Populations of Focus

Adults with Preventive Care Needs Guide

Version 3 – June 2026

KEY ACTIVITY #2:

Develop or Update the Practice’s Cancer Screening Protocols

 

This key activity involves the following elements of person-centered population-based care: operationalize clinical guidelines; implement condition-specific registries; proactive patient outreach and engagement; pre-visit planning and care gap reduction; care coordination.

Overview

This activity provides general guidance for developing or refining a cancer screening protocol that aligns with the PHMI clinical guidelines, establishes clinical and supportive processes that provide a framework for implementing the guidance safely, and leverages the capabilities of appropriate staff to carry out the protocols. It is the foundation of many of the remaining key activities in this implementation guide.

Cancer screening is essential to early detection and treatment of cancers. Aligning a practice’s screening protocols with the relevant guidelines and ensuring a standard team-based approach to identify and address screening status helps to ensure that your practice is able to identify and offer cancer screening to all eligible patients. Early detection and treatment are of critical importance among populations that have a higher incidence of breast, colon and cervical cancer.

The cancer screening protocol includes applying an equity lens to help ensure that barriers to cancer screening are addressed, including economic, social, historical and cultural barriers, and all patients who are eligible for and due for screening, especially those who are at high risk for cancer, receive appropriate screening and follow-up. Key activities in the protocols should be prepared to address relevant social, cultural and linguistic barriers and needs of the population.

Relevant HIT capabilities to support this activity include care guidelines, registries, clinical decision-making support, care dashboards and reports, quality reports, outreach and engagement, and care management and care coordination (See Appendix E: Guidance on Technological Interventions). Reports should have the capacity to filter by provider, location and care team (where applicable).

Access to outside data may be a consideration or requirement (e.g., California Immunization Registry (CAIR) or immunization registry data and data from other practices), as services received outside the health center may be an important part of screening and follow-up. Ideally, this is accomplished by real-time data exchange, but where not possible, it may require manual entry. Reports may need to include not only the EHR but care coordination and population health management applications or freestanding referral registries. While claims data may be helpful in this regard, lag time may impact its usefulness. Patient-facing applications should be strongly considered to promote patient activation by helping assure that patients are informed and appreciative of the nature and importance of recommended care.

Action steps and roles

1. Understand the latest recommendations on who is eligible and needs to be screened for colorectal cancer, breast cancer and/or cervical cancer and how abnormal findings on those screenings should be managed.

Suggested team member(s) responsible: Medical director or their designee.

See the clinical practice guidelines section earlier in this guide. Ensure your practice uses the latest guidelines.

2. Develop or update a colorectal cancer screening protocol for your practice.

Suggested team member(s) responsible: Medical director or their designee.

  • In addition to the USPSTF recommendations linked to in step 1, review the National Cancer Institute’s Colorectal Cancer Screening (PDQ ®) - Health Professional Version and the CDC's Screening for Colorectal Cancer for additional practical guidance on colorectal cancer screening.
  • Download an Example Colorectal Cancer Screening Policy and Procedure to modify for your practice.
  • Include a summary statement on colorectal cancer screening, including:
    • The evidence base for colorectal cancer screening.
    • Benefits of colorectal cancer screening.
    • Potential risks of colorectal cancer screening.
    • Recent changes to the practice’s colorectal cancer screening protocol, if any.
    • Management of abnormal or suspicious findings, including patient contact information.
  • The colorectal cancer screening protocol should include the following sections:
    • Who the screening protocol applies to, including initiation age and cessation age for those at average risk, and high-risk individuals.
    • The screening methods available, including (for each method):
      • Name and brief description of the screening method.
      • Who and when the screening method are indicated for and any exclusionary criteria for this method.
      • The known risks and benefits of the screening method.
      • Recommended frequency of screening using this method.
      • Who – meaning which role(s) within the practice – can initiate and/or provide screening using this method (see also Key Activity 5: Develop and Implement Standing Orders).
      • Guidance for patients on using this method and preparing for the test, including the opportunity for them to ask questions and have them answered.
      • Guidance on documenting the screening, including the screening method in the patient’s record.
      • Guidance and documentation for patient declination. For more information, see Key Activity 7: Refine and Implement a Pre-Visit Planning Process for guidance on documenting when a patient declines.
      • Follow-up of abnormal or suspicious findings for each technique.
      • Date the protocol was approved for use.

Here is a sample colorectal cancer screening decision tree that your practice can adapt to meet your protocols.

Preventive healthcare includes participation in select screening tests that have been shown to identify disease early—before symptoms develop—and when treatment is most likely to be effective. This guide addresses steps to support screening for patients at average risk for breast, cervical, and colorectal cancer. Those who are at average risk should be encouraged and supported to undergo screening tests at the frequency noted in the PHMI clinical guidelines.

Some people, however, are at elevated risk for certain types of cancer, and they should be screened using specific screening methodologies at intervals that may differ from routine screening. Those at elevated risk should not be advised to follow the routine screening guidance outlined in the Implementation Guides but should follow individualized screening guidance in accordance with their risk for a particular disease.

Conditions and circumstances that elevate a person’s risk may be related to the presence of signs or symptoms suggestive of cancer, a personal history of cancer or of pre-cancerous conditions, a close family member with a specific cancer or certain types of exposure. When determining if a person is at elevated risk, it is useful to review their health history and ask the following questions at regular intervals, because an individual’s risk status may change over time:

  • Have you ever been diagnosed with breast/cervical/colorectal cancer or a precancerous condition?
  • Do you have a first degree relative (biological parent or sibling) who has been diagnosed with cancer or a precancerous condition?
  • Do you have a genetic marker or syndrome associated with higher cancer risk?
  • Do you have any medical conditions that place you at higher risk for cancer (for example, Crohn’s disease increases the risk for CRC cancer)?
  • Have you had exposure to drugs or radiation that might affect your risk for cancer?

If a patient is identified as having an elevated risk for breast, cervical, or colorectal cancer, the primary care provider should discuss this risk with the patient and advise the patient of the modified recommendations for persons at elevated risk.

For additional information concerning increased risk for breast cancer, review the following guidance:

For additional information concerning increased risk for cervical cancer, review the following guidance:

For additional information concerning increased risk for colorectal cancer, review the following guidance:

 

Guidance Provided by:

  • Margaret Franckhauser, MS, MPH, RN
  • Adults with Preventive Health Needs Subject Matter Expert

References:

3. Develop or update a breast cancer screening protocol for your practice.

Suggested team member(s) responsible: Medical director or their designee.

  • Practices should consult the guidelines for breast cancer screening in the clinical practice guidelines section earlier in this guide. Practices should also review the National Cancer Institute’s Breast Cancer Screening (PDQ ®) - Health Professional Version, and the CDC’s The Cancer Screening Change Packages for additional practical guidance on breast cancer screening.
  • Download an Example Breast Cancer Screening Policy and Procedure to modify for your practice.
  • Include a summary statement on breast cancer screening, including:
    • The evidence base for breast cancer screening.
    • Benefits of breast cancer screening.
    • Potential risks of breast cancer screening.
    • Recent changes to the practice’s breast cancer screening protocol, if any.
  • The breast cancer screening protocol should include the following sections:
    • Who the screening protocol applies to, including initiation and cessation ages, and high-risk individuals.
    • The screening method available, including:
      • Name and brief description of the screening method (e.g., screening mammography).
      • Who the screening method is indicated for and any exclusionary criteria for this method.
      • Recommended frequency of screening using this method.
      • Who – meaning which role(s) at the practice – can initiate and/or provide screening using this method (see also Key Activity 5: Develop and Implement Standing Orders).
      • Guidance for patients on using this method and preparing for the method, including the opportunity for them to ask questions and have them answered.
      • Guidance on documenting the screening in the patient’s record.
      • Recommended follow-up of abnormal or suspicious findings.

 

4. Develop or update a cervical cancer screening protocol for your practice.

Suggested team member(s) responsible: Medical director or their designee.

  • Practices should consult the guidelines for cervical cancer screening in the clinical practice guidelines section in this guide . Practices should also review the National Cancer Institute’s Cervical Cancer Screening (PDQ ®) - Health Professional Version for additional practical guidance on cervical cancer screening.
  • Include a summary statement on cervical cancer screening, including:
    • The evidence base for cervical cancer screening.
    • Benefits of cervical cancer screening.
    • Potential risks of cervical cancer screening.
    • Recent changes to the practice’s cervical cancer screening protocol, if any.
  • The cervical cancer screening protocol should include the following sections:
    • Who the screening protocol applies to, including initiation and cessation ages, and high-risk individuals.
    • The Screening Methods available, including (for each method):
      • Name and brief description of the screening method.
      • Who the screening method is indicated for and any exclusionary criteria for this method.
      • Recommended frequency of screening using this method.
      • Who – meaning which role(s) at the practice – can initiate and/or provide screening using this method (see also Key Activity 5: Develop and Implement Standing Orders).
      • Guidance for patients on using this method, including the opportunity for them to ask questions and have them answered.
      • Guidance on documenting the screening in the patient’s record.
      • Follow-up of abnormal or suspicious findings.

 

5. Monitor the cancer screening protocol for accuracy and completeness.

Suggested team member(s) responsible: Quality improvement lead or their designee.

It is critical to have a system to review and update the cancer screening protocols on a periodic basis, as new research often results in refinements, changes and updates of national recommendations. Ideally, at least one clinical member of the implementation team should be tasked with reviewing the protocols on a periodic basis (six months or 12 months) and bringing suggested revisions before the team for consideration in modifying the protocols.

Other members of the implementation team should serve in a supportive role to bring identified changes forward to the team for review and consideration.

In addition, the implementation team should create a feedback loop with the practice’s care team about any real or potential gaps or errors in the cancer screening protocol. The cancer screening protocol should be modified as needed whenever changes, errors or gaps are discovered.

See also these related key activities:

 

Example workflow

Step 1: A member of the clinical care delivery team (e.g., MD, DO, APRN, PA) is assigned to be a protocol update lead and will scan the literature, review the cancer screening protocols, and bring suggested updates to the implementation team.

Step 2: At each meeting of the implementation team, a protocol update agenda item is addressed. The protocol update lead brings forward any identified gaps, errors or changes in national standards for the team’s consideration.

Step 3: New information, research and national standards (via USPSTF and others) are brought forward for consideration by the protocol update lead and the evidence base is reviewed. Team members suggest changes and discuss how these changes will be operationalized in the protocol.

Step 4: The protocol update lead drafts the suggested protocol changes and presents them to the implementation team for review and finalization. This process may continue until the implementation team is satisfied with the changes and the new protocol.

Step 5: The protocol update lead assumes responsibility for sharing the new protocol with all members of the team involved in implementation.

Implementation tips

  • Assign one or two members of the team to receive and follow up on updates from the USPSTF. These updates automatically alert providers when new recommendations are posted and finalized.
  • Review any changes in the guidelines with clinicians and clinical support so that discussions with patients reflect the current recommendations.
  • Note the availability of choices in certain types of cancer screening, such as colorectal cancer, and inform patients of the differing testing schedule based on the type of test selected.
  • Be sensitive to barriers, such as out-of-pocket expenses, transportation needs, and scheduling needs that affect a patient’s ability to carry out the screening.
  • See also Appendix D: Peer Examples and Stories from the Field to learn about how others are implementing this activity.

Evidence base for this activity

Crosby D, Bhatia S, Brindle KM, Coussens LM, Dive C, Emberton M, Esener S, Fitzgerald RC, Gambhir SS, Kuhn P, Rebbeck TR, Balasubramanian S. Early detection of cancer. Science. 2022 Mar 18;375(6586):eaay9040. doi: 10.1126/science.aay9040. Epub 2022 Mar 18. PMID: 35298272.