An intervention that may improve colorectal cancer screening rates

An intervention including fecal occult blood testing (FOBT) greatly increased adherence to annual colorecatal cancer screening (CRC), indicating the possibility for improvement in screening in vulnerable populations by using low-cost strategies facilitated by health information technologies, according to a study published online June 16 by JAMA Internal Medicine.

Disparities in income, education, race, language and insurance coverage persist in CRC screening and while the most common modality used for screening is colonoscopy, studies indicate the utility of FOBT and sigmoidoscopy in reducing CRC mortality.

In order to reduce mortality, high levels of adherence to annual or biennial FOBT are needed. “Policy makers and clinicians need to understand the rate of adherence to annual FOBT to guide programs and policies to address CRC screening disparities,” wrote lead author David W. Baker, MD, MPH, of Northwestern University in Chicago, and colleagues. The researchers sought to determine the effectiveness of an intervention at a community health center to maximize adherence to annual FOBT.

The patient-level randomized controlled trial was conducted in a network of community health centers and included 450 patients who had previously completed a home FOBT from March 2011 to February 2012. Of the participants, 72 percent were women, 87 percent were Latino, 83 percent said Spanish was their preferred language and 77 percent were uninsured.

The study’s intervention was comprised of usual care that included computerized reminders, standing orders for medical assistants to give patients home fecal immunochemical tests and clinician feedback on CRC screening rates. The intervention group also received the following: a mailed reminder letter, a free fecal immunochemical test with low-literacy instructions, a postage-paid return envelope, an automated telephone and text message with a screening reminder and notification that a test would be mailed soon, an automated telephone and text reminder two weeks later for those who did not return their tests and a personal telephone outreach by a CRC screening navigator after three months.

The intervention patients were much more likely than those in usual care to complete FOBT, as 82.2 percent completed the test versus 37.3 percent, respectively. Out of the 185 intervention patients who completed screening, 10.2 percent completed it prior to their due date without intervention, 39.6 percent completed it within two weeks after the initial intervention, 24 percent within two to 13 weeks after the automated call and text reminder and 8.4 percent completed the test between 13 and 26 weeks after receiving a personal call.

“Although further follow-up is needed to understand long-term adherence rates, our study suggests that it is possible to achieve high annual FOBT adherence rates even among highly vulnerable patient populations,” wrote Baker and colleagues.

In an associated editorial, Beverly B. Green, MD, MPH, of the Group Health Research Institute in Seattle, and Gloria D. Coronado, PhD, of the Kaiser Permanente Center for Health Research Northwest in Portland, Oregon, wrote: “A disappointing result in the study by Baker et al was that only 60 percent of individuals with a positive screening FOBT result completed follow-up diagnostic colonoscopy, even though it was offered at no cost and a health professional navigator provided support with scheduling, preparation, and transportation.”

The authors contend the result is problematic due to the vital importance of follow-up colonoscopy; lack of follow-up defeats the purpose of a FOBT screening program. For many, the barriers to the procedure are many, including limited availability and cost. While the Affordable Care Act (ACA) requires that screening tests recommended by the U.S. Preventive Services Task Force be covered in full with no out-of-pocket expenses for patients, this mandate does not apply to follow-up colonoscopy.

“Decreasing CRC disparities will require an ACA policy change to cover CRC screening by FOB as a 2-part test, with diagnostic colonoscopy after a positive FOBT results as the second part,” wrote Green and Coronado.