Mailed Letter Versus Phone Call to Increase Uptake of Cancer Screening

A Pragmatic, Randomized Trial

Tara Kiran, MD, MSc; Sam Davie, MSc; Rahim Moineddin, PhD; Aisha Lofters, MD, PhD


J Am Board Fam Med. 2018;31(6):857-868. 

In This Article

Abstract and Introduction


Background: There is good evidence that cancer-specific patient outreach improves rates of cervical, breast, and colorectal cancer screening. However, it is unclear how primary care practices should implement integrated outreach for all 3 types of cancer screening. We aimed to understand whether integrated outreach using mailed letters or phone calls were more effective at increasing screening uptake in a primary care organization.

Method: We conducted a pragmatic randomized trial comparing outreach by mailed letter or personalized phone call for patients overdue for cervical, breast, or colorectal cancer screening. The study was conducted at 6 clinics within an academic primary care organization in Toronto, Canada. Our primary outcome was an uptake of at least 1 screening test for which the patient was overdue. Our primary analysis was an intention-to-treat, unadjusted comparison of proportions, using a χ 2 test. We also compared costs per additional patient screened. All analyses were stratified by sex.

Results: A total of 3733 females and 1537 males were randomized to receive 1 of the interventions. Among women, 33.0% allocated to receive a reminder letter and 41.2% allocated to receive a reminder phone call received at least 1 screening test for which they were due (absolute difference, 8.1%; 95% CI, 5.1%–11.2%, P < .001). Among men, 24.8% allocated to receive a reminder letter and 28.8% allocated to a reminder phone call received screening for colorectal cancer (absolute difference, 4.1%; 95% CI, −0.4% to 8.5%, P = .073). For women and men, the letters cost approximately CaD $5.07 and CaD $7.16, respectively, for each completed screening test compared with CaD $8.71 and CaD $12.00 for the phone calls.

Conclusions: Phone calls were more effective than mailed letters at increasing uptake for cervical, breast, and colorectal cancer screening among women. However, phone calls were more expensive than letters. Primary care practices should consider integrating phone call reminders into their practice, possibly as part of a targeted or staged approach to outreach for cancer screening.


Screening for cervical, breast, and colorectal cancer reduces morbidity and mortality and is widely recommended by clinical practice guidelines.[1,2] Primary care practices play a central role in counseling patients and performing or facilitating relevant screening maneuvers. Practices in North America have historically taken an opportunistic approach to screening that relies on a physician or patient raising the issue during an encounter.[3] Opportunistic approaches risk uneven screening uptake among different groups within a population. In contrast, there is good evidence that proactive patient outreach improves screening rates[4,5] and at a population level, has the potential to reduce income-related inequities.[3,6,7] In a proactive approach, practices identify which patients are due for screening and reaches out to invite them for counseling.

Although evidence suggests that patient outreach improves screening rates, it is still unclear which outreach methods are most effective in a primary care practice. Several studies have found that a mailed letter, telephone communication, or a combination of both can increase screening rates compared with no intervention, but there are fewer studies comparing different methods of outreach.[4] In addition, most studies have evaluated patient outreach specific to 1 or 2 types of cancer screening[8] even though a patient may be due for all 3. There is limited guidance as to how a primary care practice should implement patient outreach that is integrated for all 3 types of cancer screening.[9]