Journal of Cancer Research and Practice

: 2019  |  Volume : 6  |  Issue : 1  |  Page : 26--29

Improving colorectal, oral, breast, and cervical cancer screening rates using an inreach approach

Lee-Kiat Ban1, Ailun Heather Tseng2, Hung-Chun Hsing3, Henry Hsin-Chung Lee4,  
1 Department of Surgery, Hsinchu Cathay General Hospital; College of Medical Technology, Nursing and Wellbeing, Yuanpei University of Medical Technology, Hsinchu, Taiwan
2 Center of Research and Teaching, Hsinchu Cathay General Hospital, Hsinchu, Taiwan
3 Department of Nursing, Hsinchu Cathay General Hospital; College of Nursing, Yuanpei University of Medical Technology, Hsinchu, Taiwan
4 Department of Surgery, Hsinchu Cathay General Hospital; Graduate Institute of Translational and Interdisciplinary Medicine, College of Health Sciences and Technology, National Central University, Taoyuan; School of Medicine, Fu Jen Catholic University, New Taipei, Taiwan

Correspondence Address:
Dr. Henry Hsin-Chung Lee
Department of Surgery, Hsinchu Cathay General Hospital, No. 678 Chung-Hwa Rood, Sect. 2, East Dist, Hsinchu


The Taiwanese national cancer screening program was established in 1985 by providing Pap smear tests for women. At the same time, trial-based screening for colorectal, oral, and breast cancer screening was initiated. In 1999, outreach services for cancer screening were started and gradually scaled up to the national level. Our hospital is located in Hsinchu, Taiwan. Like many hospitals in Taiwan, we provide cancer screening services to the community. Our baseline screening rate was 96.6% in 2016. Aiming to increase the overall cancer (including colorectal, oral, breast, and cervical cancer) screening rates, we implemented two strategies. First, we modified the cancer screening workflow so that patients could receive screening counseling before the scheduled appointment. Second, we redesigned the clinic waiting room layout by moving check-in and cancer screening counters next to each other. By the end of 2017, the overall cancer screening rate increased from 96.6% to 105.4%. Our future efforts will be focused on collecting patient feedback, increasing coverage of hard-to-reach populations, and understanding barriers to cancer screening for specific groups of patients.

How to cite this article:
Ban LK, Tseng AH, Hsing HC, Lee HH. Improving colorectal, oral, breast, and cervical cancer screening rates using an inreach approach.J Cancer Res Pract 2019;6:26-29

How to cite this URL:
Ban LK, Tseng AH, Hsing HC, Lee HH. Improving colorectal, oral, breast, and cervical cancer screening rates using an inreach approach. J Cancer Res Pract [serial online] 2019 [cited 2021 Mar 5 ];6:26-29
Available from:

Full Text


Cancer is the second leading cause of death globally and was responsible for 8.8 million deaths in 2015.[1] The concept of the early detection of cancer was reported by the World Health Organization in 1968.[2] Since then, various countries have implemented programs with the aim of early detection to reduce mortality and morbidity. Evidence demonstrates that the incidence of cervical and colorectal cancer has been declining, for the most part, due to adherence to Pap test screening and fecal occult blood tests,[3],[4] respectively. However, effective strategies are still required to increase cancer screening rates.

Outreach and inreach approaches are used by several countries to increase the uptake of cancer screening for patients who are eligible for detection.[4] Outreach delivers on-site screening services outside the medical setting,[5] whereas inreach provides services to those who have already engaged in the health-care system for treatment unrelated to screening for cancers.[6],[7] In Europe, most nations adopt an outreach approach, while in the US, both approaches are used.[4] In Taiwan, outreach services for cancer screening were launched in 1999. To increase accessibility to screening, the government further added inreach screening services in qualified hospitals and clinics in 2010.[8]

In the outreach approach, invitations for cancer screening are given via mail, telephone calls, mass media, and public campaigns,[9] whereas in the inreach approach, patients or persons accompanying patients are invited while waiting in the clinic waiting rooms.[4] In addition, posters and videos relating to cancer screening are displayed in hospital corridors or clinic waiting rooms to promote and educate patients about cancer screening. Several studies have evaluated the effectiveness of the inreach approach,[4],[10],[11] however, no studies have investigated whether redesigning the waiting room could affect cancer screening rates.

Our hospital is located in Hsinchu, Taiwan. We have on average 1,500 appointments per day. The peak times are between 10 and 11:30 in the morning and 2:30–3:30 in the afternoon. Before 2017, the screening process was inefficient and time-consuming. The check-in counter and cancer screening counter were placed far apart from each other, and they were small, only being able to serve two patients at a time. Furthermore, the boring and distressing wait to see the doctor meant that the patients were unwilling to spend more time in the hospital for screening consultation. In this study, we sought to create a method to increase cancer screening rates by changing the screening process and layout using the inreach approach.


The Taiwan nationwide cancer screening program is funded by the Health Promotion Administration, Ministry of Health and Welfare (formerly Bureau of Health Promotion). The screening system is a stepwise protocol which includes surveillance of potential participants for screening. All screening data are collected and analyzed for outcome evaluation, including cancer screening rates. In addition, the program requires all of the participating hospitals to achieve a target goal of 9000 patients per year for cancer screening. In December 2016, our baseline screening rate for colorectal, oral, breast, and cervical cancers combined was 96.6% (n = 8730).

The eligibility criteria for colorectal cancer screening were adults aged 50–70 years who had not had a fecal occult blood test or colonoscopy in the past 2 years. The eligibility criteria for oral cancer were adults aged older than 30 years who were current smokers and/or betel nut chewers who had not had a test in the past 2 years. For breast cancer, women aged 45–70 years who had not had a mammogram within the past 2 years were eligible, and for cervical cancer, women aged 30–70 years who had not had a Pap smear within the past 3 years. Second, to increase the screening rates, we modified our waiting room layout.


Strategy #1: Identifying eligible patients for cancer screening before scheduled appointments.

We reviewed our registry system and selected two departments with the most appointments from January to December 2017. We proactively identified patients eligible for colorectal, oral, breast, and/or cervical cancer screening from any two apartments that had the most appointments and recorded the information in the electronic reminder system. When the patients checked-in, the reminders would alert the staff of the eligible patients. The staff would then tell the patients that they were eligible for cancer screening, but they could also request the test. Patients not part of the list and persons accompanying the patients were also welcome to undergo cancer screening.

Strategy #2: Changing the order of cancer screening counseling from after to before treatment

We changed the order of cancer screening counseling from after seeing the doctor to before seeing the doctor. The cancer screening process is shown in [Figure 1].{Figure 1}

Strategy #3: Redesigning the layout of the clinic waiting room

We redesigned the layout of the clinic waiting room [Figure 2]. The check-in and cancer screening counters were originally 5 meters apart. We moved the counters next to each other so that patients could easily transfer from counter to counter.{Figure 2}


We successfully increased the cancer screening rates by screening eligible patients before office hours and proactively inviting the patients for screening during any interaction with the staff. To improve the patients' experience of care, we modified the cancer screening process and space design. For example, the boring and distressing wait before seeing the doctor was replaced by an efficient cancer screening process; furthermore, the “bundling” of check-in and cancer screening counters avoided crowding and inconvenience of transfer from counter to counter. By December 2017, the cancer screening rates of all cancers combined increased from 96.6% (n = 8730) to 105.4% (n = 9450) [Figure 3].{Figure 3}


The present study evaluated the performance of the inreach approach in the delivery of cancer screening. First, proactive identification and invitation of patients for cancer screening generated higher screening rates than the previous year. Second, the change in the screening process from after appointments to before appointments helped the patients alleviate the stress of waiting. Third, the space redesign shortened the travel distance between counters.

Time may have been the major factor in increasing screening rates in the first 6 months of the years. By July 2016, the rates increased slowly and remained stable for 3 months. Nevertheless, by the end of 2016, we had not reached the target goal. In 2017, knowing that the trend could be similar to the past year, we decided to implement several strategies as described above. Although we successfully reached the target, the screening rates did not increase significantly. Changing the order of cancer screening consultation from after to before seeing the doctor contributed only part of the overall screening rate. The patients who were willing to undergo screening consultation were those who disliked waiting; however, a large number of patients still preferred to see the doctor first. Proactively inviting patients to undergo cancer screening was the most effective method. We found that the patients appreciated being invited by our health staff. Several studies have examined the inreach approach to increase cancer screening rates. One study in North Carolina found that the use of either brochures or promotional material made no difference in screening rates, but with additional counseling over the phone, the screening rates increased significantly.[12] However, Feldman et al. reported that although phone calls were effective, the process was difficult and consumed significant staff resources.[11] Similar to our study, Chou et al. recruited patients for cancer screening while on-site.[4] Their study suggested that the inreach approach alone was beneficial in improving coverage rate, but that integrating both outreach and inreach approaches could engage more subjects to participate in screening.

Although a mixed approach was not the main focus of this study, other studies have suggested that integrating both outreach and inreach approaches are effective in promoting cancer screening services.[4],[6],[13] The findings are plausible. As the national screening program provides free screening for colorectal, oral, breast, and cervical cancers every 2–3 years, health-care providers may face what is called the “business cycle” where the screening rates fluctuate. Hence, when the screening rate drops to its lowest point, health-care providers should compensate by switching between approaches depending on the situation.

Few studies have discussed the impact of waiting room design on cancer screening rates. Klabunde et al. briefly mentioned that office redesign could improve the efficiency and quality of screening services.[14] Donetto et al. examined the relationship between building environment and quality of care.[15] By applying Pallasmaa's theory,[16] the authors suggested that “peripheral” perception, that is seeing and hearing, was central to the social relationship between nursing staff and patients. In our study, we realized that changing the space design was the least effective method for increasing screening rates. It only reduced the hassle of transferring from one space to another. In the future, we plan to improve visibility and create a wider space for screening consultation.


Changing the cancer screening procedure and waiting room design could improve overall cancer screening rates and possibly provide a better patient experience of care. Our future efforts will focus on space redesign, collecting patient feedback, increasing coverage of hard-to-reach populations, and understanding barriers to cancer screening for specific groups of patients. Meanwhile, we continue to increase screening rates and test different methods.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.


1World Health Organization. World Health Organization Fact Sheet: Cancer. World Health Organization; 2018. Available from: [Last accessed on 2018 Jun 11].
2Wilson JMG, Jungner G. Principles and Practice of Screening for Disease. Geneva, Switzerland: WHO; 1968. [Report No.: 34].
3Brouwers MC, De Vito C, Bahirathan L, Carol A, Carroll JC, Cotterchio M, et al. What implementation interventions increase cancer screening rates? A systematic review. Implement Sci 2011;6:111.
4Chou CK, Chen SL, Yen AM, Chiu SY, Fann JC, Chiu HM, et al. Outreach and inreach organized service screening programs for colorectal cancer. PLoS One 2016;11:e0155276.
5Logan RF, Patnick J, Nickerson C, Coleman L, Rutter MD, von Wagner C, et al. Outcomes of the bowel cancer screening programme (BCSP) in England after the first 1 million tests. Gut 2012;61:1439-46.
6Paskett ED, Tatum CM, D'Agostino R Jr., Rushing J, Velez R, Michielutte R, et al. Community-based interventions to improve breast and cervical cancer screening: Results of the Forsyth county cancer screening (FoCaS) project. Cancer Epidemiol Biomarkers Prev 1999;8:453-9.
7Boehm JE, Rohan EA, Preissle J, DeGroff A, Glover-Kudon R. Recruiting patients into the CDC's colorectal cancer screening demonstration program: Strategies and challenges across 5 sites. Cancer 2013;119 Suppl 15:2914-25.
8Health Promotion Administration MoHaW. Taiwan Breast Cancer, Oral Cancer, and Colorectal Cancer Screening Programs; 2016. Available from: [Last accessed on 2013 Jun 13].
9Sano H, Goto R, Hamashima C. What is the most effective strategy for improving the cancer screening rate in Japan? Asian Pac J Cancer Prev 2014;15:2607-12.
10McPhee SJ, Detmer WM. Office-based interventions to improve delivery of cancer prevention services by primary care physicians. Cancer 1993;72:1100-12.
11Feldman J, Davie S, Kiran T. Measuring and improving cervical, breast, and colorectal cancer screening rates in a multi-site urban practice in Toronto, Canada. BMJ Qual Improv Rep 2017;6. pii: u213991.w5531.
12Rimer BK, Conaway M, Lyna P, Glassman B, Yarnall KS, Lipkus I, et al. The impact of tailored interventions on a community health center population. Patient Educ Couns 1999;37:125-40.
13Rees I, Jones D, Chen H, Macleod U. Interventions to improve the uptake of cervical cancer screening among lower socioeconomic groups: A systematic review. Prev Med 2018;111:323-35.
14Klabunde CN, Lanier D, Breslau ES, Zapka JG, Fletcher RH, Ransohoff DF, et al. Improving colorectal cancer screening in primary care practice: Innovative strategies and future directions. J Gen Intern Med 2007;22:1195-205.
15Donetto S, Penfold C, Anderson J, Robert G, Maben J. Nursing work and sensory experiences of hospital design: A before and after qualitative study following a move to all-single room inpatient accommodation. Health Place 2017;46:121-9.
16Pallasmaa J. The Eyes of the Skin: Architecture and the Senses. Chichester: John Wiley and Sons; 2012.