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). (2,3,4)

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

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 cancer (6,7,8) 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

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).

View figure source.

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. (29,30,31)

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 programs (32) and a call for improved electronic health record (EHR) tools to support screening programs. (33)

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.

Sources

Targeting Healthcare Provider Source: Peterson EB, et al. Prev Med. 2016;93:96-105. [PubMed Abstract]

Table 2 Sources: National Colorectal Cancer Roundtable. Home page [Internet]. Atlanta (GA): American Cancer Society; [cited 2021 Jun 9]. [Available Online]. National HPV Vaccination Roundtable. Home page [Internet]. Atlanta (GA): American Cancer Society; [cited 2021 Oct 2]. [Available Online]. National Lung Cancer Roundtable. Home page [Internet]. Atlanta (GA): American Cancer Society; [cited 2021 Oct 2]. [Available Online]. National Navigation Roundtable. Home page [Internet]. Atlanta (GA): American Cancer Society; [cited 2021 Oct 2]. [Available Online].