Two new studies support the use of mailed fecal immunochemical colorectal cancer screening kits with follow-up to improve colorectal cancer screening. Mailing at-home FIT screening kits and providing coordinated follow-up tripled screening completion rates compared with usual care at federally qualified health centers in one study, and mailed FIT with patient navigation increased screening rates in a Medicaid population in another.

Although researchers have known that this kind of intervention is effective in large, integrated health systems, the FQHC study is the first to show it works in that setting, which involves small, grant-funded entities that often lack resources and serve as safety-net care providers (JAMA Netw Open 2024;7[11]:e2446693).

Centralized Outreach With FIT Is Efficient and Effective

“Centralized mailed [fecal immunochemical testing] outreach combined with patient navigation to facilitate colonoscopy completion for those with positive FIT is an efficient and effective way to help federally qualified health centers increase their colorectal cancer screening rates,” said investigator Daniel S. Reuland, MD, MPH, the director of the Carolina Cancer Screening Initiative (CCSI) Intervention and Implementation Research Program at the UNC Lineberger Comprehensive Cancer Center, in Chapel Hill.

The study, called SCORE (Scaling Colorectal Cancer Screening through Outreach, Referral, and Engagement), was conducted in partnership with two FQHCs in North Carolina and included 4,002 people between the ages of 50 and 75 years who had an average CRC risk and were not current with recommended screening guidelines. Half of the participants received usual care, and the other half received the FIT test intervention in addition to usual care.

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The CCSI outreach team mailed the free, at-home FIT kits, coordinated result tracking and followed up on positive FIT results. Those in the intervention arm also were provided with navigation services for follow-up colonoscopies if their FIT was positive. In collaboration with the FQHC staff, the patient navigator ensured that the information was entered into electronic health records and communicated with the patient’s primary care providers.

The investigators sought to determine how many individuals would complete a CRC screening within six months and how many would undergo a colonoscopy within six months after a positive FIT result.

Intervention Increased Screening

They found that individuals in the intervention group were three times more likely to be screened for CRC within six months compared with the usual care group (30% vs. 9.7%). By 12 months, screening completion rates increased to 34.6% in the intervention group and 16.6% in the control group.

Those in the intervention group who had a positive FIT result had a higher follow-up colonoscopy rate than the usual care group (68.8% vs. 44.4%), with advanced colorectal neoplasia detected in 29 intervention participants (1.4%) and 15 control participants (0.7%).

The investigators noted that the intervention was effective regardless of insurance type.

“The study shows we can use population outreach strategies to augment visit-based care and increase CRC screening completion,” Dr. Reuland said. It also demonstrated that FIT outreach paired with patient navigation is an effective and likely scalable way to help patients with a positive FIT test complete a follow-up colonoscopy in this context, he noted. “The combined intervention not only led to greater overall screening completion compared to usual care alone, but it also [resulted in] improved detection of advanced neoplasia.”

Benefit in Medicaid Population

In a second recent study (JAMA Netw Open 2025;8[3]:e250928), researchers showed that a mailed FIT outreach with patient navigation increased screening rates in a Medicaid population. “We conducted this study because we knew that colorectal cancer screening rates were low in rural populations and in populations enrolled in Medicaid,” said lead study author Gloria Coronado, PhD, a professor of epidemiology in the University of Arizona’s College of Public Health, in Tucson.

In their study, Dr. Coronado and her co-investigators worked with rural Medicaid health plans (called coordinated care organizations in Oregon), and their affiliated primary care clinics. They identified 28 clinics; 14 were allocated to the intervention and 14 were allocated to receive usual care. For intervention clinics, the health plans generated lists of enrollees who were due for colorectal cancer screening. Clinic staff then reviewed the lists, removing any patient who was ineligible for screening or who hadn’t established care.

The health plans then contracted with vendors to mail FITs to patients who were due. The health plans and clinics then sent follow-up reminders to patients via text message or phone. Patients with an abnormal FIT result were navigated to receive a follow-up colonoscopy. The study included 5,614 Medicaid enrollees (2,613 in intervention clinics and 3,001 in usual care clinics).

The researchers found that the mailed FIT outreach and patient navigation program led to a 7.3% increase in colorectal cancer screening over usual care.

“Our program reached many first-time screeners, laying the foundation for a habit of routine screening,” said Dr. Coronado. “Our partnership among Medicaid health plans, clinics and direct-mail vendors could substantially increase screening for a leading cause of cancer death in the United States.”

Evangelos Messaris, MD, PhD, the chief of the Division of Colon and Rectal Surgery at Beth Israel Deaconess Medical Center, in Boston, who was not involved with either study, underscored the benefits of such programs. They create “the potential to reduce colorectal cancer death rates because increased screening leads to earlier detection of polyps and cancer, improving survival rates.”

Suggesting that an expanded centralized screening approach could potentially improve national screening rates, such as [is done] in Europe, where countries use these types of tests to increase national screening rates for CRC, he said, “governments, health organizations and policymakers should consider funding and implementing mailed FIT programs in primary care and public health settings.”

However, Dr. Messaris pointed to an area that still needs to be addressed. “While patient navigation improves colonoscopy completion, nearly one-third of FIT-positive patients still do not get follow-up [colonoscopy].”

—Kate O’Rourke

Drs. Messaris and Reuland reported no relevant financial disclosures.

This article is from the May 2025 print issue.