Organized Outreach Using Mailed FIT for Colorectal Cancer Screening

In the United States, colorectal cancer is the second-leading cause of cancer-related deaths. Approximately 50,000 people die from colorectal cancer each year. Screening can prevent CRC by identifying polyps for removal before they become cancerous. Screening can also detect CRC at an early stage when treatment is more likely to be successful. The U.S. Preventive Services Task Force recommends regular screening beginning at age 45 and continuing until age 75 using high-sensitivity fecal occult blood test (FOBT), fecal immunochemical test (FIT), sigmoidoscopy, or colonoscopy. Interventions are needed to help increase and sustain CRC screening for eligible patients.

Organized Outreach Using Mailed FIT for Colorectal Cancer Screening is a mail-based intervention designed to promote cost-effective colorectal cancer screening among low-income, primarily minority patients. The program components are as follows:

-- Information postcard: Patients receive a postcard alerting them that a colon cancer screening test will arrive at their home within the month. The postcard also provides information about colon cancer risk and explains how testing can detect colon cancer.

-- Outreach calls: Using a script, a staff member calls patients up to two times to verify receipt of the postcard. If a patient has not received the postcard, the staff checks the accuracy of the mailing address. The staff member asks about current screening status, provides a description of various CRC tests (e.g., colonoscopy, flexible sigmoidoscopy), helps patients overcome barriers to screening, and for eligible patients, informs them that a FIT kit will be mailed to them.

Although the original intervention used outreach calls, the use of communication methods may be tailored. For example, outreach calls may not increase FIT completion among patients who previously have completed a FIT, so calls can be limited to patients who are new to FIT testing. Further, automated messaging via text or patient portals can be used in the place of calls.

-- FIT kit mailing: The patients receive a mailing including a letter with basic information on CRC, the test, a glove, a lab request form, a prepaid envelope, and low-literacy wordless instructions for completing the test.

-- Reminder calls: A staff member identifies patients who have not returned the test and, using a script, calls them up to two times. The staff asks if the patient completed and mailed the test, addresses barriers, answers questions, and provides instructions if needed. If a patient has not received the FIT kit, the staff checks the accuracy of the mailing address.

Some of the program materials are available in Chinese and Spanish.

Time is required to identify eligible patients, establish a relationship with a mail fulfillment vendor, and coordinate patient communications with mailing.

The intervention is intended for low-income minority patients who are not up to date on their CRC screening.

The program is suitable for implementation in home settings.

Required resources to implement the program include the following:
-- Advanced notification postcard
-- Advanced notification call script
-- Wordless instructions for FIT testing
-- Reminder call script
-- FIT Kit

For costs associated with this program, click on Contact Program Developer on the Program Materials page.

A pragmatic randomized controlled trial enrolled patients who were eligible for CRC screening from eight primary care clinics in the San Francisco Health Network (SFHN), a safety net health system providing care to low-income populations. Patients in these clinics were randomly assigned to the intervention (n=5,386) or usual care (n=5,434). Eligible patients were between 50 and 75 years old and past due for CRC screening. Patients who were homeless; previously had an abnormal FIT result but no colonoscopy; or had a colectomy, late-stage cancer, or advanced comorbidities were excluded from the study. Usual care was dependent on individual providers from their respective eight clinics.

Across the eight clinics, approximately 53% were men and 47% were women, 24% were Hispanic, 22% were non-Hispanic Black, 22% were non-Hispanic White, and 19% were Asian. The majority were insured by Medicaid. 

The primary outcome, FIT screening, was captured using electronic health records.

• The rate of FIT completion was higher in the intervention group than in the usual care group (57.9% vs. 37.4%, p<.001).

Additional Findings

• The approximate cost per patient was $23, and the approximate cost per additional patient screened was $112.
• Ethnic minorities had the highest screening participation (i.e., the rate was 69.3% among Asian patients and 65.2% among Hispanic patients).
• Patients who previously completed a FIT were more likely to complete a FIT in the study (70.2% vs. 34.8%; p<.001).