Results Summary
What was the research about?
Getting screened for cancer at a doctor’s visit can lead to early detection and treatment. But it can be hard for people with depression and limited resources to stay up to date with their care by scheduling regular visits and screenings.
In this study, the research team compared two programs to help women get up to date on screenings for breast, cervical, or colorectal cancer:
- Collaborative Care Intervention, or CCI, focused both on improving cancer screening and on depression symptoms. The research team developed the CCI program for this study.
- Prevention Care Management, or PCM, focused only on improving cancer screening.
Women in the study had symptoms of depression, lived in an urban area, and were overdue for breast, cervical, or colorectal cancer screening.
What were the results?
After one year, more women in both programs were up to date with their cancer screenings. But the two programs didn’t differ in the percent of women who were up to date.
Also, women in the two programs didn’t differ in their reports of
- Depression symptoms
- Quality of life
- Knowledge and feelings about cancer screening
- Whether a doctor referred them for cancer screening
- Confidence or feeling judged about depression
- Having office visits or taking medicine for mental health
- Whether they took medicines for mental health regularly
- How satisfied they were with their health care and their decision to take part in cancer screening or mental health care
Who was in the study?
The study included 757 women with depression receiving care at one of six health centers in Bronx, New York, that serve people with limited resources. Of these, 20 percent were African American, 4 percent were white, and 76 percent marked their race as other. In addition, 78 percent were Hispanic. The average age was 56.
What did the research team do?
The research team assigned women by chance to either the CCI or PCM program. In both programs, care managers made monthly phone calls to women in the study. Care managers helped women think about barriers to cancer screening, mailed educational handouts, and scheduled appointments. In the CCI program, care managers also
- Checked women’s depression symptoms
- Helped women create mental health action plans
- Found social services the women could use
The research team looked at women’s health records to see if they were up to date for cancer screenings. The team also gave study participants a survey about cancer screening before the study started and again 6 and 12 months later.
Patients, health professionals, and care managers provided input on the study.
What were the limits of the study?
All health centers in the study offered mental health care as well as cancer screening. Results may differ for centers that don’t offer mental health care. This study took place in one city. Results may differ in other places.
Future research could study these programs in other locations.
How can people use the results?
Health centers can use the results when considering ways to improve cancer screening among women with depression symptoms and limited resources.
Professional Abstract
Objective
To compare the effectiveness of two preventive care programs—Collaborative Care Intervention (CCI) and Prevention Care Management (PCM)—on increasing cancer screening among women with depression and limited resources who live in an urban area
Study Design
| Design Elements | Description |
|---|---|
| Design | Randomized controlled trial |
| Population | 757 women ages 50–64 with depression and limited resources living in Bronx, NY |
| Interventions/ Comparators |
|
| Outcomes |
Primary: cancer screening for breast, cervical, and colorectal cancers Secondary: depression symptoms, depression‐related stigma, mental healthcare utilization, self‐efficacy, cancer screening knowledge and attitudes, provider referrals, adherence to medication for mental health, quality of life, satisfaction with care, satisfaction with decision to participate in cancer screening or mental health care |
| Timeframe | 1-year follow-up for primary outcomes |
This randomized controlled trial compared the effectiveness of the CCI and PCM programs in improving women’s cancer screening consistent with current guidelines. The CCI program addressed cancer screening and depression, and the PCM program focused on cancer screening only. The research team identified women at six federally qualified health centers who were overdue for breast, cervical, or colorectal cancer screening.
The research team randomized women to receive one of the two programs. In both programs, care managers made monthly phone calls to women in the study. Care managers helped women identify and solve barriers to cancer screening, mailed educational materials and reminders about cancer screening recommendations, and scheduled appointments for patients to get screened. For women in the CCI program, care managers also
- Monitored depression symptoms
- Helped women develop mental health action plans
- Connected women with social services
The study included 757 women living in Bronx, New York. Of these, 20% were African American, 4% were white, and 76% marked their race as other. In addition, 78% were Hispanic. The average age was 56.
The research team reviewed electronic health records to assess cancer screening behaviors. To assess secondary study outcomes, the team administered a survey at baseline and again 6 and 12 months later.
Patients, clinicians, mental health professionals, administrators, and care managers provided input on study outcomes, intervention delivery, and plans for dissemination.
Results
After one year, women in both programs showed significant improvements in being up to date for breast, cervical, and colorectal cancer screenings (each p<0.001). However, the two programs did not differ significantly in whether women were up to date with their cancer screening.
The two programs did not differ in any secondary outcomes.
Limitations
All health centers in the study provided integrated mental health services, and women had access to on-site mental health treatment. This access may explain the lack of differences between the two programs in depression symptom improvement. The study took place in Bronx, New York; findings may differ in other locations.
Conclusions and Relevance
CCI and PCM were equally effective at improving screening for breast, cervical, and colorectal cancer.
Future Research Needs
Future research could study these programs in other health centers or include populations from different geographic regions.
Final Research Report
View this project's final research report.
Peer-Review Summary
Peer review of PCORI-funded research helps make sure the report presents complete, balanced, and useful information about the research. It also assesses how the project addressed PCORI’s Methodology Standards. During peer review, experts read a draft report of the research and provide comments about the report. These experts may include a scientist focused on the research topic, a specialist in research methods, a patient or caregiver, and a healthcare professional. These reviewers cannot have conflicts of interest with the study.
The peer reviewers point out where the draft report may need revision. For example, they may suggest ways to improve descriptions of the conduct of the study or to clarify the connection between results and conclusions. Sometimes, awardees revise their draft reports twice or more to address all of the reviewers’ comments.
Peer reviewers commented, and the researchers made changes or provided responses. The comments and responses included the following:
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Reviewers noted that this study did not demonstrate a difference between interventions in the planned analyses, and that the additional analyses the researchers performed did not have a clear rationale. Reviewers expressed concern that the report put too much emphasis on the results of these additional analyses in drawing conclusions. The researchers agreed and removed discussion of the post hoc as well as any language in the report indicating superiority of the more intensive intervention.
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Reviewers asked about the potential effects of unmeasured variables in the study, such as behavioral activation and health-related motivation, noting that these factors could be influencing intervention outcomes. The researchers agreed, adding some of these factors to their theoretical model, (Figure 1) of the intervention pathways. They also expanded their discussion of study limitations to address how these factors [MS1] may have affected cancer screening behavior and reduced the differences between interventions.
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Reviewers wondered at the assertion that study subjects received high-quality care from the outset, with little room for major improvement, given the apparently low cancer-screening rates and high depression scores of study participants. The researchers said they defined high- quality care based [MS1] on these offices having well-established systems for cancer screening and mental health services, and on study participants being established patients of their practices, on average for three years.