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Cancer Screening: Multicomponent Interventions—Colorectal Cancer


What the CPSTF Found

About The Systematic Review

The CPSTF finding is based on evidence from a systematic review of 88 studies (search period January 2004 - November 2013) that evaluated intervention effects on breast (33 studies), cervical (20 studies) or colorectal cancer (56 studies) screening use—services recommended by the U.S. Preventive Services Task Force (2016a External Web Site Icon, 2018 External Web Site Icon, 2016b External Web Site Icon, respectively).

The systematic review was conducted on behalf of the CPSTF by a team of specialists in systematic review methods, and in research, practice, and policy related to cancer prevention and control.


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Summary of Results

Detailed results from the systematic review are available in the CPSTF Finding and Rationale Statement pdf icon [PDF - 309 kB].

  • Compared with no intervention, multicomponent interventions changed colorectal cancer screening using the following tests:
    • Any test (colonoscopy, FOBT, or flexible sigmoidoscopy): median increase of 15.4 percentage points (39 study arms).
    • Colonoscopy: median increase of 10.2 percentage points (9 study arms)
    • FOBT: median increase of 7.7 percentage points (21 study arms)
    • Flexible sigmoidoscopy: median decrease of 0.5 percentage points (5 study arms)
  • Multicomponent interventions vary in the number and type of approaches or strategies used. The review team conducted stratified analyses to understand the influence of these factors on cancer screening use.
    • Studies of interventions to increase breast, cervical, and colorectal cancer screening were considered for these analyses.
    • Intervention approaches are categorized into three strategies: increasing community demand, increasing community access, or increasing provider delivery of screening.
      • Multicomponent interventions that used all three strategies increased cancer screening by a median of 24.2 percentage points (5 study arms).
      • Multicomponent interventions that used strategies to increase community demand and access increased cancer screening by a median of 11.2 percentage points (48 study arms).
  • Multicomponent interventions that used two or more approaches increased cancer screening.
    • Interventions that used five or more approaches showed a larger increase than interventions with fewer approaches.
    • Cancer screening increased independent of which approaches were used.
  • Multicomponent interventions that included approaches to reduce structural barriers increased cancer screening rates.
    • Providing language translation services led to the largest increase (median increase of 62.7 percentage points, 4 studies).
    • Addressing transportation needs led to the next largest increase (median increase of 18.4 percentage points, 11 studies).
    • None of the included studies evaluated interventions that provided child care.

Summary of Economic Evidence

Detailed results from the systematic review are available in the CPSTF Finding and Rationale Statement pdf icon [PDF - 309 kB].

The CPSTF finds that multicomponent interventions to increase screening for colorectal cancer are cost-effective. Results also showed the interventions led to cost savings from averted treatment costs that exceed intervention costs.

A systematic search for economic evidence (search period January 2004–January 2018) identified 53 studies, 33 of which focused on colorectal cancer screening. Two studies focused on both breast and colorectal cancer screening. Studies evaluated interventions that used FOBT (26 studies), colonoscopy (8 studies), and flexible sigmoidoscopy (1 study).

The majority of these studies were conducted in the United States with 9 studies conducted in other high-income countries. All monetary values are reported in 2016 U.S. dollars.

  • Overall, the median cost per participant was $36.63 (42 study arms).
    • The median cost per participant for interventions that increased community demand was $44.07 (3 study arms).
    • The mean cost per participant for interventions that increased provider delivery was $366.51 (2 study arms).
    • The median cost per participant for interventions that increased both community demand and access was $30.82 (33 study arms).
  • Across all studies, the median incremental cost per additional person screened was $582.44 (15 study arms).
    • The median incremental cost per additional person screened for interventions that increased both community demand and community access was $582.44 (11 study arms).
    • There was no consistent relationship between the baseline-screening rate (median: 44%; 9 estimates) and the incremental cost per additional person screened.
  • Two good quality, modeled studies with societal perspectives calculated incremental cost per quality-adjusted life year (QALY) gained. Both reported declines in the incremental cost per QALY gained, indicating these interventions are cost-effective.
    • The incremental cost per QALY gained declined $3,817 and $1,651 (2 studies).
    • QALYs gained from screening were associated with treatment cost savings that outweighed the intervention costs.


Based on results for interventions to increase breast, cervical, or colorectal cancer screening, findings should be applicable to the following:

  • U.S. or non-U.S. populations
  • Urban or rural settings
  • Healthcare systems, communities, or both
  • Different racial or ethnic groups
  • Age groups recommended for regular cancer screening (specified in USPSTF recommendations)
  • People who are, or are not, up-to-date with recommended cancer screenings
  • People with average risk for developing breast, cervical, or colorectal cancers

Based on results for interventions that had a range of characteristics, findings should be applicable to interventions that used the following:

  • Intervention approaches to increase community demand, alone or in combination with approaches from other strategies
  • Community health workers, patient navigators, or clinical providers to deliver interventions

Based on the limited evidence available, findings are likely applicable to people with different levels of income or health coverage.

Evidence Gaps

Additional research and evaluation are needed to answer the following questions and fill existing gaps in the evidence base.

  • What are intervention effects on repeat cancer screening rates?
  • How effective are interventions that only include strategies to increase community access and provider delivery?
  • What is the magnitude of effect for multicomponent interventions that provide language translation services, and does it vary across population subgroups?
  • What are the effects of specific combinations of intervention approaches?
  • How well do interventions work among people who have low health literacy?
  • How cost-effective are these interventions?

More consistent terminology and reporting of study details would improve future assessments of intervention effectiveness.

  • What specific activities were used as part of an intervention approach?
  • How were structural barriers reduced?
  • Who delivered the intervention approaches?
  • Who were the study participants (e.g., demographic characteristics including income and health insurance status)?

Study Characteristics

The following characteristics were summarized from all included studies.

  • Intervention settings
    • The United States (76 studies), Canada (5 studies), Australia (2 studies), the United Kingdom (1 study), Italy (1 study), Taiwan (1 study), Singapore (1 study), and Israel (1 study)
    • Primarily urban (43 studies) or mixed settings (15 studies)
  • Study population characteristics
    • Mean age of 58.2 years (51 studies reporting)
    • African American (median of 27%, 35 studies reporting), Hispanic (median of 11%, 25 studies reporting), Asian American (median of 5%, 15 studies reporting), White (median of 51%, 39 studies reporting)
    • Majority low-income study participants (38 studies)
    • High school education or less (median of 43%, 39 studies reporting)