Improving Colorectal Cancer Screening in a Rural Setting: A Randomized Study

Am J Prev Med. 2020 Sep;59(3):404-411. doi: 10.1016/j.amepre.2020.03.019. Epub 2020 Jul 16.


Introduction: Colorectal cancer screening has been shown to prevent or detect early colorectal cancer and reduce mortality; yet, adherence to screening recommendations remains low, particularly in rural settings.

Study design: RCT.

Setting/participants: Adults (n=7,812) aged 50-75 years and due for colorectal cancer screening in a largely rural health system were randomly assigned to either the intervention (n=3,906) or the control (n=3,906) group in September 2016, with analysis following through 2018.

Intervention: A mailed motivational messaging screening reminder letter with an option to call and request a free at-home fecal immunochemical screening test (intervention) or the standard invitation letter detailing that the individual was due for screening (control). Multifaceted motivational messaging emphasized colorectal cancer preventability and the ease and affordability of screening, and communicated a limited supply of test kits.

Main outcome measures: Colorectal cancer screening participation within 6 months after mailed invitation was ascertained from the electronic medical record.

Results: Colorectal cancer screening participation was significantly improved in the intervention (30.1%) vs the usual care control group (22.5%; p<0.001). Individuals randomized to the intervention group had 49% higher odds of being screened over follow-up than those randomized to the control group (OR=1.49, 95% CI=1.34, 1.65). A total of 13.2 screening invitations were needed to accomplish 1 additional screening over the usual care. Of the 233 fecal immunochemical test kits mailed to participants, 154 (66.1%) were returned, and 18 (11.7%) tested positive.

Conclusions: A mailed motivational messaging letter with a low-cost screening alternative increased colorectal cancer screening in this largely rural community with generally poor adherence to screening recommendations. Mailed colorectal cancer screening reminders using motivational messaging may be an effective method for increasing screening and reducing rural colorectal cancer disparities.

Publication types

  • Randomized Controlled Trial
  • Research Support, Non-U.S. Gov't

MeSH terms

  • Adult
  • Aged
  • Colorectal Neoplasms* / diagnosis
  • Colorectal Neoplasms* / prevention & control
  • Early Detection of Cancer
  • Female
  • Humans
  • Male
  • Mass Screening
  • Middle Aged
  • Occult Blood
  • Rural Population*