Image: PD Instruments used in endoscopy
1. Compared with usual care, fecal immunochemical test (FIT) outreach tripled colorectal cancer (CRC) screening rates and colonoscopy outreach doubled screening rates.
2. Of participants with abnormal fecal immunochemical test (FIT) results, 18% failed to follow-up with colonoscopy.
Evidence Rating Level: 1 (Excellent)
Study Rundown: Despite effective colorectal screening methods, screening rates remain low among uninsured and minority populations. This study found that organized mailed outreach efforts substantially increased CRC screening participation among underserved populations. The findings suggest that large-scale public health interventions to detect CRC should focus on the promotion of fecal immunochemical test (FIT) and other noninvasive tests over colonoscopy. However, this study only reflects screening participation after 1 round of invitation. Given the necessity for more frequent screening with FIT and the additional work-up necessary following an abnormal test, it remains unclear whether FIT is a superior CRC screening modality at the population level. Repeated outreach invitations could lead to higher rates of colonoscopy completion and adenoma detection. So while this study provides useful guidance for the development of programs and policies that may address disparities in CRC detection and outcomes, more longitudinal studies which include cost-effectiveness analysis are necessary to determine the long-term comparative effectiveness of various screening modalities.
In-Depth [prospective, randomized, comparative effectiveness study]: This study aimed to determine (1) if organized mailed outreach boosts screening compared with usual care and (2) if FIT is superior to colonoscopy outreach for screening participation. Participants included 5970 uninsured men and women, aged 54 to 64 years old, who were enrolled in a medical assistance program in Tarrant County, TX in 2011-2012. Patients were randomly assigned to FIT outreach (1593), colonoscopy outreach (479), or usual care (3898). Outreach interventions included a mailed invitation to complete no-cost screening, 2 prerecorded phone messages, up to 2 live phone reminders for patients who didn’t complete screening within 3 weeks of initial invitation. FIT outreach recipients were mailed a 1-sample FIT test, and colonoscopy outreach recipients were given a phone number to call and subsequent aid with scheduling and counseling in colonoscopy preparation. Usual care included opportunistic, clinic visit–based offers to complete screening with gFOBT, colonoscopy, barium enema, or sigmoidoscopy at the discretion of primary care providers. The study was powered to detect a 10% or more difference in the primary outcome of screening participation (completion of any CRC screening test within 1 year of follow-up after randomization).
Screening participation was 40.7% (95%CI, 38.3%-43.1%) for FIT outreach, 24.6% (95% CI, 20.8%-28.5%) for colonoscopy outreach, and 12.1% (95% CI, 11.1%-13.1%) for usual care. Outreach was consistently superior to usual care, with FIT outreach most successful, among all sex and ethnicity strata examined. Rate of CRC identification were equal among FIT and colonoscopy outreach (0.4%) than for usual care (0.2%). Of 60 patients with abnormal FIT results, 11 (18%) did not complete subsequent colonoscopy.
By Elizabeth Kersten and Andrew Bishara
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