Wednesday, March 29, 2023
| Variable | Group 1, Usual Careb (n = 566) | Group 2, Mailing Alonec (n = 361) | Group 3, Mailing + Outreachd (n = 361) | Total (N = 1,288) |
|---|---|---|---|---|
| Center | ||||
| 1 | 257 (45.4) | 133 (36.8) | 133 (36.8) | 523 (40.6) |
| 2 | 95 (16.8) | 95 (26.3) | 95 (26.3) | 285 (22.1) |
| 3 | 214 (37.8) | 133 (36.8) | 133 (36.8) | 480 (37.3) |
| Age, ye | ||||
| Mean, (standard deviation) | 60.6 (7.0) | 60.8 (6.8) | 59.8 (6.7) | 60.4 (6.9) |
| 50–59 | 284 (50.3) | 170 (47.2) | 194 (53.7) | 648 (50.4) |
| 60–69 | 204 (36.1) | 149 (41.4) | 131 (36.3) | 484 (37.6) |
| 70–75 | 77 (13.6) | 41 (11.4) | 36 (10.0) | 154 (12.0) |
| Women | 291 (51.4) | 179 (49.6) | 200 (55.4) | 670 (52.0) |
Table. Colorectal Cancer Screening Interventions in 3 Tribally Operated Health Care Centers Using the Fecal Immunochemical Test (FIT), 3 Intervention Groups, April–November 2014a
a Values are number (percentage) unless otherwise indicated.
bNo outreach apart from provider screening advice given during clinic visits.
c Mailing FIT kit with instructions for use.
d Mailing FIT kit with instructions for use. If no response, follow-up telephone call after 4 weeks, follow-up home visit after 8 weeks, and telephone call after 12
weeks.
e Values for 3 groups may not equal totals because some participants did not provide age.
This activity is intended for primary care physicians, gastroenterologists, and other physicians who care for patients at risk for CRC.
The goal of this activity is to evaluate the efficacy of mailed FIT test kits, with or without interventions from community health representatives (CHRs).
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Screening rates for colorectal cancer are low in many American Indian and Alaska Native (AI/AN) communities. Direct mailing of a fecal immunochemical test (FIT) kit can address patient and structural barriers to screening. Our objective was to determine if such an evidence-based intervention could increase colorectal cancer screening among AI/AN populations.
We recruited study participants from 3 tribally operated health care facilities and randomly assigned them to 1 of 3 study groups: 1) usual care, 2) mailing of FIT kits, and 3) mailing of FIT kits plus follow-up outreach by telephone and/or home visit from an American Indian Community Health Representative (CHR).
Among participants who received usual care, 6.4% returned completed FIT kits. Among participants who were mailed FIT kits without outreach, 16.9% returned the kits — a significant increase over usual care (P < .01). Among participants who received mailed FIT kits plus CHR outreach, 18.8% returned kits, which was also a significant increase over usual care (P < .01) but not a significant increase compared with the mailed FIT kit–only group (P = .44). Of 165 participants who returned FIT kits during the study, 39 (23.6%) had a positive result and were referred for colonoscopy of which 23 (59.0%) completed the colonoscopy. Twelve participants who completed a colonoscopy had polyps, and 1 was diagnosed with colorectal cancer.
Direct mailing of FIT kits to eligible community members may be a useful, population-based strategy to increase colorectal cancer screening among AI/AN people.
Colorectal cancer (CRC) is the second leading cause of death from cancer among American Indian and Alaska Native (AI/AN) men and third among AI/AN women [1]. Although screening has been shown to reduce death rates, the percentage of people up to date with CRC screening is low in many AI/AN communities. Less than half (48.4%) of AI/AN adults aged 50 to 75 were up to date with CRC screening in 2015 [2].
The US Preventive Services Task Force (USPSTF) recommends stool-based tests and direct visualization tests (colonoscopy, flexible sigmoidoscopy, or virtual colonoscopy) for CRC screening. [3]. In health care systems with limited capacity to provide direct-visualization screening tests, stool-based tests such as high-sensitivity, guaiac-based fecal occult blood tests (FOBT) and fecal immunochemical tests (FIT) are often the most accessible options for CRC screening. However, various patient and structural barriers exist to completing FOBT and FIT: geographic isolation, lack of a regular health care provider, failure of providers to recommend screening, lack of clinical tracking and reminder systems, lack of transportation, embarrassment, privacy concerns, distrust of the health care system, and insufficient knowledge about CRC, its risk factors, and screening recommendations [4]. Many of these barriers can be mitigated. According to the Community Preventive Services Task Force, there is sufficient evidence that using patient reminders and small media (eg, letters, pamphlets, brochures, flyers) can increase CRC screening with stool tests [5]. Reducing structural barriers (eg, eliminating or simplifying administrative procedures required for CRC screening, reducing time or distance for screening services) is also an effective way to increase the use of stool tests [6]. Direct mailing of FOBT or FIT is an approach that can address both patient and structural barriers. Mailing FOBT or FIT kits to patients and providing outreach through telephone calls and home visits can reduce patient and structural barriers, and both have been shown to be effective strategies to improve participation in CRC screening in various underserved populations [7–10]. The objective of our study was to determine if such evidence-based interventions could also lead to increased CRC screening among rural AI/AN populations.
