Direct Mailing Stool Tests Increases Colorectal Cancer Screening Rates in Hard-to-reach Patients

Annually mailing stool kits, an alternative to the often-dreaded colonoscopy, to patients has helped to boost rates of lifesaving screening for colon cancer, according to new research published in Cancer (doi:10.1002/cncr.29734).

The researchers, from Group Health Research Institute in Seattle, Washington, mailed an easy-to-use at-home stool kit to test more than 1,000 patients for signs of cancers of the colon and rectum. This boosted the screening rate from less than 4 in 10, to more than half of these hard-to-reach patients, who had never undergone colonoscopy and were overdue for screening.

"Once again, Group Health is proving that preventive medicine is the best approach to keeping members healthy," said study leader Beverly B. Green, MD, MPH, a family physician at Group Health and an associate investigator at Group Health Research Institute. "By offering patients of average risk a choice of the stool kit or colonoscopy, we keep narrowing the gap to achieve better colorectal cancer screening rates."

The care providers with Group Health discuss the pros and cons of both colonoscopy and stool tests with patients in shared decision making. Screening colonoscopy is done once a decade and can remove polyps if present, but it often requires time off work, along with an unpleasant bowel-clearing preparation the night before. Colonoscopy involves using a flexible scope to visually inspect the inside of the colon; the stool test, however, is less expensive and done quickly at home but should be done every year. If the results indicate blood in the stool, which suggests cancer, a follow-up colonoscopy is still needed.

"Screening has been proven to reduce deaths from colorectal cancer, but only if people are screened regularly, as advised for 50- to 75-year-olds of average risk, but too often not done," Green said. "What matters most is maximizing how many people are screened regularly. The best test is the one that gets done."

Green's team had previously proven the effectiveness and cost-effectiveness of the approach used in the Systems of Support to Increase Colon Cancer Screening and Follow-up (SOS) randomized controlled trial. Over the first 2 years of the 10-year study, colorectal cancer screening rates for Group Health patients who had previously been overdue for screening doubled, while health care costs were significantly lowered. SOS used electronic health records to identify patients who were not screened regularly for colon cancer, to encourage these patients with automated reminders to be screened, and to mail them at-home stool kits. Nurse navigators helped the patients to get needed follow-up care after positive screening tests.

The researchers report that this approach continues to be effective in its third year. Of the more than 1,000 Group Health patients included in the third year of the centralized electronic health record-linked program, 53% were screened for colorectal cancer vs. 37% in those receiving usual care during that year. This difference was entirely due to greater completion of stool tests, rather than colonoscopy, which was also offered as an option.

"Ours is the first randomized controlled trial to test the effectiveness of such a program in a health care setting over 3 years," said Green. This kind of long-term evidence is important for health systems seeking to maintain high screening levels over the long haul.

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