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Mailings may up colon cancer screening rates in underserved

By Andrew M. Seaman

NEW YORK (Reuters Health) - Reminding uninsured people to get screened for colon cancer by sending them letters and calling them at home increases testing rates compared to asking them at doctors' offices, says a new study.

Researchers found uninsured people in one Texas community were twice as likely to be screened if they were offered a colonoscopy free of charge by mail and over the phone.

The same people were three times more likely to opt for screening when they were offered a stool test that needs no preparation and can be done at home, compared to those who received standard treatment.

"Clearly the outreach worked and it was a lot better than usual care, but we did see a significant difference in whether we offered colonoscopy or the (fecal immunochemical test)," said Dr. Samir Gupta, the study's lead author from the University of California, San Diego.

Colon and rectal cancers are the second leading cause of cancer-related deaths in the U.S., according to the Centers for Disease Control and Prevention (CDC). Approximately 52,000 people died from the cancers in 2009.

Screening rates for colon cancer have increased over the past few years, but the CDC says about 22 million people aren't up-to-date with the tests. That's especially true for minorities and the uninsured, write the authors in JAMA Internal Medicine.

The government-backed U.S. Preventive Services Task Force (USPSTF) recommends that people between ages 50 and 75 get screened by colonoscopy every 10 years.

During a colonoscopy, a doctor uses a long flexible tube equipped with a tiny video camera to see the interior of the colon.

Alternatively, the USPSTF says people in that age group can have a high-sensitivity fecal occult blood test every year, or a sigmoidoscopy - which is similar to a colonoscopy - every five years in addition to fecal occult blood testing every three years.

For the new study, Gupta and his colleagues randomly assigned 5,970 uninsured patients in the John Peter Smith Health Network in Fort Worth and Tarrant County, Texas, to one of three groups in January 2011.

One group of 3,898 people received usual care, which consisted of doctors asking patients while they were at the clinic for an appointment if they'd like to be screened for colon cancer.

People in the other two groups received letters in English and Spanish with information on colon and rectal cancer and an invitation to get a free screening. The participants in the outreach groups also received two automated phone messages, two phone calls from real people and help setting up appointments for screening.

Within the outreach group, 479 people were offered colonoscopies and 1,593 people were offered a fecal occult blood test known as a fecal immunochemical test (FIT) that they could complete at home.

By February 2012, 12 percent of the usual care group had been screened for colon cancer. That compared to 25 percent in the colonoscopy outreach group and 41 percent in the stool test group.

Colonoscopies are usually seen as the most thorough colon cancer screening, but Gupta said the better response in the stool test group may make up for its inferiority.

"Clearly (the results) show that outreach works and it raises the possibility that programs offering FIT could have a similar or even better impact than colonoscopy," he told Reuters Health.

But that would also depend on people getting FIT every year, as recommended by the USPSTF.

Gupta said his group is also looking at the relative cost effectiveness of the different tests. While a colonoscopy can cost a couple thousand dollars, a single FIT costs about $30, but a positive test needs to be confirmed by colonoscopy.

Dr. Barbara Turner, director of the Center for Research to Advance Community Health in San Antonio, Texas, said the screening rates with FIT and colonoscopy outreach may look high when compared to usual care, which didn't consist of much in this study.

"But I think there is a compelling argument from this and other studies that there are other things we can be doing to get these people in for screening," Turner, who wasn't involved with the new study, told Reuters Health.

She added that previous studies have also found that having access to reliable primary care, such as a family doctor, is linked to better screening rates.

"We really need to have an array of ways to deal with it, but the anchor is primary care," Turner said.

SOURCE: http://bit.ly/11PkA8e JAMA Internal Medicine, online August 5, 2013.

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