CHICAGO—A study of more than 20,000 average-risk adults has shed some light on the best way to offer colorectal cancer screening to 45- to 49-year- olds—an age group that is new to the screening guidelines.
A randomized study conducted at UCLA Health, in Los Angeles, evaluated four screening approaches and found that screening completion was highest among adults who were mailed an unsolicited fecal immunochemical test.
“A mailed FIT kit resulted in higher screening participation than offering a choice between FIT and colonoscopy, offering FIT alone or offering colonoscopy alone,” said investigator Artin Galoosian, MD, MA, a first-year gastroenterology fellow at Loma Linda University, in California.
The increasing rates of CRC in people younger than 50 years make identifying the most effective screening approach in this age group crucial, and formal guidance on the topic is lacking. The study addresses this unmet need, Dr. Galoosian noted.
“It tackles the important question of how best to screen patients within a health system who are now newly eligible for screening,” he said. “We found that a routine mailed FIT outreach program similar to what we currently use for patients over age 50 may be sufficient.”
Large Group of Young Adults
The study, which Dr. Galoosian reported as a late-breaking abstract at the Digestive Disease Week 2023 (abstract 913d), was conducted with 20,509 adults 45 to 49 years of age within UCLA Health, a large, diverse and urban integrated healthcare system. Most patients identified themselves as non-Hispanic White (50.8%), followed by other race/ethnicity (17.9%), non-Hispanic Asian (13.7%), Hispanic (13.4%) and non-Hispanic Black (4.2%). All patients were at average risk for CRC, had not undergone previous CRC screening, had been assigned to a primary care provider within the UCLA network and had active electronic patient portals.
The patients were randomized to one of four screening strategies: 1) FIT invitation (option to request a mailed FIT); 2) colonoscopy invitation (option to request colonoscopy); 3) choice between FIT and colonoscopy; or 4) mailed FIT outreach (the standard of care), which is the protocol for UCLA Health patients who are overdue for screening (Figure 1). In addition, for both arms that offered FIT, patients were informed they could pursue colonoscopy screening instead.
“These messages were carefully designed in partnership with our colleagues at the UCLA Anderson School of Management and Carnegie Mellon University’s Department of Social and Decision Sciences to incorporate principles of behavioral economics that would ensure a limited potential for biases,” Dr. Galoosian said.
All invitations were sent to patients via the UCLA Health electronic patient portal and USPS mail. They were followed with two text message reminders within the next month. For patients who agreed to colonoscopy (by invitation or choice), the colonoscopy order also was sent to their primary care provider, who could sign it or decline. Patients in the mailed FIT outreach group were sent a FIT kit in the initial mailing. Those who agreed to FIT (by invitation or choice) were mailed the FIT kit as requested. The primary outcome was completion of any CRC screening at 26 weeks.
Mailed FIT Comes Out on Top
The overall screening completion rate was 18.6%. Screening completion was significantly higher in the mailed FIT outreach group than in the other three groups, in which patients were required to opt in to a screening modality or choose between screening modalities (Figure 2).
Although the patients mailed the FIT kit had the highest screening completion rate, the results also showed that choice was important to patients, with those able to choose between FIT and colonoscopy being significantly more likely to complete screening of any kind than patients offered one modality or the other. Within the choice group, 12.1% asked for colonoscopy and only 5.6% asked for FIT (P<0.01).
Another notable finding was that about 10% of patients in both the FIT invitation and mailed FIT outreach groups ultimately converted to colonoscopy for screening.
Acknowledging some limitations of the study, Dr. Galoosian said the results were based on the diverse yet largely middle-class/affluent Southern California population and thus may not be widely generalizable. The study also relied heavily on communication via the electronic patient portal and data from the electronic health record. In addition, he said the post-pandemic backlog of colonoscopy cases hindered timely colonoscopy scheduling.
Despite these limitations, Dr. Galoosian said the study “highlights the effectiveness of multilevel and multicomponent interventions to increase participation in CRC screening. … We learned that patient engagement impacts screening.”
Folasade P. May, MD, PhD, MPhil, the director of UCLA’s Melvin and Bren Simon Gastroenterology Quality Improvement Program and the study’s senior author, said, “The study also highlights that interventions pushed to patients through the health system can off-load busy primary care providers and increase screening participation in a relatively short period of time.”
Study Results Called Encouraging
David Lieberman, MD, a professor of medicine and the head of the Division of Gastroenterology and Hepatology at Oregon Health & Science University, in Portland, found the 26% screening completion rate to be quite encouraging, “especially for this age group, who generally are not even thinking about colon cancer and screening.”
Dr. Lieberman told Gastroenterology & Endoscopy News that he would still prefer to offer patients a choice of modalities, even though that was not the approach with the highest completion rate in the study.
“I think the study demonstrates that you can get people in this age group interested in screening, and you can get the information to them through the electronic system [patient portal],” Dr. Lieberman said. Whether the U.S. healthcare system has the “capacity” to offer colonoscopy to an additional 18 million or so young adults remains to be seen, he added, noting that while CRC risk is rising in young adults, it is still relatively low.
—Caroline Helwick
Dr. Galoosian conducted this research as a GI quality improvement fellow at UCLA’s Melvin and Bren Simon Gastroenterology Quality Improvement Program. Drs. Galoosian and May reported no relevant financial disclosures. Dr. Lieberman reported financial relationships with ByHeart, Geneoscopy, Perrigo, Physiologic, Sanofi Pinnacle and Reckitt Mead-Johnson.
This article is from the June 2023 print issue.