A pragmatic randomized trial of mailed fecal immunochemical testing to increase colorectal cancer screening among low‐income and minoritized populations

Abstract

AbstractBackgroundColorectal cancer (CRC) screening is underused, particularly among low‐income and minoritized populations, for whom the coronavirus disease 2019 (COVID‐19) pandemic has challenged progress in achieving equity.MethodsA hub‐and‐spoke model was used. The hub was a nonacademic organization and the spokes were three community health center (CHC) systems overseeing numerous clinic sites. Via a cluster‐randomized trial design, nine clinic sites were randomized to intervention and 16 clinic sites were randomized to usual care. Patient‐level interventions included invitation letters, mailed fecal immunochemical tests (FITs), and call/text‐based reminders. Year 1 intervention impact, which took place during the COVID‐19 pandemic, was assessed as the proportion completing screening among individuals not up to date at baseline, which compared intervention and nonintervention clinics accounting for intraclinic cluster variation; confidence intervals (CIs) around differences not including 0 were interpreted as statistically significant.ResultsAmong 26,736 patients who met eligibility criteria, approximately 58% were female, 55% were Hispanic individuals, and 44% were Spanish speaking. The proportion completing screening was 11.5 percentage points (ppts) (95% CI, 6.1–16.9 ppts) higher in intervention versus usual care clinics. Variation in differences between intervention and usual care clinics was observed by sex (12.6 ppts [95% CI, 7.2–18.0 ppts] for females; 8.8 ppts [95% CI, 4.7–13.9 ppts] for males) and by racial and ethnic group (13.8 ppts [95% CI, 7.0–20.6 ppts] for Hispanic individuals; 13.0 ppts [95% CI, 3.6–22.4 ppts] for Asian individuals; 11.3 ppts [95% CI, 5.8–16.8 ppts] for non‐Hispanic White individuals; 6.1 ppts [95% CI, 0.8–10.4 ppts] for Black individuals).ConclusionsA regional mailed FIT intervention was effective for increasing CRC screening rates across CHC systems serving diverse, low‐income populations.