Providing More Testing Choices Does Not Increase Colorectal Cancer Screening Rates

PHILADELPHIA – Offering patients the choice between home screening or in-office colonoscopy does not increase participation in colorectal cancer screening, according to a new Penn Medicine study. However, the framing of choice did impact patient decision-making, as the proportion of colonoscopies — the gold standard for colorectal cancer screening — fell when the home screening option was presented as an available option. This study was published in JAMA Network Open.

“As clinicians, we should think carefully about the choices that we offer to patients: While they’re well-meaning and seemingly more patient-centered, choices may actually be overwhelming and could impede decision-making,” said the study’s lead author, Shivan Mehta, MD, MBA, associate chief innovation officer at Penn Medicine and an assistant professor of Medicine. “It is important for us to simplify choices as much as possible, but also think about how we frame them.” 

One in three people in the United States are not up-to-date on their screening for colorectal cancer, the second deadliest cancer in the United States, so doctors and researchers like Mehta and his team are working on ways to make tests more widespread and/or easier to complete. For this study, they explored whether offering fecal immunochemical testing (FIT), a stool test that can be completed at home and mailed to a lab as an alternative choice to colonoscopies would boost screening completion. FIT kits are often viewed as more convenient, but they need to be completed yearly to keep patients up to date. Colonoscopies are more comprehensive, allowing for the removal of potentially harmful tissues, and only need to be performed once a decade.

“We know from behavioral science that we all tend to overweigh present-time risks as compared to future benefits,” Mehta explained. “In the short term, it’s easier to get stool testing done, but the need to do it yearly presents more opportunities for a patient to get behind on their screening. Conversely, colonoscopies are more challenging in the short term, but they keep patients up-to-date longer.”

A group of 438 patients overdue for screening were equally separated into three different study arms. Each received a letter from their primary care physician about the benefits of screening. The first group also received a phone number to call to schedule a colonoscopy. If they didn’t schedule within in four weeks, they got a follow-up letter with the same information.

Patients in the second group received a number they could call for scheduling a colonoscopy, in addition to the letter. But if they, too, didn’t schedule one within four weeks, they were then mailed a reminder letter along with a FIT kit (with instructions and a stamped envelope with which to return it).

Finally, patients in the third arm received the colonoscopy scheduling number and the FIT kit immediately. In four weeks, without either screening completed, they would then get a letter with information both about colonoscopy scheduling and the FIT kit.

The study showed that colonoscopy popularity fell as FIT kits became more readily available, with colonoscopies being used in 90 percent of the completed screenings in the first arm, 52 percent in the second, and just 38 percent in the third. However, overall screening rates did not vary significantly, with each group having roughly the same numbers.

“One interpretation of our results is that any of these strategies can be deployed by health systems with reasonable effectiveness,” Mehta said.

Moving forward, Mehta said he would like to examine the long-term effects of these choices with more participants, as there may be small but significant differences in response rate. In particular, he’d like to examine variations of the sequential choice option — the second arm that offered colonoscopy information before mailing a FIT kit four weeks later.

“Specifically, we would like to explore how long we should wait before we offer stool testing when patients do not participate in colonoscopy,” Mehta said. “This may offer a clue as to whether there is a better timing option that might increase screening rates while accounting for the need to repeat stool testing annually.”

This study was funded by the Penn Roybal Center through the Institute of Aging (grant number P30AG034546) and the National Cancer Institute of the National Institutes of Health (K08CA234326 and R01CA213645).

Other authors include Vikranth Induru, MD; David Santos; Catherine Reitz, MPH; Timothy McAuliffe; Charles Orellana, MD; Kevin G. Volpp, MD, PhD; David A. Asch, MD, MBA; Chyke A. Doubeni, MD, MPH.