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Multicomponent interventions increase colorectal cancer screening rates
A combination of interventions, particularly those that include fecal blood test outreach and patient navigation, were linked to improvements in completion of colorectal cancer screening, according to findings published in JAMA Internal Medicine.
“Colorectal cancer screening is recommended by all major U.S. medical organizations but remains underused,” Michael K. Dougherty, MD, MSCR, from the University of North Carolina at Chapel Hill, and colleagues wrote.
Dougherty and colleagues conducted a systematic review and meta-analysis of 73 randomized clinical trials including 366,766 patients to identify interventions that improved colorectal cancer screening rates. The trials had low or medium risk of bias and evaluated completion of colorectal cancer screening, colonoscopy after an abnormal initial screening test result and continued rounds of annual fecal blood tests.
The researchers found that improved colorectal cancer screening completion rates were linked to the following interventions:
- fecal blood test outreach (risk ratio [RR] = 2.26; 95% CI, 1.81-2.81; risk difference [RD] = 22%; 95% CI, 17%-27%);
- patient navigation (RR = 2.01; 95% CI, 1.64-2.46; RD = 18%; 95% CI, 13%-23%);
- patient education (RR = 1.2; 95% CI, 1.06-1.36; RD = 4%; 95%CI, 1%-6%);
- patient reminders (RR = 1.2; 95% CI, 1.02-1.41; RD = 3%; 95% CI, 0%-5%);
- clinician interventions of academic detailing (RD = 10%; 95% CI, 3%-17%); and
- clinician reminders (RD = 13%; 95% CI, 8%-19%).
Multicomponent interventions demonstrated greater increases in screening completion than single component interventions (RR = 1.18; 95% CI, 1.09-1.29; RD = 7%; 95% CI, 3%-11%). When fecal blood tests with navigation were mailed repeatedly, annual fecal blood test completion increased (RR = 2.09; 95% CI, 1.91-2.29; RD = 39%; 95% CI, 29%-49%).
There was no association between patient navigation and colonoscopy completion after an initial abnormal screening test result (RR = 1.21; 95% CI, 0.92-1.60; RD = 14%; 95% CI, 0%-29%).
Combined interventions “can be the foundational tools to meet the national goal of reducing colorectal cancer burden and disparities in the United States,” Dougherty and colleagues concluded. “Future research should move away from pure efficacy trials and toward studies aimed at understanding how best to implement and scale these strategies and the comparative cost-effectiveness of these interventions from various perspectives (those of society and sponsoring organizations).”
In an accompanying editorial, Beverly B. Green, MD, MPH, a physician scientist from Kaiser Permanente Washington Health Research Institute, wrote that the study by Dougherty and colleagues should inform decisions because it clearly shows that outreach with fecal blood tests and patient navigation increase screening rates for colorectal cancer.
“We need research in other areas of the colorectal cancer control continuum, including how best to implement evidence-based strategies and adaptations needed for different settings and populations, how to ensure follow-up after a positive colorectal cancer test result, what interventions increase adherence to ongoing colorectal cancer screening, and ultimately, what association colorectal cancer control programs have with colorectal cancer incidence, mortality, and health equity,” she wrote. – by Alaina Tedesco
Disclosures: Dougherty and Green report no relevant financial disclosures. Please see study for all other authors’ relevant financial disclosures.
Perspective
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There is general agreement that early detection of colorectal cancer leads to cure for the vast majority of patients.
The American Cancer Society updated the recommendation earlier in 2018 for screening colonoscopy to begin by age 45 in the general population, instead of at age 50 as has been the case for decades. This is in part due to rising incidence of colorectal cancer among younger individuals.
It is currently acknowledged that any screening for colorectal cancer is better than no screening, and thus current practice includes in addition to colonoscopy, flexible sigmoidoscopy, various fecal blood tests or CT colonography. Despite the potential benefits of screening for colorectal cancer, unfortunately only 63% of individuals are up to date with screening guidelines and this rate is even lower among minorities and those lacking adequate insurance coverage. The current national goal is 80%.
The authors of the JAMA Internal Medicine paper reviewed the literature to evaluate 73 randomized clinical trials that tested interventions designed to increase colorectal cancer screening rates in the United States. The combination of patient navigation and fecal blood test outreach each of which has been shown to increase screening rates by 20%, among other interventions, was found to be supported by strong clinical evidence for effectiveness.
There needs to be more awareness of the simple yet effective screening intervention approaches that can ultimately reduce the morbidity and mortality from colorectal cancer in the United States.