Elsevier

Preventive Medicine

Volume 93, December 2016, Pages 96-105
Preventive Medicine

Review Article
Impact of provider-patient communication on cancer screening adherence: A systematic review

https://doi.org/10.1016/j.ypmed.2016.09.034Get rights and content

Highlights

  • Provider recommendation is necessary but not sufficient for optimal screening rates.

  • Future research should focus on quality of clinical communication about screening.

  • Provider communication training is an effective tool for improving recommendations.

Abstract

Cancer screening is critical for early detection and a lack of screening is associated with late-stage diagnosis and lower survival rates. The goal of this review was to analyze studies that focused on the role of provider-patient communication in screening behavior for cervical, breast, and colorectal cancer. A comprehensive search was conducted in four online databases between 1992 and 2016. Studies were included when the provider being studied was a primary care provider and the communication was face-to-face. The search resulted in 3252 records for review and 35 articles were included in the review. Studies were divided into three categories: studies comparing recommendation status to screening compliance; studies examining the relationship between communication quality and screening behavior; and intervention studies that used provider communication to improve screening behavior. There is overwhelming evidence that provider recommendation significantly improves screening rates. Studies examining quality of communication are heterogeneous in method, operationalization and results, but suggest giving information and shared decision making had a significant relationship with screening behavior. Intervention studies were similarly heterogeneous and showed positive results of communication interventions on screening behavior. Overall, results suggest that provider recommendation is necessary but not sufficient for optimal adherence to cancer screening guidelines. Quality studies suggest that provider-patient communication is more nuanced than just a simple recommendation. Discussions surrounding the recommendation may have an important bearing on a person's decision to get screened. Research needs to move beyond studies examining recommendations and adherence and focus more on the relationship between communication quality and screening adherence.

Introduction

Adherence to cancer screening is critical for early detection and treatment of several types of cancer, and a lack of screening is associated with late-stage diagnosis and lower survival rates. As recommended by current preventive health guidelines,1 several screening tools have proven effective in reducing the burden of various cancers, including cytology (Pap smear) for cervical cancer (Whitlock et al., 2011), mammography for breast cancer (Nelson et al., 2009), and fecal occult blood testing (FOBT), sigmoidoscopy, colonoscopy, and fecal immunochemical test (FIT) for colorectal cancer (Levin et al., 2008, Whitlock et al., 2008), and, more recently, low dose helical computed tomography (LDCT) for lung cancer (Moyer, 2014). Despite benefits, cancer screening continues to be underutilized in the United States and worldwide (Han et al., 2011, Tsai et al., 2015). Given the ability of screening tests to reduce cancer morbidity and mortality, improving adherence to cancer screening is of critical importance to public health.

Many factors such as health literacy (Davis et al., 2002), risk perception (Atkinson et al., 2015), lack of health insurance (Collazo et al., 2015) and social influence (Paskett et al., 2013) are associated with cancer screening rates. However, provider-patient communication regarding screening tests may play one of the strongest modifiable roles in cancer screening behavior (Steinwachs et al., 2010). Physicians and other primary health care providers can serve as a key health information source by assessing patient screening eligibility, negotiating a course of action, and helping to coordinate screening tests and follow-up care (Lafata et al., 2014). The impact of provider recommendation on cancer screening behaviors was recently emphasized in a consensus statement released by the National Institutes of Health (Steinwachs et al., 2010). Moreover, the U.S. Department of Health and Human Services included increasing provider counseling about screening tests as a main objective in the Healthy People 2020 goals (DHHS, 2016).

Until recently, most research examining the impact of a primary care provider recommendation on cancer screening has used simple, narrow questions (e.g., “Did your physician recommend a screening test?”). More recent work has suggested that the presence or absence of a provider recommendation alone may not be sufficient and has focused on the content and quality of the provider-patient communication surrounding screening tests (Lafata et al., 2014). While several screening tools have been developed and adapted to investigate the content of provider-patient conversations about screening tests (e.g., investigator-created informed-decision making scales), these studies have not been systematically reviewed. In addition, several interventions have been proposed to increase and improve provider-patient communication about screening. These interventions have focused mainly on improving patient reminders (Baker et al., 2014), conducting communication skills training for physicians (Price-Haywood et al., 2014) and using “patient navigators” (Steinwachs et al., 2010) to increase screening rates.

In this paper, we aimed to systematically review studies that focused on the role of provider-patient communication in screening behavior. We included studies that assessed provider recommendation alone, studies that explored the quality and content of provider-patient discussions about screening, and interventions designed to improve provider-patient communication about screening and subsequent screening behaviors.

We chose to focus this review solely on screening tests that currently hold a “B” recommendation or higher for the general population from the U.S. Preventative Services Task Force (USPSTF), including mammograms, Pap smears and colorectal cancer screening. Other common cancer screening tests, such as the prostate specific antigen (PSA), were excluded from analysis due to the high risk of false-positive tests and low grade from the USPSTF. Despite its B rating, lung cancer screening was excluded from analysis as these recommendations are relatively new (2013), and therefore a parallel literature on provider-patient communication is not yet adequate for systematic review.

Section snippets

Method

We followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines for this review (Moher et al., 2009).

Summary of included articles

The systematic search resulted in 3252 records to be searched. Fig. 1 contains the PRISMA flow chart for this review. A total of 35 articles were considered suitable for inclusion in the review. All but six of the articles were from the United States–other represented countries included Canada (Mah and Bryant, 1997, Todd et al., 2011), Singapore (Wong et al., 2013), Israel (Giveon and Kahan, 2000), France (Aubin-Auger et al., 2016) and Italy (Dal Maso et al., 2010). Many articles focused on

Discussion

There should be no doubt that provider recommendations are important to patient adherence to cancer screening. A positive association between provider recommendation and patient screening adherence was present in nearly every study and across many different types of populations and types of cancer screened. However, a dichotomous provider recommendation measure explains only part the variance in screening behavior. For example, in one study of Korean Americans living in California, screening

Conflict of interests

None.

Acknowledgements

This publication was supported in part by the National Institutes of Health (NIH K07 CA140778 (PI: Bylund)). Its contents are solely the responsibility of the authors and do not necessarily reflect the official views of the National Institutes of Health (T32 CA009461 (PI: Jamie Ostroff; P30 CA008748 PI: Craig Thompson, MD)).

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