Project SAFe (Screening Adherence Follow-Up Program)

Timely breast cancer screening through early detection, follow-up surveillance, and treatment is believed to improve breast cancer survival rates. However, low-income, ethnic-minority women are more likely than other women to delay or miss follow-up appointments after receiving an abnormal mammogram. This is due to barriers such as cultural norms, language, low health literacy, lack of insurance, irregular sources of medical care, uncoordinated treatment services, and psychological distress. Patient navigation counseling and case management that is sensitive to the barriers faced by low-income, ethnic-minority women may improve adherence to recommendations for regular screening and treatment follow-up after an abnormal mammogram. 

Project SAFe (Screening Adherence Follow-Up Program) is a system of patient navigation counseling and case management designed to help low-income, ethnic-minority women overcome barriers to timely breast cancer screening and follow-up after receiving an abnormal mammogram. The service involves a structured interactive telephone assessment of screening-adherence risk (i.e., barriers), health counseling, and follow-up services, including patient tracking, appointment reminders, and referral to community resources. 

Project SAFe is focused on individual cognitive, affective, and environmental factors that may impede timely breast cancer screening and follow-up. The level of service provided by SAFe is matched to the patients' needs. All women receive a 30-minute scripted phone call from a Patient Navigator (PN) who conducts an assessment of potential barriers a patient may face and provides health education and counseling to help overcome the barriers. All women receive appointment scheduling, reminders, and follow-up calls at 6 and 12 months that provide a reinforcing educational message about the value of follow-up and subsequent rescreening. If the PN determines during the assessment phone call that a patient is experiencing mild psychological distress, has poor understanding of the need for follow-up, has comorbid physical illnesses, or has system navigation or community-based referral needs, the PN may provide more intensive assistance to overcome environmental barriers (e.g., transportation) and systems navigation issues. Such issues may include patient-medical provider communication and referral. If the patient currently has cancer, or the PN determines that the patient is experiencing severe psychological distress, an individual with a master's degree in social work (M.S.W.) may be called in to conduct further assessment, brief counseling, and referral to psychosocial oncology and mental health services. 

The Implementation Guide is a resource for implementing this program. It provides important information about the staffing and functions necessary for administering this program in the user's setting. Additionally, the steps needed to carry out the research-tested program, relevant program materials, and information for evaluating the program are included. The Implementation Guide can be viewed and downloaded in the Products page.

This program is an example of client reminder interventions (Breast Cancer Screening) and one-on-one education interventions (Breast Cancer Screening), which are recommended by the Community Preventive Services Task Force, as found in the Guide to Community Preventive Services.

To implement this intervention, an organization must identify targeted patients, train counselors, and implement the intervention (e.g., make phone calls, check medical records for adherence to follow-up subsequent to diagnosis). Time required will vary according to the efficiency of the procedure to identify targeted patients, time needed to prepare e-mails or brochures for mailing, and the number of patients targeted.

The intervention is targeted to low-income, ethnic-minority women aged 19 years and older and the health care providers that serve them.

The intervention is suitable for implementation in health care centers and clinical practices. 

Required resources include the following: Project SAFe: The Screening Adherence Follow-Up (SAFe) Program Toolkit and the Executive Summary.  PNs typically have a bachelor's degree and/or relevant experience in community-based health care programs. An individual with a master's degree in social work (M.S.W.) may be needed for more intensive services for women experiencing severe psychological distress. For information on cost, please contact the developer.

Eligible women were identified from a centralized list of women who had an abnormal mammography at a public medical center serving low-income women. Two hundred and four patients agreed to participate and were randomly assigned to either the intervention condition (96 women) or a usual-care control condition, in which they received only a mailed, appointment-reminder postcard (108 women). The majority of participants were foreign-born, non-English-speaking Latinas. A bilingual PN attempted to reach each woman to inform her about the study using scripted materials in Spanish or English. The PN explained the purpose of the study and study design, obtained consent, and conducted a scripted Adherence Risk Assessment designed to ascertain potential barriers to keeping appointments. The barriers assessed included concerns about diagnostic procedures, lack of understanding of the nature of the follow-up test, worry about costs, transportation, perceived emotional support, and family problems or responsibilities that could interfere with adherence.

Outcomes included completed follow-up appointments (i.e., adherence) and timely follow-up appointments (i.e., timeliness of adherence). Outcomes were assessed based on a periodic review of patients' medical records.

• Patients in the intervention group were more likely than patients in the usual-care group to adhere to recommendations for diagnostic follow-up appointments (90% vs. 66%, respectively; p<.001). 

• Patients in the intervention group were also more likely than patients in the usual-care group to adhere to recommendations for diagnostic follow-up appointments in a timely fashion (77% vs. 57%, respectively; p=.01).

• In addition, 44 patients were randomly selected to be surveyed by telephone regarding their satisfaction with SAFe services. Of the 35 women (80%) who responded to the survey, 88.6% rated SAFe services "good" to "excellent"; 85.7% said they "got what they wanted" from SAFe, and 94.3% were "mostly" or "very" satisfied overall. More than 90% of the women surveyed rated their likelihood of getting a future mammogram and a follow-up test after an abnormal mammogram as very high (e.g., 9 or 10 on 1-10 point scale). 

Ell, K., Vourlekis, B., Lee, P-J., & Xie, B. (2007). Patient navigation and case management following an abnormal mammogram: A randomized clinical trial. Preventive Medicine, 44 , 26-33.

Ell K, Vourlekis B, Muderspach L, Nissly J, Padgett D, Pineda D, Sarabia O, Lee PJ. (2002). Abnormal Cervical Screen Follow-Up among Low-Income Latinas: Project SAFe. Journal of women's health & gender-based medicine, 11 (7), 639-651.

Ell K, Vourlekis B, Nissly J, Padgett D, Pineda D, Sarabia O, Walther V, Blumenfield S, Lee PJ. (2002, August). Integrating Mental Health Screening and Abnormal Cancer Screening Follow-Up: An Intervention to Reach Low-Income Women. Community Mental Health Journal, 38 (4), 311-325.

Ell, K., Padgett, D., Vourlekis, B., Nissly, J., Pineda, D. Sarabia, O., Walther, V., Blumenfield, S., & Lee, P-J. (2002). Abnormal mammogram follow-up: A pilot study in women with low income. Cancer Practice, 10 (3), 130-138.