Comparative Effectiveness of 2 Interventions to Increase Breast, Cervical, and Colorectal Cancer Screening Among Women in the Rural US

Abstract

ImportanceWomen living in rural areas have lower rates of breast, cervical, and colorectal cancer screening compared with women living in urban settings.ObjectiveTo assess the comparative effectiveness of (1) a mailed, tailored digital video disc (DVD) intervention; (2) a DVD intervention plus telephonic patient navigation (DVD/PN); and (3) usual care with simultaneously increased adherence to any breast, cervical, and colorectal cancer screening that was not up to date at baseline and to assess cost-effectiveness.Design, Setting, and ParticipantsThis randomized clinical trial recruited and followed up women from rural Indiana and Ohio (community based) who were not up to date on any or all recommended cancer screenings. Participants were randomly assigned between November 28, 2016, and July 1, 2019, to 1 of 3 study groups (DVD, DVD/PN, or usual care). Statistical analyses were completed between August and December 2021 and between March and September 2022.InterventionThe DVD interactively assessed and provided messages for health beliefs, including risk of developing the targeted cancers and barriers, benefits, and self-efficacy for obtaining the needed screenings. Patient navigators counseled women on barriers to obtaining screenings. The intervention simultaneously supported obtaining screening for all or any tests outside of guidelines at baseline.Main Outcomes and MeasuresReceipt of any or all needed cancer screenings from baseline through 12 months, including breast, cervical, and colorectal cancer, and cost-effectiveness of the intervention. Binary logistic regression was used to compare the randomized groups on being up to date for all and any screenings at 12 months.ResultsThe sample included 963 women aged 50 to 74 years (mean [SD] age, 58.6 [6.3] years). The DVD group had nearly twice the odds of those in the usual care group of obtaining all needed screenings (odds ratio [OR], 1.84; 95% CI, 1.02-3.43; P = .048), and the odds were nearly 6 times greater for DVD/PN vs usual care (OR, 5.69; 95% CI, 3.24-10.5; P < .001). The DVD/PN intervention (but not DVD alone) was significantly more effective than usual care (OR, 4.01; 95% CI, 2.60-6.28; P < .001) for promoting at least 1 (ie, any) of the needed screenings at 12 months. Cost-effectiveness per woman who was up to date was $14 462 in the DVD group and $10 638 in the DVD/PN group.Conclusions and RelevanceIn this randomized clinical trial of rural women who were not up to date with at least 1 of the recommended cancer screenings (breast, cervical, or colorectal), an intervention designed to simultaneously increase adherence to any or all of the 3 cancer screening tests was more effective than usual care, available at relatively modest costs, and able to be remotely delivered, demonstrating great potential for implementing an evidence-based intervention in remote areas of the midwestern US.Trial RegistrationClinicalTrials.gov Identifier: NCT02795104

Patient Navigation Plus Tailored Digital Video Disc Increases Colorectal Cancer Screening Among Low-Income and Minority Patients Who Did Not Attend a Scheduled Screening Colonoscopy: A Randomized Trial

“…Several studies conducted by our team and others tested similar interventions that effectively increased CRC screening uptake [ 24 , 26 , 44 , 58 , 79–81 ]. Prior randomized trials of computer-tailored interventions and telephone-based PN conducted by our team showed that these approaches are highly effective at increasing CRC screening [ 24 , 26 , 58 , 80 ].…”

“…Several studies conducted by our team and others tested similar interventions that effectively increased CRC screening uptake [ 24 , 26 , 44 , 58 , 79–81 ]. Prior randomized trials of computer-tailored interventions and telephone-based PN conducted by our team showed that these approaches are highly effective at increasing CRC screening [ 24 , 26 , 58 , 80 ]. PN has consistently been shown to be effective at increasing completion of screening colonoscopy, especially among minority and low-income populations [ 40 , 44 , 48–50 , 52 , 79 ].…”

“…Both computer-tailored small media (digital video disc, DVD) and PN interventions have been shown to increase uptake of CRC screening and improve bowel preparation, but only one other study has evaluated the additive effect of combining these two approaches for CRC screening [ 58 ]. People differ on the types and levels of intensity of interventions needed to move them to complete CRC screening [ 59 ].…”

The Promise of Cancer Health Justice

“…Most interventions that engage the community to improve colorectal cancer outcomes are focused on improving screening uptake in populations who are due for or overdue for screening. We have previously described effective patient navigation methods and multilevel provider and system-level interventions (including use of multimedia and mailed materials) in increasing uptake of colon cancer screening tools (fecal occult blood testing [FOBT], flexible sigmoidoscopy, colonoscopy) in Black patients, 22 with similar interventions on a larger scale and prospective basis showing promise in rural minoritized populations 23,24 . Hispanic and Latino patients represent an important minority group, as despite generally having lower incidence and mortality from colon cancer, uptake of colorectal cancer screening for this population is below that of non-Hispanic Whites and varies widely by place of origin 25…”

“…We have previously described effective patient navigation methods and multilevel provider and system-level interventions (including use of multimedia and mailed materials) in increasing uptake of colon cancer screening tools (fecal occult blood testing [FOBT], flexible sigmoidoscopy, colonoscopy) in Black patients, 22 with similar interventions on a larger scale and prospective basis showing promise in rural minoritized populations. 23,24 Hispanic and Latino patients represent an important minority group, as despite generally having lower incidence and mortality from colon cancer, uptake of colorectal cancer screening for this population is below that of non-Hispanic Whites and varies widely by place of origin. 25 Patient navigation, use of small media, and community health worker (CHW)-led interventions have been successfully implemented to improve colorectal cancer screening behaviors in Hispanic and Latino patients.…”