This chapter focuses on the question of whether telemedicine, particularly telephone counselling, can improve the uptake of screening in three population screening programs available in Australia (colorectal, breast and cervical cancer).
Screening for colorectal cancer by faecal occult blood test (FOBT) or faecal immunochemical test (FIT) plus colonoscopy decreases the mortality of colorectal cancer. This is through the detection of earlier stage disease which is more likely to be cured by therapy. Screening also decreases the incidence of cancer due to detection of precancerous polyps which can be removed. Screening for people 50 and over is recommended but the uptake is currently low.
The mortality benefit associated with population-based mammography screening is greatest for women aged 50–69. The introduction of the BreastScreen Australia program is associated with a 22% decrease in breast cancer mortality in this group.
Screening for cancer of the cervix in Australia has halved cases from 17.2 new cases per 100,000 women in 1991 to 9 new cases per 100,000 women from 2002 to 2010, for women aged 20–69. There have only been 2 deaths per 100,000 over the past few years.
Colorectal cancer screening
Randomised trials comparing telephone counselling to print notification for colorectal cancer screening in different populations have yielded a spectrum of outcomes. In a trial with 456 urban minority participants in the USA, telephone outreach compared to direct mail showed a 4.4 times greater participation in screening in the telephone outreach group within the following 6 months. A similar result was recorded for 1,413 low income and minority women in New York City where the screening rates for colorectal cancer as well as breast and cervix improved when they received multiple calls as compared to usual care. Likewise a randomised study of telephone counselling in first degree relatives of patients with polyps promoted better screening adherence.
The cost of telephone counselling has been calculated to be $US100 per additional screening test (Smith et al 2012). Another study study showed that there are fewer wasted faecal immunochemical tests if a telephone call first ascertains if people want the test mailed to them.
However, there was no improvement in the rate of colorectal screening in a study that randomised 80,000 patients from a health plan (20,938 of whom were eligible because they had not previously been screened) to automated telephone outreach with speech recognition or usual care. Likewise, randomising 2,817 eligible primary care patients to computer assisted telephone counselling following the mailing of a booklet or control showed no increase in colorectal screening in the intervention group, but the intention to screen increased. This suggests that the intervention had educated but not motivated the patients. Both of the above studies suggested that physician recommendation may have improved the outcome.
This is borne out in an uncontrolled study testing the feasibility of physicians referring patients for telephone counselling and in a randomised study testing a web-based and nurse-led telephone intervention where utilisation was low but family physician recommendation of screening increased colorectal screening rates.
For those patients with positive FOBT’s telephone interviews pre-colonoscopy increased attendance in comparison with prior face to face interviews. However, a large randomised trial showed that although telephone consultation was just as successful in encouraging patients to attend a pre-colonoscopy consultation, it resulted in significantly lower colonoscopy participation rates. In contrast, for relatives of patients with colorectal cancer who were randomly assigned to telehealth-based risk assessment and behaviour change strategies, the rate of colonoscopy was tripled compared to those receiving colonoscopy alone.
|Telephone counselling can improve the uptake of screening for colorectal cancer in specific patient populations (such as lower socioeconomic groups and relatives of patients with polyps or colorectal cancer) but not consistently in the general population.||II||, , , , , , |
|Telephone counselling to increase participation in colorectal screening should be considered for patients in lower socioeconomic groups and relatives of patients with polyps or colorectal cancer.||C|
|Physician recommendation of telephone counselling or of colorectal screening increased the participation rate in colorectal screening||II|||
|It is recommended that physicians refer patients for telephone counselling or directly for colorectal screening.||C|
Breast cancer screening
In a randomised study of 3,880 women who did not attend mammographic screening a telephone call plus a letter was compared to a letter alone. This resulted in 22% having a mammogram, which was 4% higher than a control group. Similarly in a randomised controlled trial of minority and low income women, telephone calls added to usual care increased the mammography rate from 0.57 to 0.68. In a Turkish study of rescreening in 740 women, before telephone reminder 3.9% had mammograms and after reminders 46.6% had mammograms.
However, in a study by Richardson et al, randomising 641 women to either letter or telephone reminders in a groups of patients who did not respond to an initial invitation to have a mammogram, there was no difference between the two groups. In contrast a study of 482 women, more women who received letters from their general practitioners were screened (56% vs 43% p=0.01) and fewer declined the invitation to be screened, demonstrating the importance of the general practitioner reinforcing the screening message. In another study of 340 women, person to person counselling was compared to telephone counselling about genetic risk. Both forms of counselling were found to be beneficial and telephone counselling allowed remote women to be counselled.
|Telephone counselling can improve the uptake of mammographic screening and intention for genetic screening, but studies are equivocal.||II||, , , , |
|Telephone counselling should be considered to improve the uptake of mammographic screening or the intention for genetic screening.||C|
|Letter from general practitioners supporting the invitation to screen increased the rate of mammographic screening without reminders||II|||
|General Practitioners should support provide letters of support to accompany invitations for mammographic screening to increase the uptake.||C|
Cervical cancer screening
In a Swedish study, non-attendees to a cervical screening program were randomised to either telephone invitation or control. Participation in the program was significantly increased in the telephone group (18.0% vs 10.6%). Likewise, minority and low income women in New York City, who were overdue for screening and who were randomly allocated to a telephone support intervention increased the Papanicolaou testing rate for those receiving telephone calls (Dietrich 2006). However, in 10,662 women in Alsace who did not respond to an initial invitation to participate in cervical screening, and were randomised to a letter or a telephone call there was no difference between the two in rates of screening.
|Some studies have shown using the telephone to contact women eligible for screening or re-screening enhances the participation in cervical screening.||II||, |
|Telephone contact should be considered for women eligible for screening or re-screening for cervical cancer.||C|
- Pignone MP, Flitcroft KL, Howard K, Trevena LJ, Salkeld GP, St John DJ. Costs and cost-effectiveness of full implementation of a biennial faecal occult blood test screening program for bowel cancer in Australia. Med J Aust 2011 Feb 21;194(4):180-5 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/21401458.
- Australian Institute of Health and Welfare. National Bowel Cancer Screening Program monitoring report: 2012–13. Canberra: AIHW; 2014. Report No.: Cancer series No. 84. Cat. no. CAN 81. Available from: http://aihw.gov.au/publication-detail/?id=60129547721.
- BreastScreen Australia Evaluation Taskforce. BreastScreen Australia Evaluation. Evaluation final report. Canberra: Australian Government Department of Health and Ageing; 2009 Jun. Report No.: Screening Monograph No.1/2009. Available from: http://cancerscreening.gov.au/internet/screening/publishing.nsf/Content/programme-evaluation.
- Australian Institute of Health and Welfare. Cervical screening in Australia 2011–2012. Canberra: AIHW; 2014. Report No.: Cancer series no.82 Cat. no. CAN 79. Available from: http://aihw.gov.au/publication-detail/?id=60129546865.
- Basch CE, Wolf RL, Brouse CH, Shmukler C, Neugut A, DeCarlo LT, et al. Telephone outreach to increase colorectal cancer screening in an urban minority population. Am J Public Health 2006 Dec;96(12):2246-53 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/17077394.
- Dietrich AJ, Tobin JN, Cassells A, Robinson CM, Greene MA, Sox CH, et al. Telephone care management to improve cancer screening among low-income women: a randomized, controlled trial. Ann Intern Med 2006 Apr 18;144(8):563-71 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/16618953.
- Rawl SM, Christy SM, Monahan PO, Ding Y, Krier C, Champion VL, et al. Tailored telephone counseling increases colorectal cancer screening. Health Educ Res 2015 May 28 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/26025212.
- Schlichting JA, Mengeling MA, Makki NM, Malhotra A, Halfdanarson TR, Klutts JS, et al. Increasing colorectal cancer screening in an overdue population: participation and cost impacts of adding telephone calls to a FIT mailing program. J Community Health 2014 Apr;39(2):239-47 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/24499966.
- Simon SR, Zhang F, Soumerai SB, Ensroth A, Bernstein L, Fletcher RH, et al. Failure of automated telephone outreach with speech recognition to improve colorectal cancer screening: a randomized controlled trial. Arch Intern Med 2010 Feb 8;170(3):264-70 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/20142572.
- Costanza ME, Luckmann R, Stoddard AM, White MJ, Stark JR, Avrunin JS, et al. Using tailored telephone counseling to accelerate the adoption of colorectal cancer screening. Cancer Detect Prev 2007;31(3):191-8 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/17646058.
- Luckmann R, Costanza ME, Rosal M, White MJ, Cranos C. Referring patients for telephone counseling to promote colorectal cancer screening. Am J Manag Care 2013 Sep;19(9):702-8 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/24304253.
- Clouston K, Katz A, Martens PJ, Sisler J, Turner D, Lobchuk M, et al. Does access to a colorectal cancer screening website and/or a nurse-managed telephone help line provided to patients by their family physician increase fecal occult blood test uptake?: results from a pragmatic cluster randomized controlled trial. BMC Cancer 2014 Apr 16;14:263 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/24739235.
- Rodger J, Steele RJ. Telephone assessment increases uptake of colonoscopy in a FOBT colorectal cancer-screening programme. J Med Screen 2008;15(2):105-7 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/18573779.
- Stoop EM, de Wijkerslooth TR, Bossuyt PM, Stoker J, Fockens P, Kuipers EJ, et al. Face-to-face vs telephone pre-colonoscopy consultation in colorectal cancer screening; a randomised trial. Br J Cancer 2012 Sep 25;107(7):1051-8 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/22918392.
- Kinney AY, Boonyasiriwat W, Walters ST, Pappas LM, Stroup AM, Schwartz MD, et al. Telehealth personalized cancer risk communication to motivate colonoscopy in relatives of patients with colorectal cancer: the family CARE Randomized controlled trial. J Clin Oncol 2014 Mar 1;32(7):654-62 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/24449229.
- Goelen G, De Clercq G, Hanssens S. A community peer-volunteer telephone reminder call to increase breast cancer-screening attendance. Oncol Nurs Forum 2010 Jul;37(4):E312-7 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/20591795.
- Baysal HY, Gozum S. Effects of health beliefs about mammography and breast cancer and telephone reminders on re-screening in Turkey. Asian Pac J Cancer Prev 2011;12(6):1445-50 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/22126479.
- Richardson A, Williams S, Elwood M, Bahr M, Medlicott T. Participation in breast cancer screening: randomised controlled trials of doctors' letters and of telephone reminders. Aust J Public Health 1994 Sep;18(3):290-2 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/7841259.
- Helmes AW, Culver JO, Bowen DJ. Results of a randomized study of telephone versus in-person breast cancer risk counseling. Patient Educ Couns 2006 Dec;64(1-3):96-103 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/16427245.
- Broberg G, Jonasson JM, Ellis J, Gyrd-Hansen D, Anjemark B, Glantz A, et al. Increasing participation in cervical cancer screening: telephone contact with long-term non-attendees in Sweden. Results from RACOMIP, a randomized controlled trial. Int J Cancer 2013 Jul;133(1):164-71 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/23233356.
- Heranney D, Fender M, Velten M, Baldauf JJ. A prospective randomized study of two reminding strategies: telephone versus mail in the screening of cervical cancer in women who did not initially respond. Acta Cytol 2011;55(4):334-40 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/21791902.