Outreach efforts improve rates of colon cancer screening

1. This randomized clinical trial showed that among persons aged 50-64 years, mailed outreach invitations offering either fecal immunochemical tests (FIT) or colonoscopies increased the proportion of persons completing the CRC screening test within 3 years.

2. The rate of screening process completion was higher with colonoscopy outreach than with FIT outreach.

Evidence Rating Level: 1 (Excellent)

Study Rundown: Colorectal cancer (CRC) is the second leading cause of cancer-related deaths in the United States, and screening can reduce CRC incidence and mortality. However, CRC screening effectiveness is limited by underuse and suboptimal adherence. Complementing visit-based screening with mailed outreach invitations is known to increase screening in racially diverse and socioeconomically disadvantaged populations; however, the outcome measures in these studies focused on single steps of the screening process and not on the completion of the entire process over time. Therefore, it is not known whether mailed outreach invitations for CRC screening will significantly increase screening process completion over time. This randomized control study found that the groups who received mailed outreach invitations for either fecal immunochemistry testing (FIT) or colonoscopy testing had significantly increased CRC screening completion rates compared to the group receiving usual care (whatever visit-based screening was recommended and ordered during a single in-person clinic visit). There was a higher completion rate of the CRC screening process in the colonoscopy group compared to the FIT group.

There are a few limitations to the study. First, because this was a pragmatic trial, mailed invitations were simple, 1-page letters and not in-depth decision aids. Secondly, participants could have received screening at outside institutions, though this is unlikely due to the insurance arrangements within the health system. Finally, the study was not powered to detect differences in CRC detection or mortality. Overall, this study provides evidence suggesting among persons aged 50-64 years receiving primary care, mailed outreach invitations offering FIT or colonoscopy, compared with usual care, increased the proportion completing the CRC screening process within 3 years, suggesting their effectiveness over usual care.

Click to read the study, published in JAMA

Relevant Reading: Comparative effectiveness of fecal immunochemical test outreach, colonoscopy outreach, and usual care for boosting colorectal cancer screening among the underserved: a randomized clinical trial.

In-Depth [randomized control study]: This randomized clinical trial studied patients aged 50-64 years receiving primary care at a publicly-funded institution at Parkland Health and Hospital System. Patients were randomized into the following groups: 1) Patients who were mailed fecal immunochemistry test outreach invitations for CRC screening 2) Patients who were mailed colonoscopy outreach invitations for CRC screening, and 3) usual care, where recommended in-person recommendations were made about CRC screening if indicated at clinic visits. The primary endpoint was screening process completion within three years, defined as (1) colonoscopy completed with no cancer detected; (2) cancer detected by colonoscopy and treatment evaluation completed within 2 or fewer months; (3) a normal FIT result repeated annually for 3 years; (4) an abnormal FIT result with colonoscopy completed within 6 or fewer months with no cancer detected; or (5) an abnormal FIT result with cancer detected by colonoscopy and treatment evaluation completed within 2 or fewer months. The study found that persons who received mailed outreach invitations for either fecal immunochemistry testing (FIT) or colonoscopy testing had significantly increased CRC screening completion rates compared to the group receiving usual care. There was a higher completion rate of the CRC screening process in the colonoscopy group compared to the FIT group.

Of 5999 persons who were included in the study, 2400 persons were assigned to the FIT outreach group; 2400 to the colonoscopy outreach group, and 1199 to the usual care group. Screening process completion was achieved in 38.4% (95% CI, 36,5% to 40.4%) of participants in the colonoscopy outreach group, 28.0% (95% CI, 26.2% to 29.8%) in the FIT outreach group, and 10.7% (95% CI, 9.1 to 12.6%) in the usual care group. Compared with the usual care group, screening process completion was 27.7% (95% CI, 25.1% to 30.4%) higher in the colonoscopy outreach group and 17.3% (95% CI, 14.8% to 19.8%) higher in the FIT outreach group and 10.4% (95% CI, 7.8% to 13.1%) higher for the colonoscopy outreach group compared to the FIT outreach group (p < 0.001 for all comparisons mentioned).

Image: PD

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