ColonCancerCheck Mailed Invitations: An Evaluation
Condition: Colorectal Disorders
Study type: Interventional

Summary: 
      This study evaluates effectiveness of mailed invitations for colorectal cancer screening
      among screen-eligible Ontarians who are due for screening. The study will evaluate the
      effectiveness of mailed invitations in general (compared to no invitation) but will also
      determine if new invitation letters (2 letters for male, 1 letter for females) are more
      effective than current invitation letters used by the ColonCancerCheck program.
    

Detailed description: 
      On April 1 2008, Ontario launched Canada's first organized province-wide CRC screening
      program, ColonCancerCheck (CCC). CCC has a dual strategy: through the primary care physician,
      FOBT is offered to people aged 50 to 74 years at average risk for colorectal cancer and
      colonoscopy to those at increased risk based on family history. In 2010-2011, approximately
      30% of Ontarians 50-74 years old were screened for colorectal cancer using the FOBT. An
      important factor in increasing screening participation is an invitation system.

      A central tenet of organized screening programs is that all persons in the target population
      be invited to participate. In 2010, CCC began implementing a correspondence program in an
      effort to improve participation in colorectal cancer screening, starting with recall letters
      to individuals who were due for repeat screening two years after a normal fecal occult blood
      test (FOBT) and invitation letters to screen-eligible individuals who are due for screening
      and have not received correspondence from CCO to participate in colorectal cancer screening
      in the past two years to complete a screening test for colorectal cancer. Individuals who are
      "due for screening" includes those who have not had a FOBT in the past 2 years, a flexible
      sigmoidoscopy in the past 5 years, and a colonoscopy in the past 10 years. Currently, CCC
      sends 10,000 invitation letters monthly to 50-54 year olds only. In October 2013, the CCC
      correspondence program expanded to also include all eligible Ontarians 55-74 years old.

      The current CCC invitation letter includes general information on the benefits of screening
      for colorectal cancer, the screening test itself (FOBT), and contact information to get more
      information. It is meant to invite individuals to speak with their primary care provider
      about colorectal screening. In 2013 Diego Llovet, a lead qualitative researcher at CCO,
      completed a series of qualitative studies examining the content of current CCC correspondence
      materials and made recommendations to improve the content of invitation letters. These
      recommendations were based on four key types of information: a) findings from seven focus
      groups with screen-eligible Ontarians (men and women, 50-74) who provided feedback on the
      messages that should be included in these letters, b) input provided by six experts in health
      communications and health promotion on the content and style of effective cancer screening
      correspondence, c) evidence from behavioral science studies on barriers to participation in
      colorectal cancer screening, and d) theories of health behavior change. Based on findings
      from focus group studies examining the content of the current CCC letter, a unisex and a
      male-tailored invitation letter were developed. A female-tailored letter was not developed as
      the focus group studies with females showed that they did not prefer female tailored
      messaging to a unisex one.

      In the current study, we propose to test the effectiveness of mailed invitations for
      colorectal cancer screening in the real world setting of the CCC program. We will evaluate
      the effectiveness of mailed invitations in general (i.e., compared to no invitation) but we
      will also determine whether letters developed based on theories from behavioural science and
      on the results of qualitative studies with Ontarians in the target population are more
      effective than those currently used by the program. The findings from this study will be used
      to inform the CCC program correspondence but will also provide valuable information for the
      development of correspondence for other screening programs at Cancer Care Ontario and in
      other jurisdictions engaged in organized screening programs.
    

Intervention name(s): Males control group: Deferred letter; Males Group 1: Current CCC invitation letter; Males Group 2: New letter with neutral gender content; Males Group 3: New letter with male-specific content; Females control group: Deferred letter; Females Group 1: Current CCC invitation letter; Females Group 2: New letter with neutral gender content
Intervention type(s): Other; Other; Other; Other; Other; Other; Other
Intervention description(s): This letter will be sent 6 months after index (mailing) date; This letter is currently used by the program in 50-54 year olds; Unisex letter; New letter tailored for men; This letter will be sent 6 months after index (mailing) date; This letter is currently used by the program in 50-54 year olds; Unisex letter
Allocation: Randomized
Intervention model: Factorial Assignment
Masking: Single (Investigator)
Primary purpose: Screening
Keywords: Mailed invitation; Fecal Occult Blood Test; Screening