Offering people the choice between home tests or a colonoscopy doesn’t increase rates of colorectal cancer screening participation, research finds.
The findings, published in JAMA Network Open, show the proportion of colonoscopies—the gold standard for colorectal cancer screening—fell when doctors presented home screening as an available option.
“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,” says lead author Shivan Mehta, associate chief innovation officer and assistant professor of medicine at Penn 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.
Upsides and downsides
For the current study, the researchers explored whether offering fecal immunochemical testing (FIT), a stool test that people can complete at home and mail to a lab, as an alternative choice to colonoscopies would boost screening completion.
People often view FIT kits as more convenient, but they need annual testing to keep patients up to date. Colonoscopies are more comprehensive, allowing for the removal of potentially harmful tissues, and patients only need them once a decade.
“We know from behavioral science that we all tend to overweigh present-time risks as compared to future benefits,” Mehta says. “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.”
Researchers separated a group of 438 patients overdue for screening equally 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 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 then received 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 then received a letter with information both about colonoscopy scheduling and the FIT kit.
Does timing matter?
The study showed that colonoscopy popularity fell as FIT kits became more readily available, with colonoscopies being used in 90% of the completed screenings in the first arm, 52% in the second, and just 38% 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 says.
Moving forward, Mehta says 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 says. “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.”
The Penn Roybal Center through the Institute of Aging and the National Cancer Institute of the National Institutes of Health funded the work.