Barriers and opportunities in fecal immunochemical test outreach

Colorectal cancer (CRC) remains the second leading cause of cancer-related deaths in the United States, a troubling fact when considering that CRC is largely preventable and treatable if caught early. The U.S. Preventive Services Task Force recommends regular CRC screening for adults between 45 and 75 years of age using various methods such as colonoscopy or stool-based tests like the fecal immunochemical test (FIT). These tests help detect colorectal abnormalities before they progress to cancer. Research shows that up-to-date screening can lower both the incidence and mortality of CRC. For instance, screening by colonoscopy allows physicians to remove polyps, which are precancerous growths, thereby preventing cancer from developing. Meanwhile, stool-based tests like FIT help in early detection, allowing timely intervention and treatment. FIT is a non-invasive screening test used to detect blood in the stool, which can be an early sign of colorectal cancer.

Despite the known benefits of screening, only about 58% of eligible adults in the U.S. are up-to-date with their CRC screening, far short of the National Colorectal Cancer Roundtable’s goal of 80%. One strategy that has gained traction in addressing this gap is mailed outreach programs, where individuals are sent stool-based tests, such as the FIT, to complete at home, therefore eliminating the need for an initial visit to a healthcare facility. Numerous studies have demonstrated the effectiveness of mailed FIT outreach in increasing CRC screening rates compared to traditional healthcare settings where patients are expected to request or attend in-person screenings. Mailed FIT programs have been found to increase screening completion by an average of 28%, offering a cost-effective solution to improve public health outcomes. Despite these successes, not all healthcare systems in the U.S. have adopted this approach, and outcomes from real-world implementations are still underreported.

Given the variability in patient populations and healthcare systems, a recent study published in Clinical and Translational Gastroenterology aimed to determine which patient-level, clinic-level, and geographical-level factors were associated with CRC screening completion through a mailed FIT outreach program within an integrated academic-community healthcare system. To investigate these factors, Drs. Rachel Issaka, Samuel Simpson and colleagues conducted a retrospective cohort study examining outcomes in the first year of the Fred Hutch/UW Medicine Population Health Colerectal Cancer screening program. They included patients aged 50 to 75 who had not completed CRC screening in the past and had a primary care encounter within the previous three years. These patients were sent a mailed outreach packet that included a letter explaining the importance of CRC screening, a FIT kit for at-home use, and a prepaid return envelope. The study tracked the completion rates of the FIT, as well as colonoscopy for those who opted for this method instead. Additionally, patients who did not return their FIT were sent up to three reminders to encourage participation. The study also gathered data from electronic health records and the CRC screening program database to analyze patient demographics, clinic assignments, geographical factors (such as the Area Deprivation Index, a measure of socioeconomic disadvantage), insurance status, and prior CRC screening history.

The study’s results were significant: approximately one-third of patients who were not up-to-date with their CRC screening completed a mailed at-home test after receiving outreach materials. Several factors were found to be associated with lower completion rates. Nonetheless, the study also revealed barriers to screening. Individuals who lived in areas with higher deprivation, were insured through Medicaid, lived without a partner, or had not visited a primary care provider in over 12 months were less likely to complete the FIT. Black patients and those whose race or ethnicity was unknown were also less likely to complete the test compared to their White counterparts. As Dr. Issaka explained, "when we examine those who were least likely to participate in screening, it forces us to ask what additional interventions are needed to ensure screening for everyone, especially those who are who are also potentially at increased risk for cancer." In response, her team is exploring additional strategies including health system navigation to support these populations in completing cancer screenings.

These findings have important implications for public health interventions. While mailed FIT outreach is a feasible and effective way to increase CRC screening rates, it is clear that certain populations face additional challenges in completing the test. Identifying and addressing these barriers is crucial for designing more targeted interventions. For instance, providing additional support to individuals with Medicaid, those living in deprived areas, or those who have not visited their primary care provider recently could help improve screening rates. Further, incorporating CRC screening into other healthcare visits, such as routine vaccinations, or using telehealth visits to educate patients about the importance of screening could also help overcome barriers to participation. By addressing these challenges, healthcare systems can improve CRC screening rates, particularly in underserved populations, and reduce the number of preventable deaths from colorectal cancer.

The study also underscores the importance of follow-up after abnormal FIT results. Approximately half of the patients who received abnormal results completed a follow-up colonoscopy, which is comparable to other studies but still leaves room for improvement. Ensuring that all patients who receive abnormal results undergo follow-up procedures is critical to reducing CRC mortality. The findings from this study provide valuable insights into the factors that influence screening completion and offer guidance for designing interventions that can further improve CRC screening rates in diverse healthcare settings.

This research was conducted and supported by the Colorectal Cancer Screening Program – a joint effort across the cancer consortium.

Fred Hutch/University of Washington/Seattle Children’s Cancer Consortium members Drs. Rachel Issaka, Alison Meisner contributed to this study.

Simpson, S., Yu, K., Bell-Brown, A., Kimura, A., Meisner, A., & Issaka, R. B. (2024). Factors associated with mailed fecal immunochemical test (FIT) completion in an integrated academic-community healthcare system. Clinical and translational gastroenterology, 10.14309/ctg.0000000000000757. Advance online publication.