Mailed Outreach Is Superior to Usual Care Alone for Colorectal Cancer Screening in the USA: A Systematic Review and Meta-analysis

Abstract

Background: Mailed outreach promoting colorectal cancer (CRC) screening with a stool blood test kit may increase participation, but magnitude and consistency of benefit of this intervention strategy is uncertain. Aim: Conduct a systematic review and meta-analysis of randomized controlled trials (RCTs) comparing mailed outreach offering stool tests to usual care, clinic-based screening offers on CRC screening uptake in the United States. Methods: We performed a systematic literature search of 5 databases for RCTs of mailed outreach January 1980 through June 2017. Primary outcome was screening completion, summarized using random-effects meta-analysis as pooled differences in proportion completing screening and relative risk of achieving screening compared to control. Subgroup analyses by test type offered-fecal immunochemical test (FIT) or guaiac fecal occult blood test (gFOBT)-, presence of telephone reminders, and presence of predominant underserved/minority population within study were performed. Quality of evidence was evaluated using the GRADE framework. Results: 7 RCTs which enrolled 12,501 subjects were included (n=5,703 assigned mailed outreach and n=6,798 usual care). Mailed outreach resulted in a 28% absolute (95%CI: 25-30%; I2=47%), and a 2.8-fold relative (RR 2.65, 95%CI: 2.03-3.45; I2=92%) increase in screening completion compared to usual care, with a number needed to invite of 3.6. Similar outcomes were observed across subgroups. Overall body of evidence was moderate quality. Conclusions: Mailed outreach offering a gFOBT or FIT is associated with a large and consistent increase in CRC screening completion and should be considered for more widespread implementation for improving screening rates nationwide.

Low Rates of Colonoscopy Follow-up After a Positive Fecal Immunochemical Test in a Medicaid Health Plan Delivered Mailed Colorectal Cancer Screening Program

“…Multivariate Model for Colonoscopy Completion within 1 Year After FIT Return With a Positive FIT (N = 164) 1,2. …”

Physician‐office vs home uptake of colorectal cancer screening using FOBT/FIT among screening‐eligible US adults

“…Therefore, current gaps in the uptake of CRC screening could be addressed by using FOBT/FIT in widespread public health programs. Some population‐based interventions have found FOBT/FIT to be particularly effective in boosting CRC screening uptake when kits are mailed to homes along with instructions and educational packages . Similarly, a systematic review revealed that outreach interventions including those utilizing mailed FOBT kits improved CRC screening in Canada, and several European countries .…”

“…15 be particularly effective in boosting CRC screening uptake when kits are mailed to homes along with instructions and educational packages. 46,48,51 Similarly, a systematic review revealed that outreach interventions including those utilizing mailed FOBT kits improved CRC screening in Canada, and several European countries. 52 This initiative should be tested for potential scalability at the national level.…”

Racial and Ethnic Disparities in Colorectal Cancer Screening Pose Persistent Challenges to Health Equity

“…Evidence-based strategies for improving screening include mailed outreach offering fecal immunochemical test, offering more than just 1 screening option, culturally tailored patient navigation, 1-on-1 education, and patient and clinician reminders, with many having been tested in racial/ethnic minority groups. [10][11][12][13][14][15][16][17][18][19] These interventions seem to be most successful when implemented as multiple, rather than single components. 20 Revisiting the findings of May et al 4 emphasizes that the commitment to investing in interventions to achieve health equity in CRC screening will need to be robust (Figure 1).…”