Management of people with positive test results and fail-safe mechanisms

The potential reduction of mortality through cancer screening can only be achieved if subjects with abnormal findings receive timely and appropriate follow-up for detected abnormalities.

The findings of a recent US survey indicated that less than 15% of health plans monitor receipt of appropriate follow-up care by patents with abnormal results. This lack of organised tracking systems probably explains the low proportion of people with abnormal screening findings who receive adequate follow-up (Yabroff et al. 2003). In particular, among patients receiving FOBT screening in the Veterans health administration, 41% of those with a positive test failed to receive appropriate assessment (Etzioni et al. 2006). The negative implications of follow-up failures are substantial, including at the population level. A previous analysis of the screening history of invasive cervical cancers identified by a population-based cancer registry showed that about 20–25% of women with invasive cancer had been recommended for an early repeat smear, but had not received adequate follow-up (Bucchi & Serafini 1992). 

Effective interventions targeting the screen-positive individuals include (Bastani et al. 2004): reducing financial and other barriers for further investigations or eliminating the costs for the patients, mail or telephone reminders, and providing written information material or telephone counselling addressing fears related to abnormal findings. All these interventions were found to be successful in increasing the proportion of people receiving timely follow-up. Few interventions have been assessed at the practice/provider level. The offer of same-day follow-up on-site colposcopy for abnormal Pap-smears (Holschneider et al. 1999) or an on-site colonoscopy following a positive sigmoidoscopy (Stern et al. 2000), has led to improved patient compliance. In a predominantly minority and indigent population targeted for cervical cancer screening, subjects managed through a specialised clinic, including nurse case manager, tracking system, reminder calls, rescheduling of missed appointments and clinical staffing with on-site colposcopy, achieved a significantly increased follow-up compared to a randomly assigned control group (Engelstad et al. 2001). The implementation of infrastructure (computerised systems for tracking and monitoring of screening abnormalities) and organisational changes (multidisciplinary team work) are required to ensure sustainability over time of effective interventions. 

Treatment and after-care service following evidence-based guidelines should be offered to all patients detected with cancer or pre-invasive lesions at the time of assessment of abnormal screening findings. 

Summary of evidence 

 Reducing the financial barriers for further investigations, utilisation of mail or telephone reminders, written information material or telephone counselling addressing fears related to abnormal findings, implementation of computerised systems for tracking and monitoring of screening abnormalities and organisational changes (multidisciplinary team work) were found to be successful in increasing timely follow-up (II).   

Recommendations 

•  In order to ensure timely and appropriate assessment, active follow-up of people with screening abnormalities should be implemented, using reminders and computerised systems for tracking and monitoring management of these patients (II - A).
•  The cost to the participant undergoing assessments should be as low as possible in order to promote equity of access (II - A).

Follow-up of population and interval cancers 

The ascertainment of interval cancers represents a key component of the evaluation of a screening programme. The documentation and evaluation process requires forward planning and linkage between screening registries and cancer registries, including data on causes of death, with no losses to follow-up. Data collection and reporting should cover all cancers appearing in the target population. 

Methods of ascertainment and follow-up may differ across countries and screening programmes depending on the availability and accessibility of data and of existing data sources: cancer/pathology registries, clinical or pathology records or death records/registries. See Chapter 3 for a description of the indicators and the data requirements.