FBT outreach and patient navigators key to improving CRC screening rates

Last Updated: 2018-10-15

By Megan Brooks

NEW YORK (Reuters Health) - A solid body of evidence now clearly shows that mailed outreach of fecal blood tests (FBTs), patient navigation, and combinations of interventions aimed at patients and providers can increase colorectal cancer (CRC) screening rates, say the authors of a meta-analytic review online today in JAMA Internal Medicine.

"The challenge now will be to find ways to implement this into routine clinical and public health practice. We also need to be sure we have the right payment policies and supports in place so that patients who test positive on an initial stool test have access to affordable colonoscopy," Dr. Daniel Reuland from University of North Carolina, Chapel Hill, told Reuters Health by email.

CRC is the second leading cause of cancer death in the U.S., "but it does not have to be," Dr. Beverly Green from Kaiser Permanente Washington in Seattle writes in a linked editorial.

While CRC screening rates have been steadily increasing, only about two-thirds of eligible adults are up-to-date for CRC screening, which falls short of national goals, Dr. Green notes.

Dr. Reuland and colleagues did a systematic review and meta-analysis of trials testing interventions to boost CRC screening rates. Their main review included 73 randomized controlled trials with nearly 367,000 participants.

FBT outreach (active distribution of FBTs aimed at circumventing structural barriers to screening) and patient navigation (having a trained individual guide a patient through the screening process) were the most frequently studied interventions. FBT outreach had the strongest evidence supporting a significant increase in CRC screening compared with usual care (pooled risk ratio, 2.26; net increase 22%), followed by patient navigation (RR, 2.01; net increase 18%).

"These two interventions each increased screening rates by approximately 20 percentage points. This finding suggests that broad implementation of either of these interventions could bring the current national screening rate of 63% close to the national goal of 80%," write Dr. Reuland and colleagues.

The results also suggest that the net benefit "could be even greater if these interventions were combined with clinician reminders or academic detailing or were implemented as part of multicomponent interventions in general," the researchers say.

"Clinicians, health administrators, and policymakers should consider how to incorporate patient navigation, FBT outreach, and/or clinician prompts into their health care settings and sociocultural contexts, using this review's findings to further support existing tools on implementation of research-tested interventions," they write.

More study is needed, they add, to identify the most effective strategies for retaining individuals in FBT screening programs and follow-up colonoscopy after abnormal FBT results.

Dr. Green says this "ambitious" analysis can and should inform decision makers.

"We can now safely say that, in general, no more studies are needed to demonstrate that outreach with FBT and patient navigation increase CRC screening," she writes in her commentary. "Instead, we need research in other areas of the CRC control continuum, including how best to implement evidence-based strategies and adaptations needed for different settings and populations, how to ensure follow-up after a positive CRC test result, what interventions increase adherence to ongoing CRC screening, and ultimately, what association CRC control programs have with CRC incidence, mortality, and health equity."

The study had no commercial funding and the authors have disclosed no relevant conflicts of interest.

SOURCE: http://bit.ly/2NHUbE5 and http://bit.ly/2NKXzhA

JAMA Intern Med 2018.