Lorenzetti DL, Lu M, Moritz S, Sykes L, Strauss S, Quan H University of Calgary CAHSPR Conference May 10 2011
Mingshan Lu University of Calgary Sabine Moritz Canadian Institute of Natural and Integrative Medicine Lindsay Sykes University of Calgary Sharon Strauss University of Toronto Hude Quan University of Calgary
- Breast colon/rectum, and cervical cancers are the most frequently diagnosed cancers in women worldwide - In 2008, breast and cervical cancers accounted for 733,500 deaths - Cervical cancer is the second leading cause of cancer death in women in Asia, Africa, and South America Jemal et al 2011
Top 10 Cancers in Women in Canada 2010 Breast 28% Lung 13% Breast Cancer Colorectal 12% Uterus 5% Thyroid 5% Non-Hodgkin Lymphoma 4% Ovary 3% Melanoma 3% Pancreas 3% Leukemia 2% Canadian Cancer Statistics 2010
Breast and cervical cancer screening rates are consistently low in Asian populations Women aged 50-69 in Canada who did not report having had a mammogram in the past 2 years by birthplace: 34.4% Asia 32.4% Europe 25.9 % North America 2008 Canadian Community Health Survey
Conduct a systematic literature review on the effectiveness of existing intervention strategies to enhance breast and cervical screening uptake among Asian women
1. 15 interdisciplinary peer reviewed & grey literature electronic databases including: MEDLINE, EMBASE, Cochrane Library, PsycINFO, ERIC and Grey Literature Report 2. Reference lists of included studies 3. Consultations with experts
Inclusion Criteria Participants are Asian women living in native or adopted countries Interventions to increase uptake of breast/cervical cancer screening Screening tests are mammograms or Pap smears Screening rates reported as outcomes Exclusion Criteria Interventions focusing on breast self-exam or screening tests that are not considered standard of care in Canada Patients with breast or cervical cancer
Database search results N=3470 Unique records after removal of duplicates N= 1892 Abstracts selected for fulltext review N= 105 Papers included in review N= 18 Additional records from other sources N= 5 Breast cancer screening uptake N= 6 Cervical cancer screening uptake N=9 Breast & cervical cancer screening uptake combined N= 3
Studies took place in: Canada (n=1), New Zealand (n=1), Singapore (n=1), Thailand (n=1), Taiwan (n=2), UK (n=2) and USA (n=11) The target populations were either Asian immigrants or Asian women living in their home countries Sample sizes ranged from 102 to 29,073 participants
Study designs of included papers: 8 randomized controlled trials 1 cohort study 9 non-randomized control groups Studies reported receipt of mammograms or Pap smears as outcomes, via self-report and/or verified by clinical record 77.1% of interventions were evaluated 1-2 years after first implementation
Patients Individual Level Media campaigns Culturally sensitive print education materials Home visits Lay health worker outreach Mobile screening Screening supports Patients Group Level Communitybased group education Work-based group education Healthcare Professionals Screening education Cultural awareness training
Mobile screening services increased mammogram screening rates for Asian American women in an RCT conducted in Los Angeles (70% vs 35% for the control). Results were further validated in a church-based controlled study involving Korean American women (72% vs 47% for the control) Cultural awareness training in a cluster RCT involving general practice reception staff in the UK resulted in a significant increase in mammogram attendance for Indian women (19% vs 5% in the control)
Media campaigns did not appear to influence screening rates in two non-randomized controlled studies in the USA
Culturally sensitive print materials were ineffective in both an RCT (Singapore) and a cohort study(new Zealand) yet effective in a non-randomized controlled study of women in Taiwan Home visits were effective in one RCT (Singapore) yet ineffective in an RCT of Pakistani and Bangladeshi women in the UK One RCT of community based health education in Taiwan was shown to increase screening rates while an RCT conducted in the USA demonstrated no effect Lay health worker outreach was ineffective in an RCT involving Cambodian American women but showed a positive effect in a nonrandomized controlled study of Vietnamese-American women
With the possible exceptions of mobile screening services and cultural awareness training for healthcare workers, no one intervention was consistently effective across studies Multiple strategies targeting specific ethnic groups appeared to be more successful than single interventions The ability of interventions to increase screening uptake appeared to be influenced by ethnicity, program delivery, and setting
11 of 18 studies reported outcomes that were based on self report. In 8 cases (including 2 RCTs) self report was not verified through clinical records In the case of media campaigns and other community-based interventions, program exposure was often difficult to determine Varying study designs, the inclusion of multiple simultaneous interventions, and different settings made evaluating intervention effectiveness a challenge Only two studies reported cost information, making it impossible to determine the cost effectiveness of any one intervention
There is some evidence to support the effectiveness of multi-pronged strategies in increasing cancer screening uptake, particularly those that incorporate culturally appropriate interventions Cost effectiveness and long-term sustainability of these programs remains questionable Future research is needed to implement vigorous evaluation methods of culturally appropriate interventions to increase screening uptake among Asian women