Colorectal cancer (CRC) is the second most common cause of cancer death in the United States and disproportionally impacts people who receive care in under-resourced settings. Fortunately, several effective screening tests are available to detect cancer early when it is most treatable. In partnership with community health centers (CHC), investigators from Mass General Brigham and UCLA Health mailed one of two stool-based screening tests to more than 5,000 participants from CHCs in Boston and Los Angeles. Researchers found that participants were more likely to complete screening if they received a newer stool-based screening test, but follow-up colonoscopy rates remained low for those with abnormal results. Findings are published in JAMA Internal Medicine .
"Rates of colorectal cancer are rising, but many eligible people are unscreened, especially in community health centers," said corresponding author Jennifer Haas, MD, MSPH, of the Division of Internal Medicine in the Mass General Brigham Department of Medicine. "CHCs are an important source of care in the United States, especially for under- or uninsured people. Since many CHCs are under-resourced, the goal of our research was to help design an intervention to specifically benefit people who receive care in these settings."
Haas and colleagues are members of the Stand Up To Cancer (SU2C) Colorectal Cancer Health Equity Dream Team that brings together leading researchers, patient advocates, community leaders, and clinicians to accomplish several goals, including improving colorectal cancer screening in medically underserved communities.
In previous studies, mailing stool-based tests to patients increased CRC screenings at CHCs, but, with multiple mail-in tests now available, it was unclear which test and which forms of patient outreach were most effective. In the current study, researchers compared completion rates for participants who received either a mailed fecal immunochemical test (FIT) or FIT-DNA kit. Both are noninvasive, at-home tests that detect blood in the stool. However, the newer FIT-DNA test also identifies abnormal DNA indicative of cancer or pre-cancerous polyps and is repeated every three years (rather than every year). Whereas CHCs bear the costs of mailing FIT tests and conducting patient outreach, the manufacturer of FIT-DNA coordinates mailing for these tests and offers a wrap-around assistance program to support patients through screening test completion.
Participants in the randomized study included adults aged 45-75 years at eight CHCs in Boston and LA.
who were due for CRC screening. Patients were predominantly Hispanic (75%) and on Medicaid (50%). Ultimately, 28% of patients who received FIT-DNA kits completed screening after 90 days, which was significantly higher than the completion rate in those who received FIT kits and automated English or Spanish text-message reminders (23%). The researchers suggest that FIT-DNA screening may have had a higher completion rate due to stronger outreach support through the patient assistance program and the potential for reduced testing frequency.
In a separate, associated study in a tribal site in South Dakota, FIT-DNA kits were associated with an increase in participation in CRC screening. Improving screening is especially important in Native American populations due to their high CRC incidence and low screening rates.
The researchers emphasize the urgency of improving access to diagnostic colonoscopy, which is necessary after a positive stool or blood test. In this study, despite participants with abnormal stool tests receiving phone calls to help educate them about and schedule their colonoscopy, completion rates were only 36% in both the FIT and FIT-DNA groups and were lower in LA than in Boston, perhaps related to access to colonoscopy or differences in insurance coverage.
"Effective screening is essential because it allows us to catch and treat cancer early," Haas said. "There are evidence-backed, preventive interventions for CRC, but they need to be implemented systematically in a way that addresses barriers for both the CHCs and the patients they are serving. The best screening test will always be the one that people are able to complete."
Authorship: In addition to Haas, co-authors include Folasade P. May, Suzanne Brodney, Jessica J. Tuan, Sapna Syngal, Andrew T. Chan, Beth Glenn, Gina Johnson Yuchiao Chang, David A. Drew, Beverly Moy, Nicolette J. Rodriguez, Erica T. Warner, Adjoa Anyane-Yeboa, Chinedu Ukaegbu, Anjelica Q. Davis, Kimberly Schoolcraft, Susan Regan, Kelley Le Beaux, Ellen T. Lee, Roopa Bhat, Alexis Gordon, Linh K. Phan, Andrea Fernanda Cortés Chirino, Caylin J. Marotta, and Rachel G. Z. Kindermann.
Disclosures: May reported being a member of scientific advisory boards with Exact Sciences, Natera, Geneoscopy, and Medtronic during the conduct of the study. Syngal reported grants from Exact Sciences, personal fees from GlaxoSmithKline and Natera outside the submitted work; in addition, Syngal had a patent for PREMM model with royalties paid from Myriad Genetics and Ambry Genetics. Chan reported
personal fees from Pfizer Inc and Boehringer Ingelheim, and grants from Freenome Holdings outside the submitted work. Rodriguez reported grants from Robert A. Winn Excellence in Clinical Trials: Career Development Award during the conduct of the study. Warner reported grants from Pfizer Inc and AstraZeneca, and nonfinancial support from Guardant Health outside the submitted work. Anyane-Yeboa reported personal fees from Exact Sciences advisory board during the conduct of the study and personal fees from Takeda Pharmaceuticals advisory board outside the submitted work.
Funding: Authors were supported by a research grant from Stand Up to Cancer, a division of the Entertainment Industry Foundation. Haas also received support from the American Cancer Society (CRP-22-0800-01-CTPS).
Paper cited: May FP et al. "Mailed Outreach for Colorectal Cancer Screening in Community Health Centers" JAMA Internal Medicine DOI: 10.1001/jamainternmed.2026.1170
