Effectiveness of patient-targeted interventions to increase cancer screening participation in rural areas: A systematic review

Abstract

Background

Cancer is a major public health problem worldwide. The GLOBOCAN estimated 18.1 million new cases of cancer and 9.6 million deaths from cancer in 2018. In some of the more frequent cancers, mortality can be significantly reduced through cancer screening programs. Nevertheless, socially disadvantaged groups have difficulties in benefitting from these screening programs, especially rural populations.

Objective

To identify, characterize and summarize patient-targeted interventions aimed at increasing cancer screening participation among rural populations.

Methods

An exhaustive literature search was performed in the most relevant bibliographic databases for biomedical research. The systematic review was reported according to the PRISMA guidelines.

Results

Twenty studies assessing 37 interventions were identified. Most of the studies were conducted in the United States and targeted women. Ninety-seven percent of the interventions were aimed at increasing community demand, 65% community access and 11% provider delivery. Our findings suggest that 21 of the 37 interventions using a multicomponent approach were effective in increasing breast, cervical and colorectal cancer screening in rural areas.

Conclusions

Multicomponent interventions were effective in increasing breast, cervical and colorectal cancer screening among rural populations, and nurse-led interventions contributed to improving cancer screening participation. Moreover, the involvement of communities in the development of interventions can facilitate the participation in cancer screening programs among rural residents.

Introduction

Cancer is a major public health problem worldwide and is the second most prevalent cause of death in every region of the world, and irrespective of the level of human development. In 2019, 1,762,450 new cancer cases and 606,880 cancer deaths are estimated to occur in the United States (Islami et al., 2017). The GLOBOCAN 2018 report included a database for 185 countries and 36 cancers. This report estimated 18.1 million new cases of cancer and 9.6 million deaths from cancer in 2018. The cumulative risk of incidence, even in low human development settings, indicates that 1 in 8 men and 1 in 10 women will develop the disease at some point in their lifetimes (Bray et al., 2018). Therefore, countries worldwide have to implement preventive measures to reduce the cancer burden in the future.

Observational and experimental studies demonstrate that screening for breast, cervical and colorectal cancer reduces mortality (Moyer, 2012, Nelson et al., 2016a, Nelson et al., 2016b, Slattery et al., 2016). One main clinical benefit of screening is that precancerous lesions can be identified and removed before they develop into cancer. Observational studies of population-based mammography screening reported a 25–31% reduction in breast cancer mortality (Nelson et al., 2016a, Nelson et al., 2016b). Also, correlational studies of cervical cancer in North America and Europe have shown a 20–60% reduction in cervical cancer mortality since the introduction of widespread screening (Moyer, 2012). As regards colorectal cancer, screening also decreases its incidence and mortality by 30–60% (Whitlock et al., 2008).

Based on the available evidence, breast cancer screening is recommended to women aged 50–74 years old with biennial mammography (Nelson et al., 2016a, Nelson et al., 2016b). Cervical cancer screening is recommended for women aged 21–65 years old with cytology (Pap smear) every 3 years, or for women aged 30–65 years old who want to lengthen the screening interval, screening with a combination of cytology and human papillomavirus (HPV) testing every 5 years (Moyer, 2012). And colorectal cancer screening is recommended for adults between 50 and 75 years old with fecal occult blood test (FOBT) or fecal immunochemical test (FIT), flexible sigmoidoscopy or colonoscopy (Lin et al., 2016). A recent meta-analysis of over three-quarters of a million participants in flexible sigmoidoscopy and fecal occult blood test (FOBT) showed that in these trials, flexible sigmoidoscopy uniquely and consistently reduced deaths attributed to colorectal cancer (Swartz et al., 2019). However, these recommendations differ between organizations and countries on the basis of evidence of benefits and harms, and the differences in values, priorities, resources and the type of evidence considered by each organization or country (Basu et al., 2018, Ebell et al., 2018, Klarenbach et al., 2018, Shimizu et al., 2016).

Systematic reviews showed there are effective interventions for increasing screening for breast, cervical and colorectal cancers in the general population (Sabatino et al., 2012). In 2016, the Community Preventive Task Force recommended multicomponent interventions to increase screening for breast, cervical and colorectal cancers based on a systematic review (Community Preventive Services Task Force, 2016). Multicomponent interventions combine two or more approaches to increase: (a) community demand (group education, one-on-one education, client reminders, mass media, and small media (videos, printed materials, etc.); (b) community access (reduce client out-of-pocket costs or interventions to reduce structural barriers) and (c) provider delivery (provider reminders, provider incentives, provider assessment and feedback). Additionally, an important element to consider for the effectiveness of these interventions is who provides the intervention. Some studies reported that nurse-delivered interventions improve participation in cancer screening (Ersin and Bahar, 2017, Secginli and Nahcivan, 2011), and this evidences the crucial role of nursing in the cancer screening process. According to the International Council of Nurses, nurses can develop secondary prevention activities by promoting cancer screening through health education, encouraging patients to participate in cancer screening programs and participating in screening activities, with the aim of increasing the participation of population in cancer screening programs (International Council of Nurses, 2010).

Literature has shown that people living in rural communities have a poorer prognosis for a variety of health conditions and life expectancy than those who live in urban areas due to, for example, differences in health risks, difficulties in health services access because of longer distances, limited transportation options, etc. (Smith et al., 2008). These disparities also affect cancer mortality, with an adjusted cancer survival rate that is 5–7% lower than their urban counterparts (Sabesan and Piliouras, 2009). Although the effectiveness of this screening has been demonstrated in the general population, it has not been yet been demonstrated in socially disadvantaged groups, particularly in rural areas.

According to our knowledge, systematic reviews that evaluate the effectiveness of interventions aimed at increasing cancer screening participation have not examined inequalities between urban and rural areas. Hence, the aim of this systematic review of clinical trials was to evaluate the effectiveness of patient-targeted interventions for improving cancer screening participation in rural areas.