Cancer Screening: Reducing Structural Barriers for Clients — Breast Cancer

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Findings and Recommendations

The Community Preventive Services Task Force (CPSTF) recommends interventions to reduce structural barriers to increase screening for breast cancers (by mammography) on the basis of strong evidence of effectiveness.

The full CPSTF Finding and Rationale Statement and supporting documents for Cancer Screening: Reducing Structural Barriers for Clients — Breast Cancer are available in The Community Guide Collection on CDC Stacks.

Intervention

Structural barriers are non-economic burdens or obstacles that make it difficult for people to access cancer screening. Interventions designed to reduce these barriers may facilitate access to cancer screening services by:

  • Reducing time or distance between service delivery settings and target populations
  • Modifying hours of service to meet client needs
  • Offering services in alternative or non-clinical settings (e.g., mobile mammography vans at worksites or in residential communities)
  • Eliminating or simplifying administrative procedures and other obstacles (e.g., scheduling assistance, patient navigators, transportation, dependent care, translation services, limiting the number of clinic visits)

Such interventions often include one or more secondary supporting measures, such as printed or telephone reminders, education about cancer screening, information about screening availability, or measures to reduce out-of-pocket costs to the client.

About The Systematic Review

The CPSTF finding is based on evidence from a Community Guide systematic review published in 2008 (Baron et al., 7 studies, search period 1966-2004) combined with more recent evidence (1 study, search period 2004-2008).

Study Characteristics

The study from the updated search period evaluated a 1-day community celebration in Hawaii with personalized recruitment, one-on-one “talk story” education sessions, and culturally relevant education brochures. Other health issues also were discussed (e.g., prostate and colorectal cancer screening).

Summary of Results

Results of the Original Review

The original breast cancer screening review included seven studies.

  • Mammography screening: median increase of 17.7 percentage points (interquartile interval [IQI]: 11.5 to 30.5 percentage points)

Results of the Updated Review

One additional study qualified for the updated review.

  • Mammography screening: increase of 18 percentage points
  • Clinical breast examinations: increase of 34 percentage points

Summary of Economic Evidence

Six studies qualified for the review. Monetary values are presented in 2009 U.S dollars.

  • Cost per woman screened from a mobile mammography program ranged from $63.09 to $150.50, depending on the number of women screened and the year of program operation (4 studies). Due to one-time, fixed costs associated with program implementation, the first year of program operation is generally more expensive
  • One study found the benefits of mobile screening outweighed the costs when distances traveled were greater than 15 miles
  • Another study reported the cost per additional screening was $208 for mobile film mammography and $267 for mobile digital mammography

Applicability

The CPSTF recommendation should apply across a range of populations and settings, provided that the program is adapted to the target population and delivery context.

Evidence Gaps

The following outlines evidence gaps for interventions to reduce structural barriers to increase breast, cervical, or colorectal cancer screening.

  • Are interventions effective for promoting colorectal cancer screening with methods other than FOBT?
  • Are interventions to promote colorectal cancer screening equally effective when addressing colorectal cancer screening more generally, as when specific to one type of test?
  • What are the incremental effects of adding intervention components to other interventions?
  • What influence do newer methods of communication (e.g., the Internet, e-mail, social media, automated interactive voice response, texting) have on intervention effectiveness?
  • What is the influence of health system factors on intervention effectiveness?

Implementation Considerations and Resources

  • Specialized resources are required to provide mobile mammography services
  • Alternative screening sites need to be identified
  • Adequate staffing is required for alternate sites or extended hours
  • When test results are abnormal, follow-up must be provided to clients lacking access to regular care

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