Mailed Colon Cancer Screening Test Works in Underserved

Megan Brooks

August 05, 2013

The best way to boost colorectal cancer (CRC) screening in underserved populations might be to mail a fecal immunochemical test (FIT) and follow it up with a phone call.

This approach proved highly effective, according to a study published online August 5 in JAMA Internal Medicine. It was even more effective than mailing an invitation for a free colonoscopy.

Dr. Samir Gupta

"Physicians shouldn't necessarily assume that the use of colonoscopies is the best and only way to reduce colon cancer rates," the study's first author, Samir Gupta, MD, associate professor of clinical medicine at University of San Diego in California, told Medscape Medical News.

"What we should ask is what type of screening is most acceptable to underserved populations? This is because the best predictor of [CRC] screening outcomes may be getting any test, rather than which test is done," he added.

"Almost everyone would agree that the most effective form of colorectal cancer screening is the one that a person will adhere to," said William Chey, MD, who was asked by Medscape Medical News to comment on the study. Dr. Chey is codirector of the Michigan bowel control program at the University of Michigan Medical Center in Ann Arbor, and coeditor-in-chief of the American Journal of Gastroenterology.

"That being the case, this study strongly argues that noninvasive tests such as FIT should remain an important part of our screening armamentarium," he added.

Comparing Different Approaches

CRC screening rates in underserved populations, such as the uninsured and minorities, remain low. Dr. Gupta and colleagues at the University of Texas Southwestern Medical Center in Dallas tested the value of different outreach approaches in a randomized comparative-effectiveness trial conducted at the John Peter Smith Health Network, which offers medical assistance to uninsured residents of Tarrant County, Texas.

The study cohort consisted of 5970 adults 54 to 64 years of age whose CRC screening was not up to date. The sample was 41% white, 24% black, 29% Hispanic, and 7% other.

Participants were assigned to 1 of 3 groups: FIT outreach, which consisted of a mailed invitation to use and return an enclosed no-cost FIT (n = 1593); colonoscopy outreach, which consisted of a mailed invitation to schedule a no-cost colonoscopy (n = 479); or usual care, which consisted of opportunistic primary care visit-based screening (n = 3898). Those in the FIT and colonoscopy outreach groups received follow-up telephone calls to promote test completion.

Screening participation — defined as completion of any CRC screening within 1 year of randomization — was significantly higher for both FIT and colonoscopy outreach than for usual care.

Table. Screening Participation by Group

Group Screening, % 95% Confidence Interval
FIT 40.7* 38.3–43.1
Colonoscopy 24.6* 20.8–28.5
Usual care 12.1 11.1–13.1

*P < .001 vs usual care


CRC screening was significantly higher with FIT outreach than with colonoscopy outreach (P < .001). FIT outreach tripled screening rates compared with usual care, whereas colonoscopy outreach only doubled the rates. The number needed to invite to accomplish 1 additional screening over usual care was 3.5 for FIT outreach and 8.0 for colonoscopy outreach.

A More Attractive Entry Point to Screening

"CRC screening saves lives," the study team notes. Their results, together with findings from similar studies, suggest that outreach strategies have the "potential to significantly improve screening rates for the underserved and merit implementation."

"For underserved populations, our findings raise the possibility that large-scale public health efforts to boost screening may be successful if noninvasive tests such as FIT are offered over colonoscopy," they add.

"This is an interesting study with not entirely unexpected results," Dr. Chey told Medscape Medical News. "The issue of improving CRC screening among the underserved through outreach programs is very important. While optical colonoscopy remains the gold standard for CRC screening because it is both diagnostic and therapeutic, these results confirm that less invasive strategies might provide a more attractive entry point to CRC screening."

"There is also the issue of finding strategies to better select the most appropriate patients for screening colonoscopy, given the resources and infrastructure needed to provide this service to the many Americans who will enter the healthcare system with the advent of the Affordable Care Act," he added.

However, Dr. Chey cautioned that it is important to realize that results obtained in real life might not be the same as those obtained in this study. "Patients received a written invitation, as well as multiple follow-up phone contacts, which could be difficult to replicate in routine clinical practice. As such, adherence rates reported in this trial likely represent the upper bound of what would be expected in real-life clinical practice," he said.

Dr. Gupta and colleagues note that delivering the outreach involved the nearly full-time efforts of a medical assistant and nurse, and acknowledge that whether these efforts can be resourced and implemented sustainably needs to be studied. Also, they did not include a cost-effectiveness analysis as part of their report, although they are looking into that now.

"These limitations," they write, "are balanced by several study strengths, including a large sample size, enrollment of a diverse population, and use of a waiver of informed consent to avoid selection/volunteer bias."

"Another issue with FIT involves the failure of some persons with an abnormal test result to schedule/undergo colonoscopy; in fact, 18% with an abnormal FIT test failed to undergo colonoscopy," Dr. Chey noted.

Funding for the study was provided in part by the Cancer Prevention and Research Institute of Texas and the National Institutes of Health. The authors and Dr. Chey have disclosed no relevant financial relationships.

JAMA Intern Med. Published online August 5, 2013. Abstract


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