendations for screening of breast, cervical, and colorec education in increasing screening for cervical cancer andtal cancer. USPSTF recommendations for breast cancer colorectal cancer, based on small numbers of studies withscreening were updated in December 2009 (www. methodologic limitations and inconsistent fndings.uspreventiveservicestaskforce.org/uspstf/uspsbrca.htm). One-on-one education. One-on-one education conUSPSTF recommendations for cervical cancer screening were veys information by telephone or in person on indicaupdated in March 2012 (www.uspreventiveservicestaskforce. tions for, benefts of, and ways to overcome barriers toorg/uspstf/uspscerv.htm). The USPSTF made its most recent screening with the goal of informing, encouraging, andrecommendations on colorectal cancer screening (www. motivating people to seek recommended screening.uspreventiveservicestaskforce.org/uspstf/uspscolo.htm) These messages are delivered by healthcare workers orin 2008. other health professionals, lay health advisors, or volun teers and are conducted by telephone or in person inIntervention Recommendations medical, community, worksite, or household settings. InA Community Preventive Services Task Force recom terventions can be untailored to address the overall targetmendation is based primarily on effectiveness of the in population or tailored, based on individual assessmentstervention as determined by the systematic literature re to address the recipients individual characteristics, beview process. In making a recommendation, however, the liefs, or perceived barriers to screening. As defned by thisTask Force balances information on effectiveness with review, one-on-one education may be accompanied by ainformation on other potential benefts or harms of the small media or client reminder component.intervention. The Task Force also considers the applica The Task Force recommends the use of one-on-onebility of effective interventions to various settings and education (www.thecommunityguide.org/cancer/screening/populations in determining the scope of the intervention. client-oriented/RROneonOneEducation_a.html) Here, the Task Force presents the recommendations to increase screening for breast and cervical cancers onfrom updated reviews on interventions designed to in the basis of strong evidence of effectiveness. The Taskcrease community demand for and access to breast, cer Force also recommends the use of one-on-one educationJuly 2012

3. 94 Community Preventive Services Task Force / Am J Prev Med 2012;43(1):9296to increase colorectal cancer screening with FOBT based evaluated the effectiveness of mass media used alone, oron suffcient evidence of effectiveness. Evidence is insuf its individual contribution to the effectiveness of multi-fcient, however, to determine the effectiveness of one- component interventions.on-one education in increasing colorectal cancer screen The Task Force fnds insuffcient evidence to detering with other tests, because only two studies assessed mine the effectiveness of mass media interventionscolonoscopy, with inconsistent results, and one study for (www.thecommunityguide.org/cancer/screening/clientflexible sigmoidoscopy found no effect. oriented/RRmassmedia_a.html) in increasing screeningClient incentives. Client incentives are small, noncoer for breast, cervical, or colorectal cancers. Although adcive rewards (e.g., cash or coupons) to motivate people to ditional studies were found during the updated reseek cancer screening for themselves or to encourage view,3 there continue to be too few studies to determineothers (e.g., family members, close friends) to seek effectiveness for breast, cervical, or colorectal cancerscreening. Incentives are distinct from interventions de screening.signed to improve access to services (e.g., transportation, Reducing out-of-pocket costs. These interventions atchild care, reducing client out-of-pocket costs). The Task tempt to minimize or remove economic barriers thatForce fnds insuffcient evidence to determine the effec impede client access to cancer screening services. Coststiveness of using client incentives (www.thecommunity can be reduced through a variety of approaches, includguide.org/cancer/screening/client-oriented/RRincentives_a. ing vouchers, reimbursements, reduction in copays, orhtml) to increase screening for breast, cervical, or colo adjustments in federal or state insurance coverage. Efrectal cancers because only one study for breast cancer forts to reduce client costs may be combined with meaand no studies for cervical and colorectal cancers were sures to provide client education, information about proidentifed. gram availability, or measures to reduce structuralClient reminders. Client reminders are textual (letter, barriers.postcard, e-mail) or telephone messages advising people The Task Force recommends reducing client out-that they are due (reminder) or overdue (recall) for of-pocket costs (www.thecommunityguide.org/cancer/screening. Client reminders may be enhanced by one or screening/client-oriented/RRoutofpocket_a.html) tomore of the following: follow-up printed or telephone increase screening for breast cancer on the basis of suffreminders; additional text or discussion with information cient evidence of effectiveness. There is insuffcient eviabout indications for, benefts of, and ways to overcome dence to determine the effectiveness of reducing out-ofbarriers to screening; and/or assistance in scheduling ap pocket costs in increasing screening for cervical orpointments. Interventions can be untailored to address colorectal cancer because too few (cervical cancer) or nothe overall target population or tailored with the intent to (colorectal cancer) studies were identifed. Nonetheless,reach one specifc person, based on characteristics unique the consistent, favorable results for interventions thatto that person, related to the outcome of interest, and reduce costs for breast cancer screening and several otherderived from an individual assessment. preventive services suggest that such interventions are The Task Force recommends the use of client remin likely to be effective for increasing cervical and colorectalders (www.thecommunityguide.org/cancer/screening/ cancer screening as well.client-oriented/RRreminders_a.html) to increase screen Reducing structural barriers. Structural barriers areing for breast and cervical cancers on the basis of strong non-economic burdens or obstacles that impede access toevidence of effectiveness. The Task Force also recom screening. Interventions designed to reduce these barrimends the use of client reminders to increase colorectal ers may facilitate access by reducing time or distancecancer screening with FOBT based on strong evidence of between service delivery settings and target populations;effectiveness. Evidence is insuffcient, however, to deter modifying hours of service to meet client needs; offeringmine effectiveness of client reminders in increasing colo services in alternative or nonclinical settings (e.g., mobilerectal cancer screening with other tests (colonoscopy, mammography vans at worksites or in residential comflexible sigmoidoscopy) because of inconsistent evidence. munities); and eliminating or simplifying administrativeMass media. Mass mediaincluding TV, radio, news procedures and other obstacles (e.g., scheduling assispapers, magazines, and billboardsare used to commu tance or patient navigators, transportation, dependentnicate educational and motivational information in com care, translation services, limiting the number of clinicmunity or larger-scale intervention campaigns. Mass visits). Such interventions often include one or moremedia interventions, however, almost always include secondary supporting measures, such as printed or teleother components or attempt to capitalize on existing phone reminders; education about cancer screening; ininterventions and infrastructure. The updated review3 formation about cancer screening availability (e.g., group www.ajpmonline.org

4. Community Preventive Services Task Force / Am J Prev Med 2012;43(1):9296 95education, pamphlets, or brochures); or measures to re suffcient because of a small magnitude of effect acrossduce client out-of-pocket costs. Interventions principally studies and because data from healthcare systems thatdesigned to reduce client costs are considered to be a include provider incentives as part of their strategies forseparate class of approaches. administration and provider compensation have not The Task Force recommends reducing structural bar been published.riers to increase screening (www.thecommunityguide.org/cancer/screening/client-oriented/RRreducingstructual Using the Recommendations andbarriers_a.html) for breast and colorectal cancers (by Findingsmammography and FOBT, respectively) on the basis of These recommendations are intended to highlight effecstrong evidence of effectiveness. Evidence is insuffcient, tive interventions, which should be considered over alterhowever, to determine whether reducing structural bar natives without documented effectiveness when decidingriers is effective in increasing colorectal cancer screening among possible approaches to increasing cancer screenby flexible sigmoidoscopy or colonoscopy because only ing. These recommendations are neither intended norone study using these screening procedures was identi expected to be applicable in all situations. Decision makfed. Evidence is also insuffcient to determine the effec ers and implementers should bear in mind that an undertiveness of the intervention in increasing screening for standing of local contextincluding known barriers tocervical cancer because only three relevant studies were screening in the target population(s), available resources,identifed, and these had methodologic limitations. and what can be implemented effectivelyis essential to the process of identifying appropriate strategies and seIncreasing Provider Delivery lecting feasible intervention approaches for a specifc setProvider assessment and feedback. Provider assess ting or population.ment and feedback interventions both evaluate provider The systematic collection of qualitative and quantitaperformance in offering and/or delivering screening to tive data can be an extremely helpful tool for developing aclients (assessment) and present providers with informa more thorough understanding of the local context. Oncetion about their performance in providing screening ser that context is understood clearly, the recommendationsvices (feedback). Feedback may describe the performance presented here and the evidence on applicability in theof a group of providers (e.g., mean performance for a accompanying evidence review3 can be used to help selectpractice) or individual providers, and may be compared appropriate interventions. Some key considerations inwith a goal or standard. using recommended interventions are noted below. The Task Force recommends provider assessment andfeedback interventions (www.thecommunityguide.org/ Choosing Interventions to Meetcancer/screening/provider-oriented/RRpaf_a.html) on Community Needsthe basis of suffcient evidence of effectiveness in increas It is important to consider the characteristics of the targeting screening for breast cancer (mammography); cervical population carefully when considering implementingcancer (Pap); and colorectal cancer (FOBT). Evidence any intervention, and this need is particularly strong forremains insuffcient, however, to determine effectiveness interventions intended to educate and increase awarenessof this intervention in increasing colorectal cancer about cancer screening (e.g., one-on-one education,screening using methods other than FOBT. group education, mass media). For example, when baseProvider incentives. Provider incentives are direct or line screening rates are high, group education or massindirect rewards intended to motivate providers to per media campaigns directed at the general population mayform cancer screening or make appropriate referral for not be the most appropriate intervention. Such interventheir patients to receive these services. Rewards are often tions may be most appropriate when directed at populamonetary, but can include nonmonetary incentives also tions or subpopulations with relatively low screening(e.g., continuing medical education credit). Because some rates, and when their messages are directed at the mostform of assessment is needed to determine whether pro relevant issues for the specifc group or individualviders receive rewards, an assessment component may be addressed.included in the intervention. Considering the specifc characteristics of the target The Task Force fnds insuffcient evidence to deter population is also important for implementing approprimine the effectiveness of provider incentives (www. ate interventions to increase cancer screening by reducthecommunityguide.org/cancer/screening/provider ing structural barriers. Many options for reducing strucoriented/RRincentives_a.html) in increasing screening tural barriers are available, and questions remain aboutfor breast, cervical, or colorectal cancers. Evidence is in whether some of these approaches are more or less effec-July 2012

5. 96 Community Preventive Services Task Force / Am J Prev Med 2012;43(1):9296tive or appropriate for use within specifc settings or with However, studies of the effects of such strategies were notspecifc populationssuch as with people who have available for evaluation and thus could not contribute tonever been screened or who may be hard to reach for Task Force fndings on their effectiveness.screening. In the absence of such research, specifc intervention approaches should be selected and implemented Additional Information and Assistanceonly after careful consideration of the most importantbarriers to screening for the target population. Additional information and assistance in selecting and implementing appropriate interventions to increase canImplementing Multiple Interventions cer screening are available through online tools, such as those available at Cancer Control P.L.A.N.E.T. (cancerIn many situations, it may be appropriate to implement two controlplanet.cancer.gov/). Its links provide helpfulor more interventions, because a single intervention might sources of information for determining cancer controlnot address adequately multiple barriers that contribute to program priorities, identifying potential partners, exlow screening rates within a community or that prevent ploring various intervention approaches, fnding repeople from adhering to screening recommendations. search-tested intervention programs and products, and The updated reviews found some evidence that imple planning and evaluating the intervention program. Almenting an intervention such as one-on-one education as though such tools can be invaluable resources, it is alsopart of a multicomponent intervention that includes helpful to draw on direct technical assistance and adviceother approaches to increasing cancer screening can pro from people with experience in implementing the intervide incremental benefts. Decisions about when to use ventions of interest.such a multicomponent approach, and which specifccombinations of interventions to implement, should bebased not only on the characteristics of the target popu No fnancial disclosures were reported by the authors of thislation and the most important barriers to screening but paper.also on whether adequate resources and infrastructureexist to deliver all components with fdelity. ReferencesConsidering the Healthcare System Context 1. Task Force on Community Preventive Services. Recommendations forRecent changes in healthcare systems are making it in client- and provider-directed interventions to increase breast, cervical,creasingly necessary to consider single-component inter and colorectal cancer screening. Am J Prev Med 2008;35(1S):215. 2. Breslow RA, Rimer BK, Baron RC, et al. Introducing the Communityventions, such as provider assessment and feedback, Guides reviews of evidence on interventions to increase screening forwithin a broader context of how care is delivered in a breast, cervical, and colorectal cancers. Am J Prev Med 2008;35(1S):given healthcare system. Some changes, such as increased 14 20.integration of computerized medical records into prac 3. Sabatino SA, Lawrence B, Elder R, et al. Effectiveness of interventions to increase screening for breast, cervical, and colorectal cancers: nine uptice, may make it easier to implement and sustain such dated systematic reviews for the Guide to Community Preventive Serinterventions. Further, it is appropriate to consider the vices. Am J Prev Med 2012;43(1):765786.role that provider assessment and feedback can play to 4. Baron RC, Melillo S, Rimer BK, et al. Intervention to increase recomimprove the delivery of recommended cancer screenings mendation and delivery of screening for breast, cervical, and colorectal cancers by healthcare providers: a systematic review of provider remindin relationship to other elements of the specifc healthcare ers. Am J Prev Med 2010;38(1):110 7.system, such as provider compensation policies. 5. Briss PA, Zaza S, Pappaioanou M, et al. Developing an evidence-based Although the Task Force found insuffcient evidence to Guide to Community Preventive Servicesmethods. The Task Force ondetermine the effectiveness of provider incentives in in Community Preventive Services. Am J Prev Med 2000;18(1S):35 43. 6. Baron RC, Rimer BK, Coates RJ, et al. Methods for conducting systemcreasing cancer screening, many healthcare systems in atic reviews of evidence on effectiveness and economic effciency ofclude provider incentives as part of a comprehensive interventions to increase screening for breast, cervical, and colorectalstrategy for administration and provider compensation. cancers. Am J Prev Med 2008;35(1S):26 33. www.ajpmonline.org