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.
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