A mailed fecal immunochemical test for colorectal cancer screening, unrequested by the recipient, proved the best way to entice adults 45 to 49 years of age to undergo CRC screening, researchers from UCLA determined.
In a randomized trial of 20,509 adults aimed to evaluate the best means of boosting CRC screening among this age group, which became eligible for screening in 2021 under guidelines set by the U.S. Preventive Services Task Force. Of the four strategies tested, the option found to be most acceptable was automatically being mailed a stool-based screening test, with no choice to “opt in” or “opt out.” This option resulted in the highest screening rates (JAMA 2025;334[9]:778-787).
“There has been an urgent need for evidence on how to reach adults in their 40s with effective, scalable screening strategies. We found that removing the need for patients to actively opt into screening can lead to better outcomes, especially when we are trying to engage generally healthy young adults who probably are not perceiving themselves at risk for cancer,” said senior investigator Folasade May, MD, an associate professor of medicine at the David Geffen School of Medicine at UCLA, in Los Angeles.
Potential Strategies
The team tested four different outreach strategies by sending information through UCLA Health’s electronic patient portal to 20,509 patients at average risk for CRC. The first three groups were asked whether they would opt into screening by either receiving a mailed FIT kit, undergoing a colonoscopy, or choosing between FIT and colonoscopy, respectively. The fourth group was simply mailed the FIT kit without being asked to opt in.
The researchers found that participants who were asked to actively opt into screening had lower overall screening rates. Screening rates were 16.4% for those opting into FIT testing, 14.5% for those opting into colonoscopy, 17.4% for those allowed to choose a screening method, and 26.2% for those who were automatically mailed an FIT kit (P<0.001 for all). Among the group of 5,125 patients who chose their screening method, 12% selected colonoscopy and 5.4% opted for FIT (P<0.001).
The researchers also reported that 73% of patients with abnormal FIT results followed up with a colonoscopy within six months, an encouraging compliance rate, according to Dr. May.
Although Dr. May acknowledged that the overall screening rates were still low, she pointed to automatically mailed FIT as an “efficient” approach to screening that “gets results quickly” and potentially helps close critical gaps in care. “More than 3,800 people were screened in just six months with minimal work required.”
‘Tailored Strategies’ May Be a Good Idea
Thomas Imperiale, MD, the Lawrence Lumeng Professor of Gastroenterology and Hepatology at Indiana University School of Medicine, in Indianapolis, commended the authors “for doing such a large, pragmatic, and internally valid study on an important topic.”
“The findings suggest that persons 45 to 49 years old are more likely to do what is easiest and most convenient,” Dr. Imperiale told Gastroenterology & Endoscopy News. “The low overall uptake of any screening strategy, however, reminds us that this is a busy age group, with most members raising a family, perhaps caring for aging parents, working full or part time, and mostly healthy, which may keep them from requiring, seeking, or complying with a regular source of healthcare.”
The generalizability of the results to other populations and other noninvasive tests, as well as to other settings and healthcare systems, is uncertain, he said, adding, “It may be that this age group requires tailored strategies based on whether and how frequently they use the healthcare system.”
—Caroline Helwick
The first authors of the study were Artin Galoosian, MD, a former fellow in the Vatche and Tamar Manoukian Division of Digestive Diseases at the David Geffen School of Medicine at UCLA, now an assistant professor at the University of Southern California, and Hengchen Dai, PhD, an associate professor of management and organizations at the UCLA Anderson School of Management.
Dr. Imperiale reported a financial relationship with Exact Sciences. Dr. May reported financial relationships with Exact Sciences, Geneoscopy, Medtronic, and Natera.
This article is from the November 2025 print issue.