Improving Cancer Screening Adherence: Using the "Teachable Moment" as a Delivery Setting for Educational Interventions

The Centers for Disease Control and Prevention project that within the next 10 years cancer will replace cardiovascular disease as the number one cause of death in the United States. Currently, malignant neoplasms are the leading cause of death in individuals under the age of 75, and they are responsible for more deaths in those aged 45-64 years than the next 3 leading causes (heart disease, accidents, and stroke) combined.¹ Although cardiovascular mortality has declined by almost 60% since 1950, no appreciable decreases in cancer mortality have been achieved over the same time period.

A Multi-Faceted Approach to Reducing Cancer Mortality Is Needed

The bulk of resources devoted to cancer research is expended on either basic science efforts to better understand why cancer occurs or on the development of effective treatments for a specific neoplasm once it arises. Indeed, when considering the cancer research enterprise (often referred to as the "War Against Cancer"), attention is too often focused on the latest "cure" for cancer or on the most recent basic science breakthrough regarding tumor genesis. These sophisticated and expensive research efforts, while extremely worthwhile, are only part of the multi-pronged approach required to decrease cancer-related mortality. Despite the extensive focus on molecular genetics and cancer therapeutics, one can argue that the return on investment on the billions of dollars spent thus far has not been very robust.

Prevention and early detection of premalignant states of more readily treatable cancerous lesions are a crucial component in a comprehensive strategy to effectively battle cancer. Cancer prevention can likely be achieved for many common cancers with lifestyle choices (eg, smoking cessation, improved diet, and more regular exercise). As the widely publicized obesity epidemic indicates, changing lifestyle for the better is extremely difficult and is unlikely to be achieved in the near future. Cancer chemoprevention, an area of intense investigation but with few proven interventions, may someday play a pivotal role in diminishing cancer risk and mortality. But until we can reliably prevent cancer, more attention should be paid to increasing adherence to those cancer-screening interventions that have been convincingly demonstrated to produce meaningful clinical benefits. It is evident that an aggressive strategy to enhance early detection of malignant or premalignant lesions has real potential to bring about meaningful reductions in the burden of cancer.

Despite rigorous evidence demonstrating life-saving potential, national surveys reveal that there is systematic underutilization of screening interventions.^2,3 Moreover, even for those willing to participate in screening, there is a wide variance in acceptance rates among proven screening tests. For example, rates of colorectal cancer screening among American women lag compared to breast and cervical cancer screening rates, despite a proven decrease in mortality from colon cancer screening.⁴

Improving Adherence With Cancer Screening: The Role of Managed Care Organizations

In a recent meta-analysis conducted by Stone, et al, the authors review interventions directed at improving breast, cervical, and colon cancer screening services, and found that organizational change (ie, establishing a separate clinic devoted to screening and prevention activities, using planned care visits for prevention, and designating nursing or clerical staff to arrange a physician visit or to identify patients in need of prevention services) consistently increased utilization of cancer screening services when compared with physiciandirected and patient-directed interventions.⁵ In addition, the authors demonstrated that coupling education about a "less effective" intervention while a patient underwent treatment for a more accepted therapy produced positive effects. In this issue of the Journal, the articles by Goldzweig et al and Klabunde et al add to this research by evaluating organizational components that enhanced screening for breast, cervical, and colorectal cancers.^6,7 Like Stone et al, these authors also found that interventions directed at the level of the patient (eg, financial incentives, reminders, and education) had modest success. These latest studies suggest that health systems have substantial opportunities to independently enhance adherence with these potentially life-saving interventions. If, as Stone suggests, the acceptance of a less effective yet proven intervention can be improved by coupling it with education around a better accepted intervention, we may have a golden opportunity to advance patient education and increase screening rates.

For example, a woman may diligently undergo breast cancer screening after her mother is diagnosed with breast cancer. Her mother's cancer diagnosis represents a teachable moment, which has been described as a naturally occurring life or health event thought to motivate individuals to spontaneously adopt risk-reducing health behaviors.⁸ The teachable moment has been extensively evaluated in smoking cessation interventions. A systematic review by McBride on smoking cessation proposed office visits, notification of abnormal test results, hospitalization, and disease diagnosis as opportune times to provide patient education and perhaps fundamentally shift patient thinking and behavior. The authors demonstrated relatively high cessation rates after these types of teachable moments versus an untimed formal intervention.

Many reasons can explain why an individual may not elect to undergo cancer screening. For example, doctors may not routinely recommend screening; patients may have an inadequate understanding of the health benefits screening provides; or patients might wrestle with the psychological dread of the specific procedures. These factors have been identified as potential barriers to adherence with cancer screening. Educational efforts alone, such as informational brochures, phone calls, or videos, when distributed in a non-cancer screening setting, only modestly improve cancer screening.⁹ In light of the modest success in non-cancer clinical settings, we believe that providing education during a screening teachable moment will likely increase the acceptance rates of underused screening tests. The effects can be significant since most Americans receive at least 1 cancer screening intervention, and many get repeated tests for this one type of cancer but neglect to be screened for other types of cancers. For women, well-accepted cancer screening tests, such as screening mammography or Pap smear, represent potential teachable moments for providing general cancer education designed to improve overall knowledge of cancer screening and to address specific psychosocial concerns.

Opportunities in the Middle

Cancer develops along a continuum. Screening interventions designed to decrease cancer-related morbidity and mortality target different time points in the evolution of the cancerous lesion. At one end of this continuum is prevention, but this preferred extreme is most difficult to achieve. At the other end is treatment - which occurs after neoplasm has already developed and is often diagnosed at a stage of disease less amenable to effective therapy. In the middle of the continuum is screening - screening for treatable malignant (or better yet, premalignant) disease. Despite strong evidence showing significant mortality reductions due to cancer screening, acceptance of these procedures is suboptimal. But as our experience with breast, cervical, and prostate cancer screening has shown, screening programs can gain widespread public acceptance. In the case of breast cancer, annual screening on a national level reaches over 80%; rates of colorectal cancer screening among women are approximately half that. As noted, many women undergo multiple repeated testing for one disease and completely neglect screening tests for other treatable cancers. Since most would agree that the first test for a particular disease (assesses prevalence) will often provide more benefit than the second test for the same disease (assesses incidence), greater emphasis on at minimum, initial testing for multiple conditions is likely to maximize the benefits of screening. It is our view (and a question that should be answered empirically) that the use of a commonly accepted event, such as mammography, can be a teachable moment having great potential to elevate screening rates of other less widely accepted, but proven interventions, such as colon cancer screening.

Managed care organizations and clinicians accept the clinical and economic benefits of early cancer detection and prevention and encourage their use. Since most Americans undergo one health screening intervention, health systems should give strong consideration to using these "teachable moments" to educate and motivate their patients to increase participation in underused yet potentially life-saving interventions.

From the Departments of Radiology (RCC) and Internal Medicine (AMF), the University of Michigan, Ann Arbor, MI.

Address correspondence to: Ruth C. Carlos, MD, MS, Department of Radiology, Radiology B2B311B UH #0030, Ann Arbor, MI 48109. E-mail: rcarlos@umich.edu

1. National Center for Health Statistics. Health, United States 2003, with chartbook on trends in the health of Americans. Hyattsville, Md; 2003.

2. From the Centers for Disease Control and Prevention: Colorectal cancer test use among persons aged ≥ 50 years - United states, 2001. JAMA. 2003;289(19):2492-2493.

Am J Prev Med.

3. Nelson DE, Bolen J, Marcus S, Wells HE, Meissner H. Cancer screening estimates for US metropolitan areas. 2003;24(4 suppl):301-309.

4. Selby JV, Friedman GD, Quesenberry CP Jr, Weiss NS. A case-control study of screening sigmoidoscopy and mortality from colorectal cancer. N Engl J Med. 1992;326(10):653-657.

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5. Stone EG, Morton SC, Hulscher ME, et al. Interventions that increase use of adult immunization and cancer screening services: a meta-analysis. 2002; 136:641-651.

6. Goldzweig CL, Washington DL, Lanto AB, Parkerton PH, Yano EM. Primary care practice and facility quality orientation: influence on breast and cervical cancer screening rates. Am J Manag Care. 2004;10(4):265-272.

Am J Manag Care.

7. Klabunde CN, Riley GF, Mandelson MT, Frame PS, Brown ML.Health plan policies and programs for colorectal cancer screening: a national profile. 2004;10(4):273-279.

8. McBride CM, Scholes D, Grothaus LC, Curry SJ, Ludman E, Albright J. Evaluation of a minimal self-help smoking cessation intervention following cervical cancer screening. Prev Med. 1999;29:133-138.

Ann Int Med.

9. Pignone M, Harris R, Kinsinger L. Videotape-based decision aid for colon cancer screening: a randomized, controlled trial. 2000;133(10):761-769.

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