Results Summary
What was the research about?
Colorectal cancer is the second leading cause of cancer deaths among US patients who are Hispanic. Screening can help find this cancer early, when it is easier to treat. Doctors mainly use two screening tests:
- A stool blood test kit. People who use this test collect samples of their stool at home and mail them to a lab. The lab tests for blood in the stool, which can be an early sign of colorectal cancer.
- A colonoscopy. In this test, doctors insert a long, flexible tube into the rectum and large intestine, or colon. A camera at the end of the tube lets doctors see changes in the colon that may indicate cancer.
In this study, the research team compared two ways to encourage Hispanic patients to get a screening test. In one way, the team mailed patients a stool blood test kit and information about how to schedule a colonoscopy. In the other way, patients got the same mailing plus a phone call to help patients decide which screening test was better for them and help them get their preferred test.
What were the results?
Compared with patients who received only the mailing, patients who also received a phone call were more likely to get a screening test for colorectal cancer in the next year.
Patients who received the phone call did not know more about colorectal cancer and screening than those who received only the mailing.
Who was in the study?
The study included 400 Hispanic patients ages 50–75 who were overdue for colorectal cancer screening. Of these, 59 percent were women, and 69 percent were ages 50–59. In addition, 83 percent spoke Spanish at home. All patients went to one of five doctors’ offices in southeast Pennsylvania.
What did the research team do?
The research team assigned patients by chance to one of two groups. In the first group, patients got a mailing that included a letter from patients’ doctors encouraging patients to get a screening, a brochure about colorectal cancer screening tests, a stool blood test kit, and instructions for scheduling a colonoscopy. The materials were in English and Spanish. The team mailed a reminder after 45 days if patients hadn’t done either screening test.
In the second group, patients received the same mailing and follow-up. In addition, a staff member called them a week after the mailing. During the call, the staff member
- Reviewed the mailed materials
- Used an online guide to help patients figure out what was keeping them from having a screening test
- Created a screening plan and sent it to the patients and their doctors
- Reviewed instructions with patients who wanted to do a stool blood test
- Scheduled a prescreening clinic visit if patients wanted a colonoscopy
After one year, the research team looked at health records to see if patients had done either test. The team also surveyed patients by phone six months after the study started. The survey asked patients what they knew about colorectal cancer and screening.
A group of patients, Hispanic community leaders, and doctors reviewed the study plan and gave feedback to the research team.
What were the limits of the study?
The study included Hispanic patients from five doctors’ offices in one healthcare system in one state. The results may be different for Hispanic patients in other healthcare settings or in different parts of the country. Future research could look at phone support for getting a screening test with people from other places or backgrounds.
How can people use the results?
Health systems could use phone support to help Hispanic patients get screening tests for colorectal cancer.
Professional Abstract
Objective
To determine whether telephone-based screening decision support and navigation, compared with mailed materials, increases colorectal cancer (CRC) screening adherence among Hispanic individuals
Study Design
| Design Elements | Description |
|---|---|
| Design | Randomized controlled trial |
| Population | 400 Hispanic individuals ages 50–75 past due for CRC screening in 5 primary care practices in 1 healthcare system in southeastern Pennsylvania |
| Interventions/ Comparators |
|
| Outcomes |
Primary: CRC screening adherence Secondary: CRC screening decision stage change, test-specific CRC screening adherence, patient knowledge of CRC and screening |
| Timeframe | 1-year follow-up for primary outcome |
This randomized controlled trial compared the effectiveness of telephone-based screening decision support and navigation in addition to mailed materials with mailed materials only on increasing CRC screening among Hispanic patients.
Researchers randomly assigned patients to one of two groups. Patients in both groups received mailed materials in English and Spanish. The materials included a letter from patients’ primary care practice encouraging CRC screening, a stool-based blood test kit with instructions, and instructions for arranging a colonoscopy. If patients did not complete either screening test within 45 days, researchers sent patients a reminder letter.
For patients receiving decision support and navigation, a patient assistant—a non-medical person trained to help patients navigate CRC screening—called patients seven days after the mailing. Phone calls were in English or Spanish. The patient assistant reviewed the mailed materials with patients, and together they determined whether patients preferred a stool blood test or colonoscopy. Next, the patient assistant and patients used an online decision-counseling program to identify barriers to completing either screening test. Then, the patient assistant sent a plan addressing these barriers to patients and their primary care physicians. The patient assistant reviewed instructions for patients who preferred the stool blood test or scheduled a prescreening visit for patients who preferred a colonoscopy.
The study included 400 Hispanic patients ages 50–75 past due for CRC screening who were receiving care at one of five primary care practices in one healthcare system in southeastern Pennsylvania. Of these, 59% were female, and 69% were ages 50–59. In addition, 83% of patients spoke Spanish at home.
Six months after randomization, researchers administered a phone-based survey assessing participants’ knowledge and perceptions of CRC screening, including perceived cancer susceptibility, health literacy, worries about cancer, and social support. The survey also assessed participants’ stage in decision making regarding screening. At one year, researchers reviewed patients’ medical records to assess adherence to CRC screening.
An advisory committee of patients, Hispanic community leaders, and clinicians reviewed study procedures and provided feedback on the study.
Results
Compared with patients who received only the mailing, patients who also received decision support and navigation were
- 4.8 times more likely to have had either screening test for CRC (p<0.001)
- 4.2 times more likely to have had a stool blood test (p<0.001)
- 8.8 times more likely to have a colonoscopy (p<0.001)
- 4.9 times more likely to have moved forward in their decision-making stage (p<0.001)
No differences appeared between groups for patient knowledge and perceptions about CRC and screening.
Limitations
The study included Hispanic patients from primary care practices in one healthcare system in one state. The results may be different for patients in other healthcare settings, other parts of the country, or of other ethnicities.
Conclusions and Relevance
Patients who had telephone decision support were more likely to complete CRC screening tests than patients who did not. Providing decision support may increase CRC screening rates among Hispanic patients, for whom CRC screening rates are low.
Future Research Needs
Future research could look at telephone decision support for getting a screening test with people from other places or backgrounds.
Final Research Report
View this project's final research report.
More to Explore...
Blogs
Encouraging Colorectal Cancer Screening among Hispanics
One of the more than 100 PCORI-funded studies that are addressing disparities in health and healthcare takes on colorectal cancer, for which early detection save lives: 90 percent of people whose colorectal cancer is early stage at diagnosis live for at least five years, but only 14 percent of people whose cancer has spread to other parts of the body survive that long. Screening rates differ between groups of people, with Hispanics/Latinos falling behind whites. In this blog post, two members of a research team share insights and results from tests of a method to increase screening among Hispanics.
Videos
Increasing Colon Cancer Screening Rates in the Hispanic Population (right)
Hear more about how this study compared the effectiveness of two communication approaches by the Lehigh Valley Health Network in Pennsylvania to increase the colon cancer screening rate among Hispanics.
Decision Support and Navigation
Study principal investigator Ronald E. Myers, PhD says that decision support and navigation—an approach studied through his study—has potential to change practice if a centralized process is adopted and implemented by health systems.
Journal Citations
Results of This Project
Stories and Videos
Peer-Review Summary
Peer review of PCORI-funded research helps make sure the report presents complete, balanced, and useful information about the research. It also assesses how the project addressed PCORI’s Methodology Standards. During peer review, experts read a draft report of the research and provide comments about the report. These experts may include a scientist focused on the research topic, a specialist in research methods, a patient or caregiver, and a healthcare professional. These reviewers cannot have conflicts of interest with the study.
The peer reviewers point out where the draft report may need revision. For example, they may suggest ways to improve descriptions of the conduct of the study or to clarify the connection between results and conclusions. Sometimes, awardees revise their draft reports twice or more to address all of the reviewers’ comments.
Peer reviewers commented, and the researchers made changes or provided responses. Those comments and responses included the following:
- Reviewers expressed concern about the substantial number of patients in the study source population who did not participate in the research and therefore, whether the patients who agreed to participate were truly representative of the source population. The researchers explained in the report that they compared characteristics of patients included in the study to those of the source population. The comparisons indicated that patients included in the study were more likely to be under 60 years old and to come from certain primary care practices than those in the source population.
- Reviewers noted that the report did not sufficiently discuss the low rates of stool blood test rescreening, despite a much higher rate of initial screenings in the navigator intervention group compared to the standard practice group. The researchers hypothesized in the report’s discussion that the low rate of rescreening in the intervention group was due to the lack of additional intervention contacts, which reduced motivation in this group. The investigators hypothesized further that comparison patients, however, had to be more self-motivated from the beginning to complete the stool blood test initially and therefore, probably had a higher rate of motivation to follow the guidelines for annual screening.