Implementing Mailed Colorectal Cancer Fecal Screening Tests in Real-World Primary Care Settings: Promising Implementation Practices and Opportunities for Improvement

Colorectal cancer (CRC) screening reduces morbidity and mortality, but screening rates in the USA remain suboptimal. The Colorectal Cancer Control Program (CRCCP) was established in 2009 to increase screening among groups disproportionately affected. The CRCCP utilizes implementation science to support health system change as a strategy to reduce disparities in CRC screening by directing resources to primary care clinics to implement evidence-based interventions (EBIs) proven to increase CRC screening. As COVID-19 continues to impede in-person healthcare visits and compel the unpredictable redirection of clinic priorities, understanding clinics' adoption and implementation of EBIs into routine care is crucial. Mailed fecal testing is an evidence-based screening approach that offers an alternative to in-person screening tests and represents a promising approach to reduce CRC screening disparities. However, little is known about how mailed fecal testing is implemented in real-world settings. In this retrospective, cross-sectional analysis, we assessed practices around mailed fecal testing implementation in 185 clinics across 62 US health systems. We sought to (1) determine whether clinics that do and do not implement mailed fecal testing differ with respect to characteristics (e.g., type, location, and proportion of uninsured patients) and (2) identify implementation practices among clinics that offer mailed fecal testing. Our findings revealed that over half (58%) of clinics implemented mailed fecal testing. These clinics were more likely to have a CRC screening policy than clinics that did not implement mailed fecal testing (p = 0.007) and to serve a larger patient population (p = 0.004), but less likely to have a large proportion of uninsured patients (p = 0.01). Clinics that implemented mailed fecal testing offered it in combination with EBIs, including patient reminders (92%), provider reminders (94%), and other activities to reduce structural barriers (95%). However, fewer clinics reported having the leadership support (58%) or funding stability (29%) to sustain mailed fecal testing. Mailed fecal testing was widely implemented alongside other EBIs in primary care clinics participating in the CRCCP, but multiple opportunities for enhancing its implementation exist. These include increasing the proportion of community health centers/federally qualified health centers offering mailed screening; increasing the proportion that provide pre-paid return mail supplies with the screening kit; increasing the proportion of clinics monitoring both screening kit distribution and return; ensuring patients with abnormal tests can obtain colonoscopy; and increasing sustainability planning and support.

Personalized colorectal cancer screening: study protocol of a mixed-methods study on the effectiveness of tailored intervals based on prior f-Hb concentration in a fit-based colorectal cancer screening program (PERFECT-FIT)

BACKGROUND

In 2014, the national population-based colorectal cancer (CRC) screening program was implemented in the Netherlands. Biennial fecal immunochemical testing (FIT) for hemoglobin (Hb) is used at a cut-off of 47 µg Hb per gram feces. The CRC screening program successfully started, with high participation rates and yield of screening. Now that the program has reached a steady state, there is potential to further optimize the program. Previous studies showed that prior fecal Hb (f-Hb) concentrations just below the FIT cut-off are associated with a higher risk for detection of advanced neoplasia (AN) at subsequent screening rounds. We aim to achieve a better balance between the harms and benefits of CRC screening by offering participants tailored invitation intervals based on prior f-Hb concentrations after negative FIT.

METHODS

This mixed-methods study will be performed within the Dutch national CRC screening program and will consist of: (1) a randomized controlled trial (RCT), (2) focus group studies, and (3) decision modelling. The primary outcome is the yield of AN per screened individual in personalized screening vs. uniform screening. Secondary outcomes are perspectives on, acceptability of and adherence to personalized screening, as well as long-term outcomes of personalized vs. uniform screening. The RCT will include 20,000 participants of the Dutch CRC screening program; 10,000 in the intervention and 10,000 in the control arm. The intervention arm will receive a personalized screening interval based on the prior f-Hb concentration (1, 2 or 3 years). The control arm will receive a screening interval according to current practice (2 years). The focus group studies are designed to understand individuals' perspectives on and acceptability of personalized CRC screening. Results of the RCT will be incorporated into the MISCAN-Colon model to determine long-term benefits, harms, and costs of personalized vs. uniform CRC screening.

DISCUSSION

The aim of this study is to evaluate the yield, feasibility, acceptability and (cost-) effectiveness of personalized CRC screening through tailored invitation intervals based on prior f-Hb concentrations. This knowledge may be of guidance for health policy makers and may provide evidence for implementing personalized CRC screening in The Netherlands and/or other countries using FIT as screening modality.

TRIAL REGISTRATION

ClinicalTrials.gov, NCT05423886, June 21, 2022, https://clinicaltrials.gov/ct2/show/NCT05423886.

Premature Fecal Immunochemical Testing in British Columbia Canada: a Retrospective Review of Physician and Screening Participant Characteristics

BACKGROUND

Colorectal cancer (CRC) screening is an evidence-based strategy to reduce CRC-related mortality.

OBJECTIVE

This study identifies physician and participant characteristics, as well as previous FIT values associated with premature FIT usage.

DESIGN

This is a retrospective review of all FITs ordered from January 1, 2016, until June 30, 2017. For each ordered FIT, the participant's chart was reviewed to identify if a previous FIT had occurred in the prior 21 months. A premature FIT was defined as an ordered test with a negative FIT in the preceding 21 months.

PARTICIPANTS

Screening participants were average risk for CRC, aged 50-74, and had a FIT ordered by their primary care provider in British Columbia, Canada.

MAIN MEASURES

The BC College of Physicians and Surgeons' database was used to identify the location of referring physician, date of graduation from medical school, and gender. The participant's age, gender, and value of previous FIT were recorded. Physician and participant variables and previous FIT value were examined with logistic regression to identify associations with premature FIT ordering.

KEY RESULTS

In total, 385,375 FITs were ordered during this period with 116,727 representing participants returning following a previous negative FIT. In total, 35,148 (30.1%) returned early for screening. Men were more likely to return early than women (OR 1.14; 95% CI 1.11-1.17; p < 0.0001). Male physicians were more likely to order premature FITs (OR 1.15; 95% CI 1.06-1.24; p < 0.0001). A higher quantitative FIT value (ng/mL) of the previous FIT was also associated with early screening (OR 1.11; 95% CI 1.09-1.14; < 0.0001).

CONCLUSIONS

This study found that approximately 30% of FIT tests, ordered for CRC screening, were ordered before they were due. This may lead to wasted resources, unnecessary participant stress, and unwarranted patient risk.

The Impact of Transitioning From Guaiac-Fecal Occult Blood Testing to Fecal Immunochemical Testing in a Canadian Colon Cancer Screening Program

Objectives

To determine the impact of transitioning from guaiac-based fecal occult blood testing (gFOBT) to fecal immunochemical testing (FIT) on the detection rate of adenomas, advanced adenomas (AA) and colorectal cancer (CRC).

Background

Recently, the health region in Edmonton, Alberta switched from gFOBT to FIT for CRC screening.

Study

A retrospective analysis of all patients, aged 50 to 74 years, referred for colonoscopy from January 1, 2013 to December 31, 2014 due to a positive gFOBT (at least one of three samples positively using the guaiac-based Hemoccult II SENSA in 2013) or FIT (≥75 µg/g of stool, using the Polymedco OC FIT-CHEK in 2014). The primary outcomes were the number of colon cancers, AA and adenomas detected in 2013 and 2014. A comparison between the two tests was also made for the composite outcome of detection of either AA or CRC.

Results

Six hundred and forty-nine patients underwent colonoscopy due to a positive gFOBT in 2013, and 2167 patients for a positive FIT in 2014. FIT compared with gFOBT detected more CRC (67 compared with 34), AA (770 compared with 147) and adenomas (1575 versus 320). By multivariable regression analysis adjusted for different demographics and endoscopic metrics, positive FIT was independently associated with higher adenoma detection rate (odds ratio [OR] 2.62; 95% confidence interval [CI] 2.13 to 3.21, P < 0.001), AA detection rate (OR 1.83, 95% CI 1.43 to 2.33, P < 0.001), and the composite outcome of AA and CRC (OR 2.04, 95% CI 1.60 to 2.59, P < 0.001).

Conclusions

Adoption of FIT compared with gFOBT led to higher detection of colon cancer, AA and adenomas.

Two-year follow-up of the effectiveness of a multifaceted intervention to improve adherence to annual colorectal cancer screening in community health centers

PURPOSE

We previously found that a multifaceted outreach intervention achieved 82 % annual adherence to colorectal cancer (CRC) screening with fecal occult blood testing (FOBT). This study assessed adherence to FOBT after a second outreach.

METHODS

We followed 225 patients in community health centers in Chicago, Illinois, who were randomized to the intervention group. Our primary analysis focused on 124 patients who completed FOBT during the first outreach and were due again for annual FOBT; 90% were Latino, 87% preferred to speak Spanish, and 77% were uninsured. Second outreach consisted of (1) a mailed reminder letter, a free fecal immunochemical test (FIT) with postage-paid return envelope, (2) automated phone and text messages, (3) automated reminders 2 weeks later if the FIT was not returned, and (4) a telephone call after 3 months. Our main outcome was completion of FIT within 6 months of the due date. We also analyzed the proportion of the original 225 patients who were fully screened for CRC over the 2-year study period.

RESULTS

A total of 88.7% of patients completed a FIT within 6 months of their second outreach. Over the 2 years since the first outreach, 71.6% of the 225 patients assigned to the intervention group were fully up to date on CRC screening, another 11.1% had been screened suboptimally, and 17.3% were inadequately screened or not screened.

CONCLUSIONS

It is possible to achieve high rates of CRC screening over a 2-year period for vulnerable populations using outreach with FIT as a primary strategy.