Outreach doubles colon cancer screening in low-income communities

In low-income and minority communities where colonoscopies may be prohibitively expensive for many residents, less-invasive, more frequent testing combined with automated reminders, can yield dramatic improvements in colorectal cancer (CRC) screening rates, according to a new Northwestern Medicine study.

The study found that community health center patients who received follow-up -– that is, outreach by mail, automated telephone and text messages, and calls by a health center staff member if no response was given in three months—were more than twice as likely to complete an at-home colon cancer screening test. This was true even though most patients in the study were poor, uninsured, had limited English proficiency and a low understanding of health information.

The study will be published in JAMA Internal Medicine June 16.

"With electronic health records, we can set up inexpensive systems to remind patients to do annual home colon cancer screening tests and achieve a very high success rate," said the study's author David Baker, M.D. "We can achieve success even for patients with multiple financial, literacy and cultural barriers to CRC screening."

Baker is chief of internal medicine and geriatrics and the Michael A. Gertz Professor of Medicine at Northwestern University Feinberg School of Medicine. He also is a physician at Northwestern Memorial Hospital.

CRC is the third most common cancer for both men and women and the second-leading cancer killer in the United States. Screening and early treatment can be extremely successful in preventing CRC deaths; approximately 90 percent of people with CRC that is found early and treated appropriately are still alive five years later.

In the U.S., the majority of CRC screening is done by colonoscopy, even though the procedure is expensive and invasive, and several safe and effective recommended alternatives exist. In this study, Baker's team used fecal occult blood testing (FOBT), which can be completed at home with a single stool sample. FOBT must be conducted annually to catch before it is too advanced to cure.

Prior to the study, it was not known whether patients would adhere to an annual at-home testing schedule for CRC.

Baker and his colleagues identified 450 patients who received their care through a network of community health centers in Chicago. The overwhelming majority of the patients studied were uninsured Latino women and all had had a negative result with a previous at-home FOBT.

Patients were divided into two groups, a usual care group and an intervention group. Usual care included computerized reminders, standing orders to give patients home tests and provider feedback. The intervention group received usual care plus the following: a mailed reminder letter; a free home test with low-literacy instructions and a postage-paid return envelope; automated phone and text messages reminding them that a home test was being mailed to them and they were due for screening; automated phone and text reminders two weeks later for those who did not return the home test; and personal outreach from a trained professional after three months if a test was not completed.

The researchers found that the intervention was very successful, with 82.2 percent of the patients in the completing the FOBT within six months of the screening due date compared to 37.3 percent of the in the usual care group.

"This intervention greatly increased adherence to annual ," Baker said. "It is possible to improve annual screening for vulnerable populations with relatively low-cost strategies, and we know that earlier detection of cancer through screening will save lives."

The next step in this work is for Baker's team is to work with community health centers that want to implement similar outreach programs to improve CRC rates. Baker noted that he has already spoken to health centers in the Midwest and Pacific Northwest, and has provided them with materials.

More information: JAMA Intern Med. Published online June 16, 2014. doi:10.1001/jamainternmed.2014.2352
JAMA Intern Med. Published online June 16, 2014. doi:10.1001/jamainternmed.2014.730

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