Mailed FIT screening for CRC effective, cost-effective in safety-net population

Patients at a federally qualified health center system in Central Texas who were not up to date on colorectal cancer (CRC) screening were mailed a packet containing an introductory letter, a fecal immunochemical test (FIT), easy-to-read instructions, and a postage-paid lab mailer.


Mailed fecal immunochemical testing (FIT) for colorectal cancer (CRC) appears cost-effective and may improve screening rates in vulnerable patients, according to a recent study.

Researchers performed a single-group intervention and economic analysis to examine the effectiveness and cost-effectiveness of the first cycle of a mailed FIT program at a federally qualified health center system in Central Texas from November 2017 to July 2019. Patients were eligible for the intervention if they were ages 50 to 75 years, had been recently seen in a system practice, and were not up to date on screening. Those who had a documented personal history of CRC were excluded.

Study participants were mailed a packet containing an introductory letter in plain language, the FIT, easy-to-read instructions, and a postage-paid lab mailer. Materials were provided in both English and Spanish. Participants were also notified that the FIT and any subsequent colonoscopy would be provided free of charge to those without insurance. Those who did not complete the FIT received a text-message reminder after two and a half weeks and a reminder letter by mail after five weeks, unless they had opted out of further contact or had declined to receive text messages.

The study's main outcome measures were screening effectiveness, based on completion of mailed FIT, and cost-effectiveness, defined as cost per person screened, including costs from the perspective of a third-party payer in 2019 U.S. dollars and direct costs based on costs of materials and labor valued at the wage rate. Patients with negative FIT results were informed in writing, those with positive results received a phone call and a letter recommending they schedule colonoscopy with the assistance of a bilingual patient navigator, those with polyps identified and removed on colonoscopy were entered into a surveillance database for future follow-up, and those with CRC were referred for treatment. The study results were published April 30 by the Journal of General Internal Medicine.

A total of 22,838 eligible patients received program materials. The mean age was 59.0 years, 51.5% were women, 43.9% were Latino, and nearly half had no traditional private or government health insurance. Overall, 19.2% of patients (4,395 of 22,838) successfully completed FIT, at an average direct cost of $5,275.70 per 500-patient mailing. When completed tests from the mailed intervention were assumed to represent incremental screening, the direct cost per patient screened was $54.83 versus no intervention. When start-up costs and indirect costs were included, total costs increased to $7,014.45 and cost per patient screened increased to $72.90. When the researchers assumed screening rates of 2.5% and 5% with no intervention, the direct and total costs per patient screened were $60.03 and $80.80 and $67.05 and $91.47, respectively.

The researchers noted that their study had no control group and that the results may not be generalizable to other populations. They concluded that mailed FIT is an effective and cost-effective population health strategy for CRC screening in vulnerable patients. “Assuming that most of the FIT screening represents new screening, it also offers the opportunity to reduce CRC-related morbidity and mortality and thus improve health equity,” the authors wrote. “We plan to expand and implement a similar program in other nearby health systems, including ones with more rural coverage.”