Colorectal cancer causes a substantial burden of suffering in the elderly VA population. Although colorectal cancer screening can reduce both the incidence and mortality from colorectal cancer, screening rates are low for the New Mexico VA Health Care System.
We used a primary care delivery model based on an electronic medical record and a new technology for fecal stool testing to improve screening rates and adherence to screening.
The electronic medical record was used to identify patients who are eligible for screening but who do not have an immediately upcoming primary care clinic appointment. We enrolled a randomly-selected sample of these patients who agreed to participate in the study and mailed them stool tests along with instructions. We compared the proportion of subjects who underwent colorectal cancer screening during the 3-month study period against control samples of eligible patients who required a clinic visit to initiate screening. We assessed whether control patients completed stool tests within 6 months of being identified as eligible for screening. Because adherence for fecal occult blood tests is low, we also evaluated a new screening technology--fecal immunochemical stool tests--which target intact human hemoglobin and can be performed without requiring patients to follow onerous dietary and medication restrictions. We evaluated whether screening adherence (proportion completing testing) was higher with fecal immunochemical testing (FIT) compared to the standard fecal occult blood test (FOBT). We also evaluated the yield of advanced neoplasia for each of the screening tests.
We enrolled 404 subjects into the randomized trial of FIT versus FOBT. The average age was 62.7 years and 97% were men. The on-protocol completion rate was significantly higher with FIT (62%) vs. FOBT (48%), P < 0.01. The odds ratio for completing colorectal cancer screening within 90 days of enrollment was significantly higher with FIT than for completing FOBT (1.62, 95% CI 1.08, 2.43) adjusting for age, race/ethnicity, gender, clinic site, comorbidity, and previous FOBT testing. Eleven patients with positive FIT tests underwent colonoscopy, 5 had adenomatous polyps and 1 had a colorectal cancer. One of the three patients with positive FOBT was found to have a dysplastic polyp on colonoscopy. The 48% completion rate for FOBT among subjects who were mailed tests as part of the intervention study was significantly higher than the test completion rates for each of three control groups--3184 subjects who were initially randomly assigned to not be invited for the intervention trial (27%), the 2525 subjects who did not respond to invitation letters (23%), and the 257 subjects who expressed interest in participating in the intervention trial but could not be reached by telephone or replied after enrollment ended (14%).
Based on the increased adherence seen with FIT versus FOBT, our medical center is adopting FIT as its standard stool test for colorectal cancer screening. Based on the success of the primary care model (using the database to identify eligible subjects and directly sending them stool test kits), we are planning a larger study to expand this model.
- Hoffman RM, Steel SR, Yee EF, Massie L, Schrader RM, Moffett ML, Murata GH. A system-based intervention to improve colorectal cancer screening uptake. The American journal of managed care. 2011 Jan 1; 17(1):49-55.
- Hoffman RM, Steel S, Yee EF, Massie L, Schrader RM, Murata GH. Colorectal cancer screening adherence is higher with fecal immunochemical tests than guaiac-based fecal occult blood tests: a randomized, controlled trial. Preventive medicine. 2010 May 1; 50(5-6):297-9.