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



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


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.


A two-armed randomized clinical trial.


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.


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).


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)

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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.


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.

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Corresponding author

Correspondence to Sarah W. Huf MBBS, PhD.

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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.

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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

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