Mailed tests, follow-up calls increase colorectal cancer screening among African Americans
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Mailed stool blood tests and follow-up phone calls are examples of effective strategies that increased colorectal cancer screening among African Americans, according to findings of a systematic review.
Even though colorectal cancer screening and treatment have improved, mortality rates associated with the disease are 47% higher in African-American men and 34% higher in African-American women compared with non-Hispanic whites, according to Siddhartha Roy, MPH, DrPH, assistant professor in the department of family and community medicine at Penn State University.
Although medical organizations like the U.S. Preventive Services Task Force (USPSTF), the American Academy of Family Physicians and the American Cancer Society all recommend stool blood testing for colorectal cancer, 2018 data indicate that the screening rate in the United States is 5.3% behind the Healthy People 2020 target of 70.5%.
“We identified a gap in the current literature regarding the effectiveness of [colorectal cancer] stool blood screening interventions among African Americans,” Roy told Healio Primary Care.
To address that gap, Roy and colleagues reviewed 11 experimental studies that included 4,364 participants — 3,334 of whom were African American. They found that colorectal cancer screening rates from baseline increased:
- 27% after receiving a telephone call;
- 30% after using a decision aid;
- 44% after watching an educational video; and
- 82% after receiving a tailored print intervention and a fecal immunochemical test kit.
The effectiveness of these interventions, measured by ORs, ranged from 1.1 to 13.
“Based on the findings from this systematic review, implementing [colorectal cancer] screening interventions in clinic-based settings may be an effective strategy for increasing screening uptake among African Americans, potentially due to clinical interactions, audit and feedback systems, or other electronic means to remind patients of screening appointments,” Roy said. “Utilizing tailored patient navigation approaches was also found to be effective in increasing screening uptake among African Americans.”
Perspective
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Sherri Sheinfeld Gorin, PhD, FSBM
This recent systematic review of interventions to increase stool blood colorectal cancer screening in African Americans raises some important clinical implications for primary care. The adage that the “best cancer screening test is the one that the patient will complete” is relevant to their findings about the continued uptake of the fecal occult blood test among African Americans.
While colonoscopy remains the gold standard for diagnosis, it is only one of several robust routine screening tests recommended by the USPSTF. However, colonoscopy is often not accessible as first-line screening; it requires bowel preparation, access to in-person specialists and sedation procedures that are not equally distributed across communities; the screening may be expensive and can lead to complications. Also, in-office preventive visits can be markedly reduced (or stopped) during pandemics like COVID-19, and patients may be too afraid of the infection risks to make appointments for care. We have found that, even during the pandemic, patients continued to use home-based colorectal cancer screening tests, however. Home stool tests, including the fecal occult blood test (gFOBT) fecal immunochemical test (FIT) and fecal immunochemical test-DNA (FIT-DNA) should remain first-line screening tests. In under-resourced communities, where completing cancer screening competes with daily challenges of food and housing insecurity, increasing access to colorectal screening by using home-based approaches becomes critical. Further, screening interventions are more effective, particularly in under-resourced communities, when they target barriers at the patient, provider and health system levels.
In my research team’s studies of colorectal cancer screening among racially/ethnically diverse urban residents in under-resourced communities, we have implemented multi-component interventions that educate primary care physicians and their staff, as well as provide audit and feedback on patient screening uptake. Our interventions have increased colorectal cancer screening. As a tailored educational approach to the physicians, we have used academic detailing with brief, tailored, repeated messages that are designed to overcome the barriers to screening uptake. We have worked with offices to alter workflow processes to increase patient screening uptake; for example, through electronic and chart prompts, and mailed reminders to patients. We have helped office staff to develop and share targeted educational materials for patients, as well as to identify gastroenterologists who accept Medicare in the local community, among other intervention components. In addition, patient navigation has been implemented in some of the primary care offices that we have studied.
Prompt diagnosis and follow-up after a positive screen for colorectal cancer is a crucial step in reducing morbidity and mortality, notably among African Americans. While the physicians’ office is a common focus of efforts to reduce diagnostic delay, the patient, too, could be prompted (with an app, for example) for follow-up. Recently, I wrote in Annals of Family Medicine about some important policy approaches, including implementing standards across health care systems to reduce total diagnostic delay to 90 days or less. These approaches, when combined with multi-level physician/provider team and patient-directed interventions to increase screening and follow-up, could begin to reduce the scourge of this largely preventable cancer.
References:
- Shankaran V, et al. J Clinc Oncol. 2009; doi:10.1200/jco.2008.20.6458.
- Sheinfeld Gorin S. Ann Fam Med. 2019;doi:10.1370/afm.2454.
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