Promoting cancer screening. A randomized, controlled trial of three interventions. Using an office system intervention to increase breast cancer screening. Improving uptake of cervical cancer screening in women with prolonged history of non-attendance for screening: a randomized trial of enhanced invitation methods. Comparison of tailored interventions to increase mammography screening in nonadherent older women. The safety net: a cost-effective approach to improving breast and cervical cancer screening. Promoting participation in a population screening program for breast and cervical cancer: a randomized trial of different invitation strategies. Cost-effectiveness comparison of five interventions to increase mammography screening. A randomised controlled trial of strategies to prompt attendance for a Pap smear. A large population-based randomized controlled trial to increase attendance at screening for cervical cancer. The impact of tailored interventions on a community health center population. A randomized trial of recruitment methods for older African American men in the Prostate, Lung, Colorectal and Ovarian (PLCO) Cancer Screening Trial. Breast and cervical cancer screening in a low-income managed care sample: the efficacy of physician letters and phone calls. Effects of a telephone counseling intervention on sisters of young women with breast cancer.
To determine effective methods of promoting routine cancer screening, we randomly assigned 62 internal medicine residents to receive cancer screening reminders (computer-generated lists of overdue tests at patients' visits), audit with feedback (monthly seminars about screening, with feedback about their performance rates), or no intervention (controls). Half of the residents in each group also were randomized to receive patient education (patients received literature and notices of overdue tests). We reviewed a sample of each physician's medical records to assess performance of seven tests during 9-month periods before and after initiating the interventions. Cancer screening reminders increased performance of six of seven tests; audit with feedback, four of seven tests; and patient education, one of two targeted breast cancer screening tests. The results indicate that the cancer screening reminders strategy was the most effective in promoting the performance of routine cancer screening tests. To evaluate an innovative approach to continuing medical education, an outreach intervention designed to improve performance rates of breast cancer screening through implementation of office systems in community primary care practices.
                Randomized, controlled trial with primary care practices assigned to either the intervention group or control group, with the practice as the unit of analysis.
                Twenty mostly rural counties in North Carolina.
                Physicians and staff of 62 randomly selected family medicine and general internal medicine practices, primarily fee-for-service, half group practices and half solo practitioners.
                Physician investigators and facilitators met with practice physicians and staff over a period of 12 to 18 months to provide feedback on breast cancer screening performance, and to assist these primary care practices in developing office systems tailored to increase breast cancer screening.
                Physician questionnaires were obtained at baseline and follow-up to assess the presence of five indicators of an office system. Three of the five indicators of office systems increased significantly more in intervention practices than in control practices, but the mean number of indicators in intervention practices at followup was only 2.8 out of 5. Cross-sectional reviews of randomly chosen medical records of eligible women patients aged 50 years and over were done at baseline (n = 2,887) and follow-up (n = 2,874) to determine whether clinical breast examinations and mammography, were performed. Results for mammography were recorded in two ways, mention of the test in the visit note and actual report of the test in the medical record. These reviews showed an increase from 39% to 51% in mention of mammography in intervention practices, compared with an increase from 41% to 44% in control practices (p = .01). There was no significant difference, however, between the two groups in change in mammograms reported (intervention group increased from 28% to 32.7%; control group increased from 30.6% to 34.0%, p = .56). There was a nonsignificant trend (p = .06) toward a greater increase in performance of clinical breast examination in intervention versus control practices.
                A moderately intensive outreach intervention to increase rates of breast cancer screening through the development of office systems was modestly successful in increasing indicators of office systems and in documenting mention of mammography, but had little impact on actual performance of breast cancer screening. At follow-up, few practices had a complete office system for breast cancer screening. Outreach approaches to assist primary care practices implement office systems are promising but need further development. To compare the effectiveness and cost-effectiveness of three methods of inviting women with a long history of non-attendance to undergo cervical screening.
                Randomized controlled trial and cost-effectiveness analysis. In all, 1140 women were identified from routine NHS screening records as having no smear for at least 15 years and randomly allocated to receive a telephone call from a nurse, a letter from a well-known celebrity (Claire Rayner) or letter from the local NHS Cervical Screening Commissioner. Uptake of screening was measured using routine data and attributed to interventions if occurring within three months. Uptake was compared with a control group. Costs of carrying out the interventions were noted from the perspective of the NHS and cost-effectiveness, as cost per additional attender, calculated.
                Uptake following all interventions was low: telephone call (1.4, 95% confidence interval [CI] 0.38-3.6%); celebrity letter (1.8, 95% CI 0.57-4.0%); commissioner letter (4.6, 95% CI 2.5-7.7%); control group (1.8, 95% CI 0.57-4.0%). There were no significant differences between groups. Telephone intervention was not possible in a quarter of women whose numbers were unlisted. Telephone intervention was the most expensive and least effective of the interventions. The commissioner letter yielded an additional attender within three months at an incremental cost of 23.21 pounds compared with taking no action.
                Neither a telephone call from a nurse nor a letter from a celebrity to encourage attendance for cervical screening were effective or cost-effective in women with a prolonged history of non-participation in the screening programme. A letter from the local cervical screening programme commissioner resulted in a small, non-significant increase in uptake. The low cost and ease of implementation of this intervention supports further research into its use in routine practice. Recent increases in mammography use have led to a decrease in mortality from breast cancer.
                Building on the Health Belief Model, the Transtheoretical Model, and past effectiveness of tailored interventions, we conducted a prospective randomized trial (n = 773) to test the efficacy on mammography adherence of tailored interventions delivered by five different methods, i.e., telephone counseling, in-person counseling, physician letter, and combinations of telephone with letter and in-person with letter.
                All five interventions increased mammography adherence significantly relative to usual care (odds ratios, 1.93 to 3.55) at 6 months post intervention. The combination of in-person with physician letter was significantly more effective than telephone alone or letter alone. Women thinking about getting a mammogram at baseline were more likely to be adherent by 6 months; even those in usual care achieved 48% adherence compared with 50-70% in the intervention groups. In contrast, women not thinking about getting a mammogram needed the interventions to increase their adherence from 13% to over 30%.
                All five interventions were effective at increasing mammography adherence. Women not thinking about getting a mammogram were most likely to benefit from these tailored interventions while other women might need less intensive interventions. The purposes of the study were (1). to assess the cost-effectiveness of three interventions to deliver breast and cervical cancer screening to women unscreened for >or=3 years and (2). to determine the relation of an invasive cervical cancer diagnosis to the interval since the last true screening test.
                In a randomized trial, women were randomly assigned to (1). usual care, (2). letter plus follow-up letter, (3). letter plus follow-up phone call, (4). phone call plus follow-up phone call. Screening within 12 weeks was the outcome. A 5-year retrospective review of cervical cancer cases and screening histories was done.
                The 8% of women not screened for >or=5 years had 62% of the invasive cervical cancer cases. Mammography outreach led to screening in 10%, 24%, 51%, and 50% of controls, letter/letter, letter/phone, and phone/phone interventions groups, respectively. Cervical cancer screening outreach led to screening in 17%, 22%, 54%, and 50% of the respective groups. Letter reminders alone produced fewer tests at substantially higher costs than did personalized telephone notification.
                For cervical cancer, only 1 person in 12 was not screened in the preceding 5 years, but these accounted for nearly two thirds of invasive cancers. Aggressive outreach to the rarely screened is an important part of screening programs. Letter reminder, followed by a telephone appointment call, was the most cost-effective approach to screening rarely screened women. Lack of accurate information on prior hysterectomy adds substantial unnecessary costs to a screening reminder program. Attendance level has been identified as a major determinant of cost-effectiveness of organized screening programs. We tested the effectiveness of 4 different invitation systems in the context of an organized population screening program for cervical and breast cancer.
                Women eligible for invitation--8385 for cervical and 8069 for breast cancer screening--listed in the rosters of 43 and 105 general practitioners (GP), respectively, who had accepted to collaborate in the program, were randomized to 4 invitation groups: Group A--letter signed by the GP, with a prefixed appointment; Group B--open-ended invitation, signed by the GP, prompting women to contact the screening center to arrange an appointment; Group C--letter (same as for group A), signed by the program coordinator, with a prefixed appointment; Group D--extended letter (highlighting the benefits of early cancer detection) signed by the GP, with a prefixed appointment. Assignment to the interventions was based on a randomized block design (block=GP).
                Assuming Group A as the reference, the overall compliance with cervical cancer screening was reduced by 39% in Group B (RR=0.61; 95% CI, 0.56-0.68) and by 14% in Group C (RR=0.86; 95% CI, 0.78-0.93); no difference was observed for Group D (RR=1.03; 95% CI, 0.95-1.1). The response pattern was similar for breast screening (Group B: RR=0.71; 95% CI, 0.65-0.76; Group C: RR=0.87; 95% CI, 0.81-0.94; Group D: RR=1.01; 95% CI, 0.94-1.08).
                Personal invitation letters signed by the woman's GP, with preallocated appointments, induce a significant increase in compliance with screening. Efficiency can be ensured through the adoption of overbooking, provided that attendance levels are regularly monitored. Mammography is the primary method used for breast cancer screening. However, compliance with recommended screening practices is still below acceptable levels. This study examined the cost-effectiveness of five combinations of physician recommendation and telephone or in-person individualized counseling strategies for increasing compliance with mammography.
                There were 808 participants who were randomly assigned to one of six groups. A logistic regression model with compliance as the dependent variable and group as the independent variable was used to test for significant differences and a ratio of cost to improvement in mammogram compliance evaluated the cost-effectiveness.
                Three of the interventions (in-person, telephone plus letter, and in-person plus letter) had significantly better compliance rates compared with the control, physician letter, or telephone alone. However, when considering costs, only one emerged as the superior strategy. The cost-effectiveness ratios for the five interventions show that telephone-plus-letter is the most cost-effective strategy, achieving a 35.6% mammography compliance at a marginal cost of $0.78 per 1% increase in women screened.
                A tailored phone prompt and physician reminder is an effective and economical intervention to increase mammography. Future research should confirm this finding and address its applicability to practice.
                Copyright 1999 American Health Foundation and Academic Press. To assess the comparative efficacy, by randomised controlled trial, of three interventions designed to encourage "at risk" women to have a Pap smear: an educational pamphlet; letters inviting attendance at a women's health clinic; and letters from physicians.
                Subjects at risk for cervical cancer who had not been adequately screened were identified by a random community survey and randomly allocated to one of the intervention groups or a control group. Six months after intervention implementation, a follow up survey assessed subsequent screening attendance. Self report was validated by comparison with a national screening data base.
                A significantly greater proportion of women (36.9%) within the group receiving a physician letter reported screening at follow up than in any other group (P = 0.012). The variables most strongly predicting screening attendance were: age, perceived frequency of screening required, use of oral contraceptives, and allocation to receive the physician letter intervention.
                The relative efficacy of the GP letter in prompting screening attendance shows that this strategy is worthy of further investigation. There remains a need to examine the barriers to screening for older women, and to develop tailored strategies for this population. Although cervical cancer is one of the potentially most preventable malignancies, it is still fairly common. In settings with established screening programs, increased compliance is important for future reduction in cervical cancer incidence, but it is presently unclear how this can be effectively achieved.
                We conducted a randomized controlled trial including all 12,240 women invited to organized screening in Sweden. To increase compliance, three successive interventions were tested: (a) modified invitation versus the standard invitation letter, (b) reminder letter to nonattenders after the first intervention versus no reminder letter, and (c) phone reminder to nonattenders after the reminder letter versus no phone reminder. We analyzed the proportion of women attending screening after each intervention and the cumulative proportion after the interventions as well as the cumulative proportions of cytologic abnormalities.
                The modified invitation did not increase attendance compared with the standard invitation letter [difference 1.3% 95% confidence interval (CI) -0.3 to 2.9]. In contrast, a reminder letter increased the proportion of women attending with 9.2% (95% CI 7.9-10.5) compared with women who did not receive a reminder letter, and a phone reminder increased the proportion of women attending with 31.4% (95% CI 26.9-35.9). Combinations of modified invitation, written reminder, and phone reminder almost doubled attendance within 12 months, and the number of detected cytologic abnormalities was more than tripled.
                Simple reminders by mail and phone can drastically increase women's participation in Papanicolaou smear screening and increase the number of detected precursor lesions and thereby save lives. We conducted a 4-year randomized study in a community health center that serves primarily low income Blacks in Durham, North Carolina. Patients (1318 at baseline) were assigned randomly to one of three study groups: provider prompting intervention alone, provider prompting and tailored print materials or the previous group and tailored telephone counseling. The purpose of the study was to determine whether increasingly intensive, tailored print and telephone interventions also were increasingly effective in promoting adherence to mammograms, Pap tests and overall cancer screening compliance. Thus, the combination of tailored print interventions (print and telephone) should have been more effective than the provider prompting intervention alone, or the print intervention and prompting combination. This is one of the few studies to examine a measure of overall cancer screening compliance and to assess the benefit of combinations of tailored interventions in promoting adherence to cancer screening. Patients gave extremely high ratings to the interventions. At the bivariate level, we found a significant effect of the most intensive group (provider prompting intervention, tailored print communications and tailored telephone counseling) on Pap test compliance (P = 0.05) and borderline significance at the multivariate level (P = 0.06) as well on overall screening compliance (P = 0.06). There was not a significant effect on mammography, probably because a majority of the patients were receiving regular mammograms. We also found some important subgroup differences. For example, a larger proportion of women reported Pap tests in the tailored print and counseling group when they believed the materials were 'meant for me.' These results show that a combination of tailored interventions may have potential for reaching the women who have too often been labeled the 'hard to reach.' Incidence rates for many types of cancer are higher among African American men than in the general population, yet African American men are less likely to participate in cancer screening trials. This paper describes the outcomes of a randomized trial (the AAMEN Project) designed to recruit African American men aged 55-74 years to a prostate, lung and colorectal cancer screening trial.
                The recruitment interventions address four types of barriers to clinical trial participation: sociocultural barriers, economic barriers, individual barriers and barriers inherent in study design. Subjects were randomized to a control group or one of three increasingly intensive intervention arms, which used different combinations of mail, phone and in person church-based recruitment.
                Of the 39,432 African American men residing in the geographically defined study population (southeastern Michigan and northern Ohio), 17,770 men (45%) could be contacted, and 12,400 (31% of 39,432) were found to be eligible to participate. No statistically significant differences in age, education or income level were found among participants in the four study arms. A significantly greater enrollment yield (3.9%) was seen in the most intensive, church-based intervention arm, compared to the enrollment yields in the other two intervention arms (2.5 and 2.8%) or the control group (2.9%) (P < 0.01).
                The intervention that involved the highest rate of face-to-face contact with the study participants produced the highest enrollment yield, but several strategies that were thought could improve yield had no effect. These findings, which are consistent with current literature on population-based recruitment, should facilitate the development of future recruitment efforts involving older African American men. A randomized trial was conducted to evaluate the combined impact of a physician reminder letter and a telephone contact on the use of Pap tests and mammograms in a low-income managed care program. Women 40 to 79 years of age who were past due for cancer screening were randomly assigned to an intervention or control group. Medical claims were reviewed after 6 months to determine intervention effectiveness. The odds of receiving all needed cancer screening tests during follow-up were four times higher in the intervention group. Women who reported having to take time off from work to see a doctor had lower odds of getting screened. Women that have a first-degree relative diagnosed with breast cancer at an early age are at increased risk of the disease, yet they often lack information about their personal risk of breast cancer and early detection measures. An intervention to provide objective risk information, reduce worries, and promote screening and healthy behaviors was developed.
                In 1999-2002, a randomized pre-post design was used to test a tailored telephone counseling intervention with a sample of 163 women whose sisters were diagnosed with breast cancer at age 50 or younger in the San Francisco Bay Area. Participants were interviewed by telephone regarding their breast cancer risk factors, perceived risk, worries, lifestyle factors, and screening behavior. A modified Gail model was used to compute an objective measure of individualized lifetime risk.
                Risk overestimates averaged 25 percentage points. The intervention was effective in reducing overestimates in women age 50 and over but not in those under 50. The intervention was effective in increasing physical activity and reinforcing the conviction to maintain good breast health, but not in decreasing worries or increasing screening.
                Telephone counseling appears to be a viable tool for reducing risk overestimates and promoting healthy behaviors among sisters of women with breast cancer.
Most active recruitment strategies for breast cancer screening programs examined in this review were more effective than no intervention. Combinations of effective interventions can have an important effect. Some costly strategies, as a home visit and a letter of invitation to multiple screening examinations plus educational material, were not effective. Further reviews comparing the effective interventions and studies that include cost-effectiveness, women's satisfaction and equity issues are needed.