Abstract PR12: CRC screening in rural community clinics using the fecal immunochemical test (FIT): Issues with repeat screening
Authors: Arnold Connie L. , Davis Terry C. , Morris James , Murphy Peggy , Mills Glenn 
Published: August 2020

Abstract
Introduction: Colorectal cancer (CRC), the second leading cause of cancer death in the United States, can be significantly reduced if it is detected early. Although overall CRC screening rates have increased significantly, disparities persist among low-income individuals, adults with low literacy and those living in rural areas. These groups all have screening completion rates below 50%.
Objectives: To assess patient knowledge, beliefs, and self-efficacy about CRC screening and compare the effectiveness of two health literacy informed telephone follow-up strategies to improve annual screening over a three-year period with fecal immunochemical test (FIT) in rural community clinics.
Methods: A two-arm, randomized controlled trial is being implemented in four community clinics. Clinics reported CRC baseline screening rates of 3% to 5%. Eligible patients, age 50-75, were recruited at the clinic prior to a scheduled appointment. A research assistant (RA) conducted a baseline structured interview measuring CRC screening knowledge, beliefs, and self-efficacy. The RA then recommended screening and gave brief literacy and culturally appropriate education using a pamphlet (4th-grade level), the FIT kit with preaddressed envelope, simplified instructions (3rd-grade level) and a demonstration of how to use it. At four weeks patients who had not returned their kit received either 1) a personal follow-up call (PC) from a central prevention coordinator using motivational interviewing skills and reminding them to complete and mail FIT kits, or 2) an automated follow-up call (AC) using plain language and motivational messages encouraging patients to complete and mail the FIT. Outcomes include FIT completion after intervention, and again at 12 and 24 months.
Results: 620 patients not up-to-date were enrolled: 308/AC and 306/PC; 66% were African American, 55% women; 40% had limited literacy. During Year 1, 69% completed screening in AC arm versus 67% in PC arm. During Year 2, percentage screened decreased: 40% screened in AC arm and 37% in PC arm. Number of patients who needed at least one follow-up call increased: 74% in both arms needed at least 1 reminder call. Among those called, 19% in the AC arm completed their kit versus 15% in the PC arm. To date in Year 3, 32% screened in AC and 34% in PC.
Conclusions: Simplified instructions accompanied by a face-to-face demonstration of FIT, and use of “teach back” to confirm understanding with a follow-up call if needed, facilitated completion rates of all patients, particularly those with limited literacy. Providing FIT + literacy appropriate education at regularly scheduled clinic visit with follow-up call (if needed) increased CRC screening rates of low-income, rural patients. Sustaining annual screening with FIT is challenging. In year 2 &lt; 40% completed FIT. Follow-up calls were essential. Only 1/4 completed FIT without phone prompt. Lower-cost automated call has proven to be just as effective as personal call in both years 1 and 2. FIT is only effective if completed annually.
This abstract is also being presented as Poster B099.
Citation Format: Connie L. Arnold, Terry C. Davis, James Morris, Peggy Murphy, Glenn Mills. CRC screening in rural community clinics using the fecal immunochemical test (FIT): Issues with repeat screening [abstract]. In: Proceedings of the Eleventh AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2018 Nov 2-5; New Orleans, LA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2020;29(6 Suppl):Abstract nr PR12.