As a gastroenterologist, I’ve had the sobering experience of delivering a colorectal cancer diagnosis for far too many patients and family members. Some meant to get screened but never found the time. Others thought it didn’t apply to them or assumed it would be too inconvenient.
It’s one thing to tell someone that early cancer or a precancerous polyp can be removed before it progresses. It’s another to tell them they already have advanced stage cancer.
Colorectal cancer claims more than 50,000 lives each year in the United States. Early detection saves lives, yet an estimated 50 to 60 million Americans are not up to date with current screening recommendations. Closing the screening gap is one of the most urgent and solvable public health challenges we can collaboratively address, by working together to improve awareness and engagement.
Some have recently raised questions about health systems and health plans mailing use-at-home stool tests to people identified as overdue for colorectal cancer screening. Based on my clinical, research, and public health experience, I believe a more balanced understanding is needed, one that recognizes the established benefits of well-designed mail-out screening and acknowledges how these programs address an urgent public health issue.
In 2021, leading gastroenterologists, primary care clinicians, and public health leaders published a national implementation guide for mail-out CRC screening, to provide a resource for practices, plans, and payers interested in adopting this approach to improve screening engagement.
Well-designed programs generally include several key elements. The program sponsor (often a health plan or health system) first identifies the plan members or patients who are due for CRC screening and appropriate for a stool test based on available data.
The program sponsor, either directly or through a third-party laboratory, then provides the patient or plan member with the test kit and information about the test and how to ask questions before deciding whether to return their sample for testing. Test results are then issued for returned kits, and any abnormal results should be followed up with a timely colonoscopy.
Mail-out CRC screening programs have been organized and applied by large health systems and payers for many years to increase adherence and improve clinical outcomes. Two notable examples include Kaiser Permanente and the federal government through the U.S. Veterans Administration health systems.
Health insurers have also used mail-out stool tests to reach large populations of plan members who are due or overdue for CRC screening. These plans are responsible for identifying adults who qualify for average-risk screening and offer an evidence-based CRC screening option at no cost to the plan member.
Oftentimes, these “care gap” programs have leveraged annual fecal immunochemical test (FIT) screening, with more recent adoption of the Cologuard test as well. A CRC screening program is just one of many health plan quality initiatives that plan members can often participate in when enrolling in a health plan.
The evidence supporting health systems or payer led mail-out CRC screening programs is strong. The STOP CRC trial showed that mailed FIT outreach increased screening by 3.4 percentage points compared with usual care. A Florida Medicaid pilot reported a 4.4-point increase after introducing mailed tests. A rural Oregon trial found a 7.3-point gain at six months, and a 2023 meta-analysis concluded that mailed outreach improved screening by 22 to 28 percentage points across diverse populations.
Long-term data are even more persuasive. At Kaiser Permanente Northern California, two decades of systematic screening, which include organized mail-out FIT screening as a key component, reduced colorectal-cancer incidence and mortality by about 30 percent and 50 percent, respectively. When use-at-home screening and follow-up colonoscopy work together, population-level benefits follow.
Some clinicians may have the impression that mail-out CRC screening programs do not include clinical input and oversight. As described above, programs that use the Cologuard test require prescription by a licensed provider to initiate any kit shipment. Further, screening results are shared with clinical providers (including the patient’s primary care provider, if specified), who then provide information about arranging follow up colonoscopy after any positive test.
Sometimes critics point to rare cases where a kit was mailed to someone who should not have received it. These uncommon instances are regrettable and reflect the fragmented nature of health-data systems that health systems or health plans rely on to identify the population due for CRC screening rather than flaws in the outreach model itself. The remedy is better data integration and coordination, not abandoning an approach that can help save lives.
Organized mail-out screening programs can screen those who otherwise wouldn’t get screened and improve health outcomes. By removing logistical barriers such as transportation, time off work, and cost, stool-based testing reaches people who might never pursue procedure-based screening, particularly in difficult to reach populations, where CRC screening rates may be lower and mortality rates higher.
Programs done at this scale—like many public health initiatives—are not without their challenges. Sponsors need to continue to work to improve communication so patients can make informed decisions about CRC screening. Better data integration can help sponsors more accurately identify appropriate individuals for their program. And in an environment where patients’ primary care providers on record are sometimes inaccurate or unknown, special attention should be paid to care coordination.
These challenges can be reduced with more robust cooperation across payers, health systems, laboratories, and primary care and gastroenterology providers, for the benefit of all patients.
Mail-out programs are not the only answer to closing the CRC screening gap, but they should be considered as part of a coordinated prevention strategy that also includes high-quality colonoscopy, strong primary care, and organized systems for appropriate follow-up.
Together, these elements form an integrated continuum of care designed to reduce the morbidity and mortality associated with a largely preventable cancer.
The status quo in CRC screening is unacceptable. These programs have been successful at screening patients who are on the sidelines—patients who are often not coming in for care nor inclined to get screened. Mail-out screening programs represent one option for improvement and can be viewed as an extension, rather than a replacement, of office-based primary care.
The science is settled: CRC screening saves lives. The ongoing challenge is developing and improving beneficial solutions for people who are currently being left behind.
