August 12, 2019
2 min read

Intervention improves colorectal cancer screening in rural areas

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A low-cost, literacy-appropriate intervention with follow-up phone calls if needed increased colorectal cancer screening among an underserved, rural population in Louisiana, according to results of a two-arm randomized trial published in Cancer.

“Healthy People 2020 has set a goal of 70% of eligible adults being up to date with colorectal cancer screening. The American Cancer Society/Centers for Disease Control and Prevention National Health Literacy Roundtable set a higher goal of 80% by 2018,” Connie L. Arnold, PhD, associate professor in the department of medicine at Louisiana State University Health Sciences Center-Shreveport, and colleagues wrote. “To meet these goals, strategies are needed to address colorectal cancer screening in underserved populations.”

In the randomized controlled trial, Arnold and colleagues evaluated the effectiveness of two health literacy intervention follow-up approaches to improve colorectal cancer screening rates among 614 patients (median age, 58.4 years; 55% women; 67% African American) who sought care at one of four rural community clinics in Louisiana. Researchers enrolled the patients consecutively upon presenting to the clinics for scheduled routine primary care visits.

The study participants, 41% of whom had limited literacy, completed a structured interview to assess demographic, health literacy and colorectal cancer screening obstacles, knowledge and attitudes. They received health literacy-guided colorectal cancer education materials, as well as a patient-friendly colorectal screening pamphlet, instructions on use of a simplified fecal immunochemical test (FIT), and a FIT kit. Research assistants used a “teach-back” method to verify patients’ understanding of the information.

Researchers then randomly assigned participants to one of two follow-up groups. In one group, 306 participants received a phone call from a prevention counselor to remind them to complete and mail the FIT kit and discuss any obstacles encountered. In the other group, 308 participants were reminded to complete and mail their FIT kit via an automated call with a culturally appropriate voice recording that provided motivational messages in a conversational tone.

Those who did not mail their FIT kit within 4 weeks received a reminder call, and those who did not return the test after 8 weeks received a second call.

Results showed an overall FIT completion rate of 68%, including 69.2% of participants in the automated call group and 67% in the personal call group. More than half of participants (59.7% in automated call group and 58.5% in personal call group) returned the test without a phone call.


The researchers did not observe a difference between the success of the follow-up calls; each type of call improved the rate of FIT test return by about 9%.

The researchers acknowledged several study limitations, including the limited generalizability of the results due to the rural, low literacy, predominantly African American, English-speaking study population.

The intervention represents an important step toward improving health care for marginalized patient populations, Kelvin A. Moses, MD, PhD, associate professor in the department of urology at Vanderbilt University Medical Center, wrote in a related editorial.

“Screening guidelines are quite clear with respect to whom screening should be offered,” Moses wrote. “However, to my knowledge, nowhere in any guidelines is there a provision for offering differential care based on race, insurance status, sex or income. Yet in nearly every type of cancer, this is the case. This fact represents an abject failure of the medical society at large to follow its own rules with respect to the most vulnerable and high-risk populations.” – by Jennifer Byrne

Disclosures: Arnold and another study author report grant support from the National Institute of General Medical Sciences of the NIH, which funds the Louisiana Clinical and Translational Science Center. Moses reports speakers’ bureau roles with Astellas, Dendreon and Pfizer.