The Forsyth County Cancer Screening Project (FoCaS)

In 2005, 11,999 women in the United States were diagnosed with cervical cancer, and 3,924 died from the disease. The same year, 186,467 women were diagnosed with breast cancer, and 41,116 died from the disease.  Older, low-income, and minority women are the most impacted by these cancers because they are less likely to be screened, which is believed to result in more late-stage cancers and lower survival rates. Underutilization of screening has been attributed to several factors including limited access and referral to preventive and therapeutic services, fear and fatalistic views of breast cancer along with distrust of the medical community, and the fact that physicians may be less likely to recommend screening to older or minority women.

The Forsyth County Cancer Screening Project (FoCaS) is designed to (a) identify barriers to breast and cervical cancer screening faced by low-income women and health care providers and (b) address these barriers in a comprehensive program to help improve participation in breast and cervical cancer screening among low-income women. FoCaS comprises both public health clinic in-reach strategies and community outreach strategies.

The public health clinic in-reach strategies include:
-- In-service and primary care conference training for health care providers
-- Visual prompts in exam rooms
-- Educational games
-- Abnormal test protocol (including alert stickers, a referral process for managing the care of women with abnormal test results, and a tracking system)
-- Posters and literature in waiting rooms
-- One-on-one counseling sessions and personalized letters for followup testing for women with abnormal results

The community outreach strategies include:
-- Monthly classes conducted by a health educator
-- A community party with food, educational classes, screenings, prizes, and information booths
-- A church program
-- Educational brochures to address barriers
-- Mass media
-- Birthday cards with the FoCaS logo
-- Targeted mailings and door knob hangers with invitations to events
-- One-on-one educational sessions in women's homes

FoCaS was originally implemented over a 4-year period (including baseline survey data collection, intervention implementation, followup survey data collection, and transfer of successful interventions to the comparison city). Because FoCaS is a multifaceted intervention, time requirements will vary when replicated based on the activities selected to be implemented.

The FoCaS program is intended for low-income women aged 40 and older.

Community outreach activities are implemented in community centers, individual homes, and community places of worship. Public heath clinic in-reach activities are implemented in the clinics' waiting and exam rooms.

Required resources include:
-- Class and community educational brochures
-- FoCaS newsletter
-- Sample birthday card
-- Church program materials (flyers and invitation and agenda for luncheon)
-- In-reach flyers for public health clinics advertising breast cancer awareness month
-- Outreach plan and community education intervention class schedule
-- Monthly class announcement flyers
-- Sample class outlines for monthly sessions and educational classes

Mass media techniques such as public bus ads and newspaper and radio ads can also be utilized. Costs associated with the program's implementation are not provided.

The FoCaS Project was conducted over a four-year period in low-income housing communities in Winston-Salem and Greensboro, North Carolina. These communities served as the intervention city and comparison city, respectively.  All public health clinic in-reach strategies and community outreach strategies were made available to the communities located in Winston-Salem, although the extent to which individuals utilized these services is unknown. Baseline and 2.5-year followup data were obtained from independent cross-sectional samples in both the intervention and comparison cities. Samples were also drawn by random selection, stratified by age, among women who resided in the communities during the intervention period.

Of the 248 women who completed baseline surveys and the 302 women who completed followup surveys, the majority were aged 65 and older (baseline: 56.5%; followup: 61.3%); the remainder were primarily between 40 and 64 years of age (baseline: 43.5%; followup: 37.1%). Most participants were African American (baseline: 72.2%; followup: 78.5%)

Women were asked in face-to-face interviews about their compliance with mammography and Pap smear screening guidelines. For mammography, women aged 40 through 49 were within guidelines if they reported that they had received a mammogram within the past 2 years. Women aged 50 and older were within guidelines if they reported that they had received a mammogram within the past year. All women were within guidelines for Pap smear screening if they reported that they had received a Pap smear within the past 3 years.

• The proportion of women in the intervention city reporting having had a mammogram within guidelines increased significantly from 31% to 56% (p=.049) over the 4 years of the intervention, with no significant increase in use of mammography in the comparison city.

• The proportion of women in the intervention city who had received a Pap smear within the past 3 years increased from 73% to 87% (p=.004), while the proportion decreased from 67% to 60% among women in the comparison city.