Text Messaging and Opt-out Mailed Outreach in Colorectal Cancer Screening: a Randomized Clinical Trial

Abstract

Background

Routine screening reduces colorectal cancer mortality, but screening rates fall below national targets and are particularly low in underserved populations.

Objective

To compare the effectiveness of a single text message outreach to serial text messaging and mailed fecal home test kits on colorectal cancer screening rates.

Design

A two-armed randomized clinical trial.

Participants

An urban community health center in Philadelphia. Adults aged 50–74 who were due for colorectal cancer screening had at least one visit to the practice in the previously year, and had a cell phone number recorded.

Interventions

Participants were randomized (1:1 ratio). Individuals in the control arm were sent a simple text message reminder as per usual practice. Those in the intervention arm were sent a pre-alert text message offering the options to opt-out of receiving a mailed fecal immunochemical test (FIT) kit, followed by up to three behaviorally informed text message reminders.

Main Measures

The primary outcome was participation in colorectal cancer screening at 12 weeks. The secondary outcome was the FIT kit return rate at 12 weeks.

Key Results

Four hundred forty participants were included. The mean age was 57.4 years (SD ± 6.1). 63.4% were women, 87.7% were Black, 19.1% were uninsured, and 49.6% were Medicaid beneficiaries. At 12 weeks, there was an absolute 17.3 percentage point increase in colorectal cancer screening in the intervention arm (19.6%), compared to the control arm (2.3%, p < 0.001). There was an absolute 17.7 percentage point increase in FIT kit return in the intervention arm (19.1%) compared to the control arm (1.4%, p < 0.001).

Conclusions

Serial text messaging with opt-out mailed FIT kit outreach can substantially improve colorectal cancer screening rates in an underserved population.

Trial Registration

clinicaltrials.gov (https://clinicaltrials.gov/ct2/show/NCT03479645)

This is a preview of subscription content, access via your institution.

Figure 1

References

  1. 1.

    Hardcastle JD, Chamberlain JO, Robinson MH, Moss SM, Amar SS, Balfour TW, et al. Randomised controlled trial of faecal-occult-blood screening for colorectal cancer. Lancet. 1996;348(9040):1472-7.https://doi.org/10.1016/S0140-6736(96)03386-7

    CAS  Article  PubMed  Google Scholar 

  2. 2.

    Hewitson P, Glasziou P, Watson E, Towler B, Irwig L. Cochrane systematic review of colorectal cancer screening using the fecal occult blood test (hemoccult): an update. Am J Gastroenterol 2008;103(6):1541-9.https://doi.org/10.1111/j.1572-0241.2008.01875.x

    Article  PubMed  Google Scholar 

  3. 3.

    Schwartz LM, Woloshin S, Fowler FJ, Jr., Welch HG. Enthusiasm for cancer screening in the United States. JAMA. 2004;291(1):71-8.https://doi.org/10.1001/jama.291.1.71

    CAS  Article  PubMed  Google Scholar 

  4. 4.

    CDC.gov. Use of Colorectal Cancer Screening Tests by State www.cdc.gov/cancer: Center for Disease Control; 2016 [Available from: https://www.cdc.gov/cancer/dcpc/research/articles/use-colorectal-screening-tests-state.htm.

  5. 5.

    Healthypeople.gov. Colorectal Cancer Screening (C-16) healthypeople.gov2018 [Available from: https://www.healthypeople.gov/2020/leading-health-indicators/2020-lhi-topics/Clinical-Preventive-Services/data.

  6. 6.

    Guessous I, Dash C, Lapin P, Doroshenk M, Smith RA, Klabunde CN, et al. Colorectal cancer screening barriers and facilitators in older persons. Prev Med 2010;50(1-2):3-10.https://doi.org/10.1016/j.ypmed.2009.12.005

    Article  PubMed  Google Scholar 

  7. 7.

    Halpern MT, Ward EM, Pavluck AL, Schrag NM, Bian J, Chen AY. Association of insurance status and ethnicity with cancer stage at diagnosis for 12 cancer sites: a retrospective analysis. Lancet Oncol 2008;9(3):222-31.https://doi.org/10.1016/S1470-2045(08)70032-9

    Article  PubMed  Google Scholar 

  8. 8.

    Tversky A, Kahneman D. The framing of decisions and the psychology of choice. Science. 1981;211(4481):453-8

    CAS  Article  Google Scholar 

  9. 9.

    Mehta SJ, Asch DA. How to help gastroenterology patients help themselves: leveraging insights from behavioral economics. Clin Gastroenterol Hepatol 2014;12(5):711-4.https://doi.org/10.1016/j.cgh.2014.02.022

    Article  PubMed  Google Scholar 

  10. 10.

    Mehta SJ, Khan T, Guerra C, Reitz C, McAuliffe T, Volpp KG, et al. A Randomized Controlled Trial of Opt-in Versus Opt-Out Colorectal Cancer Screening Outreach. Am J Gastroenterol 2018.https://doi.org/10.1038/s41395-018-0151-3

  11. 11.

    Giorgi Rossi P, Grazzini G, Anti M, Baiocchi D, Barca A, Bellardini P, et al. Direct mailing of faecal occult blood tests for colorectal cancer screening: a randomized population study from Central Italy. J Med Screen 2011;18(3):121-7.https://doi.org/10.1258/jms.2011.011009

    Article  PubMed  Google Scholar 

  12. 12.

    Kahneman D TA. Prospect Theory: An Analysis of Decision under Risk. Econometrica. 1979;47(2):263-92.https://doi.org/10.2307/1914185

    Article  Google Scholar 

  13. 13.

    Samuelson W, Zeckhauser, R. . Status quo bias in decision making. J Risk Uncertain 1988;1:7-59

    Article  Google Scholar 

  14. 14.

    Rutter DR. Attendance and reattendance for breast cancer screening: A prospective 3-year test of the Theory of Planned Behaviour. Br J Health Psychol 2000;5(1).https://doi.org/10.1348/135910700168720

  15. 15.

    Sharot T. The Optimism Bias: Why We’re Wired to Look on the Bright Side: Constable & Robinson; 2012.

  16. 16.

    Weinstein ND, Marcus SE, Moser RP. Smokers’ unrealistic optimism about their risk. Tob Control. 2005;14(1):55-9. https://doi.org/10.1136/tc.2004.008375

    CAS  Article  PubMed  PubMed Central  Google Scholar 

  17. 17.

    Cialdini RB. Influence : the psychology of persuasion. Rev. ed. New York: Collins; 2007. xiv, 320 p. p.

    Google Scholar 

  18. 18.

    Fehr EG, Simon. Fairness and Retaliation: The Economics of Reciprocity. J Econ Perspect 2000;14(3):159-81

    Article  Google Scholar 

  19. 19.

    Tinmouth J, Patel J, Austin PC, Baxter NN, Brouwers MC, Earle C, et al. Increasing participation in colorectal cancer screening: results from a cluster randomized trial of directly mailed gFOBT kits to previous nonresponders. Int J Cancer 2015;136(6):E697-703.https://doi.org/10.1002/ijc.29191

    CAS  Article  PubMed  Google Scholar 

  20. 20.

    Cole SR, Smith A, Wilson C, Turnbull D, Esterman A, Young GP. An advance notification letter increases participation in colorectal cancer screening. J Med Screen 2007;14(2):73-5. https://doi.org/10.1258/096914107781261927

    CAS  Article  PubMed  Google Scholar 

  21. 21.

    Libby G, Bray J, Champion J, Brownlee LA, Birrell J, Gorman DR, et al. Pre-notification increases uptake of colorectal cancer screening in all demographic groups: a randomized controlled trial. J Med Screen 2011;18(1):24-9.https://doi.org/10.1258/jms.2011.011002

    Article  PubMed  Google Scholar 

  22. 22.

    Hewitson P, Ward AM, Heneghan C, Halloran SP, Mant D. Primary care endorsement letter and a patient leaflet to improve participation in colorectal cancer screening: results of a factorial randomised trial. Br J Cancer 2011;105(4):475-80.https://doi.org/10.1038/bjc.2011.255

    CAS  Article  PubMed  PubMed Central  Google Scholar 

  23. 23.

    Cole SR, Young GP, Byrne D, Guy JR, Morcom J. Participation in screening for colorectal cancer based on a faecal occult blood test is improved by endorsement by the primary care practitioner. J Med Screen. 2002;9(4):147-52. https://doi.org/10.1136/jms.9.4.147

    CAS  Article  PubMed  Google Scholar 

  24. 24.

    Zajac IT, Whibley AH, Cole SR, Byrne D, Guy J, Morcom J, et al. Endorsement by the primary care practitioner consistently improves participation in screening for colorectal cancer: a longitudinal analysis. J Med Screen 2010;17(1):19-24.https://doi.org/10.1258/jms.2010.009101

    CAS  Article  PubMed  Google Scholar 

  25. 25.

    de Nooijer DP, de Waart FG, van Leeuwen AW, Spijker WW Participation in the Dutch national screening programme for uterine cervic cancer higher after invitation by a general practitioner, especially in groups with a traditional low level of attendance. Ned Tijdschr Geneeskd 2005;149(42):2339-43

    PubMed  Google Scholar 

  26. 26.

    Kahneman D TA. Anomalies: Utility Maximization and Experienced Utility. J Econ Perspect 2006;20(1):221-34

    Article  Google Scholar 

  27. 27.

    Paul Dolan DDH, King D, Vlaev I, Hallsworth M MINDSPACE Influencing behaviour through public policy. 2010.

  28. 28.

    Acera A, Manresa JM, Rodriguez D, Rodriguez A, Bonet JM, Sanchez N, et al. Analysis of three strategies to increase screening coverage for cervical cancer in the general population of women aged 60 to 70 years: the CRICERVA study. BMC Womens Health 2014;14:86.https://doi.org/10.1186/1472-6874-14-86

    Article  PubMed  PubMed Central  Google Scholar 

  29. 29.

    USPTF. The Community Guide, What works to promote health. Cancer Prevention and Control: Client-Oriented Interventions to Increase Breast, Cervical, and Colorectal Cancer Screening 2016 [Available from: http://www.thecommunityguide.org/cancer/screening/client-oriented/index.html.

  30. 30.

    Prevention CfDCa. Increasing Colorectal Cancer Screening: An Action Guide for Working with Health Systems. Atlanta: Centers for Disease Control and Prevention, US Dept of Health and Human Services;; 2013 [Available from: https://www.cdc.gov/cancer/crccp/pdf/colorectalactionguide.pdf.

  31. 31.

    Baker DW, Brown T, Buchanan DR, Weil J, Balsley K, Ranalli L, et al. Comparative effectiveness of a multifaceted intervention to improve adherence to annual colorectal cancer screening in community health centers: a randomized clinical trial. JAMA Intern Med 2014;174(8):1235-41. https://doi.org/10.1001/jamainternmed.2014.2352

    Article  PubMed  Google Scholar 

  32. 32.

    Duffy SW, Myles JP, Maroni R, Mohammad A. Rapid review of evaluation of interventions to improve participation in cancer screening services. J Med Screen 2016.https://doi.org/10.1177/0969141316664757

  33. 33.

    Uy C, Lopez J, Trinh-Shevrin C, Kwon SC, Sherman SE, Liang PS. Text Messaging Interventions on Cancer Screening Rates: A Systematic Review. J Med Internet Res. 2017;19(8):e296. https://doi.org/10.2196/jmir.7893

    Article  PubMed  PubMed Central  Google Scholar 

  34. 34.

    Hagoel L, Neter E, Stein N, Rennert G. Harnessing the Question-Behavior Effect to Enhance Colorectal Cancer Screening in an mHealth Experiment. Am J Public Health 2016;106(11):1998-2004. https://doi.org/10.2105/AJPH.2016.303364

    Article  PubMed  PubMed Central  Google Scholar 

  35. 35.

    Muller CJ, Robinson RF, Smith JJ, Jernigan MA, Hiratsuka V, Dillard DA, et al. Text message reminders increased colorectal cancer screening in a randomized trial with Alaska Native and American Indian people. Cancer. 2017;123(8):1382-9.https://doi.org/10.1002/cncr.30499

    Article  PubMed  Google Scholar 

  36. 36.

    Hirst Y, Skrobanski H, Kerrison RS, Kobayashi LC, Counsell N, Djedovic N, et al. Text-message Reminders in Colorectal Cancer Screening (TRICCS): a randomised controlled trial. Br J Cancer 2017;116(11):1408-14.https://doi.org/10.1038/bjc.2017.117

    Article  PubMed  PubMed Central  Google Scholar 

  37. 37.

    Huf S, Kerrison RS, King D, Chadborn T, Richmond A, Cunningham D, et al. Behavioral economics informed message content in text message reminders to improve cervical screening participation: Two pragmatic randomized controlled trials. Prev Med. 2020;139:106170. https://doi.org/10.1016/j.ypmed.2020.106170

    Article  PubMed  Google Scholar 

  38. 38.

    Asch DA, Ziolek TA, Mehta SJ. Misdirections in Informed Consent - Impediments to Health Care Innovation. N Engl J Med 2017;377(15):1412-4.https://doi.org/10.1056/NEJMp1707991

    Article  PubMed  Google Scholar 

  39. 39.

    Mehta SJ, Oyalowo A, Reitz C, Dean O, McAuliffe T, Asch DA, et al. Text messaging and lottery incentive to improve colorectal cancer screening outreach at a community health center: A randomized controlled trial. Prev Med Rep 2020;19:101114.https://doi.org/10.1016/j.pmedr.2020.101114

    Article  PubMed  PubMed Central  Google Scholar 

  40. 40.

    www.caremessage.org. CareMessage [Available from: www.caremessage.org.

  41. 41.

    Senore C, Ederle A, DePretis G, Magnani C, Canuti D, Deandrea S, et al. Invitation strategies for colorectal cancer screening programmes: The impact of an advance notification letter. Prev Med 2015;73:106-11.https://doi.org/10.1016/j.ypmed.2015.01.005

    Article  PubMed  Google Scholar 

  42. 42.

    Zajac IT, Duncan AC, Flight I, Wittert GA, Cole SR, Young GP, et al. Theory-based modifications of an advanced notification letter improves screening for bowel cancer in men: A randomised controlled trial. Soc Sci Med. 2016;165:1-9. https://doi.org/10.1016/j.socscimed.2016.06.036

    Article  PubMed  Google Scholar 

  43. 43.

    Halpern SD, Ubel PA, Asch DA. Harnessing the power of default options to improve health care. N Engl J Med 2007;357(13):1340-4.https://doi.org/10.1056/NEJMsb071595

    CAS  Article  PubMed  Google Scholar 

Download references

Acknowledgments

The clinical care and IT team at the Family Planning and Counseling Network, where this trial was completed, were integral in the successful completion this RCT.

Funding

Dr. Huf’s time is supported by the Commonwealth Fund through the Harkness Fellowship. Dr. Volpp’s time is supported by the NIA P30 Penn Roybal Center on Behavioral Economics and Health. Dr. Mehta’s time is supported by grant number K08CA234326 from the National Cancer Institute.

Author information

Affiliations

Authors

Corresponding author

Correspondence to Sarah W. Huf MBBS, PhD.

Ethics declarations

Conflict of Interest

Dr. Huf has nothing to disclose; Dr. Asch reports other from Principle at the behavioral consulting firm VAL, outside the submitted work; Dr. Volpp reports grants from National Institute on Aging P30 Penn Roybal Center on Behavioral Economics and Health, personal fees from Consulting income CVS Caremark, other from Research funding CVS Caremark, other from Research funding Humana, other from Research funding Discovery (South Africa), other from Research funding Hawaii Medical Services Association, other from Research funding Oscar, other from Research funding Weight Watchers, other from Principle at behavioral economics consulting firm VAL Health, outside the submitted work; Ms. Reitz has nothing to disclose; Dr. Mehta reports grants from K08CA234326 from the National Cancer Institute, outside the submitted work.

Additional information

Publisher’s Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Supplementary Information

ESM 1

(DOCX 142 kb)

Rights and permissions

Reprints and Permissions

About this article

Verify currency and authenticity via CrossMark

Cite this article

Huf, S.W., Asch, D.A., Volpp, K.G. et al. Text Messaging and Opt-out Mailed Outreach in Colorectal Cancer Screening: a Randomized Clinical Trial. J GEN INTERN MED (2021). https://doi.org/10.1007/s11606-020-06415-8

Download citation

KEY WORDS

  • colorectal cancer screening
  • behavioral economics
  • text message reminders
  • fecal immunochemistry test (FIT)
  • mailed outreach