Comparative Effectiveness of Multifaceted Outreach to Initiate Colorectal Cancer Screening in Community Health Centers: A Randomized Controlled Trial

Despite evidence that several colorectal cancer (CRC) screening strategies can reduce CRC mortality, screening rates remain low. This study aimed to determine whether the approach by which screening is recommended influences adherence. We used a cluster randomization design with clinic time block as the unit of randomization. Persons at average risk for development of CRC in a racially/ethnically diverse urban setting were randomized to receive recommendation for screening by fecal occult blood testing (FOBT), colonoscopy, or their choice of FOBT or colonoscopy. The primary outcome was completion of CRC screening within 12 months after enrollment, defined as performance of colonoscopy, or 3 FOBT cards plus colonoscopy for any positive FOBT result. Secondary analyses evaluated sociodemographic factors associated with completion of screening. A total of 997 participants were enrolled; 58% completed the CRC screening strategy they were assigned or chose. However, participants who were recommended colonoscopy completed screening at a significantly lower rate (38%) than participants who were recommended FOBT (67%) (P < .001) or given a choice between FOBT or colonoscopy (69%) (P < .001). Latinos and Asians (primarily Chinese) completed screening more often than African Americans. Moreover, nonwhite participants adhered more often to FOBT, while white participants adhered more often to colonoscopy. The common practice of universally recommending colonoscopy may reduce adherence to CRC screening, especially among racial/ethnic minorities. Significant variation in overall and strategy-specific adherence exists between racial/ethnic groups; however, this may be a proxy for health beliefs and/or language. These results suggest that patient preferences should be considered when making CRC screening recommendations. Trial Registration  clinicaltrials.gov Identifier: NCT00705731.

The U.S. Preventive Services Task Force requested a decision analysis to inform their update of recommendations for colorectal cancer screening. To assess life-years gained and colonoscopy requirements for colorectal cancer screening strategies and identify a set of recommendable screening strategies. Decision analysis using 2 colorectal cancer microsimulation models from the Cancer Intervention and Surveillance Modeling Network. Derived from the literature. U.S. average-risk 40-year-old population. Societal. Lifetime. Fecal occult blood tests (FOBTs), flexible sigmoidoscopy, or colonoscopy screening beginning at age 40, 50, or 60 years and stopping at age 75 or 85 years, with screening intervals of 1, 2, or 3 years for FOBT and 5, 10, or 20 years for sigmoidoscopy and colonoscopy. Number of life-years gained compared with no screening and number of colonoscopies and noncolonoscopy tests required. Beginning screening at age 50 years was consistently better than at age 60. Decreasing the stop age from 85 to 75 years decreased life-years gained by 1% to 4%, whereas colonoscopy use decreased by 4% to 15%. Assuming equally high adherence, 4 strategies provided similar life-years gained: colonoscopy every 10 years, annual Hemoccult SENSA (Beckman Coulter, Fullerton, California) testing or fecal immunochemical testing, and sigmoidoscopy every 5 years with midinterval Hemoccult SENSA testing. Annual Hemoccult II and flexible sigmoidoscopy every 5 years alone were less effective. The results were most sensitive to beginning screening at age 40 years. The stop age for screening was based only on chronologic age. The findings support colorectal cancer screening with the following: colonoscopy every 10 years, annual screening with a sensitive FOBT, or flexible sigmoidoscopy every 5 years with a midinterval sensitive FOBT from age 50 to 75 years.

Screening for colorectal cancer (CRC) is widely accepted, but there is no consensus on the preferred strategy. We conducted a randomised trial comparing participation and detection rates (DR) per screenee of guaiac-based faecal occult blood test (gFOBT), immunochemical FOBT (FIT), and flexible sigmoidoscopy (FS) for CRC screening. A representative sample of the Dutch population (n = 15 011), aged 50-74 years, was 1:1:1 randomised prior to invitation to one of the three screening strategies. Colonoscopy was indicated for screenees with a positive gFOBT or FIT, and for those in whom FS revealed a polyp with a diameter > or = 10 mm; adenoma with > or = 25% villous component or high grade dysplasia; serrated adenoma; > or = 3 adenomas; > or = 20 hyperplastic polyps; or CRC. The participation rate was 49.5% (95% confidence interval (CI) 48.1 to 50.9%) for gFOBT, 61.5% (CI, 60.1 to 62.9%) for FIT and 32.4% (CI, 31.1 to 33.7%) for FS screening. gFOBT was positive in 2.8%, FIT in 4.8% and FS in 10.2%. The DR of advanced neoplasia was significantly higher in the FIT (2.4%; OR, 2.0; CI, 1.3 to 3.1) and the FS arm (8.0%; OR, 7.0; CI, 4.6 to 10.7) than the gFOBT arm (1.1%). FS demonstrated a higher diagnostic yield of advanced neoplasia per 100 invitees (2.4; CI, 2.0 to 2.8) than gFOBT (0.6; CI, 0.4 to 0.8) or FIT (1.5; CI, 1.2 to 1.9) screening. This randomised population-based CRC-screening trial demonstrated superior participation and detection rates for FIT compared to gFOBT screening. FIT screening should therefore be strongly preferred over gFOBT screening. FS screening demonstrated a higher diagnostic yield per 100 invitees than both FOBTs.