In adults aged 45 to 49 y, active screening choices via patient portal reduced screening rates vs. mailed FIT at 6 mo
The finding that trial participants preferred mailed fecal immunochemical testing (FIT) to active choice of colonoscopy or FIT suggests that those in this age group are more likely to accept screening when it is easy and convenient and could benefit from a menu of targeted interventions, an ACP Journal Club commentary said.
In a randomized clinical trial of 20,509 participants in California, researchers tested four colorectal cancer (CRC) screening strategies: active choice of fecal immunochemical test (FIT) only, active choice of colonoscopy only, active choice of FIT or colonoscopy, and usual care (mailed FIT outreach). The three strategies that required active choice through the patient portal were significantly less effective than the default strategy of unsolicited mailed FIT outreach, with completion rates of 16.4%, 14.5%, and 17.4% versus 26.2%, respectively.
The trial results were published Aug. 4 by JAMA and summarized in the August ACP Gastroenterology Monthly. The following commentary, by Thomas F. Imperiale, MD, FACP, was published in the ACP Journal Club section of Annals of Internal Medicine on Nov. 4.
Due to the rise in incidence of CRC in persons aged <50 years, comparable prevalence of advanced precancerous polyps between ages 45 to 49 and 50 to 54 years, and simulation models showing cost-effectiveness of screening, the American Cancer Society and the U.S. Preventive Services Task Force currently recommend screening for CRC for persons ≥45 years of age. In the USA, half of CRC cases in persons aged <50 years occur in those aged 45 to 49 years but only 37% of this age group is current with screening.
The trial by Galoosian and colleagues showed that a mailed FIT increased screening within 6 months more than any of 3 portal-based, active choice strategies. This FIT strategy is well-established in persons ≥50 years, with an effect on screening uptake similar to that of the current trial. The 3 portal-based strategies performed similarly and were inferior to mailed FIT despite endorsement by primary care providers and text reminders.
The trial has a high degree of internal validity, but its generalizability to other patient populations, other noninvasive tests, and different health care settings and systems is less certain. Nonetheless, the findings suggest that persons aged 45 to 49 years are more likely to accept screening when the intervention is easy and convenient, although most persons remained unscreened. This challenging age group may be balancing responsibilities of caring for children and aging parents and working; are likely relatively healthy; and may not seek, require, or adhere to regular medical care.
What may be best suited to this age group—for CRC screening and preventive services in general—is a menu of interventions targeted to how individuals use the health care system (e.g., which providers, how often, and with what degree of adherence). Patient-specific electronic health record–generated reminders about recommended preventive services could be sent to providers and discussed with patients who use the health care system, with face-to-face provider endorsement. Less frequent users or nonusers may require a stepped intervention with reminders by mail, text, or e-mail. Such interventions could be followed up by prevention navigators or coaches with the goal of bundling and facilitating access to other preventive services, such as vaccines and cancer screening, optimizing uptake and efficiency based on patient need and preference.