Signed, sealed, delivered: Mailed outreach improves colorectal screening rates

Mailed fecal immunochemical test (FIT) outreach and colonoscopy outreach can improve colorectal cancer (CRC) screening rates, according to new research published by JAMA.

CRC screening for men and women ages 50 to 75 is given a strong recommendation by the U.S. Preventive Services Task Force, the study’s authors explained, yet not nearly enough patients are being screened.

“Effectiveness is limited by underuse and suboptimal adherence to guideline-recommended follow-up, including repeat testing for normal test results and diagnostic follow-up of abnormal test results,” wrote lead author Amit G. Singal, MD, MS, division of digestive and liver diseases at the University of Texas Southwestern in Dallas, and colleagues. “Studies have demonstrated failures at each step in the screening process, which are associated with increased CRC mortality: 30 percent to 50 percent of patients do not initiate screening, 40 percent to 60 percent of patients with normal results do not undergo repeat screening, and more than 50 percent of patients with abnormal results do not complete a follow-up evaluation.”

With these issues in mind, Singal et al. performed a randomized clinical trial on more than 5,900 patients ages 50 to 64 years old who were receiving care within the same health system and not up to date on CRC screenings. Between March 2013 and July 2016, more than 2,000 patients were mailed FIT outreach, more than 2,000 patients were mailed colonoscopy outreach and more than 1,100 went through the system’s usual care process.

Mailed outreach involved an invitation letter, in both English and Spanish, that included information about the patient’s CRC risk. Follow-up phone calls were also placed by bilingual research staff. FIT outreach included a test kit with instructions and a return envelope with prepaid postage.

Overall, more than 38 percent of the colonoscopy outreach group completed CRC screening, compared to 28 percent of the FIT outreach group and more than 10 percent for the group receiving usual care. The authors noted that this was a significant improvement, but that there was still work to be done to better combat one of the leading causes of cancer-related death in the United States. “Screening process completion for both outreach groups remained below 40 percent, highlighting the potential for further improvement,” they wrote.

The authors also examined potential reasons why patients may be more likely to follow through with a colonoscopy than FIT.

“Although studies suggest FIT invitations are more effective than colonoscopy outreach for 1-time screening, participants in this study who were offered colonoscopy outreach had higher screening process completion and adenoma detection when followed for a longer duration,” the authors wrote. “FIT has lower barriers to one-time participation but requires annual screening and diagnostic evaluation of abnormal results. In contrast, colonoscopy is both a screening and diagnostic test, so a single examination can satisfy screening process completion for up to 10 years.”