Researchers have demonstrated that a targeted intervention may increase screening rates in patients who do not adhere to current colorectal cancer screening recommendations, according to a recent study published by Reuland et al in JAMA Network Open.
Background
Colorectal cancer screening is often an effective tool for detecting the disease early when it’s most treatable; however, screening is underused in patient populations who receive primary care at federally qualified health centers.
Previous research has shown that a combination of at-home screening kits and coordinated outreach could be effective in large, integrated health systems. Nonetheless, its impact is unknown in federally qualified health centers—which operate as small, grant-funded entities that are often underresourced and serve as safety-net care providers.
Increasing the screening rate at federally qualified health centers, which provide care to nearly 10% of individuals in the United States, could reduce the rate of colorectal cancer incidence and mortality as well as improve the care of many underserved populations.
“Reaching a largely unscreened, predominantly low-income population using centralized mailed screening kits and patient navigation for those with abnormal tests can substantially increase guideline-recommended colorectal cancer screening in federally qualified health centers,” emphasized lead study author Daniel Reuland, MD, MPH, the Robert A. Ingram Distinguished Professor at the University of North Carolina (UNC) School of Medicine and Co-Director of the Carolina Cancer Screening Initiative at the UNC Lineberger Comprehensive Cancer Center.
North Carolina’s community health centers currently serve patient populations and communities that have low colorectal cancer screening rates. Many individuals in these communities have never received such cancer screening.
The National Cancer Institute estimated that more than 152,000 individuals in the United States will be diagnosed with colorectal cancer in 2024, and the disease will result in approximately 53,000 deaths. Although these rates have declined in patients aged 65 and older, cases and deaths among those younger than age 50 have been rising since 1990.
Study Methods and Results
In the SCORE study, the researchers assigned 4,002 participants aged 50 to 75 who had an average colorectal cancer risk and were not current with recommended screening guidelines to undergo either a combination of at-home screening, community outreach, and usual care or usual care alone. The participants who received at-home screening were mailed a free fecal immunochemical testing (FIT) kit and provided navigation services for follow-up colonoscopies if the at-home FIT was positive—indicating trace amounts of blood in the stool, an early sign of colorectal cancer. The research was conducted in partnership with two federally qualified health centers in North Carolina: Blue Ridge Health and Roanoke Chowan Community Health Center.
The researchers aimed to measure how many participants would complete a colorectal cancer screening within 6 months and how many of them would undergo a colonoscopy within 6 months following a positive FIT result. In collaboration with the federally qualified health center staff, the outreach team distributed the FIT kits, coordinated result tracking, and followed up on positive FIT results. The navigator ensured that the information was entered into the participants’ electronic health records and communicated with their primary care providers.
The researchers found that the targeted intervention may have tripled screening completion rates compared with usual care. For instance, compared with those who underwent usual care alone, the participants who underwent the intervention were more likely to receive colorectal cancer screening within 6 months (30% vs 9.7%) and 12 months (34.6% vs 16.6%).
Among those who had a positive FIT result, the participants in the intervention group had a higher follow-up colonoscopy rate, with 68.8% of them completing the procedure compared with 44.4% of those in the usual care alone group.
Conclusions
“Mailed FIT is an excellent complement to usual care screening services,” highlighted senior study author Alison Brenner, PhD, MPH, Associate Professor at the UNC School of Medicine and Deputy Director of the Carolina Cancer Screening Initiative at the UNC Lineberger Comprehensive Cancer Center. “It reaches a lot of patients who, for whatever reason, aren’t getting screened in usual care and significantly increases screening rates. A centralized approach, like the SCORE trial demonstrated, can relieve both the underresourced [federally qualified health centers] as well as the overpacked agenda of primary care by taking care of this preventive service outside of the clinic visit,” she suggested.
The researchers are currently investigating how to expand the targeted intervention, including having preliminary conversations with officials at North Carolina Medicaid, which expanded eligibility this past year to cover more patients.
“Our team is completing a cost analysis of the intervention. FIT testing is inexpensive, so we anticipate this kind of outreach will be a very cost-effective way to improve population screening. In tandem with this, we’re working to find ways to scale and sustain this kind of intervention to have greater impact,” Dr. Reuland underscored. “There is limited colonoscopy capacity in many parts of North Carolina, and with the Medicaid expansion, the need for colonoscopies is increased. This kind of FIT-based outreach strategy could help us increase screening while making optimal use of limited colonoscopy capacity,” he concluded.
Disclosure: The research in this study was supported by the National Cancer Institute, the University Cancer Research Fund, and gifts from John Goodacre and Donna and Greg Schmidt. For full disclosures of the study authors, visit jamanetwork.com.
