Home-Based Colorectal Cancer Screening Significantly Improves Screening Rates among Overdue Veterans in a Rural State
Since most colorectal cancer (CRC) arises from precancerous polyps or adenomas, population screening approaches focused on early detection can significantly decrease incidence. While overall CRC screening rates are high among VA healthcare users (80%) compared to the non-VA population (63%), 1 in 5 VA users remain unscreened. Previous reports suggest transportation problems, difficulty following pre-procedural instructions (e.g., colonoscopy prep), rural residence, and longer drive times to the nearest VAMC as barriers to screening. Fecal occult blood tests (FOBTs) are often referred to as "at-home tests" because they are typically sent home with a patient and returned by mail. The fecal immunochemical test (FIT) is a type of FOBT that has superior sensitivity/specificity, requires no diet/medication restrictions prior to use, and has better compliance because only 1 sample is required as opposed to 3 for traditional FOBT. This study sought to determine whether a simple 1-step mailing of a FIT accompanied by educational materials (n=500) would improve screening rates in Veterans who were overdue compared to Veterans who received educational materials only (n=499) and to Veterans in a usual care group (n=500) who received no mailings (those with current symptoms or a personal/family history of CRC were excluded). Veterans were ages 51 to 64, asymptomatic, at average risk for CRC, and had received care in the Iowa City VA Healthcare System, which includes a large rural population. Demographics and reasons why a colonoscopy or at-home test had not been taken also were assessed. Using VA data, outcomes were measured at six months to assess screening and at one year to assess appropriate follow-up, if needed.
- Mailing FITs and educational materials to Veterans overdue for CRC screening resulted in significantly higher screening rates than usual care or educational materials alone. At six months, 21% of Veterans in the FIT group had received CRC screening by any method compared to 6% in the educational materials-only group and 6% in the usual care group. Among respondents eligible for FIT, 90% completed and returned a FIT.
- Among Veterans in the FIT group, 8 (12%) received positive results. Of these Veterans, 6 received a colonoscopy, while the other 2 were advised against the procedure by their physicians due to terminal conditions (e.g., leukemia and metastatic lung cancer)
- The most frequently reported reasons for not having a colonoscopy included concerns about pain (39%), not recommended by a provider (37%), confusion about screening options (35%), and preference for at-home testing (34%). The overwhelming reason for not having at-home testing was that it was not recommended by their provider (62%).
- Data did not capture screening performed outside VA.
- A formal cost-effectiveness analysis was not completed; however, investigators estimated the cost of mailing 500 FIT kits plus postage to return them to the labs was about $5,000. In contrast, the cost of treating one Veteran in the first year following a stage III CRC diagnosis is nearly $42,000.
This study was partly funded by HSR&D and by VA's Office of Rural Health and the VA Rural Health Resource Center — Central Region. Drs. Charlton and Mengeling are part of HSR&D's Center for Comprehensive Access & Delivery Research and Evaluation, Iowa City, IA.
Charlton M, Mengeling M, Halfdanarson T, et al. Evaluation of a Home-Based Colorectal Cancer Screening Intervention in a Rural State. Journal of Rural Health October 25, 2013;e-pub ahead of print.