BACKGROUND & AIMS: Primary colonoscopy and fecal immunochemical testing (FIT) are considered first-tier tests for colorectal cancer (CRC) screening. Although colonoscopy is considered the most efficacious test, FIT might achieve higher participation rates. It is uncertain what the best strategy is for offering population-wide CRC screening.
METHODS: This was a multicenter randomized health services study performed within the framework of the Polish Colonoscopy Screening Program between January 2019 and March 2020 on screening-naïve individuals. Eligible candidates were randomly assigned in a 1:1:1 ratio to participate in 1 of 3 competing invitation strategies: control (invitation to screening colonoscopy only); sequential (invitation to primary colonoscopy and invitation for FIT for initial nonresponders); or choice (invitation offering a choice of colonoscopy or FIT). The primary outcome was participation in CRC screening within 18 weeks after enrollment into the study. The secondary outcome was diagnostic yield for advanced neoplasia.
RESULTS: Overall, 12,485 individuals were randomized into the 3 study groups. The participation rate in the control group (17.5%) was significantly lower compared with the sequential (25.8%) and choice strategy (26.5%) groups (P < .001 for both comparisons). The colonoscopy rates for participants with positive FITs were 70.0% for the sequential group and 73.3% for the choice group, despite active call-recall efforts. In the intention-to-screen analysis, advanced neoplasia detection rates were comparable among the control (1.1%), sequential (1.0%), and choice groups (1.1%).
CONCLUSIONS: Offering a combination of FIT and colonoscopy as a sequential or active choice strategy increases participation in CRC screening. Increased participation in strategies with FIT do not translate into higher detection of advanced neoplasia. ClinicalTrials.gov, Number NCT03790475.
Useful to consider not only screening tests but the strategies within which they are offered. Having more than one option increases uptake, which is a useful message.
Interesting and useful negative study. I continue to encourage whatever might work.
CRC screening is shown to reduce morbidity and mortality. General practitioners have a role to encourage their patients to participate in screening. This study, however, is designed to test some alternatives to simply offering colonoscopy as the screening test, but not the alternative that is used in Australia. That is, a two-stage screening test beginning with FIT, and only offering colonoscopy to test persons with positive results. It is a pity that this strategy was not one of the options tested in this health services comparison.
This is a behavioral intervention study designed for the primary care practitioner to improve compliance with screening. The GI endoscopist will find this of little use because they are not at the point of monitoring or enforcing compliance with recommended screening protocols.
This social intervention study finds that offering an active choice strategy increases participation in colorectal cancer screening. This is definitively good evidence to improve our health interventions.