Mailing fecal immunochemical tests to patients due for colorectal cancer screening increased screening uptake

Compared with usual care clinics, intervention clinics had a significantly higher adjusted clinic-level proportion of participants who completed a mailed fecal immunochemical test and more participants who completed any colorectal cancer screening.


A mailed fecal immunochemical test (FIT) outreach program significantly increased the number of patients who completed colorectal cancer screening compared with usual care, a cluster randomized trial found.

Researchers randomized 26 federally qualified health center clinics in Oregon and California to implement the outreach program (n=13; 21,134 patients) or provide care as usual (n=13; 20,059 patients). Participants (55.8% women) were 58.5 years old on average and were overdue for colorectal cancer screening between an accrual period of Feb. 4, 2014, to Feb. 3, 2015.

The study used tools embedded in the electronic health record to identify eligible adults, and the intervention included an introductory letter, a mailed FIT, and a reminder letter. Intervention clinics also received training in the use of these tools, a collaborative environment for continued learning, and a standardized practice improvement process.

The primary outcome was the clinic-level proportion of participants who completed FIT or, secondarily, any colorectal cancer screening within 12 months of accrual or through Aug. 3, 2015 (when clinics in the usual care group received access to study tools). Results were published online on Aug. 6 by JAMA Internal Medicine.

Compared with usual care clinics, intervention clinics had a significantly higher adjusted clinic-level proportion of participants who completed a FIT (13.9% vs. 10.4%; difference, 3.4 percentage points [95% CI, 0.1 to 6.8 percentage points]). In addition, more participants at intervention clinics than usual care clinics completed any colorectal cancer screening (18.3% vs. 14.5%; difference, 3.8 percentage points [95% CI, 0.6 to 7.0 percentage points]).

There were variations across clinics in effectiveness (FIT completion differences range, −7.4 percentage points to 17.6 percentage points) and implementation (proportion who were mailed a FIT range, 6.5% to 68.2%). The overall FIT return rate was 21% among participants who were mailed a test (1,304 of 6,308 participants). The number needed to mail to achieve one completed FIT was 4.8 overall and 4.0 in clinics that mailed a FIT reminder.

A limitation of the study was the fact that some clinics were unable to process completed FIT samples that were missing collection dates, potentially leading to underreporting, the study authors noted. Regarding the secondary outcome of any colorectal cancer screening, they added that colonoscopy is subject to under-capture in primary care records and that they could not distinguish between screening and diagnostic colonoscopy. Finally, Medicaid expansion and other external factors may have influenced FIT completion rates in usual care clinics during the study period, potentially diluting the impact of the intervention, the authors said.

Rates of colorectal cancer screening are low, particularly among the underserved, and fecal-based screening options are as effective as colonoscopy but more convenient for patients, according to an accompanying editor's note. “The success of this intervention should encourage health centers to engage clinicians and patients to increase [colorectal cancer] screening efforts,” the journal editor wrote.