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Faecal immunochemical test outreach and colonoscopy outreach improves CRC screening

Wed, 09/06/2017 - 15:27
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Screenings based on sigmoidoscopy or faecal tests are associated with a decreased ten-year mortality rate

Outreach and notification to patients and physicians improved colorectal cancer (CRC) screening among patients who were not up-to-date or nonadherent with CRC screening, according to two studies published in JAMA.

In the first study, ‘Effect of Colonoscopy Outreach vs Fecal Immunochemical Test Outreach on Colorectal Cancer Screening Completion - A Randomized Clinical Trial,’ Dr Amit G Singal of the University of Texas Southwestern Medical Center, Dallas, and colleagues compared the effectiveness of faecal immunochemical test (FIT) outreach and colonoscopy outreach to increase completion of the CRC screening process (screening initiation and follow-up) within three years.

Colorectal cancer is the second leading cause of cancer-related death in the United States; screening can reduce CRC incidence and death. However, screening effectiveness is limited by underuse and suboptimal adherence to guideline-recommended follow-up, including repeat testing for normal test results and diagnostic follow-up of abnormal test results.

In this study, patients ages 50 to 64 years who were not up-to-date with CRC screenings were randomly assigned to mailed FIT outreach (n=2,400), mailed colonoscopy outreach (n=2,400), or usual care with clinic-based screening (n=1,199). Outreach included processes to promote repeat annual testing for individuals in the FIT outreach group with normal results and completion of diagnostic and screening colonoscopy for those with an abnormal FIT result or assigned to colonoscopy outreach.

The researchers found that screening process completion within three years was 38.4 percent in the colonoscopy outreach group, 28 percent in the FIT outreach group, and 10.7 percent in the usual care group. Compared with the usual care group, between-group differences for completion were higher for both outreach groups, and highest in the colonoscopy outreach group.

Compared with usual care, the between-group differences in adenoma and advanced neoplasia detection rates were higher for both outreach groups, and highest in the colonoscopy outreach group.

“Sscreening process completion for both outreach groups remained below 40 percent, highlighting the potential for further improvement,” the authors note. "These data can help clinicians weigh the pros and cons of different CRC screening strategies in their patient population and practice environment. It is important to consider patients' barriers to screening initiation when recommending colonoscopy and the need for annual screening or diagnostic colonoscopy when recommending FIT."

The study notes some limitations, including because it was a pragmatic trial, mailed invitations were simple, 1-page letters and not in-depth decision aids.

In a second study, ‘Effect of Physician Notification Regarding Nonadherence to Colorectal Cancer Screening on Patient Participation in Fecal Immunochemical Test Cancer Screening - A Randomized Clinical Trial’, Dr Cedric Rat of the Faculty of Medicine, Nantes, France, and colleagues examined whether providing general practitioners (GPs) in France a list of patients who are nonadherent to colorectal cancer (CRC) screening improves patient participation in faecal immunochemical testing (FIT), which is a major challenge in countries that have implemented CRC screening programs. Screenings based on sigmoidoscopy or faecal tests are associated with a decreased ten-year mortality rate.

This study included patients (50-74 years of age) who were at average risk of CRC and not up-to-date with CRC screening. General practitioners were randomly assigned to one of three groups: 496 received a list of patients who had not undergone CRC screening (patient-specific reminders group, 10,476 patients); 495 received a letter describing region-specific CRC screening adherence rates (generic reminders group, 10,606 patients); and 455 did not receive any reminders (usual care group, 10,147 patients).

The researchers found that at one year, 24.8 percent of patients in the specific reminders group, 21.7 percent in the generic reminders group, and 20.6 percent in the usual care group participated in the FIT screening.

"Providing GPs with a list of patients who were nonadherent to CRC screening was associated with a modest increase in FIT participation compared with providing GPs with generic reminders about regional CRC screening rates or providing no reminders," the authors write.

The study notes some limitations, including the small magnitude of the increase in participation (4.2 percent).