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Mailing FIT or gFOBT directly to patients increases uptake of colorectal cancer screening
Clinical Question
Does mailing a fecal occult blood test to patients improve screening rates compared with usual care?
Bottom line
Mailed outreach significantly increases rates of colorectal cancer screening, with a "number needed to mail" of 4 to screen 1 more person. Other countries take this approach, with screening managed by the public health service rather than relying on physician or patient memory and motivation. Health systems in the United States should adopt this approach and insurers should support these efforts. 1a
Reference
Study design: Meta-analysis (randomized controlled trials)
Funding: Self-funded or unfunded
Setting: Population-based
Synopsis
Mailed outreach consists of mailing a test for fecal occult blood to patients and asking them to provide a sample and mail it back. The goal is to improve adherence to colorectal cancer screening, which is currently approximately 62% in the United States, by reducing barriers. This meta-analysis identified US studies that randomized patients to 1 of 4 groups: (1) mailed outreach using a guaiac-based fecal occult blood test (gFOBT), (2) mailed outreach using a fecal immunochemical test (FIT), (3) mailed outreach using a combined FIT/multitarget DNA test, or (4) usual care based on opportunistic office-based screening. After a thorough search the authors identified 7 studies, of which 4 used gFOBT and 3 used FIT; 3 also included a telephone reminder. The studies were judged to be at low (n = 3) or moderate (n = 4) risk of bias. The authors found a 28% absolute increase in screening rates, which did not differ for FIT vs gFOBT or for telephone reminder vs no telephone reminder. Although the authors describe moderate heterogeneity based on the I2 statistic, this is misleading with so few studies; visual inspection of the forest plot actually shows very good homogeneity among studies, with all confidence intervals but one overlapping.
Reviewer
Mark H. Ebell, MD, MS
Professor
University of Georgia
Athens, GA