Precision Patient Navigation to Improve Rates of Follow-up Colonoscopy, An Individual Randomized Effectiveness Trial

Patient Navigation to Improve Colonoscopy Completion After an Abnormal Stool Test Result : A Randomized Controlled Trial

BACKGROUND

Patient navigation is a recommended practice of the Guide to Community Preventive Services; little is known about whether it improves colonoscopy completion for adults who have received an abnormal stool test result.

OBJECTIVE

To determine whether patient navigation delivered to persons with an abnormal stool test result increased follow-up colonoscopy completion (primary) at 1 year.

DESIGN

Randomized controlled trial. (ClinicalTrials.gov: NCT03925883).

SETTING

A federally qualified health center (n = 32 clinics) in Washington state.

PATIENTS

Persons aged 50 to 75 years with an abnormal fecal test result in the prior month.

INTERVENTION

A 6-topic, telephone-based patient navigation program delivered by bilingual (English and Spanish) clinical staff.

MEASUREMENTS

Receipt of follow-up colonoscopy at 1 year (primary); time to colonoscopy receipt (secondary); and program effectiveness by patient characteristics, including patients' probability of obtaining a colonoscopy without navigation, derived using health record data (secondary).

RESULTS

Of 985 participants enrolled (mean age, 61 years [SD, 6.8]; 170 [18%] had a Spanish-language preference listed in the medical record), 967 were included in the primary intention-to-treat analysis (479 in patient navigation, 488 in usual care). Receipt of follow-up colonoscopy was higher in the patient navigation group than in the usual care group (55.1% vs. 42.1%; risk difference, 13.0 percentage points [95% CI, 6.5 to 19.4 percentage points]). The intervention effect was not moderated by patients' probability of obtaining a colonoscopy without navigation.

LIMITATION

The study was primarily done during the height of the COVID-19 pandemic, which created additional barriers to colonoscopy at the health system and patient levels.

CONCLUSION

These findings support the effectiveness of patient navigation for follow-up colonoscopy completion.

PRIMARY FUNDING SOURCE

National Cancer Institute.

Mailed Outreach and Patient Navigation for Colorectal Cancer Screening Among Rural Medicaid Enrollees: A Cluster Randomized Clinical Trial

Importance

Approximately 60 million adults live in rural regions of the US, which historically have low rates of colorectal cancer (CRC) screening and follow-up. Rural residents enrolled in Medicaid have particularly low CRC screening and follow-up rates.

Objective

To determine the effectiveness and implementation of a collaborative Medicaid health plan-clinic program of mailed fecal immunochemical test (FIT) outreach and patient navigation to colonoscopy following an abnormal FIT result when implemented in rural clinics as part of standard care.

Design, Setting, and Participants

This cluster randomized clinical trial was conducted at 28 rural clinic units in Oregon affiliated with 3 Medicaid health plans. The clinics were randomized to the intervention (n = 14) or to usual care (n = 14). Participants were Medicaid enrollees (aged 50-75 years) due for CRC screening. The intervention was delivered from May 11, 2021, through June 4, 2022, and analyses were performed from June 2023 through September 2024.

Intervention

The stepwise intervention involved (1) mailed FIT outreach and (2) patient navigation to colonoscopy following an abnormal FIT result. Implementation support included practice facilitation, training, collaborative learning, and patient tracking tools.

Main Outcomes and Measures

The primary effectiveness outcome was completion of any CRC screening within 6 months of eligibility determination. An additional effectiveness outcome was follow-up colonoscopy completion within 6 months of an abnormal FIT result. Implementation was measured as (1) the proportion of intervention-eligible enrollees who were mailed an FIT and who were sent an advance notification or reminder and (2) the proportion with an abnormal FIT result who were offered patient navigation.

Results

This study included 5614 Medicaid enrollees (2613 in intervention clinics and 3001 in usual care clinics). Enrollees had a mean (SD) age of 58.2 (5.5) years; most (4940 [88.0%]) were aged 50 to 64 years. A total of 2948 enrollees (52.5%) were female, 325 (6.2%) were Hispanic and 3774 (67.2%) were White, and 4457 (79.4%) lived in rural regions. Compared with Medicaid enrollees in usual care clinics, enrollees in intervention clinics had a higher adjusted 6-month proportion of any CRC screening completion (11.8% vs 4.5%; difference, 7.3 [95% CI, 5.3-9.2] percentage points). Implementation was 100% (all 1489 intervention-eligible enrollees) for mailed FIT outreach, 88.5% for advance notification, 78.1% for reminders, and 57.9% for patient navigation.

Conclusions and Relevance

In this cluster randomized clinical trial of rural clinics, mailed FIT outreach and patient navigation boosted participation in CRC screening among Medicaid enrollees. More efforts are needed to address low participation in both FIT testing and follow-up colonoscopy.

Trial Registration

ClinicalTrials.gov Identifier: NCT04890054.

Young Adult Community Health Advisor-Led Intervention to Promote Colorectal Cancer Screening Uptake Among South Asians in Hong Kong: A Randomized Controlled Trial

BACKGROUND

Colorectal cancer is the most common cancer globally, and its prevalence is high in minority populations.

OBJECTIVES

To investigate the effectiveness of a young adult community health advisor (YACHA)-led intervention in enhancing the colorectal cancer (CRC) screening uptake rate among asymptomatic South Asians aged 50 to 75 years residing in Hong Kong and to investigate the acceptability of this intervention.

METHODS

A randomized controlled trial design was adopted. Eighty asymptomatic South Asian participants aged 50 to 75 years were recruited from the community in Hong Kong and then randomly allocated either to a YACHA-led intervention group or a control group. The intervention group received YACHA-led intervention, whereas the control group would receive the intervention after all follow-up assessments. The outcome measure was the uptake of CRC screening test. The acceptability of the intervention was explored through semistructured interviews.

RESULTS

The findings showed that the CRC screening uptake rate of the intervention group was significantly higher than that of the control group (85.0% vs 2.5%, P < .001). All the interviewees were satisfied with the intervention.

CONCLUSION

The YACHA-led intervention improves the uptake of CRC screening among asymptomatic South Asians.

IMPLICATIONS FOR PRACTICE

It is suggested that more resources should be allocated to empower young members of minority groups to reduce the health disparity.

Cost-Effectiveness of Noninvasive Colorectal Cancer Screening in Community Clinics

Importance

Several noninvasive tests for colorectal cancer screening are available, but their effectiveness in settings with low adherence to screening and follow-up colonoscopy is not well documented.

Objective

To assess the cost-effectiveness of and outcomes associated with noninvasive colorectal cancer screening strategies, including new blood-based tests, in a population with low adherence to screening and ongoing surveillance colonoscopy.

Design, Setting, and Participants

The validated microsimulation model used for the decision analytical modeling study projected screening outcomes from 2025 to 2124 for a simulated cohort of 10 million individuals aged 50 years in 2025 and representative of a predominantly Hispanic or Latino patient population served by a Federally Qualified Health Center in Southern California. The simulated population had low adherence to first-step noninvasive testing (45%), second-step follow-up colonoscopy after an abnormal noninvasive test result (40%), and ongoing surveillance colonoscopy among patients with high-risk findings at follow-up colonoscopy (80%).

Exposures

Colorectal cancer screening strategies included no screening, an annual or biennial fecal immunochemical test, a triennial multitarget stool DNA test, and a triennial blood-based test. Using a blood-based test was assumed to increase first-step adherence by 17.5 percentage points.

Main Outcomes and Measures

Outcomes included colorectal cancer incidence and mortality, life-years gained and quality-adjusted life-years gained relative to no screening, costs, and net monetary benefit assuming a willingness to pay of $100 000 per quality-adjusted life-year gained.

Results

Under realistic adherence assumptions, a program of annual fecal immunochemical testing was the most effective and cost-effective strategy, yielding 121 life-years gained per 1000 screened individuals and a net monetary benefit of $5883 per person. Triennial blood testing was the least effective, yielding 23 life-years gained per 1000, and was not cost-effective, with a negative net monetary benefit. Annual fecal immunochemical testing with 45% first-step adherence and 80% adherence to follow-up and surveillance colonoscopy yielded greater benefit than triennial blood testing with perfect adherence (88 vs 77 life-years gained per 1000).

Conclusions and Relevance

This study suggests that in a federally qualified health care setting, prioritizing the convenience of blood tests over less costly and more effective existing stool-based tests could result in higher costs and worse population-level outcomes. Novel screening modalities should be carefully evaluated for performance in community settings before widespread adoption.

Performance of OC-Auto Micro 80 Fecal Immunochemical Test in an Integrated Academic-Community Health System

GOALS

We aimed to determine the performance of the OC-Auto Micro 80 fecal immunochemical test (FIT) in an average-risk population receiving care in an integrated, academic-community health system.

BACKGROUND

The FIT is the most used colorectal cancer (CRC) screening test worldwide. However, many Food and Drug Administration-cleared FIT products have not been evaluated in clinical settings.

STUDY

We performed a retrospective cohort study of patients (50 to 75 y old) in the University of Washington Medicine health care system who were screened for CRC by OC-Auto Micro 80 FIT between March 2016 and September 2021. We used electronic health records to extract patient-level and clinic-level factors, FIT use, colonoscopy, and pathology findings. The primary outcomes were the FIT positivity rate and neoplasms detected at colonoscopy. Secondary outcomes were FIT positivity by sex and safety-net versus non-safety-net clinical settings.

RESULTS

We identified 39,984 FITs completed by 26,384 patients; 2411 (6.0%) had a positive FIT result (>100 ng/mL of hemoglobin in buffer), and 1246 (51.7%) completed a follow-up colonoscopy. The FIT positive rate was 7.0% in men and 5.2% in women ( P <0.01). Among those who completed a colonoscopy after an abnormal FIT result, the positive predictive value for CRC, advanced adenoma, and advanced neoplasia was 3.0%, 20.9%, and 23.9%, respectively.

CONCLUSIONS

In a retrospective analysis of a large heterogeneous population, the OC-Auto Micro 80 FIT for CRC screening demonstrated a positivity rate of 6.0% and a positive predictive value for CRC of 3.0%.

Colonoscopy Outreach for Rural Communities (CORC): A study protocol of a pragmatic randomized controlled trial of a patient navigation program to improve colonoscopy completion for colorectal cancer screening

BACKGROUND

Colonoscopy is one of the primary methods of screening for colorectal cancer (CRC), a leading cause of cancer mortality in the United States. However, up to half of patients referred to colonoscopy fail to complete the procedure, and rates of adherence are lower in rural areas.

OBJECTIVES

Colonoscopy Outreach for Rural Communities (CORC) is a randomized controlled trial to test the effectiveness of a centralized patient navigation program provided remotely by a community-based organization to six geographically distant primary care organizations serving rural patients, to improve colonoscopy completion for CRC.

METHODS

CORC is a type 1 hybrid implementation-effectiveness trial. Participants aged 45-76 from six primary care organizations serving rural populations in the northwestern United States are randomized 1:1 to patient navigation or standard of care control. The patient navigation is delivered remotely by a trained lay-person from a community-based organization. The primary effectiveness outcome is completion of colonoscopy within one year of referral to colonoscopy. Secondary outcomes are colonoscopy completion within 6 and 9 months, time to completion, adequacy of patient bowel preparation, and achievement of cecal intubation. Analyses will be stratified by primary care organization.

DISCUSSION

Trial results will add to our understanding about the effectiveness of patient navigation programs to improve colonoscopy for CRC in rural communities. The protocol includes pragmatic adaptations to meet the needs of rural communities and findings may inform approaches for future studies and programs.

TRIAL REGISTRATION

National Clinical Trial Identifier: NCT05453630.

TRIAL REGISTRATION

ClinicalTrials.gov. Identifier: NCT05453630. Registered July 6, 2022.

Trends in colorectal cancer screening compliance and incidence among 60- to 74-year-olds in China

BACKGROUND

Compliance with colonoscopy among elderly individuals participating in colorectal cancer (CRC) screening programs is unsatisfactory, despite a high detection rate of bowel-related diseases. In this study, our aim was to analyze the impact of risk factors on the trends of compliance and detection rates in colonoscopy among high-risk individuals aged 60-74.

METHODS

A retrospective study was conducted on the high-risk individuals aged 60-74 participating in the 2021 CRC screening program in Tianjin, China. Logistic regression analyses, including both univariate and multivariate analyses, were performed to explore the impact of different risk factors on colonoscopy compliance among the high-risk individuals. Besides, the study investigated the influence of various risk factors on the detection rates of bowel-related diseases among the high-risk individuals who underwent colonoscopy.

RESULTS

A total of 24,064 high-risk individuals were included, and 5478 individuals received a free colonoscopy, with an overall compliance of 22.76%. Among them, the adenoma detection rate was 55.46%. Males and individuals with a positive FIT had high compliance and detection rates for CRC, advanced adenomas (AA), advanced colorectal neoplasia (ACN), and colorectal neoplasm (CN). Individuals aged 70-74 were associated with low compliance but high CRC, ACN, and CN detection rates. Individuals who reported a history of chronic constipation, bloody mucous, and CRC in first-degree relative showed high compliance but no significantwere associated with the detection rates of CRC, AA, and CN.

CONCLUSION

This study reported several risk factors associated with the screening behaviors for CRC. Patterns and trends in CRC, AA, ACN, and CN compliance and detection rates correlate with risk factors.

Examining the Sustainability of Core Capacity and Evidence-Based Interventions for FIT-Based CRC Screening: California Colorectal Cancer Control Program

OBJECTIVES

We examined the extent to which funded satellite clinics could sustain the California Colon Cancer Control Program (C4P) strategies implemented in health systems to increase uptake of the fecal immunochemical test (FIT) or immunochemical fecal occult blood test (iFOBT) for colorectal cancer (CRC) screening in the absence of future C4P funds.

INTRODUCTION

Seven health systems consisting of 38 satellite clinics participated in C4P to examine the sustainability of the program in the absence future Centers for Disease Control and Prevention (CDC) funding.

METHODS

Quantitative and qualitative methods with a close and open-ended survey approach, and a prospective cohort design were used to examine the sustainability of the C4P in health systems.

RESULTS

A total of 61% of satellite clinics could not sustain funding stability. Only 26% could sustain funding stability. About, 71%, 26%, and 21% of the satellite clinics could sustain the small media platform, patient navigation services, and community health workers (CHWs), respectively. All the satellite clinics sustained the provider reminder system and professional development. Roughly, 71% and 42% of funded satellite clinics could not sustain the patient navigators and CHWs, respectively. The satellite clinics that could sustain funding stability, sustained patient navigation services and CHWs. Health systems that could not sustain funding stability, could not sustain patient navigation services and CHWs. Qualitatively, the need to support uninsured priority populations, health educators, patient navigators, care coordination activities, outreach services, and provision of enhanced services emerged. The need to support enhanced quality measures, expansion of funding, Medi-Cal Public Hospital Redesign and Incentive coverage, health plan, community linkages, resource sharing, and best practices specifically on CRC screening emerged. Themes such as automated reminder, limited personalized care delivery and capacity, transportation barriers, staff salary, expansion of care through patient navigation, and culturally appropriate media campaign also emerged.

CONCLUSION

Overall, to address sustainability barriers, funding stability should be maintained in the health systems.

Abnormal Colorectal Cancer Test Follow-Up: A Quality Improvement Initiative at a Federally Qualified Health Center

INTRODUCTION/OBJECTIVES

Colonoscopy completion rates after an abnormal fecal immunochemical test (FIT) are suboptimal, resulting in missed opportunities for early detection and prevention of colorectal cancer. Patient navigation and structured follow-up may improve colonoscopy completion, but implementation of these strategies is not widespread.

METHODS

We conducted a quality improvement study using a Plan-Do-Study-Act (PDSA) Model to increase colonoscopy completion after abnormal FIT in a large federally qualified health center serving a diverse and low-income population. Intervention components included patient navigation, and a checklist to promote completion of key steps required for abnormal FIT follow-up. Primary outcome was proportion of patients achieving colonoscopy completion within 6 months of abnormal FIT, assessed at baseline for 156 patients pre-intervention, and compared to 208 patients during the intervention period from April 2017 to December 2019. Drop offs at each step in the follow-up process were assessed.

RESULTS

Colonoscopy completion improved from 21% among 156 patients with abnormal FIT pre-intervention, to 38% among 208 patients with abnormal FIT during the intervention (P < .001; absolute increase: 17%, 95% CI: 6.9%-25.2%). Among the 130 non-completers during the intervention period, lack of completion was attributable to absence of colonoscopy referral for 7.7%; inability to schedule a pre-colonoscopy specialist visit for 71.5%; failure to complete a pre-colonoscopy visit for 2.3%; the absence of colonoscopy scheduling for 9.2%; failure to show for a scheduled colonoscopy for 9.2%.

CONCLUSIONS

Patient navigation and structured follow-up appear to improve colonoscopy completion after abnormal FIT. Additional strategies are needed to achieve optimal rates of completion.

Adapting a Remotely Delivered Patient Navigation Program for Colorectal Cancer Screening in Primary Care: Important Considerations for Rural Contexts

INTRODUCTION

Colonoscopy is a critical component of colorectal cancer (CRC) screening and patient navigation (PN) improves colonoscopy completion. A lay navigator remotely providing navigation across rural primary care organizations (PCOs) could increase PN access. In preparation for the Colonoscopy Outreach for Rural Communities (CORC) study, we examined partners' perspectives on contextual factors that could influence CORC program implementation, and adaptations to mitigate potential barriers.

METHODS

We interviewed 29 individuals from 6 partner PCOs and the community-based organization (CBO) delivering the PN program. An analysis approach informed by Miles, Huberman, and Saldana identified critical themes. Results are reported using the Framework for Reporting Adaptations and Modifications-Enhanced (FRAME).

RESULTS

Potential barriers included that rural patients are hard to reach remotely and might mistrust the navigator, and the CBO is unfamiliar with the patient communities and does not have patient care experience or pre-existing communication pathways with the PCOs. Program content and navigator training was adapted to mitigate these challenges.

CONCLUSIONS

Our study highlights contextual factors to account for before implementing a remote, centralized patient navigation program serving rural communities. Gathering partner perspectives led to intervention adaptations intended to address potential barriers while leaving the core components of the evidence-based intervention intact.

Reach and effectiveness of a centralized navigation program for patients with positive fecal immunochemical tests requiring follow-up colonoscopy

Completion rates for follow-up colonoscopies after an abnormal fecal immunochemical test (FIT) are suboptimal in federally qualified health center (FQHC) settings. We implemented a screening intervention that included mailed FIT outreach to North Carolina FQHC patients from June 2020 to September 2021 and centralized patient navigation to support patients with abnormal FITs in completing follow-up colonoscopy. We evaluated the reach and effectiveness of navigation using electronic medical record data and navigator call logs detailing interactions with patients. Reach assessments included the proportion of patients successfully contacted by phone and who agreed to participate in navigation, intensity of navigation provided (including types of barriers to colonoscopy identified and total navigation time), and differences in these measures by socio-demographic characteristics. Effectiveness outcomes included colonoscopy completion, timeliness of follow-up colonoscopy (i.e., within 9 months), and bowel prep adequacy. Among 514 patients who completed a mailed FIT, 38 patients had an abnormal result and were eligible for navigation. Of these, 26 (68%) accepted navigation, 7 (18%) declined, and 5 (13%) could not be contacted. Among navigated patients, 81% had informational needs, 38% had emotional barriers, 35% had financial barriers, 12% had transportation barriers, and 42% had multiple barriers to colonoscopy. Median navigation time was 48.5 min (range: 24-277 min). Colonoscopy completion differed across groups - 92% of those accepting navigation completed colonoscopy within 9 months, versus 43% for those declining navigation. We found that centralized navigation was widely accepted in FQHC patients with abnormal FIT, and was an effective strategy, resulting in high colonoscopy completion rates.

Characteristics of patient navigation programs in the Cancer Moonshot ACCSIS colorectal cancer screening initiative

BACKGROUND

Although patient navigation has shown promise for increasing participation in colorectal cancer screening and follow-up, little evidence is available to guide implementation of patient navigation in clinical practice. We characterize 8 patient navigation programs being implemented as part of multi-component interventions of the National Cancer Institute's Cancer Moonshot Accelerating Colorectal Cancer Screening and Follow-Up Through Implementation Science (ACCSIS) initiative.

METHODS

We developed a data collection template organized by ACCSIS framework domains. The template was populated by a representative from each of the 8 ACCSIS research projects. We report standardized descriptions of 1) the socio-ecological context in which the navigation program was being conducted, 2) navigation program characteristics, 3) activities undertaken to facilitate program implementation (eg, training), and 4) outcomes used in program evaluation.

RESULTS

ACCSIS patient navigation programs varied broadly in their socio-ecological context and settings, the populations they served, and how they were implemented in practice. Six research projects adapted and implemented evidence-based patient navigation programs; the remaining projects developed new programs. Five projects began navigation when patients were due for initial colorectal cancer screening; 3 projects began navigation later in the screening process, when patients were due for follow-up colonoscopy after an abnormal stool-test result. Seven projects relied on existing clinical staff to deliver the navigation; 1 hired a centralized research navigator. All project researchers plan to evaluate the effectiveness and implementation of their programs.

CONCLUSIONS

Our detailed program descriptions may facilitate cross-project comparisons and guide future implementation and evaluation of patient navigation programs in clinical practice.

Development and Evaluation of Patient Navigation Training for Rural and Appalachian Populations

The Appalachian region of the USA includes 423 counties in 13 states positioned along the spine of the Appalachian Mountains stretching from New York to Mississippi. Approximately 42% of Appalachia is rural, and while the economy of Appalachia has diversified over the past two decades from reliance on agriculture and coal mining, 176 (41.6%) of the 423 counties are classified as economically distressed or at-risk. Patient navigation (PN) has been shown to be effective as an approach to address multiple barriers and enhance access to healthcare services, and yet there are no known PN programs focusing on the Appalachian population. This project was designed to develop, implement, and evaluate a curriculum and training program for PN for cancer prevention and control in Appalachia. The training program was developed through formative evaluation and offered daylong workshops that provided instruction in 60-90-min modules. Workshop topics included an introduction to PN, Appalachian culture, community needs assessment, communication, financial navigation, and navigation for screening and diagnostic follow-up for breast, cervical, and colorectal cancers. A total of 20 workshops were conducted with 334 attendees. The workshops were evaluated using a mixed-method approach using pre- and posttests and participant evaluations. The overall mean posttest scores increased by 4% from pretest (p < 0.05). Evaluation also showed that attendees valued the focus on Appalachian culture and judged the content relevant and useful. Attendees also expressed interest in additional opportunities for similar workshops that expanded upon current topics and allowed for exploration of Appalachian health-related issues.

Predictors of treatment refusal in patients with colorectal cancer: A systematic review

This systematic review was conducted to investigate predictors of treatment refusal in colorectal cancer (CRC) patients. An understanding of these predictors would inform statistical models for the identification of high-risk patients who might benefit from interventions that seek to improve treatment compliance. We performed a search of PubMed and Scopus to identify potentially relevant studies on predictors of treatment refusal in CRC patients that were published between January 1, 2000 and December 31, 2021. We screened manuscripts using predefined eligibility criteria. Information on study design, study location, patient characteristics, treatments, rates and predictors of treatment refusal, and the impact of treatment refusal on mortality or survival were collected from eligible studies. Study quality was assessed using the Newcastle-Ottawa score. The overall findings of the review process were summarized using descriptive statistics and a narrative synthesis. A total of 13 studies were included in this review. Ten studies reported on refusal of CRC surgery, refusal rate: 0.25%-3.26%; three studies reported on chemotherapy refusal (one of which reported on both surgery and chemotherapy refusal), refusal rate: 7.8%-41.5%; and one study reported on refusal of any cancer treatment, refusal rate: 8.7%. The bulk of the published literature confirmed the harmful association between treatment refusal and poor survival outcomes in CRC patients. Frequently cited predictors of treatment refusal included patient demographic characteristics (age, race, gender), clinical characteristics (disease stage, comorbidity), and factors that impact access to cancer care services (healthcare insurance, facility level). Potentially high rates of treatment refusal pose a challenge to CRC control. This review has identified several factors which must be considered when attempting to reduce treatment refusal in CRC patients. Furthermore, these factors should be tested as components of predictive risk models for this important outcome.

Commencing colorectal cancer screening at age 45 years in U.S. racial groups

Screening for colorectal cancer (CRC) is cost-effective for reducing its mortality among the average-risk population. In the US, CRC incidence and mortality differ among racial/ethnic groups, with non-Hispanic Blacks (NHB) and American Indian/Alaska Natives showing highest incidence and mortality and earlier presentation. Since 2005, some professional societies have recommended CRC screening for NHB to commence at 45 years or earlier; this was not implemented due to lack of recommendation from key groups that influence insurance payment coverage. In 2017 the highly influential U.S. Multi-Society Task Force for Colorectal Cancer recommended screening to commence at 45 years for NHB; this recommendation was supplanted by data showing an increase in early-onset CRCs in non-Hispanic Whites approaching the under-50-year rates observed for NHB. Subsequently the American Cancer Society and the USPSTF recommended that the entire average-risk population move to commence CRC screening at 45 years. Implementing screening in 45–49-year-olds has its challenges as younger groups compared with older groups participate less in preventive care. The US had made extensive progress pre-COVID-19 in closing the disparity gap for CRC screening in NHB above age 50 years; implementing screening at younger ages will take ingenuity, foresight, and creative strategy to reach a broader-aged population while preventing widening the screening disparity gap. Approaches such as navigation for non-invasive and minimally invasive CRC screening tests, removal of financial barriers such as co-pays, and complete follow up to abnormal non-invasive screening tests will need to become the norm for broad implementation and success across all racial/ethnic groups.

Mailed fecal testing and patient navigation versus usual care to improve rates of colorectal cancer screening and follow-up colonoscopy in rural Medicaid enrollees: a cluster-randomized controlled trial

Background

Screening reduces incidence and mortality from colorectal cancer (CRC), yet US screening rates are low, particularly among Medicaid enrollees in rural communities. We describe a two-phase project, SMARTER CRC, designed to achieve the National Cancer Institute Cancer Moonshot^SM objectives by reducing the burden of CRC on the US population. Specifically, SMARTER CRC aims to test the implementation, effectiveness, and maintenance of a mailed fecal test and patient navigation program to improve rates of CRC screening, follow-up colonoscopy, and referral to care in clinics serving rural Medicaid enrollees.

Methods

Phase I activities in SMARTER CRC include a two-arm cluster-randomized controlled trial of a mailed fecal test and patient navigation program involving three Medicaid health plans and 30 rural primary care practices in Oregon and Idaho; the implementation of the program is supported by training and practice facilitation. Participating clinic units were randomized 1:1 into the intervention or usual care. The intervention combines (1) mailed fecal testing outreach supported by clinics, health plans, and vendors and (2) patient navigation for colonoscopy following an abnormal fecal test result. We will evaluate the effectiveness, implementation, and maintenance of the intervention and track adaptations to the intervention and to implementation strategies, using quantitative and qualitative methods. Our primary effectiveness outcome is receipt of any CRC screening within 6 months of enrollee identification. Our primary implementation outcome is health plan- and clinic-level rates of program delivery, by component (mailed FIT and patient navigation). Trial results will inform phase II activities to scale up the program through partnerships with health plans, primary care clinics, and regional and national organizations that serve rural primary care clinics; scale-up will include webinars, train-the-trainer workshops, and collaborative learning activities.

Discussion

This study will test the implementation, effectiveness, and scale-up of a multi-component mailed fecal testing and patient navigation program to improve CRC screening rates in rural Medicaid enrollees. Our findings may inform approaches for adapting and scaling evidence-based approaches to promote CRC screening participation in underserved populations and settings.

Trial registration

Registered at clinicaltrial.gov (NCT04890054) and at the NCI’s Clinical Trials Reporting Program (CTRP #: NCI-2021-01032) on May 11, 2021.