Mailing at-home test boosts colorectal cancer screening in adults under 50

In a new study aimed at identifying the best approach to promote colorectal cancer screening in adults ages 45 to 49, UCLA researchers found that simply mailing a stool-based test directly to people's homes was the most effective strategy for increasing screening rates.

The study, published in JAMA, compared four strategies to increase colorectal cancer screening in this population, which only recently became eligible for screening. Of the four options tested, the researchers found that automatically mailing a stool-based screening test without an option to opt in or out resulted in the highest screening rates. 

Only about 15% to 17% of people completed screening when they had to actively opt into screening or pick a screening test. But when an at-home test was automatically mailed to them, more than 26% got screened. 

"When national guidance recommended screening adults age 45 to 49 for colorectal cancer for the first time, it wasn't clear how to best reach and screen this newly eligible population," said Dr. Folasade May, a gastroenterologist and cancer prevention researcher at the UCLA Health Jonsson Comprehensive Cancer Center and senior author of the study. "Removing the need for patients to actively opt into screening can lead to better outcomes, particularly when trying to engage younger, generally healthy adults who may not yet perceive themselves at risk for cancer."

The study, which included more than 20,000 patients, is among the first large-scale efforts to examine how to effectively engage this newly eligible age group in potentially life-saving colorectal cancer screening.

This is vital as colorectal cancer rates have been rising among younger adults. It is now the leading cause of cancer-related deaths in men aged 20 to 49 years and the second leading cause in women in the same age group. In 2021, the U.S. Preventive Services Task Force lowered the recommended screening age from 50 to 45. Yet participation among this newly eligible group has remained dismally low, with fewer than 2% getting screened within 20 months of the guideline change. 

"There has been an urgent need for evidence on how to reach adults in their 40s with effective, scalable screening strategies," said May, an associate professor of medicine at the David Geffen School of Medicine at UCLA. 

The team tested four different outreach strategies by sending information through UCLA Health's electronic patient portal to 20,509 patients who were considered at average risk for colorectal cancer. The researchers wanted to see which approach led to the most people actually getting screened, which type of test they chose and whether certain groups were more or less likely to participate. 

The four strategies were:

1. Asking patients if they would like to opt into screening by receiving a mailed stool test (known as a FIT kit).
2. Asking patients if they would like to opt into screening with a colonoscopy.
3. Asking patients if they would like to opt into screening and to make a choice between FIT and colonoscopy.
4. Simply mailing the FIT kit to patients without asking them to opt in.

The researchers found that participants who were asked to actively opt into screening (strategies 1-3) had lower overall screening rates. Among those offered the option to opt into the at-home stool test (FIT), 16.4% completed screening. In the group offered to opt into colonoscopy, the rate was 14.5%. When patients were given the option to opt into FIT or colonoscopy, 17.4% completed screening. 

The most effective strategy involved default mailing patients a FIT kit without requiring them to opt into screening or to make a choice between screening tests, resulting in a screening rate of 26.2%.

The team also found that 73% of those with abnormal FIT results followed up with a colonoscopy within six months, a key next step in cancer screening and encouraging given typically low follow-up rates. 

Although mailing the FIT kit directly performed best, overall screening rates were still low, researchers note. Still, this approach represents a meaningful step forward, highlighting a simple, low-cost intervention that can help close critical screening gaps and save lives. Further research is needed to optimize and tailor mailed FIT outreach strategies to boost participation even more.

"Our study showed that automated outreach can get results quickly and efficiently," said May. "More than 3,800 people were screened in just six months with minimal work required from our busy doctors. That's thousands of opportunities to catch cancer early or prevent it altogether."

The first authors of the study are Dr. Artin Galoosian, a former fellow in the Vatche and Tamar Manoukian Division of Digestive Diseases at the David Geffen School of Medicine at UCLA, and Dr. Hengchen Dai, Associate Professor of Management and Organizations, Anderson School of Management at UCLA. Additional authors include Dr. Folasade May (senior author), Dr. Daniel Croymans, Dr. Maria Han, Dr. Sitaram Vangala, Dr. Sadie De Silva, and Dr. Gregory Goshgarian from the department of medicine at UCLA, Dr. Craig Fox from the Anderson School of Management at UCLA, and Dr. Silvia Saccardo from Carnegie Mellon University and the Anderson School of Management at UCLA.