Equitable Implementation of Mailed Stool Test-Based Colorectal Cancer Screening and Patient Navigation in a Safety Net Health System

J Gen Intern Med. 2023 May;38(7):1631-1637. doi: 10.1007/s11606-022-07952-0. Epub 2022 Dec 1.


Background: Mailed stool testing programs increase colorectal cancer (CRC) screening in diverse settings, but whether uptake differs by key demographic characteristics is not well-studied and has health equity implications.

Objective: To examine the uptake and equity of the first cycle of a mailed stool test program implemented over a 3-year period in a Central Texas Federally Qualified Health Center (FQHC) system.

Design: Retrospective cohort study within a single-arm intervention.

Participants: Patients in an FQHC aged 50-75 at average CRC risk identified through electronic health records (EHR) as not being up to date with screening.

Interventions: Mailed outreach in English/Spanish included an introductory letter, free-of-charge fecal immunochemical test (FIT), and lab requisition with postage-paid mailer, simple instructions, and a medical records update postcard. Patients were asked to complete the FIT or postcard reporting recent screening. One text and one letter reminded non-responders. A bilingual patient navigator guided those with positive FIT toward colonoscopy.

Main measures: Proportions of patients completing mailed FIT in response to initial cycle of outreach and proportion of those with positive FIT completing colonoscopy; comparison of whether proportions varied by demographics and insurance status obtained from the EHR.

Key results: Over 3 years, 33,606 patients received an initial cycle of outreach. Overall, 19.9% (n = 6672) completed at least one mailed FIT, 5.6% (n = 374) tested positive during that initial cycle, and 72.5% (n = 271 of 374) of those with positive FIT completed a colonoscopy. Hispanic/Latinx, Spanish-speaking, and uninsured patients were more likely to complete mailed FIT compared with white, English-speaking, and commercially insured patients. Spanish-speaking patients were more likely to complete colonoscopy after positive FIT compared with English-speaking patients.

Conclusions: Mailed FIT outreach with patient navigation implemented in an FQHC system was effective in equitably reaching patients not up to date for CRC screening.

Keywords: colorectal cancer; fecal immunochemical testing; health equity; patient navigation; preventive screening.

Publication types

  • Research Support, U.S. Gov't, Non-P.H.S.

MeSH terms

  • Colonoscopy
  • Colorectal Neoplasms* / diagnosis
  • Colorectal Neoplasms* / prevention & control
  • Early Detection of Cancer
  • Humans
  • Mass Screening
  • Occult Blood
  • Patient Navigation*
  • Retrospective Studies
  • Texas / epidemiology