PerspectiveIn the Journals

Multifaceted intervention improved colorectal cancer screening adherence

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June 16, 2014

Reminders via mail, telephone and text message improved adherence to colorectal cancer screening with fecal occult blood tests among a low-income, ethnically diverse population, according to results of a randomized, controlled trial.

The analysis included 450 patients from a network of community health centers. All participants completed a fecal occult blood test (FOBT) the year prior and received a negative result. A majority of participants were women (72%), Latino/Hispanic (87%) and uninsured (77%).

Researchers assigned participants 1:1 to usual care or to the intervention arm.

Usual care at the community health centers included directives for medical assistants to give patients home fecal immunochemical tests, as well as computerized reminders for patients.

Those in the intervention cohort received a free fecal immunochemical test with a postage-paid return envelope, a mailed reminder letter, and an automated telephone and text message reminder alerting them they were due for a screening. If participants did not return the test within 2 weeks, they received another automated call and text reminder. If they did not return the test after 3 months, they were contacted by a colorectal cancer screening navigator. 

Overall, significantly more patients in the intervention arm completed FOBT within 6 months of their due date (82.2% vs. 37.3%; P˂.001). The median time to FOBT completion for participants who completed screening was 13 days in the intervention cohort and 83 days in the usual care cohort.

Of those in the intervention cohort who completed screening (n=185), 10.2% did so prior to the due date without any interventions, and 39.6% completed the test after the first intervention. Twenty-four percent completed screening after the second intervention, and 8.4% completed screening after the call from the colorectal cancer screening navigator.

Researchers estimated a $34.59 cost of the intervention per participant in the intervention group, and a $43.13 cost for each completed test.

Beverly B. Green, MD, MPH 

Beverly B. Green

Ten participants (5.4%) in the intervention cohort received positive FOBT results. After 6 months of follow-up, six participants underwent colonoscopy, resulting in the detection of three adenomatous polyps and one inflammatory polyp. Nineteen patients (23%) in the usual care cohort received positive FOBT results. Eleven of them underwent colonoscopy, and four had an adenomatous polyp.

Despite increased participation in FOBT screening in the intervention cohort, the fact 40% of those who received positive FOBT results did not undergo follow-up colonoscopy is concerning, Beverly B. Green, MD, MPH, of Group Health Research Institute in Seattle and Gloria D. Coronado, PhD, of Kaiser Permanente Center for Health Research Northwest in Portland, Ore., wrote in an accompanying editorial.

“Follow-up colonoscopy is crucial, since the chance of colorectal cancer is as high as 4% in individuals with a positive FOBT result, and almost one-third have advanced precancerous adenomas,” Green and Coronado wrote. “Lack of follow-up colonoscopy defeats the purpose of a FOBT screening program. Baker et al do not describe the reasons for low rates of follow-up diagnostic colonoscopy, but for many people in the United States, the barriers to this procedure are substantial and include limited availability and cost.”

For more information:

  • Baker DW. JAMA Intern Med. 2014;doi:10.1001/jamainternmed.2014.2352.
  • Green BB. JAMA Intern Med. 2014;doi:10.1001/jamainternmed.2014.730.

Disclosure: The researchers report no relevant financial disclosures.

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PERSPECTIVE
Brintha Enestvedt

Brintha Enestvedt

Any efforts to improve colorectal cancer screening deserve applause, as we know that screening colonoscopies decreases the likelihood of death from this disease by 50%. This is a powerful tool; not many screening tests in oncology actually reduce cancer mortality.
We also know, however, that only almost 40% of adults in the United States who should be screened do not receive a colonoscopy. Screening rates are even lower for those who face barriers to health care access, such as a lack of insurance or a language difficulty.
Although colonoscopy is the most widely used screening test in the United States, flexible sigmoidoscopy and fecal occult blood testing (FOBT) also are available — the latter being easy to administer, inexpensive and widely available. However, integral to the success of an FOBT screening program is adherence to repeat follow-up tests annually to achieve a similar impact on colorectal cancer mortality as colonoscopy.
The findings of the well-designed and executed study by Baker et al adds optimism and hope for gastroenterologists, primary care physicians and oncologists that we can engage more patients in screening tests at a low cost, even in a vulnerable patient population. The goal of the study was to improve adherence to repeat FOBT by providing paid postage for the tests, telephone and text message reminders, and a personal phone call from a navigator.
This study emphasizes the importance of persistent medical contact to help engage patients in their health care — ie, persistent reminders result in higher rates of adherence. Given we know this level of contact is effective and low cost (approximately $40 per person in this study), we need to find a way for these kinds of strategies to be implemented more widely. In this highly technological era, there are perhaps other communication options, as well.
The clinical impact of $40 to get more individuals screened for colonoscopy is astonishing compared with the cost of discovering advanced colon cancer in those who have not undergone prior screening. Clearly, our job is not done. Even in this study, in which all patients with positive FOBT were offered a free colonoscopy and free transportation, only 60% of study participants went on to have a diagnostic colonoscopy. Nationwide public health efforts are undoubtedly needed to help bridge disparities if we are to make further headway.

Brintha Enestvedt, MD, MBA
Assistant professor of medicine
Division of Gastroenterology & Hepatology
Knight Cancer Institute at Oregon Health & Science University

Disclosure: Enestvedt reports no relevant financial disclosures.