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Evaluation of Interventions Intended to Increase Colorectal Cancer Screening Rates in the United StatesA Systematic Review and Meta-analysis

Educational Objective
To identify interventions associated with increasing colorectal cancer (CRC) screening rates and their effect sizes.
1 Credit CME
Key Points

Question  Which interventions increase completion of colorectal cancer screening tests in the United States?

Findings  In this sytematic review and meta-analysis of 73 randomized clinical trials, Patient navigation and fecal test outreach had the strongest evidence supporting a significant increase in completion of initial screening; combining interventions (eg, navigation with test outreach) was associated with further increases in screening.

Meaning  Multicomponent programs, including screening test outreach with as-needed patient navigation, should be implemented to reach national goals for colorectal cancer screening rates.


Importance  Colorectal cancer screening (CRC) is recommended by all major US medical organizations but remains underused.

Objective  To identify interventions associated with increasing CRC screening rates and their effect sizes.

Data Sources  PubMed, Cumulative Index to Nursing and Allied Health Literature, the Cochrane Library, and ClinicalTrials.gov were searched from January 1, 1996, to August 31, 2017. Key search terms included colorectal cancer and screening.

Study Selection  Randomized clinical trials of US-based interventions in clinical settings designed to improve CRC screening test completion in average-risk adults.

Data Extraction and Synthesis  At least 2 investigators independently extracted data and appraised each study’s risk of bias. Where sufficient data were available, random-effects meta-analysis was used to obtain either a pooled risk ratio (RR) or risk difference (RD) for screening completion for each type of intervention.

Main Outcomes and Measures  The main outcome was completion of CRC screening. Examination included interventions to increase completion of (1) initial CRC screening by any recommended modality, (2) colonoscopy after an abnormal initial screening test result, and (3) continued rounds of annual fecal blood tests (FBTs).

Results  The main review included 73 randomized clinical trials comprising 366 766 patients at low or medium risk of bias. Interventions that were associated with increased CRC screening completion rates compared with usual care included FBT outreach (RR, 2.26; 95% CI, 1.81-2.81; RD, 22%; 95% CI, 17%-27%), patient navigation (RR, 2.01; 95% CI, 1.64-2.46; RD, 18%; 95% CI, 13%-23%), patient education (RR, 1.20; 95% CI, 1.06-1.36; RD, 4%; 95% CI, 1%-6%), patient reminders (RR, 1.20; 95% CI, 1.02-1.41; RD, 3%; 95% CI, 0%-5%), clinician interventions of academic detailing (RD, 10%; 95% CI, 3%-17%), and clinician reminders (RD, 13%; 95% CI, 8%-19%). Combinations of interventions (clinician interventions or navigation added to FBT outreach) were associated with greater increases than single components (RR, 1.18; 95% CI, 1.09-1.29; RD, 7%; 95% CI, 3%-11%). Repeated mailed FBTs with navigation were associated with increased annual FBT completion (RR, 2.09; 95% CI, 1.91-2.29; RD, 39%; 95% CI, 29%-49%). Patient navigation was not associated with colonoscopy completion after an initial abnormal screening test result (RR, 1.21; 95% CI, 0.92-1.60; RD, 14%; 95% CI, 0%-29%).

Conclusions and Relevance  Fecal blood test outreach and patient navigation, particularly in the context of multicomponent interventions, were associated with increased CRC screening rates in US trials. Fecal blood test outreach should be incorporated into population-based screening programs. More research is needed on interventions to increase adherence to continued FBTs, follow-up of abnormal initial screening test results, and cost-effectiveness and other implementation barriers for more intensive interventions, such as navigation.

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Article Information

Corresponding Author: Daniel S. Reuland, MD, MPH, Division of General Medicine and Clinical Epidemiology, Department of Medicine, University of North Carolina at Chapel Hill, 101 E Weaver St, CB 7923, Carrboro, NC 27510 (daniel_reuland@med.unc.edu).

Accepted for Publication: July 19, 2018.

Published Online: October 15, 2018. doi:10.1001/jamainternmed.2018.4637

Author Contributions: Drs Dougherty and Reuland had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.

Concept and design: Dougherty, Brenner, Crockett, Coker-Schwimmer, Cubillos, Wheeler, Reuland.

Acquisition, analysis, or interpretation of data: Dougherty, Brenner, Crockett, Coker-Schwimmer, Cubillos, Gupta, Malo, Reuland.

Drafting of the manuscript: Dougherty, Crockett, Coker-Schwimmer, Cubillos, Reuland.

Critical revision of the manuscript for important intellectual content: All authors.

Statistical analysis: Dougherty.

Obtained funding: Reuland.

Administrative, technical, or material support: Brenner, Coker-Schwimmer, Cubillos, Gupta, Malo, Wheeler.

Supervision: Brenner, Crockett, Wheeler, Reuland.

Conflict of Interest Disclosures: Dr Wheeler received unrelated grant funding to her institution from Pfizer as PI of a Pfizer/National Comprehensive Cancer Network Independent Grant for Learning and Change. No other disclosures were reported.

Funding/Support: Major funding for the study was provided by the University of North Carolina Lineberger Comprehensive Cancer Center through its University Cancer Research Fund (Drs Brenner, Wheeler, Malo, and Reuland, Mr Coker-Schwimmer, and Ms Cubillos). Dr Reuland was also supported by American Cancer Society grant RSG-13-165-01-CPPB. In addition, the investigators received support from National Institutes of Health grants T32 DK007634 (Dr Dougherty) and KL2TR001109 (Dr Crockett), and from the Centers for Disease Control and Prevention– and National Cancer Institute (NCI)–supported Cancer Prevention and Control Research Network grant 3 U48 DP005017-01S8 (Drs Brenner, Wheeler, and Reuland). This work was supported in part by the University of North Carolina at Chapel Hill’s Connected Health Applications & Interventions Core through NCI grant P30-CA16086 to the Lineberger Comprehensive Cancer Center.

Role of the Funder/Sponsor: The funding organizations had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

Additional Contributions: The review’s literature searches were conducted by Christiane Voisin, MSLS (librarian, Sheps Center for Health Services Research, University of North Carolina at Chapel Hill). Charli Randolph, MCS, LC (research assistant, Sheps Center for Health Services Research, University of North Carolina at Chapel Hill), Shynah James, MPH (research assistant, Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill), Oluoma Chukwu, MHA, and Samuel Lee (graduate students Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina at Chapel Hill), Adrian Compean Garcia (research assistant, Department of Medicine, University of North Carolina at Chapel Hill), and Jewels Rhode, MPH (research associate, Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill), provided assistance extracting data and retrieving publications. Ms James, Mss Rhodes and Chukwu also assisted with review of publications for inclusion. Dan Jonas, MD, MPH (associate professor, Division of General Medicine and Clinical Epidemiology, University of North Carolina at Chapel Hill), provided multiple consultations throughout the course of the review and reviewed an earlier draft of the manuscript. Mss Voisin and Chukwu, Mr Lee, and Dr Jonas did not receive compensation for their contributions to this work; the other contributors did.

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