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

Abstract

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.

Figure 1.. Summary of Evidence Search and Study Selection

Seventy-three randomized clinical trials were described in a total of 78 articles. The extra articles were either reports or extended follow-up or additional analyses. CINAHL indicates Cumulative Index to Nursing and Allied Health Literature; CRC, colorectal cancer; KQ, key question; ROB, risk of bias; USPSTF, United States Preventive Services Task Force.

Figure 2.. Risk Ratio for Completion of Colorectal Cancer (CRC) Screening Test

The fecal test outreach plots are stratified by mailed or visit-based fecal blood test (FBT) distribution (A) and the navigation plots by FBT or colonoscopy outreach components (B). Principal meta-analyses excluded studies at high risk of bias. Principal analyses also excluded 1 study of patients with recently completed fecal tests and another of patients already referred by their health care professionals for colonoscopy despite lower risks of bias. Including these studies did not change the result (risk ratio [RR], 2.25; 95% CI, 1.82-2.77; I² = 97%; RR, 1.94; 95% CI, 1.61-2.34; I² = 95% for FBT outreach and patient navigation, respectively), and they were included in the sensitivity analysis along with the studies at high risk of bias. The difference between CRC completion in navigation interventions with and without either predistribution of FBT or colonoscopy referral or else universal ability of the navigator to distribute or refer for these tests (B) was nonsignificant (P = .09). The difference between mailed and visit-based FBT distribution (A) was nonsignificant (P = .84).