Increased Colorectal Cancer Screening Sustained with Mailed Fecal Immunochemical Test Outreach

BACKGROUND & AIMS

Reports of mailed fecal immunochemical test (FIT) outreach effectiveness over time are minimal. We aimed to better evaluate a mailed FIT program with longitudinal metrics.

METHODS

A total of 10,771 patients aged 50 to 75 years not up-to-date with colorectal cancer screening were randomized to intervention or usual care. The intervention arm received an advanced notification call and informational postcard prior to a mailed FIT. Usual care was at the discretion of the primary care provider. Patients were followed for up to 2.5 years. The primary outcome was the difference in cumulative proportion of completed FIT screening between arms. Screening was further examined with the proportion of time up-to-date, consistency of adherence, and frequency of abnormal FIT.

RESULTS

The cumulative proportion of FIT completion was higher in the outreach intervention (73.2% vs 55.1%; P < .001). The proportion of time covered by screening was higher in the intervention group (46.8% vs 27.3%; Δ19.6%; 95% confidence interval, 18.2%-20.9%). Patients assigned to FIT outreach were more likely to consistently complete FITs (2 completed of 2 offered) (50.1% vs 21.8%; P < .001). However, for patients who did not complete the FIT during the first cycle, only 17.1% completed a FIT during the second outreach cycle. The number and overall proportion of abnormal FIT was significantly higher in the outreach intervention (6.9% Outreach vs 4.1% Usual Care; P < .01).

CONCLUSIONS

Organized mailed FIT outreach significantly increased colorectal cancer screening over multiple years in this safety-net health system. Although mailing was overall effective, the effect was modest in patients who did not complete FIT in first cycle of intervention. (ClincialTrials.gov, NCT02613260).

Effectiveness and Cost of Organized Outreach for Colorectal Cancer Screening: A Randomized, Controlled Trial

BACKGROUND

Colorectal cancer (CRC) screening remains underused, especially in safety-net systems. The objective of this study was to determine the effectiveness, costs, and cost-effectiveness of organized outreach using fecal immunochemical tests (FITs) compared with usual care.

METHODS

Patients age 50-75 years eligible for CRC screening from eight participating primary care safety-net clinics were randomly assigned to outreach intervention with usual care vs usual care alone. The intervention included a mailed postcard and call, followed by a mailed FIT kit, and a reminder phone call if the FIT kit was not returned. The primary outcome was screening participation at 1 year and a microcosting analysis of the outreach activities with embedded long-term cost-effectiveness of outreach. All statistical tests were two-sided.

RESULTS

A total of 5386 patients were randomly assigned to the intervention group and 5434 to usual care. FIT screening was statistically significantly higher in the intervention group than in the control group (57.9% vs 37.4%, P < .001; difference = 20.5%, 95% confidence interval = 18.6% to 22.4%). In the intervention group, FIT completion rate was higher in patients who had previously completed a FIT vs those who had not (71.9% vs 35.7%, P < .001). There was evidence of effect modification of the intervention by language, and clinic. Outreach cost approximately $23 per patient and $112 per additional patient screened. Projecting long-term outcomes, outreach was estimated to cost $9200 per quality-adjusted life-year gained vs usual care.

CONCLUSION

Population-based management with organized FIT outreach statistically significantly increased CRC screening and was cost-effective in a safety-net system. The sustainability of the program and any impact of economies of scale remain to be determined.

Obesity and metabolic outcomes in a safety-net health system

In the United States, obesity has increased in prevalence over time and is strongly associated with subsequent outcomes such as diabetes mellitus (DM) and nonalcoholic fatty liver disease (NAFLD). It is unclear, however, as to how the magnitude of NAFLD risk from obesity and DM is increased in safety-net health system settings. Among the San Francisco Health Network (SFHN) patients (N = 47,211), we examined the association between Body Mass Index (BMI) and elevated liver enzyme levels, including interaction by DM status. Our findings revealed that 32.2 percent of SFHN patients were obese, and Pacific Islanders in the safety-net had the highest rates of obesity compared to other racial groups, even after using higher race-specific BMI cutoffs. In SFHN, obesity was associated with elevated liver enzymes, with the relationship stronger among those without DM. Our findings highlight how obesity is a stronger factor of NAFLD in the absence of DM, suggesting that practitioners consider screening for NAFLD among safety-net patients with obesity even if DM has not developed. These results highlight the importance of directing efforts to reduce obesity in safety-net health systems and encourage researchers to further examine effect modification between health outcomes in such populations.

Abstract C123: The San Francisco Cancer Initiative: Addressing disparities in colorectal cancer screening in community health centers

Background: Despite being among the wealthiest cities in the United States, San Francisco continues to suffer from disparities in colorectal cancer (CRC) screening and diagnostic follow up among low-income and ethnically diverse residents served by community health centers (CHCs). The San Francisco Cancer (SF CAN) Initiative, a collaborative effort to reduce cancer in San Francisco, is dedicated to decreasing these and other cancer-related disparities. Purpose: To describe the approach and preliminary outcomes of the SF CAN’s CRC Task Force. Methods: Using principles of community engagement and implementation science, we developed a logic model to address CRC screening disparities. As inputs, the logic model features a partnership with the San Francisco Community Clinic Consortium (SFCCC) and its partner nonprofit community health centers. The goal is to increase screening with fecal immunochemical testing (FIT) and when needed, follow up colonoscopy, for its patient population. Continuous program evaluation utilizes the Reach, Effectiveness, Adoption, Implementation, and Maintenance (RE-AIM) Framework. Results: The SFCCC has created a quarterly reporting system to track CRC screening rates and facilitate collaborative goal setting for its partner CHCs. Six SFCCC clinical sites serving 18,815 adults aged 50-75 have used SF CAN’s technical assistance and Quality Improvement Stipends (QIS) to engage in an analysis of barriers and facilitators to screening and implement multi-level evidence-based interventions tailored to their identified specific needs. Barriers include low literacy, language, economic, and social obstacles to CRC screening such as lack of transportation or reliable access to housing or a private bathroom. The Task Force has assisted with staff training, patient education materials, and strategies for FIT distribution and collection. We have helped several sites switch from multi-sample FIT kits to evidence-based, user-friendly single sample FIT, and encouraged the development of tracking and navigation systems for abnormal FIT. In the first six months of QIS program, 5,199 patients were provided with FIT, and 3,932 (75.6%) successfully completed it. In addition, a first-ever review of 298 patients with abnormal FIT at these sites revealed that only 144 (48%) completed colonoscopy within 6 months, a finding that may lead to new initiatives to improve patient navigation. Additional SFCCC clinical sites will join the QIS program in the coming year. Conclusion: The SF CAN CRC Task Force has provided a model of academic and community partnership through which interventions to address CRC screening disparities in medically underserved communities can be implemented.

Citation Format: Robert Hiatt, Carly Rachocki, Michael B. Potter, Ma Somsouk, David Ofman. The San Francisco Cancer Initiative: Addressing disparities in colorectal cancer screening in community health centers [abstract]. In: Proceedings of the Twelfth AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2019 Sep 20-23; San Francisco, CA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2020;29(6 Suppl_2):Abstract nr C123.