Program to Improve Colorectal Cancer Screening in a Low-Income, Racially Diverse Population: A Randomized Controlled Trial

Abstract

PURPOSE More effective strategies are needed to improve rates of colorectal cancer screening, particularly among the poor, racial and ethnic minorities, and individuals with limited English profi ciency. We examined whether the direct mailing of fecal occult blood testing (FOBT) kits to patients overdue for such screening is an effective way to improve screening in this population. METHODSAll adults aged 50 to 80 years who did not have documentation of being up to date with colorectal cancer screening as of December 31, 2009, and who had had at least 2 visits to the community health center in the prior 18 months were randomized to the outreach intervention or usual care. Patients in the outreach group were mailed a colorectal cancer fact sheet and FOBT kit. Patients in the usual care group could be referred for screening during usual clinician visits. The primary outcome was completion of colorectal cancer screening (by FOBT, sigmoidoscopy, or colonoscopy) 4 months after initiation of the outreach protocol. Outcome measures were compared using the Fisher exact test.RESULTS Analyses were based on 104 patients assigned to the outreach intervention and 98 patients assigned to usual care. In all, 30% of patients in the outreach group completed colorectal cancer screening during the study period, compared with 5% of patients in the usual care group (P <.001). Nearly all of the screenings were by FOBT. The groups did not differ signifi cantly with respect to the percentage of patients making a clinician visit or the percentage for whom a clinician placed an order for a screening test. CONCLUSIONSThe mailing of FOBT kits directly to patients was effi cacious for promoting colorectal cancer screening among a population with high levels of poverty, limited English profi ciency, and racial and ethnic diversity. Non-visit-based outreach to patients may be an important strategy to address suboptimal rates of colorectal cancer screening among populations most at risk for not being screened. Appropriate screening and early detection can greatly reduce colorectal cancer-associated morbidity and mortality, and several national guidelines recommend regular screening for colorectal cancer among adults aged 50 years and older with high-sensitivity fecal occult blood testing (FOBT), sigmoidoscopy, or colonoscopy.2-4 Nearly one-half of eligible adults are not up to date on colorectal cancer screening, however. 5Moreover, despite overall improvements in the rate of colorectal cancer screening, marked disparities persist, with lower rates of colorectal cancer screening among racial and ethnic minorities, individuals with lower income or lower educational attainment, the uninsured, and individuals Muriel Jean-Jacques, MD The direct mailing of FOBT kits to patients who are due for colorectal cancer screening has been shown to be both clinically effective 9-14 and cost-effective 15,16 for increasing colorectal cancer screening rates. The vast majority of studies assessing the effi cacy of this strategy have not included sizable...

Comparative Effectiveness of Fecal Immunochemical Test Outreach, Colonoscopy Outreach, and Usual Care for Boosting Colorectal Cancer Screening Among the Underserved

“…23,24,26,27 Two groups have studied effects of outreach with patient navigation, including mailed invitation, telephone follow-up, and patient navigation among underserved primary care patients, reporting increases in screening of 13% to15.5% above usual care. 26,27 Lasser et al 26 offered choice of colonoscopy or gFOBT, while Percac-Lima et al 27 offered colonoscopy alone.…”

“…13,18–22 Mailed outreach efforts with stool testing have been successful in underserved populations, but these efforts used the more cumbersome guaiac fecal occult blood test (gFOBT), which requires multiple stool samples and strict diet restrictions. 23–25 Mailed outreach with colonoscopy invitations has also been tested among the underserved, and shown promise. 26,27 Whether mailed outreach with the more convenient FIT, which does not require diet restriction and can be performed with 1 sample, is effective in for underserved populations, and how FIT outreach compares with colonoscopy outreach are unknown and merit further study.…”

Knowledge and Practice of Colorectal Screening in a Suburban Group of Iraqi American Women

“…These included, for example, those based on telephone outreach and the mailing of FOBT kits directly to at-risk individuals [45], and health-fair style screening for the uninsured [46]. …”

Strategies and Opportunities to STOP Colon Cancer in Priority Populations: Design of a cluster-randomized pragmatic trial

“…Previous evaluations of clinic-based programs to improve rates of CRC screening have shown that direct mailing of fecal occult blood tests (gFOBT) or fecal immunochemical tests (FIT) consistently led to 6–30% increases in CRC screening, regardless of clinical setting [11–15;15;16]. Some studies have shown that use of health educators and screening information tailored to specific cultural and language needs can be effective in raising CRC screening rates [11;13;17–19].…”