Mailing free tests to patients’ homes boosts colon cancer screening rates in underserved populations
Colon cancer screening rates increased by nearly 40 percent when free stool tests were mailed to patients’ homes, according to results of a pilot study published in the journal BMC Cancer.
The study, funded by the National Institutes of Health (NIH), included 869 patients who received their health care from community health centers in the Portland, Ore. metropolitan area. The clinics serve many Latino patients who live below the poverty level. About half of them have no health insurance.
“We are very happy that so many of the patients who received the screening kits in the mail actually completed the tests and mailed them back,” said Gloria Coronado, PhD, lead author and senior investigator at the Kaiser Permanente Center for Health Research. “Colon cancer screening rates are low among the general population, but even lower among minorities and those without health insurance. This sets the stage for our larger STOP Colon Cancer study, which aims to increase screening among thousands more patients who receive their care from community health clinics.”
The pilot study was conducted in three clinics operated by Virginia Garcia Memorial Health Center. In the first clinic, 112 patients received an introductory letter written in English and Spanish, and two weeks later they received a stool test. If they hadn’t returned the tests within three weeks, these patients received a reminder postcard. In the second clinic, 101 patients received the introductory letters, the mailed stool tests and reminder postcards, as well as an additional phone call if they hadn’t returned the tests within a month. The third clinic, with 656 patients, served as a control. These patients received no stool test in the mail but may have been given a test during a routine clinic visit.
Only 1 percent of the patients in the control clinic completed a screening stool test, compared to 39 percent who received screening tests in the mail and 37 percent of patients who received the screening tests with the additional phone reminder.
Colorectal cancer is the second leading cause of cancer death in the United States, according to the Centers for Disease Control and Prevention. Yet one in three adults is not adequately screened. A 2012 CDC survey found that 66 percent of non-Latino whites were adequately screened, compared to 53 percent of Latinos and 37 percent of uninsured patients.
“Many patients don’t understand that a simple stool test called FIT, or fecal immunochemical test, can save their lives,” said Tanya Kapka, MD, MPH, co-author and family physician at Virginia Garcia Memorial Health Center. “The FIT test can be done at home, it only takes a few minutes, and, if conducted annually, is effective for determining which patients are most likely to have colon cancer.”
Unlike older stool tests, FIT does not require people to restrict their diets or to stop taking medications. The test detects small amounts of blood in the stool. People who test positive on FIT need a follow-up colonoscopy to look for cancer or pre-cancerous polyps.
Patients who lack health insurance usually have no way to pay for a colonoscopy, so practitioners may be hesitant to recommend the initial screening test. For the pilot study, researchers worked with Project Access Now, a local community organization in Portland, Ore. The program provides specialty medical services to uninsured patients and agreed to provide follow-up colonoscopies to patients who had a positive FIT.
The FIT is recommended annually and is one of several options to detect colon cancer. Other options recommended by The U.S. Preventive Services Task Force include a more invasive test called a sigmoidoscopy, which examines the lower colon and is recommended every five years along with a stool test every three years. A colonoscopy, which examines the entire colon, is recommended every 10 years. People with no specific risks for colon cancer should start screening at age 50, and most people should continue until age 75.
?Researchers have received NIH funding to expand the pilot to 26 federally qualified health centers in Oregon and California. The STOP Colorectal Cancer pragmatic trial will begin in February 2014. “Increasing colon cancer screening among Latinos is a key target in our own health disparities work at Kaiser Permanente,” said Winston Wong, MD, MS, medical director, Kaiser Permanente Community Benefit, and director, Disparities Improvement and ?Quality Initiatives. “This study not only brings attention to the health care inequities faced by minorities and those with limited economic means, but also underscores the importance of partnering with organizations that deliver care to the most vulnerable populations.”
The pilot study was funded by grants from the Health Care Systems Research Collaboratory at the National Institutes of Health (UH2ATOO7782). The Collaboratory ?seeks to strengthen national capacity to implement cost-effective large-scale pragmatic studies that can be implemented in health care systems.
Authors include Gloria D. Coronado, PhD, William M. Vollmer, PhD, Amanda Petrik, MS, Jennifer Sanchez, MA, and Sally Retecki, MBA, of the Kaiser Permanente Center for Health Research; Josue Aguirre and Tran Miers, RN, and Ann Turner, MD, of the Virginia Garcia Memorial Health Center; Tanya Kapka, MD, MPH, of the Kaiser Permanente Center for Health Research and Virginia Garcia; Jennifer DeVoe, MD, DPhil, Jon Puro, MPA, HA, Jennifer Lembach, MUS, and Christine Nelson, RN, PhD, of OCHIN; and Beverly Green, MD, MPH, of Group Health Research Institute.
Kaiser Permanente Research