President's Cancer Panel

Closing Gaps in Cancer Screening:

Connecting People, Communities, and Systems to Improve Equity and Access

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Goal 1: Improve and Align Cancer Screening Communication

General awareness of cancer screening in the United States is high, and a large proportion of people believe regular screening is important and can save lives.1 A substantial portion of Americans undergo regular screening for cancer, leading to the early detection of many cancers and precancers. Despite this, many people are missing out on the benefits of cancer screening. Although many factors influence screening uptake, understanding the benefits and options for screening and knowing how to access it are critical. The public and healthcare providers alike need to have accurate, digestible, and actionable information about cancer screening.

Recommendation 1.1

Develop effective communications about cancer screening that reach all populations.

Communications campaigns and education have increased awareness of cancer screening, particularly for more established screening tests for breast, cervical, and colorectal cancer screening. However, lack of knowledge and misconceptions about screening have been reported among many populations with low rates of cancer screening, including racial/ethnic minority groups, individuals with low income or low educational achievement, and populations with low access to healthcare (e.g., living in rural/remote areas, lacking health insurance).2-4

A renewed commitment to effective large- and small-scale targeted communications about cancer screening is needed to ensure that screening reaches all populations. Communications about cancer screening should be developed and disseminated in ways that empower people to apply information to make decisions about their health and increase the likelihood they will adopt proven interventions. Use of a four-part health literacy framework has been suggested to guide health communications about screening (Figure 3).5

Figure 3

Health Literacy Framework

Access

Make it easy for people to find or be exposed to information about screening. Disseminate information through outlets that are used and trusted by target populations. Multiple outlets should be used to maximize reach (e.g., radio, television, social media, newspaper, pamphlets, healthcare settings).

Understand

Use plain language that is easy to comprehend across a range of literacy levels. Address common concerns and misconceptions directly and concisely. Materials should be available in different languages. Members of the target community should be involved in authoring and translating communications to ensure they are accurate.

Appraise

Frame information in ways that allow people to evaluate how it applies to them. Create messages that align with the culture and values of the target population. Engage members of the community in development of materials and messages to ensure they are culturally appropriate.

Apply

Empower people to take action by clearly defining the next step and making it as easy as possible to take that step.

Communications should emphasize the benefits of cancer screening—including improved prognosis associated with early detection and, in some cases, prevention of cancer—and the importance of regular screening. Targeted messaging is needed for each cancer type for which screening is available. These messages should be tailored to different populations, as needed, and designed to help individuals overcome identified barriers to optimal cancer screening.

General Cancer Screening Messages

  • Cancer screening saves lives and reduces the burden of cancer. Cancer screening can identify cancer at earlier stages when it is easier to treat and when treatment is more likely to be effective. In some cases, screening tests can even prevent cancer through detection of precancerous lesions.
  • Regular screening and follow-up for abnormal screening results are essential. To achieve the full benefits of cancer screening, screening tests must be performed at recommended intervals (e.g., annually, every 3 years) and recommended follow-up for abnormal screening test results must be received in a timely manner.

Breast Cancer Screening Messages

  • Women should undergo regular screening in accordance with any of the major guidelines. Differences in breast cancer screening guidelines with respect to age at initiation and screening interval for women at average risk of breast cancer6-8 have resulted in confusion among the public and providers.9,10 However, adherence to any of the major screening guidelines is expected to reduce the risk of death from breast cancer.11
  • Risk assessment for breast cancer should be done for all women by age 25. Women at high risk of breast cancer may benefit from earlier initiation of screening and enhanced screening with magnetic resonance imaging in addition to mammography; however, risk assessment and supplemental screening currently are underutilized.12 Providers should assess risk based on family and personal history. Genetic testing and counseling should be offered to those at risk of inheriting mutations in cancer susceptibility genes and supplemental screening recommended as appropriate.

Cervical Cancer Screening Messages

  • Human papillomavirus (HPV) testing is a highly effective option for cervical cancer screening. The annual Pap test has been the mainstay of cervical cancer screening for more than 50 years; however, guidelines have evolved over the past few decades. Women now have the option to be screened via Pap test or using the more sensitive HPV test, either alone or in combination with the Pap test. Screening intervals have been extended to 3 years for Pap tests and 5 years for HPV testing with or without a Pap test. Inadequate adherence to current guidelines has been documented, in part due to the mistaken belief that HPV testing is less effective than the Pap test.13
  • Cervical cancer screening should continue through age 65 and sometimes beyond. Major guidelines recommend that cervical cancer screening begin at 21 or 25 years of age (depending on the guideline) and continue through age 65. However, compared with younger women, fewer women between 51 and 65 years of age are up to date for cervical cancer screening.14 Screening also may be indicated for women older than 65 if they have not been adequately screened or if they have been recently treated for a precancerous lesion.

Colorectal Cancer Screening Messages

  • There are multiple effective options for colorectal cancer screening, including noninvasive stool-based tests. Major guidelines recommend either direct visualization tests (e.g., colonoscopy, flexible sigmoidoscopy, virtual colonoscopy) or stool-based tests (e.g., fecal immunochemical test [FIT], FIT-DNA) for colorectal cancer screening. Nearly 90 percent of colorectal screening in the United States is being completed through colonoscopy,15,16 likely because many providers believe colonoscopy is the best colorectal cancer screening modality.17,18 While colonoscopy is an excellent option for colorectal cancer screening, stool-based tests offer some logistical benefits over colonoscopy, and there is no evidence they are less effective than colonoscopy for people at average risk. Survey data show that many people would select a stool-based test over colonoscopy if given the choice,19 and offering stool-based tests can increase rates of colorectal cancer screening.20
  • Colorectal cancer risk is increasing among younger adults. Colorectal cancer screening should begin at age 45 for average-risk individuals. Incidence rates of colorectal cancer in individuals aged 65 and older have been falling since the 1990s, largely due to increased screening. However, rates of colorectal cancer have been increasing among younger adults, including those younger than 50 years of age.21 It is projected that colorectal cancer will become the leading cancer-related cause of death for those 20 to 49 years old in the United States by 2030.22 This trend has led guideline makers, most recently the U.S. Preventive Services Task Force (USPSTF),23 to recommend that colorectal cancer screening begin at age 45 rather than age 50.
  • Risk assessment for colorectal cancer should occur by age 20. Individuals at high risk for colorectal cancer—such as those with Lynch syndrome or other inherited cancer syndromes—may benefit from earlier and/or more frequent screening; however, risk assessment for colorectal cancer and inherited cancers is underutilized.24 Providers should regularly collect a comprehensive family and personal history to assess colorectal cancer risk beginning by age 20 since initiation of screening is recommended at this age for some high-risk individuals.25 Genetic testing and counseling should be offered to those at risk for inherited cancer syndromes and supplemental screening recommended as appropriate.

Lung Cancer Screening Messages

  • Lung cancer screening is available and can save lives. Lung cancer screening—first recommended by USPSTF in 2013—is relatively new. Lack of public awareness and lack of provider familiarity with guidelines have been identified as key barriers to lung cancer screening.26 In addition, many people hold fatalistic beliefs about lung cancer, viewing the disease as untreatable.27 Thus, communications campaigns should focus on increasing familiarity with lung cancer screening and its potential to reduce mortality.
  • Lung cancer screening can benefit current and former smokers. Lung cancer screening currently is recommended for adults aged 50 to 80 years based on smoking history (e.g., at least a 20-pack-year history of smoking). The stigma surrounding smoking and lung cancer may hinder some eligible people from pursuing lung cancer screening. Communications campaigns with targeted empathic messages may help overcome this stigma. Messages and decision aids tailored based on current smoking status also may resonate better with people eligible for lung cancer screening.28

Large and small organizations—including federal, state, and local government agencies; national advocacy organizations; healthcare systems; and community organizations—should develop and implement communications campaigns focused on cancer screening. Organizations with a strong national presence—such as the Centers for Disease Control and Prevention (CDC) and American Cancer Society (ACS)—are well positioned to deliver messages to the broader public and healthcare providers. Healthcare systems should conduct both large- and small-scale information campaigns tailored to the populations they serve. Regional and local advocacy organizations also can play very important roles in ensuring that messages are accessible, appropriate, and actionable for the people in their communities.

TARGETING HEALTHCARE PROVIDERS

Icon of a target with an arrow in the middle

Healthcare providers play a critical role in people’s decisions to be screened for cancer. However, guidelines frequently are updated based on new evidence and evaluation, which makes it challenging for providers to stay up to date on all guidelines relevant to their practice. Communications campaigns targeted to various types of providers are needed to ensure that current guidelines are disseminated, understood, and adopted. These campaigns should be carried out by professional societies, public health organizations, and healthcare systems. Education and training in key areas also will help providers assess cancer risk and appropriately promote screening for their patients (see Education and Training for Healthcare Teams in Goal 3).

Source: Peterson EB, et al. Prev Med. 2016;93:96-105. Available from: https://www.ncbi.nlm.nih.gov/pubmed/27687535

Recommendation 1.2

Expand and strengthen National Cancer Roundtables that include a focus on cancer screening.

The most effective way to improve cancer screening in the United States is through coordinated national efforts that involve all stakeholders. The National Roundtable model provides mechanisms to accomplish this. The first cancer roundtable—the National Colorectal Cancer Roundtable (NCCRT)—was cofounded by ACS and CDC in 1997 with the primary goal of increasing colorectal cancer screening rates among eligible U.S. adults. A key feature of NCCRT then and now is the involvement of organizations and individuals from numerous sectors that work together to address barriers to screening. A notable achievement of NCCRT is the 80% by 2018 initiative launched in 2014 to activate organizations to invest in colorectal cancer screening. More than 1,800 organizations participated in the initiative; more than 350 organizations reported reaching the 80 percent goal, and hundreds of others reported increased colorectal cancer screening rates. National colorectal cancer screening rates increased from about 65 percent to nearly 70 percent over the course of the campaign. To build on the momentum created by 80% by 2018, NCCRT has launched 80% in Every Community to address disparities in cancer screening and follow-up care in racial/ethnic minority, low-income, and rural communities.29-31

Based on the success of NCCRT, ACS partnered with many organizations and companies to form roundtables for HPV vaccination, patient navigation, and lung cancer (Table 2). The National Lung Cancer Roundtable (NLCRT) addresses various aspects of lung cancer screening, including shared decision-making, implementation of screening programs, access to high-quality screening, and delivery of tobacco cessation treatment in the context of lung cancer screening. NLCRT has issued proposed quality metrics for lung cancer screening programs32 and a call for improved electronic health record (EHR) tools to support screening programs.33

Table 2

Current National Cancer Roundtables

Roundtable Year Established Goal(s)
National Colorectal Cancer Roundtable 1997

Increase the use of proven colorectal cancer screening tests among the entire population for whom screening is appropriate.

National HPV Vaccination Roundtable 2014

Raise HPV vaccination rates and prevent HPV cancers in the United States.

National Navigation Roundtable 2014

Achieve health equity and access to quality care across the cancer continuum through effective patient navigation.

National Lung Cancer Roundtable 2017

Reduce lung cancer incidence and mortality in the United States through coordinated leadership, strategic planning, advocacy, and action.

View Table Sources

Sources: National Colorectal Cancer Roundtable. Home page [Internet]. Atlanta (GA): American Cancer Society; [cited 2021 Jun 9]. Available from: https://nccrt.org; National HPV Vaccination Roundtable. Home page [Internet]. Atlanta (GA): American Cancer Society; [cited 2021 Oct 2]. Available from: https://hpvroundtable.org; National Lung Cancer Roundtable. Home page [Internet]. Atlanta (GA): American Cancer Society; [cited 2021 Oct 2]. Available from: https://nlcrt.org; National Navigation Roundtable. Home page [Internet]. Atlanta (GA): American Cancer Society; [cited 2021 Oct 2]. Available from: https://navigationroundtable.org

The Panel believes that the National Roundtable model provides an ideal framework for bringing stakeholders together and addressing gaps in cancer screening and follow-up care after an abnormal screening test result, including inequities experienced by various sociodemographic groups. Roundtables are well positioned to identify and amplify high-priority messages about cancer screening to providers and the public using modern communications platforms. ACS, CDC, and other key partners should invest resources to expand the National Roundtable model to increase coordination and promotion of high-quality cancer screening. New roundtables that include a strong focus on screening should be created for breast cancer and cervical cancer. Financial support for the NCCRT and NLCRT should be increased to allow important work on colorectal and lung cancer screening to continue and expand their reach to communities with low rates of screening and follow-up care. The roundtable for cervical cancer should coordinate with the National HPV Vaccination Roundtable given their overlapping interest in cervical cancer prevention.

National Roundtables should make health equity and alignment of messaging about cancer screening and cancer screening guidelines high priorities. Roundtable membership should represent the geographic, socioeconomic, and racial/ethnic diversity of the United States to ensure that the voices and perspectives of all populations inform activities and messaging. NLCRT should implement a large-scale campaign, similar to 80% by 2018, to raise awareness of and commitment to lung cancer screening.

References

  1. Schwartz LM, Woloshin S, Fowler FJ Jr, Welch HG. Enthusiasm for cancer screening in the United States. JAMA. 2004;291(1):71-8. Available from: https://www.ncbi.nlm.nih.gov/pubmed/14709578
  2. White PM, Itzkowitz SH. Barriers driving racial disparities in colorectal cancer screening in African Americans. Curr Gastroenterol Rep. 2020;22(8):41. Available from: https://www.ncbi.nlm.nih.gov/pubmed/32647903
  3. Morey BN, Valencia C, Lee S. The influence of Asian subgroup and acculturation on colorectal cancer screening knowledge and attitudes among Chinese and Korean Americans. J Cancer Educ. 2021. [Epub 2021 Jun 9]. Available from: https://www.ncbi.nlm.nih.gov/pubmed/34106449
  4. Zhu X, Parks PD, Weiser E, et al. An examination of socioeconomic and racial/ethnic disparities in the awareness, knowledge and utilization of three colorectal cancer screening modalities. SSM - Population Health. 2021;14:100780. Available from: https://pubmed.ncbi.nlm.nih.gov/33898727
  5. Best AL, Vamos C, Choi SK, et al. Increasing routine cancer screening among underserved populations through effective communication strategies: application of a health literacy framework. J Cancer Educ. 2017;32(2):213-7. Available from: https://www.ncbi.nlm.nih.gov/pubmed/28275965
  6. Monticciolo DL, Newell MS, Hendrick RE, et al. Breast cancer screening for average-risk women: recommendations from the ACR Commission on Breast Imaging. J Am Coll Radiol. 2017;14(9):1137-43. Available from: https://www.ncbi.nlm.nih.gov/pubmed/28648873
  7. Oeffinger KC, Fontham ET, Etzioni R, et al. Breast cancer screening for women at average risk: 2015 guideline update from the American Cancer Society. JAMA. 2015;314(15):1599-614. Available from: https://www.ncbi.nlm.nih.gov/pubmed/26501536
  8. U.S. Preventive Services Task Force. Final recommendation statement: breast cancer: screening. Rockville (MD): USPSTF; 2016 Jan 11. Available from: https://www.uspreventiveservicestaskforce.org/uspstf/recommendation/breast-cancer-screening
  9. Siedlikowski S, Ells C, Bartlett G. Scrutinizing screening: a critical interpretive review of primary care provider perspectives on mammography decision-making with average-risk women. Public Health Rev. 2018;39(1). Available from: https://pubmed.ncbi.nlm.nih.gov/29876139
  10. Dederich L. A widely used guideline said I didn't need a mammogram. It was wrong. Stat [Internet]. 2018 Oct 12 [cited 2021 Sep 28]. Available from: https://www.statnews.com/2018/10/12/breast-cancer-screening-guidelines-wrong
  11. Mandelblatt JS, Cronin KA, Berry DA, et al. Modeling the impact of population screening on breast cancer mortality in the United States. Breast. 2011;20(3 Suppl):S75-81. Available from: https://www.ncbi.nlm.nih.gov/pubmed/22015298
  12. Miles R, Wan F, Onega TL, et al. Underutilization of supplemental magnetic resonance imaging screening among patients at high breast cancer risk. J Womens Health (Larchmt). 2018;27(6):748-54. Available from: https://www.ncbi.nlm.nih.gov/pubmed/29341851
  13. Tatar O, Wade K, McBride E, et al. Are health care professionals prepared to implement human papillomavirus testing? A review of psychosocial determinants of human papillomavirus test acceptability in primary cervical cancer screening. J Womens Health (Larchmt). 2020;29(3):390-405. Available from: https://www.ncbi.nlm.nih.gov/pubmed/31479381
  14. Sabatino SA, Thompson TD, White MC, et al. Cancer screening test receipt: United States, 2018. MMWR Morb Mortal Wkly Rep. 2021;70(2):29-35. Available from: https://www.ncbi.nlm.nih.gov/pubmed/33444294
  15. National Cancer Institute. Online summary of trends in U.S. cancer control measures: colorectal cancer screening [Internet]. Bethesda (MD): NCI; [updated 2020 Mar; cited 2021 Jun 7]. Available from: https://progressreport.cancer.gov/detection/colorectal_cancer#field_data_source
  16. QuickStats: percentage of adults aged 50–75 years who met colorectal cancer (CRC) screening recommendations—National Health Interview Survey, United States, 2018. MMWR Morb Mortal Wkly Rep. 2020 Mar 20;69(11):314. Available from: https://www.cdc.gov/mmwr/volumes/69/wr/mm6911a7.htm
  17. Brown T, Lee JY, Park J, et al. Colorectal cancer screening at community health centers: a survey of clinicians' attitudes, practices, and perceived barriers. Prev Med Rep. 2015;2:886-91. Available from: https://www.ncbi.nlm.nih.gov/pubmed/26844165
  18. Montana Cancer Control Programs. Primary care provider survey: colorectal cancer screening knowledge and attitudes. Helena (MT): Montana Department of Public Health and Human Services; 2020 Jun 1. Available from: https://dphhs.mt.gov/assets/publichealth/Cancer/HealthSystems/PrimaryCareProviderSurveyColorectalCancerScreeningKnowledgeandAttitudes.pdf
  19. Zhu X, Parks PD, Weiser E, et al. National survey of patient factors associated with colorectal cancer screening preferences. Cancer Prev Res (Phila). 2021;14(5):603-14. Available from: https://www.ncbi.nlm.nih.gov/pubmed/33888515
  20. Dougherty MK, Brenner AT, Crockett SD, et al. Evaluation of interventions intended to increase colorectal cancer screening rates in the United States: a systematic review and meta-analysis. JAMA Intern Med. 2018;178(12):1645-58. Available from: https://www.ncbi.nlm.nih.gov/pubmed/30326005
  21. Siegel RL, Miller KD, Goding Sauer A, et al. Colorectal cancer statistics, 2020. CA Cancer J Clin. 2020;70(3):145-64. Available from: https://www.ncbi.nlm.nih.gov/pubmed/32133645
  22. Rahib L, Wehner MR, Matrisian LM, Nead KT. Estimated projection of U.S. cancer incidence and death to 2040. JAMA Netw Open. 2021;4(4):e214708. Available from: https://www.ncbi.nlm.nih.gov/pubmed/33825840
  23. U.S. Preventive Services Task Force. Final recommendation statement: colorectal cancer: screening. Rockville (MD): USPSTF; 2021 May 18. Available from: https://www.uspreventiveservicestaskforce.org/uspstf/recommendation/colorectal-cancer-screening
  24. Hampel H, de la Chapelle A. The search for unaffected individuals with Lynch syndrome: do the ends justify the means? Cancer Prev Res (Phila). 2011;4(1):1-5. Available from: https://www.ncbi.nlm.nih.gov/pubmed/21205737
  25. Giardiello FMS, Allen JI, Axilbund JE, et al. Guidelines on genetic evaluation and management of Lynch syndrome: a consensus statement by the U.S. Multi-Society Task Force on colorectal cancer. Gastroenterology. 2014;147(2):502-26. Available from: https://www.ncbi.nlm.nih.gov/pubmed/25043945
  26. Wang GX, Baggett TP, Pandharipande PV, et al. Barriers to lung cancer screening engagement from the patient and provider perspective. Radiology. 2019;290(2):278-87. Available from: https://www.ncbi.nlm.nih.gov/pubmed/30620258
  27. Quaife SL, Marlow LAV, McEwen A, et al. Attitudes towards lung cancer screening in socioeconomically deprived and heavy smoking communities: informing screening communication. Health Expectations. 2017;20(4):563-73. Available from: https://pubmed.ncbi.nlm.nih.gov/27397651
  28. Hamann HA, Ver Hoeve ES, Carter-Harris L, et al. Multilevel opportunities to address lung cancer stigma across the cancer control continuum. J Thorac Oncol. 2018;13(8):1062-75. Available from: https://pubmed.ncbi.nlm.nih.gov/29800746
  29. Wender R, Brooks D, Sharpe K, Doroshenk M. The National Colorectal Cancer Roundtable: past performance, current and future goals. Gastrointest Endosc Clin N Am. 2020;30(3):499-509. Available from: https://www.ncbi.nlm.nih.gov/pubmed/32439084
  30. Wender RC, Doroshenk M, Brooks D, et al. Creating and implementing a national public health campaign: the American Cancer Society's and National Colorectal Cancer Roundtable's 80% by 2018 initiative. Am J Gastroenterol. 2018;113(12):1739-41. Available from: https://www.ncbi.nlm.nih.gov/pubmed/30413821
  31. National Colorectal Cancer Roundtable. Home page [Internet]. Atlanta (GA): American Cancer Society; [cited 2021 Jun 9]. Available from: https://nccrt.org
  32. Mazzone PJ, White CS, Kazerooni EA, et al. Proposed quality metrics for lung cancer screening programs: a National Lung Cancer Roundtable project. Chest. 2021;160(1):368-78. Available from: https://www.ncbi.nlm.nih.gov/pubmed/33539838
  33. Fathi JT, White CS, Greenberg GM, et al. The integral role of the electronic health record and tracking software in the implementation of lung cancer screening—a call to action to developers. Chest. 2020;157(6):1674-9. Available from: https://pubmed.ncbi.nlm.nih.gov/31877270