Navigation, FIT may increase CRC screening

Patient navigation and mailed fecal immunochemical test (FIT) outreach are the most effective strategies for increasing colorectal cancer screening uptake, significantly outperforming usual care, according to a network meta-analysis of randomized trials published in Gastroenterology.

Study design and intervention strategies

The systematic review and network meta-analysis of 76 randomized clinical trials including 400,638 patients evaluated eight intervention strategies to improve colorectal cancer screening uptake: patient navigation, mailed FIT outreach, educational multimedia, reminder-only, choice-based outreach, colonoscopy outreach, multistep, and usual care. Searches spanned multiple databases through March 2024, with screening completion as the primary outcome.

Compared with usual care, patient navigation increased screening uptake by 58%, while mailed FIT outreach increased screening uptake by 36%. Educational multimedia and reminder-only interventions showed smaller increases of 27% and 24%, respectively. Choice-based outreach and colonoscopy outreach did not significantly improve screening over usual care.

Direct comparisons showed mailed FIT outreach was 1.35 times more effective than colonoscopy outreach, and patient navigation was 1.48 times more effective than reminder-only strategies. Ranking analyses supported these findings, with patient navigation and mailed FIT outreach having the highest probability of being the most effective interventions.

Absolute effects were reported using a pooled baseline screening rate of 31%. Patient navigation increased screening by 18%, corresponding to one additional patient screened for every six treated, while mailed FIT outreach increased screening by 11%, or one additional patient screened for every nine treated.

Baseline screening uptake

Subgroup analyses demonstrated variation by baseline screening uptake. In populations with baseline uptake below 30%, mailed FIT outreach was associated with a threefold increase in screening, while patient navigation and educational multimedia also showed increased effectiveness. In populations with baseline uptake of at least 30%, educational multimedia was the only intervention with statistically significant benefit, while mailed FIT outreach showed smaller gains.

Temporal analyses showed patient navigation had the highest effectiveness in earlier study periods, while educational multimedia ranked highest in more recent studies from 2021 to 2024. In analyses restricted to US-based trials, mailed FIT outreach demonstrated the strongest effect, followed by choice-based outreach and patient navigation.

Most included studies were assessed as low risk of bias or with some concerns, and certainty of evidence ranged from moderate for patient navigation and mailed FIT outreach to low or very low for other interventions, largely due to heterogeneity and imprecision.

"Clinicians should recognize that not all colorectal cancer screening interventions are equally effective," said lead researcher Daryl Ramai, MD, MPH, MSc, in an interview with GI & Hepatology News. "This analysis demonstrates that patient navigation and mailed fecal immunochemical test outreach are very impactful strategies for increasing screening uptake, consistently outperforming usual care. Patient navigation offers the greatest overall benefit, particularly for patients facing structural or socioeconomic barriers, while mailed FIT outreach provides a scalable and practical solution that can be deployed at the population level."

The effectiveness of these interventions varies by context. “Mailed FIT outreach is especially powerful in low baseline screening populations, whereas educational multimedia may play a larger role in settings where screening rates are higher," said Dr. Ramai, director of Third Space Endoscopy, director of Endoscopic Research, Assistant Professor of Medicine, Division of Gastroenterology, Hepatology, and Nutrition, at the Spencer Fox Eccles School of Medicine, University of Utah.

Limitations 

Limitations included substantial variability in intervention effects, lack of evaluation of combination strategies, and limited assessment of long-term adherence beyond initial screening completion.

"Clinicians must remain mindful of the limitations of FIT, including its potential to miss intermittently bleeding lesions and the need for repeated annual testing," said Dr. Ramai. "Improving initial screening uptake is only one step; ensuring appropriate follow-up after abnormal results remains critical to achieving the full benefit of screening programs."

He also noted that reminder-only strategies and colonoscopy-focused outreach, when used in isolation, appear insufficient and should not be relied upon as primary interventions. "Instead, clinicians and health systems should tailor their approach based on patient population characteristics, resource availability, and existing screening infrastructure, integrating more intensive strategies where barriers to care are greatest," he said.

Cautions to consider

Dr. Ramai noted that the certainty of evidence was moderate for patient navigation and mailed FIT outreach but lower for other strategies, and that intervention effectiveness may vary depending on health care system factors, patient demographics, and implementation fidelity. He also pointed out that patient navigation, while highly effective, is resource-intensive and may be challenging to scale in all settings.

"In contrast, mailed FIT outreach is more scalable but may require complementary strategies to ensure follow-up and sustained adherence over time," he explained.

Next steps 

Dr. Ramai highlighted the need for future research to assess combination strategies that integrate navigation, outreach, and digital tools to maximize effectiveness. "Implementation science approaches will be critical to understanding how best to adapt these interventions across diverse health care environments. Additionally, further work is needed to explore the evolving role of digital and multimedia interventions, particularly as technology (including artificial intelligence) becomes more integrated into patient engagement and education," he concluded.

One researcher reported consulting and research relationships with multiple medical device and pharmaceutical companies; another reported consulting for a device manufacturer.