The Safety Net: A Cost-Effective Approach to Improving Breast and Cervical Cancer Screening

Purpose: The purposes of the study were (1) to assess the cost-effectiveness of three interventions to deliver breast and cervical cancer screening to women unscreened for ≥3 years and (2) to determine the relation of an invasive cervical cancer diagnosis to the interval since the last true screening test.

Methods: In a randomized trial, women were randomly assigned to (1) usual care, (2) letter plus follow-up letter, (3) letter plus follow-up phone call, (4) phone call plus follow-up phone call. Screening within 12 weeks was the outcome. A 5-year retrospective review of cervical cancer cases and screening histories was done.

Results: The 8% of women not screened for ≥5 years had 62% of the invasive cervical cancer cases. Mammography outreach led to screening in 10%, 24%, 51%, and 50% of controls, letter/letter, letter/phone, and phone/phone interventions groups, respectively. Cervical cancer screening outreach led to screening in 17%, 22%, 54%, and 50% of the respective groups. Letter reminders alone produced fewer tests at substantially higher costs than did personalized telephone notification.

Conclusions: For cervical cancer, only 1 person in 12 was not screened in the preceding 5 years, but these accounted for nearly two thirds of invasive cancers. Aggressive outreach to the rarely screened is an important part of screening programs. Letter reminder, followed by a telephone appointment call, was the most cost-effective approach to screening rarely screened women. Lack of accurate information on prior hysterectomy adds substantial unnecessary costs to a screening reminder program.