Cancer Screening: Patient Navigation Services to Increase Breast Cancer Screening and Advance Health Equity

Related Pages

Findings and Recommendations

The Community Preventive Services Task Force (CPSTF) recommends interventions that engage community health workers to increase screening for breast cancer by mammography. Evidence shows these interventions increase breast cancer screening rates when community health workers deliver them independently or as part of an implementation team.

Interventions that engage community health workers to increase breast cancer screening are typically implemented in underserved communities to improve health and can enhance health equity.

The full CPSTF Finding and Rationale Statement and supporting documents for Cancer Screening: Interventions Engaging Community Health Workers — Breast Cancer are available in The Community Guide Collection on CDC Stacks.

Intervention

Interventions that engage community health workers (CHWs) to increase breast cancer screening implement one or more interventions reviewed by the CPSTF to do the following:

CHWs are trained frontline health workers who serve as a bridge between communities and healthcare systems. They are from, or have a close understanding of, the community served. They often receive on-the-job training and work without professional titles. Organizations may hire CHWs or recruit volunteers to act in this role. CHWs may work alone or as part of an intervention team that includes other healthcare professionals.

About The Systematic Review

The CPSTF recommendation is based on evidence from a systematic review of 66 studies (search period through July 2017). Included studies evaluated intervention effects on breast (36 studies), cervical (29 studies), or colorectal (17 studies) cancer screening use services recommended by the U.S. Preventive Services Task Force (2016a, 2018, 2016b, respectively).

The systematic review was conducted on behalf of the CPSTF by a team of specialists in systematic review methods, and in research, practice, and policy related to cancer prevention and control.

Study Characteristics

  • Studies were conducted in urban and rural areas of the United States (62 studies) and other high-income countries (8 studies).
  • Participants reported a mean age of 53 years and represented African American, Hispanic, Asian American, and white populations.

Summary of Results

The systematic review included 66 studies. Studies evaluated intervention effects on breast (36 studies), cervical (29 studies), or colorectal (17 studies) cancer screening use.

Breast Cancer Screening

  • Interventions that engaged community health workers, alone or as part of a team, increased breast cancer screening by a median of 12.7 percentage points when compared with no intervention or usual care (35 studies).

Breast, Cervical, or Colorectal Cancer Screening

The following results are based on an analysis of all included studies across breast, cervical, or colorectal cancer screening. Stratified analyses were performed for each cancer type and findings were comparable.

  • When compared to interventions that increase community demand or access alone, interventions that aimed to both increase community demand, and access to, screening services reported the largest increases in screening rates (median increase of 18.5 percentage points, 22 studies with 24 study arms).
  • Interventions engaged community health workers to implement between one and six intervention components.
    • While all of the studies reported increases in cancer screening, larger increases were seen when community health workers implemented more intervention components.
    • Interventions that provided group education produced larger increases in cancer screening (15.0 percentage points, 31 studies with 35 study arms) than those that provided one-on-one education (9.8 percentage points, 37 studies with 42 study arms).
    • Among studies that aimed to increase access to screening services, larger increases were reported when community health workers assisted with translation (30.2 percentage points, 4 studies with 4 study arms) or transportation barriers (26.8 percentage points, 9 studies with 9 study arms).
  • Lower baseline screening rates were associated with greater increases.

Summary of Economic Evidence

The systematic review of economic evidence included five studies specific to breast cancer screening by mammography (search period through April 2019). Monetary values are reported in 2018 U.S. dollars.

  • There was not enough economic evidence to determine cost-effectiveness for interventions engaging CHWs to increase breast cancer screening because none of the included studies reported incremental cost per quality-adjusted life year gained.
  • The median cost per person was $1,578 for an intervention in the United Kingdom during which CHWs promoted cancer screening and helped clients manage chronic conditions, such as asthma and diabetes.
  • The median cost per person was $58 for CHW interventions in the United States (2 studies).
  • The median incremental cost per additional woman screened was $215 in the United States (1 study) and $7,891 in the United Kingdom (1 study of a comprehensive CHW intervention).

Applicability

Based on results from the systematic review, findings are applicable to all adults and adults aged 65 years or older with different baseline screening statuses, across educational levels, employment, and insurance status.

Evidence suggests programs can be offered in urban or rural settings, include different intervention components, and be delivered by a range of providers who work alone or as part of a team.

Evidence Gaps

CPSTF identified several areas that have limited information. Additional research and evaluation could help answer the following questions and fill remaining gaps in the evidence base. Evidence gaps were identified for breast, cervical, and colorectal cancer screenings. (What are evidence gaps?)

CPSTF identified the following questions as priorities for research and evaluation:

  • How effective are patient navigation services in increasing the following?
    • Repeat screenings (the U.S. Preventive Services Task Force recommends repeating breast, cervical, and colorectal cancer screenings at appropriate intervals [USPSTF 2016, 2018, 2021]); the included studies examined one-time screenings
    • The proportion of patients with positive screening tests who receive follow-up diagnostic tests
    • Cervical cancer screening for younger females (USPSTF recommends females start regular cervical cancer screening at age 21 years [USPSTF 2018]); the included studies recruited participants with a median age of 59.5 years.
  • What is the cost-effectiveness of patient navigation services to increase cervical cancer screening?

Remaining questions for research and evaluation identified by CPSTF:

  • How effective are patient navigation services in increasing the following?
    • Cervical cancer screening that includes HPV tests (following the 2018 update from USPSTF that recommended high risk HPV testing alone or in combination with cytology for women aged 30 to 65 years)
    • Colorectal cancer screening for adults aged 45-49 years (following the 2021 update from USPSTF that lowered the starting age for colorectal cancer screenings)
    • Colorectal cancer screening using other USPSTF-recommended tests such as the stool DNA test, flexible sigmoidoscopy, or computed tomography colonography
  • Does intervention effectiveness vary by the following?
    • Participants’ health literacy
    • Number of interactions between service deliverers and participants
  • What is the precise economic impact of patient navigation services within comprehensive health promotion interventions?

Implementation Considerations and Resources

The following considerations for implementation are drawn from studies included in the evidence review, the broader literature, and expert opinion. They apply to interventions engaging community health workers to increase breast, cervical, or colorectal cancer screening.

  • While these interventions were effective across a wide range of settings and population groups, greater increases in screening were seen in the included studies when:
    • More than two components were used
    • Components increased both demand for, and access to, screening services
    • Group education was offered instead of one-on-one education
  • Interventions that engage community health workers were effective across all population groups examined and can be modified for specific populations.
    • Interventions can be modified to target population groups experiencing screening disparities, usually minority groups, or groups with low income or no insurance
    • Reducing structural barriers may be especially effective. Programs may want to consider:
      • Providing language translation services to largely non-English speaking populations
      • Offering transportation services to populations without ready access to healthcare services