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Of All Things To Entice People To Get Screened For Colon Cancer: Reminders In The Mail

Thousands of patients at Parkland Health & Hospital were mailed letters urging them to be screened for colon cancer. Some received an at-home test kit as well.
UT Southwestern Medical Center
Thousands of patients at Parkland Health & Hospital were mailed letters urging them to be screened for colon cancer. Some received an at-home test kit as well.

What, if anything, can convince people to get tested for colorectal cancer?


Researchers have tried a variety of methods — from reminding patients during yearly checkups to paying them — but there may be a cheaper, easier way to boost screening rates, using snail mail.



For decades, the percentage of people who die from colorectal cancer in the U.S. has been declining, which is why a medical study earlier this year was such a shock. It showed deaths from colorectal cancer increasing for some young and middle-aged Americans. While screening is one effective way to detect and even prevent the cancer, only about 60 percent of Americans are up to date.


“People have strong concerns or worries or are grossed out by the idea of testing,” says Dr. Ethan Halm, professor of internal medicine and clinical sciences at the University of Texas Southwestern Medical Center.


Regular testing, Halm says, is the best way to detect the microscopic bumps inside the intestines that, over time, can become cancer. Traditionally, if a patient is due for screening, a doctor will recommend it during the checkup with the hope that the patient will follow up. Butfollow-up rates are low.


Halm and his colleagues at UT Southwestern decided to test two reminder systems on thousands of patients at Parkland Hospital over a period of three years. The first group of patients received a letter in the mail — you know, the kind you get from your dentist — reminding them to complete screening. The other group received an at-home test kit called FIT. That cute name stands for fecal immunochemical test.


“This newer one sample FIT test came out that’s much more sensitive than the older cards," Halm says. “It’s much easier to use, it’s more accurate and doesn’t require any changes in your diet.”


Both groups of patients who received a reminder or a reminder plus a test kit were more likely to get screened than the control group. In fact, they were three times more likely. The results of the study were published in JAMA. The surprise, Halm says, was that patients who received the simple colonoscopy letter — no free FIT kit included — were the most likely to complete screening for all three years.


“Almost a third of the people who did the first FIT test didn’t end up doing it every year as recommended,” Halm says.


Or, they had a positive test result, and never followed up with a colonoscopy.


Mail proves more effective than money


Still, the overall increase in screening rates impresses Dr. Douglas Corley. He’s a research scientist at Kaiser Permanente who focuses on colorectal cancer screening.


“In a nutshell,” Corley says, “it seems that any outreach increases your likelihood of screening, and having more than one option for screening increases your likelihood of getting screened by at least something.”


Corley says there are other incentives researchers have tried to entice patients to get colonoscopies, like paying them.


“It seems like [money] may increase rates, but doesn’t increase them a lot, certainly not in the magnitude that was seen here,” Corley says.


That’s not to say that giving someone $1,000 wouldn’t work, but Dr. Halm made a deliberate choice to test two low-tech, affordable strategies that could be scaled up if they were successful.


“We wanted to try something that we thought could be implemented and disseminated in real-world practice if it worked,” Halm says.


Based on the success of the study, UT Southwestern received more than $1 million from the Cancer Prevention Research Institute of Texas to expand the program and start sending reminder letters to more Parkland patients.


Halm’s takeaway? There’s a lot that can be done with pretty basic interventions.


Oh, and snail mail isn’t dead.


Lauren Silverman was the Health, Science & Technology reporter/blogger at KERA News. She was also the primary backup host for KERA’s Think and the statewide newsmagazine  Texas Standard. In 2016, Lauren was recognized as Texas Health Journalist of the Year by the Texas Medical Association. She was part of the Peabody Award-winning team that covered Ebola for NPR in 2014. She also hosted "Surviving Ebola," a special that won Best Long Documentary honors from the Public Radio News Directors Inc. (PRNDI). And she's won a number of regional awards, including an honorable mention for Edward R. Murrow award (for her project “The Broken Hip”), as well as the Texas Veterans Commission’s Excellence in Media Awards in the radio category.