Colorectal cancer screening participation among newly eligible adults aged 45 to 49 years was significantly higher when fecal immunochemical test kits were mailed by default compared with three active choice strategies requiring patients to select screening options through an electronic patient portal, according to two studies published in JAMA.
Among individuals aged 45 to 49 years, up to date (UTD) colorectal cancer (CRC) screening prevalence increased from 20.8% in 2019 and 19.7% in 2021 to 33.7% in 2023, colonoscopy prevalence increased from 19.5% in 2019 and 17.8% in 2021 to 27.7% in 2023, and stool-based testing increased from 1.3% in 2019 and 2.7% in 2021 to 7.1% in 2023.
The randomized clinical trial involving 20,509 UCLA Health patients found that "participation was significantly lower in each of the 3 active choice groups (fecal immunochemical test (FIT) only, 841 of 5,131; colonoscopy only, 743 of 5,127; dual-modality FIT or colonoscopy, 890 of 5,125) than in the usual care default mailed FIT group (1,342 of 5,126; all P < .001)."
The companion observational study using National Health Interview Survey data from 2019-2023 revealed substantial increases in screening uptake following the 2021 U.S. Preventive Services Task Force recommendation to begin screening at age 45. Across survey years, individuals aged 45 to 49 years were primarily White and privately insured.
Methodology and Key Findings
The UCLA Health randomized trial, conducted from May 2-13, 2022, with 6-month follow-up, assigned participants 1:1:1:1 to four outreach strategies: FIT-only active choice, colonoscopy-only active choice, dual-modality (FIT or colonoscopy) active choice, and usual care default mailed FIT outreach.
Among 20, 509 participants (53.9% female, 4.2% Black and 50.8% non-Hispanic White; mean [SD] age, 47.4 [1.5] years), 3,816 (18.6%) underwent screening.
"There was notable crossover in the FIT-only groups to colonoscopy (502 of 5,131 [9.8%; FIT-only active choice] and 501 of 5,126 [9.8%; usual care default mailed FIT]). Crossover from colonoscopy to FIT was modest (137 of 5,127 [2.7%; colonoscopy-only active choice])," noted researchers on the trial's secondary outcomes.
Among participants offered dual-modality choice, "colonoscopy was more common than FIT."
Population-Level Trends
The National Health Interview Survey analysis examined 18,645, 17,300, and 17,293 respondents aged 40 to75 years in 2019, 2021, and 2023, respectively, with 14.8%, 13.9%, and 14.0% aged 45 to 49 years. The study found that "screening remained mostly stable for all other age groups." Although CRC completion was lower with the 3 active choice interventions compared with usual care in a randomized trial involving adults aged 45 to 49 years.
Importantly, the observational study revealed disparities in screening uptake. Among adults aged 45 to 49 years, UTD CRC screening increased only for college graduates (24.0%–39.4%; APR, 1.66) and the privately insured (21.6%–36.6%; APR, 1.70); rates were unchanged for the uninsured and those without a high school education.
Clinical Implications
The findings may have immediate implications for population health strategies targeting the newly eligible age group. From 2019 to 2023, CRC screening rose among U.S. adults aged 45 to 49 years, echoing earlier trends seen in 2021 to 2022 data in insured populations. The researchers noted that, "This trend is encouraging because screening reduces CRC mortality, mostly through the detection and removal of potentially precancerous lesions."
Study Limitations and Context
Both studies acknowledged limitations that may affect generalizability. The UCLA trial included only average-risk individuals with a mean Social Vulnerability Index score of 31.0 (SD, 24.8), indicating relatively low to medium vulnerability. The observational study noted potential respondent bias from self-reporting and emphasized that, compared with claims-based data, which are less affected by respondent bias, UTD screening estimates were higher but may be less generalizable.
"Study limitations included potential respondent bias from nonresponse, social desirability, and inaccurate recall and the associated risk of overestimation."
The research comes as colorectal cancer incidence continues rising in younger adults, as colorectal cancer has become the most common cause of cancer death in men aged 20 to 49 years and the second most common in women of the same age group.
The UCLA study authors reported no relevant financial conflicts of interest, while disclosures for the research letter authors are detailed in the published article.
Source: JAMA Investigation and Research Letter
