Stepwise strategy to improve cervical cancer screening adherence (SCAN-Cervical Cancer) - Automated text messages, phone calls and reminders: Population based randomized controlled trial

Comparative efficacy of telehealth interventions on promoting cancer screening: A network meta-analysis of randomized controlled trials

BACKGROUND

Cancer screening is a pivotal method for reducing mortality from disease, but the screening coverage is still lower than expected. Telehealth interventions demonstrated significant benefits in cancer care, yet there is currently no consensus on their impact on facilitating cancer screening or on the most effective remote technology.

DESIGN

A network meta-analysis was conducted to detect the impact of telehealth interventions on cancer screening and to identify the most effective teletechnologies.

METHODS

Six English databases were searched from inception until July 2023 to yield relevant randomized controlled trials (RCTs). Two individual authors completed the literature selection, data extraction, and methodological evaluations using the Cochrane Risk of Bias tool. Traditional pairwise analysis and network meta-analysis were performed to identify the overall effects and compare different teletechnologies.

RESULTS

Thirty-four eligible RCTs involving 131,644 participants were enrolled. Overall, telehealth interventions showed statistically significant effects on the improvement of cancer screening. Subgroup analyses revealed that telehealth interventions were most effective for breast and cervical cancer screening, and rural populations also experienced benefits, but there was no improvement in screening for older adults. The network meta-analysis indicated that mobile applications, video plus telephone, and text message plus telephone were associated with more obvious improvements in screening than other teletechnologies.

CONCLUSION

Our study identified that telehealth interventions were effective for the completion of cancer screening and clarified the exact impact of telehealth on different cancer types, ages, and rural populations. Mobile applications, video plus telephone, and text message plus telephone are the three forms of teletechnologies most likely to improve cancer screening. More well-designed RCTs involving direct comparisons of different teletechnologies are needed in the future.

CLINICAL RELEVANCE

Telehealth interventions should be encouraged to facilitate cancer screening, and the selection of the optimal teletechnology based on the characteristics of the population is also necessary.

The implementation and mechanisms of advance notification for cancer screening: A scoping review

OBJECTIVE

To describe and synthesise information on the content and delivery of advance notifications (information about cancer screening delivered prior to invitation) used to increase cancer screening participation and to understand the mechanisms that may underlie their effectiveness.

METHODS

Searches related to advance notification and cancer screening were conducted in six electronic databases (APA PsycINFO, CINAHL, Cochrane Library, Embase, PubMed, Web of Science) and results were screened for eligibility. Study characteristics, features of the advance notifications (cancer type, format, delivery time, and content), and the effect of the notifications on cancer screening participation were extracted. Features were summarised and compared across effective versus ineffective notifications.

RESULTS

Thirty-two articles were included in this review, reporting on 33 unique advance notifications. Of these, 79% were sent via postal mail, 79% were distributed prior to bowel cancer screening, and most were sent 2 weeks before the screening offer. Twenty-two full versions of the advance notifications were obtained for content analysis. Notifications included information about cancer risk, the benefits of screening, barriers to participation, social endorsement of cancer screening, and what to expect throughout the screening process. Of the 19 notifications whose effect was tested statistically, 68% were found to increase screening (by 0.7%-16%). Effectiveness did not differ according to the format, delivery time, or content within the notification, although some differences in cancer type were observed.

CONCLUSION

Future research should explore the effectiveness of advance notification via alternative formats and for other screening contexts and disentangle the intervention- and person-level factors driving its effect on screening participation.

Impact of health education intervention on demand of women for cervical cancer screening: a cluster-randomized controlled trial

Background

Cervical cancer is considered preventable disease, though it is the second largest killer of women’s cancer in low and middle-income countries. Despite the government’s attempts to broaden screening facilities, the screening service utilization was poor. Our study evaluated the impact of health education intervention on women’s demand for cervical cancer screening.

Methods

Community-based cluster-randomized controlled trial was conducted in thirty district towns as clusters in Tigray region, Ethiopia. A total of 700 women aged 20 to 60 years were recruited for both groups using simple random sampling from April to July, 2018. After baseline data collection, health education intervention was given to the intervention group by trained health professionals using power point presentation and peer group discussion at the nearest health institution. The health education was given for three days followed by subsequent consultations for 6 months. The outcome variable was demand of women for cervical cancer screening. The intent-to-treat and per-protocol analysis were considered to evaluate the inflation of the loss to follow-up on effect size. Chi-square test was used to assess the difference of variables between control and intervention groups at baseline data. Finally, difference in difference analysis was used to see the true effect of the intervention on outcome variable.

Results

A total of 674 participants (340 in intervention and 334 in control groups) were able to complete the follow-up, making a response rate of 96.3%. At baseline, the differences in proportion of all outcome variables in control and intervention groups were not statistically significant. After follow-up, a statistically significant difference between control and intervention groups was observed in the proportion of willingness to screen (p value = 0.000), having plan to screen (p value = 0.000), ever screened (p value = 0.000), and the overall demand for cervical cancer screening (p value = 0.000). Finally, the impact of intervention was explained by the difference in differences in the proportion of willingness to screen (36.6%) (p value < 0.000), having plan to screen (14.6%) (p value < 0.000), ever screened (16.9%) (p value < 0.000), and overall demand for cervical cancer screening (36.9%) (p value < 0.000).

Conclusion

This study revealed that health education intervention could increase in overall demand of women for cervical cancer screening. Thus, it would be helpful to consider health education in health planning and service provision.

Trial registration

The registration number is PACTR201808126223676; date registered: 23 April 2018, and the type is “retrospectively registered.”

Supplementary Information

The online version contains supplementary material available at 10.1186/s13063-022-06765-0.

Effect of Text Message Reminders on Attendance at Cervical Cancer Screening Appointments in a Predominantly Hispanic Population

Hispanic women have the highest rates of incident cervical cancer in the United States (U.S.) and are 1.9 times more likely to die from cervical cancer than non-Hispanic Whites. Objective: Assess the impact of text message reminders on cervical cancer screening attendance and completion. Design: Pragmatic non-randomized study design using propensity matched analysis. Setting: Community-dwelling low-income females in the U.S./Mexico border community. A total of 2,255 mainly Hispanic females aged 21-65. Methods: Text message reminders in addition to usual care (telephone call reminders). Results: After adjusting for significant factors and propensity score matching, individuals in the text reminder group had 11% lower screening incidence than individuals without text reminders (risk difference [RD] = -0.11, 95% CI: -0.16, -0.05; p < .001). Conclusion: Participants with text reminders were less likely to complete cervical screening than usual practice in a predominantly Hispanic population. Our study demonstrates that reminders' content rather than method may be vital to improving our population's cancer screening rates.

Interventions targeted at women to encourage the uptake of cervical screening

BACKGROUND

This is an update of the Cochrane review published in Issue 5, 2011. Worldwide, cervical cancer is the fourth commonest cancer affecting women. High-risk human papillomavirus (HPV) infection is causative in 99.7% of cases. Other risk factors include smoking, multiple sexual partners, the presence of other sexually transmitted diseases and immunosuppression. Primary prevention strategies for cervical cancer focus on reducing HPV infection via vaccination and data suggest that this has the potential to prevent nearly 90% of cases in those vaccinated prior to HPV exposure. However, not all countries can afford vaccination programmes and, worryingly, uptake in many countries has been extremely poor. Secondary prevention, through screening programmes, will remain critical to reducing cervical cancer, especially in unvaccinated women or those vaccinated later in adolescence. This includes screening for the detection of pre-cancerous cells, as well as high-risk HPV. In the UK, since the introduction of the Cervical Screening Programme in 1988, the associated mortality rate from cervical cancer has fallen. However, worldwide, there is great variation between countries in both coverage and uptake of screening. In some countries, national screening programmes are available whereas in others, screening is provided on an opportunistic basis. Additionally, there are differences within countries in uptake dependent on ethnic origin, age, education and socioeconomic status. Thus, understanding and incorporating these factors in screening programmes can increase the uptake of screening. This, together with vaccination, can lead to cervical cancer becoming a rare disease.

OBJECTIVES

To assess the effectiveness of interventions aimed at women, to increase the uptake, including informed uptake, of cervical screening.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL), Issue 6, 2020. MEDLINE, Embase and LILACS databases up to June 2020. We also searched registers of clinical trials, abstracts of scientific meetings, reference lists of included studies and contacted experts in the field.

SELECTION CRITERIA

Randomised controlled trials (RCTs) of interventions to increase uptake/informed uptake of cervical screening.

DATA COLLECTION AND ANALYSIS

Two review authors independently extracted data and assessed risk of bias. Where possible, the data were synthesised in a meta-analysis using standard Cochrane methodology.

MAIN RESULTS

Comprehensive literature searches identified 2597 records; of these, 70 met our inclusion criteria, of which 69 trials (257,899 participants) were entered into a meta-analysis. The studies assessed the effectiveness of invitational and educational interventions, lay health worker involvement, counselling and risk factor assessment. Clinical and statistical heterogeneity between trials limited statistical pooling of data. Overall, there was moderate-certainty evidence to suggest that invitations appear to be an effective method of increasing uptake compared to control (risk ratio (RR) 1.71, 95% confidence interval (CI) 1.49 to 1.96; 141,391 participants; 24 studies). Additional analyses, ranging from low to moderate-certainty evidence, suggested that invitations that were personalised, i.e. personal invitation, GP invitation letter or letter with a fixed appointment, appeared to be more successful. More specifically, there was very low-certainty evidence to support the use of GP invitation letters as compared to other authority sources' invitation letters within two RCTs, one RCT assessing 86 participants (RR 1.69 95% CI 0.75 to 3.82) and another, showing a modest benefit, included over 4000 participants (RR 1.13, 95 % CI 1.05 to 1.21). Low-certainty evidence favoured personalised invitations (telephone call, face-to-face or targeted letters) as compared to standard invitation letters (RR 1.32, 95 % CI 1.11 to 1.21; 27,663 participants; 5 studies). There was moderate-certainty evidence to support a letter with a fixed appointment to attend, as compared to a letter with an open invitation to make an appointment (RR 1.61, 95 % CI 1.48 to 1.75; 5742 participants; 5 studies). Low-certainty evidence supported the use of educational materials (RR 1.35, 95% CI 1.18 to 1.54; 63,415 participants; 13 studies) and lay health worker involvement (RR 2.30, 95% CI 1.44 to 3.65; 4330 participants; 11 studies). Other less widely reported interventions included counselling, risk factor assessment, access to a health promotion nurse, photo comic book, intensive recruitment and message framing. It was difficult to deduce any meaningful conclusions from these interventions due to sparse data and low-certainty evidence. However, having access to a health promotion nurse and attempts at intensive recruitment may have increased uptake. One trial reported an economic outcome and randomised 3124 participants within a national screening programme to either receive the standard screening invitation, which would incur a fee, or an invitation offering screening free of charge. No difference in the uptake at 90 days was found (574/1562 intervention versus 612/1562 control, (RR 0.94, 95% CI: 0.86 to 1.03). The use of HPV self-testing as an alternative to conventional screening may also be effective at increasing uptake and this will be covered in a subsequent review. Secondary outcomes, including cost data, were incompletely documented. The majority of cluster-RCTs did not account for clustering or adequately report the number of clusters in the trial in order to estimate the design effect, so we did not selectively adjust the trials. It is unlikely that reporting of these trials would impact the overall conclusions and robustness of the results. Of the meta-analyses that could be performed, there was considerable statistical heterogeneity, and this should be borne in mind when interpreting these findings. Given this and the low to moderate evidence, further research may change these findings. The risk of bias in the majority of trials was unclear, and a number of trials suffered from methodological problems and inadequate reporting. We downgraded the certainty of evidence because of an unclear or high risk of bias with regards to allocation concealment, blinding, incomplete outcome data and other biases.

AUTHORS' CONCLUSIONS

There is moderate-certainty evidence to support the use of invitation letters to increase the uptake of cervical screening. Low-certainty evidence showed lay health worker involvement amongst ethnic minority populations may increase screening coverage, and there was also support for educational interventions, but it is unclear what format is most effective. The majority of the studies were from developed countries and so the relevance of low- and middle-income countries (LMICs), is unclear. Overall, the low-certainty evidence that was identified makes it difficult to infer as to which interventions were best, with exception of invitational interventions, where there appeared to be more reliable evidence.

Interventions using mHealth strategies to improve screening rates of cervical cancer: A scoping review

MHealth interventions are extensively used to inform and remind women about cervical cancer and their upcoming screening appointments. Our scoping review aims to examine the effectiveness these interventions targeted to increase the uptake of cervical cancer screening along with its barriers and facilitators. We searched 4 databases (PsycINFO. PUBMED, CINAHL, and MEDLINE) for studies that were published between January 1, 2009 and October 2019. References were further screened manually for additional papers. Studies were included in the review if they used interventions including phone calls, text messages and mobile applications as their primary strategy to contact women. We identified 12 unique studies that met the inclusion criteria; seven were international studies. Most studies sent multiple messages (informative and reminder) and/or made numerous phone calls (manual/automated) to inform participants about cervical cancer screening, their nearest screening clinic, and their upcoming appointments. Five studies documented a significant increase in the uptake of cervical cancer screenings during the follow-ups conducted within 12 months. Qualitative studies suggested participants prefer particular communication mediums, and they were concerned about privacy and confidentiality issues when text messages were sent with their health information. Findings suggest mHealth interventions may be an effective strategy to reach women for improving their cervical cancer uptake. Barriers including transportation cost, inaccessibility, and inability to come for walk-in appointments in the health clinics need to be addressed, beyond reminders, in mobile phone-based interventions to facilitate their presence in their next appointment.

Assessing the implementation of interventions addressing socioeconomic inequalities in cancer screening in high-income countries

Background: The context of an intervention may influence its effectiveness and success in meeting the needs of the targeted population. Implementation science frameworks have been developed, but previous literature in this field has been mixed. This paper aimed to assess the implementation success of interventions, identified from a systematic review, that reduced inequalities in cancer screening between people in low and high socioeconomic groups.

Design and Methods: The implementation framework by Proctor et al. was utilised to assess the potential success of 6 studies reporting on 7 interventions in the “real-world” environment. A standardised rating system to identify the overall implementation success of each intervention was established.

Results: Four interventions (57%) demonstrated high potential to be implemented successfully. Interventions included enhanced reminder letters and GP-endorsed screening invitations, containing evidence on the acceptability, from participants and stakeholders, appropriateness and direct cost of the intervention.

Conclusion: While some interventions reduced socioeconomic inequalities in cancer screening participation, there have been missed opportunities to integrate the experiences of the targeted population into design and evaluation components. This has limited the potential for transferability of outcomes to other settings.

The impact of interventions addressing socioeconomic inequalities in cancer-related outcomes in high-income countries: A systematic review

Background: High cancer mortality is a major source of burden. Population-wide programs have been developed to improve cancer outcomes, and although effective in improving outcomes overall, the socioeconomically disadvantaged population have disproportionately benefited. This systematic review evaluated interventions aimed at addressing inequalities in cancer-related outcomes between low and high socioeconomic groups within high-income countries. Materials and Methods: The Cochrane Register of Controlled Trials, EMBASE, and PubMed searches were completed in October 2018. Data extraction and quality appraisal were guided by established mechanisms. Impact of interventions, using odds ratios, with respective 95% confidence intervals were presented, where available. Results: Sixteen studies reporting on 19 interventions were included. Seven interventions (37%) reduced socioeconomic inequalities in cancer-related outcomes, focusing on participation in cancer screening. Interventions included pre-formulated implementation intentions; GP-endorsed screening invitations; enhanced reminder letters; text message reminders; and implementation of an organised screening program. Conclusions: This systematic review found limited evidence on the efficacy of existing interventions that aimed to reduce inequalities in cancer-related outcomes between people living in low and high socioeconomic areas among high-income countries. Future interventions should consider the specific needs of people living in socioeconomically disadvantaged areas to improve the efficacy of an intervention.

Cost-effectiveness of a stepwise intervention to promote adherence to cervical cancer screening

BACKGROUND

Cervical cancer screening is effective in reducing mortality, but adherence is generally low. We aimed to investigate the cost-effectiveness of a stepwise intervention to promote adherence to cervical cancer screening in Portugal.

METHODS

We developed a decision tree model to compare the cost-effectiveness of four competing interventions to increase adherence to cervical cancer screening: (i) a written letter (standard-of-care); (ii) automated short message service text messages (SMS)/phone calls/reminders; (iii) automated SMS/phone calls/reminders + manual phone calls; (iv) automated SMS/phone calls/reminders + manual phone calls + face-to-face interviews. The main outcome measure was cost per quality-adjusted life year (QALY) measured over a 5-year time horizon. Costs were calculated from the societal and provider perspectives.

RESULTS

From the societal perspective, the optimal strategy was automated SMS/phone calls/reminders, below a threshold of €8171 per QALY; above this and below €180 878 per QALY, the most cost-effective strategy was automated SMS/phone calls/reminders + manual phone calls and above this value automated SMS/phone calls/reminders + manual phone calls + face-to-face interviews. From the provider perspective, the ranking of the three strategies in terms of cost-effectiveness was the same, for thresholds of €2756 and €175 463 per QALY, respectively.

CONCLUSIONS

Assuming a willingness-to-pay threshold of one time the national gross domestic product (€22 398/QALY), automated SMS/phone calls/reminders + manual phone calls is a cost-effective strategy to promote adherence to cervical cancer screening, both from the societal and provider perspectives.

A 3-step intervention to improve adherence to cervical cancer screening: The SCAN randomized controlled trial

The aim of this study was to test the effectiveness of a stepwise intervention with an increasing level of complexity and cost to increase adherence to organized cervical cancer screening. This was a randomized (1: 1) controlled trial, conducted among 13 Portuguese primary health care units. Participants (n = 1220) were women aged 25-49 years, eligible for cervical cancer screening, with a mobile phone number available. The tested intervention was a 3-step invitation to screening, based on automated text messages/phone calls (step 1), manual phone calls (step 2) and face-to-face interviews (step 3), applied sequentially to non-adherent women after each step. Participants in the control group were invited through a written letter (standard of care). The primary outcome was the proportion of women screened, which was assessed after step 1 (45 days after the initial invitation), steps 1 + 2 (90 days after the initial invitation) and steps 1 + 2 + 3 (150 days after the initial invitation). Adherence to cervical cancer screening was significantly higher among women assigned to the intervention than those in the control group for step 1 (39.9% vs. 25.7%, p < 0.001), steps 1 + 2 (48.6% vs. 30.7%, p < 0.001) and steps 1 + 2 + 3 (51.2% vs. 34.0%, p < 0.001). In conclusion, adherence to cervical cancer screening was higher by 17% among women invited through the 3-step intervention, compared to those receiving the standard invitation letter. The former strategy has the potential to be broadly implemented due to the low requirements of technology and training. Clinical Trial Registration: NCT03122275.