Unifying screening processes within the PROSPR consortium: a conceptual model for breast, cervical, and colorectal cancer screening

Abstract

General frameworks of the cancer screening process are available, but none directly compare the process in detail across different organ sites. This limits the ability of medical and public health professionals to develop and evaluate coordinated screening programs that apply resources and population management strategies available for one cancer site to other sites. We present a trans-organ conceptual model that incorporates a single screening episode for breast, cervical, and colorectal cancers into a unified framework based on clinical guidelines and protocols; the model concepts could be expanded to other organ sites. The model covers four types of care in the screening process: risk assessment, detection, diagnosis, and treatment. Interfaces between different provider teams (eg, primary care and specialty care), including communication and transfer of responsibility, may occur when transitioning between types of care. Our model highlights across each organ site similarities and differences in steps, interfaces, and transitions in the screening process and documents the conclusion of a screening episode. This model was developed within the National Cancer Institute-funded consortium Population-based Research Optimizing Screening through Personalized Regimens (PROSPR). PROSPR aims to optimize the screening process for breast, cervical, and colorectal cancer and includes seven research centers and a statistical coordinating center. Given current health care reform initiatives in the United States, this conceptual model can facilitate the development of comprehensive quality metrics for cancer screening and promote trans-organ comparative cancer screening research. PROSPR findings will support the design of interventions that improve screening outcomes across multiple cancer sites.

Figure 1.

Population-based Research Optimizing Screening through Personalized Regimens (PROSPR) trans-organ conceptual model for breast, cervical, and colorectal cancer screening. = Type of care: care delivered to accomplish a specific goal, such as diagnosis. = Step: medical actions or encounters within a type or transition in care. = Interface: transfer of information and/or responsibility between two different health provider teams (e.g., primary care & specialist). = Transition: steps and interfaces necessary to move from one type of care to another. Abbreviations: ASC, atypical squamous cells; ASC-H, atypical squamous cells-cannot exclude high-grade squamous intraepithelial lesion; ASC-US, atypical squamous cells of undetermined significance; ASCCP, American Society for Colposcopy and Cervical Pathology; BI-RADS, Breast Imaging-Reporting and Data System; CIN, cervical intraepithelial neoplasia; FIT, fecal immunochemical test; gFOBT, guaiac-based fecal occult blood test; HPV, human papillomavirus; HSIL, high-grade squamous intraepithelial lesion; LSIL, low-grade squamous intraepithelial lesion; Pap, Papanicolaou; SIG, sigmoidoscopy. * Risk level determined by age and other risk factors; if at elevated risk, then follow alternate guidelines (28,29,33–35,67,68). † Breast: BI-RADS 0; BI-RADS 3, 4, & 5 are typically reported only after a diagnostic mammogram but in some cases are reported after a screening mammogram. BI-RADS 4 or 5 from a screening mammogram may lead directly to biopsy. Cervical: Go to additional testing (ASC-US or LSIL & HPV– or Pap– & HPV+) or to colposcopy (≥LSIL or ASC-US & HPV+, or HPV 16/18+). Some HSIL cases may go immediately to excisional treatment. Colorectal: gFOBT+, FIT+, or SIG+. ‡ Breast: Go to repeat testing (BI-RADS 3) or to biopsy (BI-RADS 4 or 5). Cervical: Go to colposcopy (≥ASC or HPV+, HPV+ after prior ASC-US, or HPV 16/18+). Management options vary for women ages 21-24 after ASC-US or LSIL and for pregnant women. § According to ASCCP guidelines, timing of repeat cotesting (e.g., 1 or 3 year interval) depends on age and results from Pap and HPV tests. Women with Pap– after prior ASC-US return to routine screening and do not undergo repeat testing. ║ Breast: Update risk assessment. Cervical: Women with no lesion go to repeat cotesting according to ASCCP guidelines before returning to routine screening. Colorectal: Normal results include benign biopsies and rectosigmoid hyperplastic polyps <1 cm. ¶ Breast: Not applicable. Cervical: Women with CIN2+ go to excisional treatment. Women with CIN1 go to repeat cotesting according to ASCCP guidelines or to excisional treatment (if preceded by ASC-H or HSIL Pap). Management options vary for women ages 21-24 and for pregnant women. Colorectal: Timing of the surveillance regimen depends on number, size, and histology of polyps detected (e.g., tubular/villous adenoma, sessile serrated polyp, hyperplastic polyp ≥1 cm). # Cervical: Excisional treatment may occur after receiving colposcopy results. Colorectal: Excisional removal of presumed precancerous lesions usually occurs at the time of the colonoscopy procedure.