Screening Program Contributed to Increased Screening Completion for CRC

Screening for colorectal cancer (CRC) increased in all demographic groups after participants were enrolled in a screening program, according to JAMA Network Open. Personalized strategies and sequential automated outreach calls were used to target patients from a variety of avenues.

Disparities in incidence and mortality have been shown to exist in the US for CRC, with non-Hispanic Black individuals having the highest mortality for CRC in the nation. These disparities could be exacerbated by the decreased amount of screening in these populations. Outreach using fecal immunochemical test (FIT) kits along with patient navigation, education, and reminders have been shown to increase CRC screenings. However, the level of resources could vary between the interventions. This study aimed to evaluate the response to individual screening program strategies in a larger screening program that was aimed at all demographic groups.

Doctor displaying healthy intestines | Image credit: Orawan - stock.adobe.com

All participants (N = 1,046,745) were from Kaiser Permanente Northern California (KPNC). Patients who were eligible for screening for CRC at the start of 2019 were included; they self-reported race and ethnicity and an electronic health record was obtained for all members of KPNC. Participants were excluded if their race and ethnicity data were missing. Sex, age, and Charlson Comorbidity Index score were also collected from all participants. The mean (SD) patient age was 61.1 (6.9) years, and 53.2% were women. The cohort was primarily White (56.5%), followed by participants who identified as Asian (18.5%), Hispanic (16.2%), and Black (7.2%), with American Indian/Alaska Native (0.4%) and Native Hawaiian/Pacific Islander (0.8%) also comprising the study cohort. White participants were older and less likely to be female compared with the other ethnicities.

The program aimed to screen all eligible participants by the end of each year through either colonoscopy or FIT. Participants started receiving outreach for screening at age 51 and were approached through age 75. They were considered up to date on their screening if they had taken an FIT within the calendar year or if they had a colonoscopy within the previous 10 years.

All participants were mailed a postcard a week before their FIT kit was mailed to them. If a participant did not return the test within 4 weeks, they would receive a telephone call; if they had not completed it over the 2 weeks following this, another postcard was sent. If 8 weeks passed with an incomplete test, the primary care physician would be informed for more personalized calls made by medical assistants. If an FIT kit could not be processed at the lab, a new one was mailed to the participant.

White participants were more likely to be up-to-date with their screening (36.4%) compared with Black (34.8%), Hispanic (30.1%), and Asian (33.1%) participants, with Native Hawaiian/Pacific Islanders being the least likely to be up-to-date (27.9%). The screening program increased the proportion of those up-to-date, although American Indian/Alaska Native participants had the lowest (74.1%) and Asian participants had the highest (83.5%).

Absolute increases in screening, after both of the automated and personalized components of the screening program, were 38.1% in Asian participants and 34.5% in White participants, which was the highest of all demographic groups; Black participants had an absolute increase of 29.5%, which was the lowest. Personalized approaches made after the initial screening led to additional completion proportions of 14.4% in Hispanic participants and 14.7% in Native Hawaiian/Pacific Islander participants, which were the highest.

Men and women had similar proportions of those up-to-date on their CRC screening. Older participants were more likely to be up-to-date with CRC both at the beginning (> 40%) of the program and at the end (> 80%) compared with younger members (20.8% and 72.1%, respectively, in those aged 50-55 years). Contributions to completion were highest in younger members who had the personalized components of the screening process (17.9%) compared with older members (10.6% in ages 61 -65 years and 7.2% in ages 71 -75 years).

There were some limitations to this study. Causality between the differential responses to outreach and the demographic categories could not be drawn due to the observational design of the study, and the effectiveness of personalized outreach vs repeating automated outreach could not be determined due to the lack of a comparison group. Also, an individual component of the screening program could not be attributed to the response, and unmeasured confounders could have played a role in the differences between racial and ethnic groups. The capacity to replicate this program outside of KPNC also could be limited.

The researchers concluded that automated and personalized reach outs to people eligible for screening for CRC showed a marked increase in all demographics, which could in turn lead to decreases in incidence and mortality. This program could be implemented across the country to increase screening in all patients, although future research should focus on the cost of such programs.

Reference

Podmore C, Selby K, Jensen CD, et al. Colorectal cancer screening after sequential outreach components in a demographically diverse cohort. JAMA Netw Open. 2024;7(4):e245295. doi:10.1001/jamanetworkopen.2024.5295