In JAMA Internal Medicine, researchers published a review of data from 73 randomized clinical trials involving 366,766 patients that tested different ways of increasing screening for colorectal cancer. Three approaches emerged as the most effective.
“We found that there are several interventions that have been very well-studied, and have been shown to be consistently effective at increasing screening rates,” said UNC Lineberger’s Daniel S. Reuland, MD, MPH, professor in the UNC School of Medicine Department of Medicine. “The strongest evidence supports three main types of interventions for increasing screening rates: mailed stool test outreach, patient navigation, and ‘multi-component’ interventions.”
The American Cancer Society estimates that more than 97,000 people will be diagnosed with colorectal cancer in the United States this year, and it will result in approximately 50,600 deaths. Colorectal cancer is the third most common type of cancer in the United States. While screening has proven effective in reducing deaths from this disease, researchers report too few people are getting screened.
Reuland and his colleagues found that of the three approaches that were most effective at boosting screening rates, the mailed outreach using stool tests, which can detect microscopic amounts of blood in the stool, “clearly” increases screening in multiple studies.
Interventions that used patient navigators, or individuals who are trained to assist people through the screening process, also consistently improved screening completion. And lastly, combining different methods, such as using patient education as well as provider education, was more effective than single interventions in isolation.
They also found some efforts to boost screening were effective in certain cases, but not consistently.
“There are several types of interventions that, when used alone, demonstrated benefits in multiple studies, but those benefits were either smaller or less consistent across studies,” said the study’s first author Michael Dougherty, MD, MSCR, a fellow in the UNC School of Medicine Division of Gastroenterology and Hepatology.
A number of these approaches could work in North Carolina, Reuland said, although he pointed to certain barriers to access, such as having many adults without insurance.
The study also revealed certain approaches that didn’t work, such as providing financial incentives for patients to complete screening exams. Financial incentives seemed to have, at most, a “marginal benefit,” Dougherty said.
The next step for the researchers is to find ways to systematically implement and scale the approaches they found to work.
“This will involve work across the state of North Carolina, and beyond,” Reuland said. “Vulnerable populations, such as those served in community health centers, are a particular focus for us.”
Dougherty added that research is needed to identify ways to overcome issues associated with stool-test screening methods, such as how to increase rates of people who go on to get a colonoscopy after getting a positive stool test result.
“The review specifically highlighted a few areas in need of further research,” Dougherty said. “In addition to finding ways to implement and scale these programs, the cost effectiveness of the different strategies remains largely to be determined as well.”
In addition to Dougherty and Reuland, other authors include Alison T. Brenner, PhD, MPH; Seth D. Crockett, MD, MPH; Shivani Gupta, MD; Stephanie B. Wheeler, PhD, MPH; Manny Coker-Schwimmer, MPH; Laura Cubillos, MPH; and Teri Malo, PhD, MPH.
The study was funded by the UNC Lineberger and the University Cancer Research Fund. Individual researchers were also supported by the American Cancer Society, the National Institutes of Health, and the U.S. Centers for Disease Control and Prevention.
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