BIRMINGHAM, ALA. – Determining whether patients prefer colonoscopy or a stool sample blood test for colorectal cancer screening, and then providing support for completing the preferred method, could increase screening rates and reduce racial disparities in screening, according to findings from two randomized, controlled trials.
Such “tailored navigation” was superior to a standard intervention in the first of the two trials, which compared these approaches with usual care in general-population primary care patients from 10 practices. The patients were considered nonadherent, because they had not undergone colorectal cancer screening.
Screening adherence at 6 months was highest at 38% in 312 patients randomized to the tailored navigation intervention, compared with 33% in 316 patients randomized to receive the standard intervention. Adherence was only 12% among 317 patients in the usual care control group, Ronald E. Myers, Ph.D., of Thomas Jefferson University, Philadelphia, said at the annual meeting of the American Society of Preventive Oncology.
That study, by Dr. Myers and his colleagues, was published in 2013 (Cancer Epidemiol. Biomarkers Prev. 2013;22:109-17).
Patients in the tailored navigation group were sent either colonoscopy instructions or stool blood tests, depending on their reported test preference at baseline. If they had no preference, they received both. All patients in that group also received a mailed reminder and a navigation call to help encourage test use.
The standard intervention group was sent both colonoscopy instructions and stool blood tests, as well as a mailed reminder.
A total of 42% of patients had no preference regarding type of screening test, 39% preferred colonoscopy, and 19% preferred stool testing. “That may be a surprise, but their primary care physicians are not pushing stool blood testing,” Dr. Myers said. “They are pushing and promoting colonoscopy.”
The difference in screening adherence was significant for both the tailored intervention and standard intervention groups, compared with the control group, but was not significant between the two intervention groups.
A secondary analysis showed that mailing the colonoscopy instructions and blood test had a substantial effect on overall screening, and that the navigation calls also had an effect on overall screening and on colonoscopy.
Patients who were mailed only the colonoscopy instructions were much less likely to do stool blood testing – largely because it wasn’t being offered in their primary care practice. However, those who received both colonoscopy instructions and a stool blood test were much more likely to do stool blood testing.
In a similar study involving only noncompliant African American primary care patients, Dr. Myers and his colleagues found that adherence at 6 months was significantly greater in 384 patients randomized to tailored navigation than in 380 patients who were randomized to the standard intervention (odds ratio, 2.1), and positive change in overall screening preference was also significantly greater in the tailored navigation group (odds ratio, 1.5).
As in the first study, the tailored intervention in the second study (J. Natl. Cancer Inst. 2014;106:pii:dju344) involved a mailed stool blood test kit or colonoscopy instructions based on patient preference. But those with no preference received only colonoscopy instructions rather than receiving both instructions and a stool blood test.
All those in the tailored navigation groups received a telephone call to encourage screening, as well as a mailed reminder. The standard intervention group received a mailed stool blood test kit, colonoscopy instructions, and a mailed reminder.
The test preferences in the second study were similar to those in the first study, with 57% having no preference, 25% of patients preferring colonoscopy, and 18% preferring stool blood testing. A survey at 6 months and a medical records review at 12 months were conducted to assess adherence, changes in screening preference, and perceptions about screening.
Despite those with no preference receiving only the colonoscopy instructions, the tailored navigation group had a significantly higher screening rate than did the standard intervention group (38% vs. 24%), Dr. Myer noted.
The higher adherence was attributed to a high screening rate (50%) among those who preferred and received the stool blood test and navigation calls. The adherence rate was 35% in those who received the colonoscopy instructions and the navigation call.
“We believe it’s the case that mailing both stool blood test and colonoscopy materials in this case increased overall adherence, but that was mostly due to stool blood testing,” Dr. Myer said. Tailored navigation increased overall adherence primarily by boosting both stool blood testing and colonoscopy.
“Preference actually influenced, not necessarily overall screening, but what type of test was performed,” he added, noting that among African Americans, tailored navigation had a greater effect on overall adherence than did the mailed stool blood test and colonoscopy materials.