Direct Mail Improves Colon Cancer Screenings in Underserved

James Brice

September 10, 2012

September 10, 2012 — Direct mail, a tried and true marketing tool, has also been shown in a randomized clinical trial to persuade medically underserved individuals from diverse racial and ethnic backgrounds to undergo colorectal cancer screenings.

US public health officials have historically had trouble convincing adults aged 50 years and older, regardless of their economic standing or ethnic background, to undergo recommended screenings for colorectal cancer.

Nearly half of all eligible adults do not undergo recommended fecal occult blood testing (FOBT), sigmoidoscopy, or colonoscopy, according to a 2010 report by the National Center for Health Statistics. Compliance rates are even lower among racial and ethnic minorities, the poor, the poorly educated, and the uninsured, according to a study by Muriel Jean-Jacques, MD, and colleagues at Northwestern University's Feinberg School of Medicine in Chicago, Illinois.

Results of the study were published in the September/October issue of the Annals of Family Medicine.

Research has shown that compliance can be raised by mailing FOBT kits directly to patients who qualify for colorectal screening, but none of these studies were targeted to low-income groups or racial and ethnic minorities.

Dr. Jean-Jacques and colleagues set out to correct this problem in a study directed at patients at the Heartland International Health Center (HIHC), a federal health center that provides primary care to a low-income, largely uninsured, and racially diverse community on the north side of Chicago. HIHC serves more than 13,000 patients annually at 8 clinical sites.

HIHC's usual colorectal cancer screening program includes periodic FOBT, flexible sigmoidoscopy, double-contrast barium enema, or colonoscopy aimed at patients between the ages of 50 and 80 years. About 17% of its patients in 2008 and 36% in 2009 complied with the HIHC's colon cancer screening recommendations.

In the trial, 98 patients eligible for screening were randomly assigned to receive the usual standard of care and 104 patients were randomly assigned to an experimental outreach intervention.

Routine care involved a referral for colorectal cancer screening, as had been done in the past during routine primary care visits. The experimental outreach intervention included a mailing with the following components:

  • a letter from their physician recommending FOBT screening,

  • a colorectal cancer fact sheet in English and Spanish from the Centers for Disease Control and Prevention,

  • a 3-sample guaiac-based FOBT test (Hemoccult II SENSA Elite kit, Beckman Coulter), and

  • manufacturer-supplied instructions covering patient preparation, sample collection, and FOBT kit handling.

Patients were instructed to return the completed FOBT kit in person or by mail, using a postage-paid envelope, to the healthcare laboratory.

Patients who did not return the completed FOBT kit received up to 3 reminder calls spaced 2 weeks apart from a health educator who was proficient in both English and Spanish. Patients who still did not comply received a second letter from their physician urging compliance 6 weeks after initial mail communications.

Communications were carried out between February 25 and April 30, 2010. All forms of colorectal cancer screening performed on the 2 groups up to June 30, 2010, were considered evidence of compliance.

Only 5% of the usual-care group completed colorectal screening compared with 30% compliance among patients receiving the outreach intervention (P < .001). Nearly all of the completed colorectal cancer screenings were FOBTs.

"Our study demonstrated that the direct-to-patient outreach intervention was efficacious even in a health care setting that had already implemented point-of-care clinician-directed electronic clinical reminders to promote appropriate colorectal cancer screening," the authors write.

Study limitations included patient selection from a single health service in a historically underserved population; however, the study design addressed the potential lack of generalizability among previously published studies. In addition, the electronic health record data warehouse used to determine patient eligibility and assess outcomes did not capture screenings performed on the study population by outside health services.

The authors conclude that the direct mailing of FOBT kits to patients for colorectal cancer screening may be a good option for improving adherence to screening guidelines in historically underserved communities.

This study was funded through a seed grant from the Northwestern University Clinical and Translational Sciences Institute. Dr. Jean-Jacques was supported in part by the National Center for Research Resources and National Institutes of Health through the Clinical and Translational Science Awards Program.

Ann Fam Med. 2012;10:412-447. Full text