Remote Interventions Increase Cancer Screening Rates Among Women Living in Rural Areas

Victoria L. Champion, PhD, RN

Remote interventions, including an educational DVD, and patient navigation services, increased the 12-month breast, cervical, and colorectal cancer screening rates among women living in rural areas, according to findings from a in a randomized clinical trial (NCT02795104) published in JAMA Network Open.¹

This trial included 963 women between the ages of 54 and 74 years and demonstrated that providing a tailored DVD intervention significantly increased the odds that that the recipient would obtain all their needed screenings compared with usual care (odds ratio [OR], 1.84; 95% CI, 1.02-3.43; P = .048). However, patients who received the tailored DVD and telephonic patient navigation (DVD/PN) were approximately 6 times more likely to obtain all their necessary screenings than patients who received usual care (OR, 5.69; 95% CI, 3.24-10.50; P < .001). Compared with women who received the DVD intervention only, women the DVD/PN group were 3 times more likely to obtain all recommended screenings (OR, 3.09; 95% CI, 2.05-4.68; P < .01).

Investigators also conducted a cost analysis to assess the additional costs of these interventions. After excluding research costs, they found that the DVD intervention resulted in a total cost of $326,012 and the patient navigation service added $344,829. On an individual basis, the cost-effectiveness per women who was up to date on their screenings was $14,462 in the DVD group and $10,638 in the DVD/PN group.

“Our findings demonstrate that interventions delivered remotely to rural women can simultaneously improve screening rates for breast, cervical, and colorectal cancer,” Victoria L. Champion, PhD, RN, of the School of Nursing and Indiana University Comprehensive Cancer Center, and co-investigators, wrote in the study. “While participants receiving only the DVD intervention were almost twice as likely to be up to date with all cancer screenings, the addition of a patient navigator was almost 6 times more effective than usual care, supporting the importance of patient navigation.”

Residents in rural areas are less likely to be up to date for screenings outlined in the Healthy People 2023 goals.^1,2 Consequently, individuals who live in rural sectors (fewer than 10,000 residents) have a 12-point higher crude cancer mortality rate, compared with individuals who live in large metropolitan areas (more than 1 million residents).³

To that end, researchers based in the Midwest sought to assess the effectiveness of 2 interventions against usual care (no intervention) to see whether there was any benefit in improved breast, cervical, and colorectal cancer screening rates.¹ The trial recruited women who lived in rural communities in Indiana and Ohio who were not up to date with their recommended cancer screenings. The US Preventive Task Force Recommendations were used to define screening status and included biennial mammography for women between 50 and 74 years of age, cervical cytology every 3 years via Papanicolaou and human papillomavirus test or cotesting completed every 5 years for women aged 21 to 65 years, and colorectal screening via either an annual fecal occult blood test or fecal immunochemical test or with a colonoscopy every 10 years.

Participants were enrolled between November 28, 2016, and July 1, 2019, and randomly assigned to 1 of the 3 study groups—usual care, the DVD intervention, or DVD/PN group. At baseline, all participants completed a survey to verify their screening status.

Investigators developed the DVD that was sent out. This DVD was interactive, and allowed users to respond to prompts and received personalized feedback to encourage the update of necessary screenings. These DVDs were also personalized. Each one provided tailored messages specific to the woman’s age, family history of cancer, perceived risk of developing the specific cancers, as well as barriers, benefits, and self-efficacy with regard to the respective screening behavior. The educational product also broke down different screening options and explained the different scheduling processes.

Patients who were in the DVD/PN group were contacted by a patient navigator within 4 weeks of video receipt. These navigators were social workers who confirmed DVD receipt, promoted the information provided in the DVD, and counseled women on any identified screening barriers. Additional phone calls were made if necessary. The mean number of calls was 3 (range, 1-14).

Overall, in a covariate-adjusted model, the DVD/PN intervention was significantly more effective than usual care in promoting an up-to-date screening status at 12 months follow-up (OR, 4.01; 95% CI, 2.60-6.28; P < .001). The DVD intervention improved screening rates numerically, but the change was not determined to be statistically significant.

Some limitations of this study included the highly educated and predominately White study sample, which infringe on the study’s translation to a more diverse and less educated population. However, it is worth noting that the DVD was narrated to make it assessable to all, regardless of education level.

Moreover, although the intervention increased costs overall, the authors asserted that by improving screening there may be cost savings for treatment at more advanced stages and reduced mortality rates.

“The DVD/PN intervention was more cost-effective in bringing participants up to date with all needed tests due to the greater effect size,” study authors concluded. “Compared with treating cancer, the costs of each intervention to bring women up to date with screening were relatively modest as, on average, cancer treatment costs $150,000 per patient in the [United States], and costs of the intervention would be lower per person at a larger scale. Thus, the additional costs required for the addition of [patient navigator] to improve screening may result in cost savings by avoiding cancer deaths or treatment at more advanced stages.”

References

1. Champion VL, Paskett ED, Stump TE, et al. Comparative effectiveness of 2 interventions to increase breast, cervical, and colorectal cancer screening among women in the rural US: a randomized clinical trial. JAMA Netw Open. 2023;6(4):e2311004. doi:10.1001/jamanetworkopen.2023.11004
2. Healthy People 2030: cancer. Office of Disease Prevention and Health Promotion. Accessed May 23, 2023. https://health.gov/healthypeople/objectives-and-data/browse-objectives/cancer
3. Callaghan TH, Ferdinand AO, Towne SD Jr, Akinlotan M, Primm K, Bolin J. Cancer mortality in rural America 1999-2016. November 2018. Accessed May 23, 2023. https://srhrc.tamu.edu/publications/cancer-mortality-in-rural-america-policy-brief.pdf