Early, FIT-Based Colorectal Cancer Screening Feasible for African American Patients

Colorectal cancer,medical anatomical illustration.
Some guidelines suggest colorectal cancer (CRC) screening by age 50 for African Americans, but data on screening uptake and yield among this population is limited.

Study data published in Gastroenterology support the feasibility of fecal immunochemical test (FIT) screening for African American patients aged 45-50 years.

While the United States Multi-Society Task Force Guideline recommends that African Americans receive colorectal cancer (CRC) screening before age 50, there is little information on the screening uptake in these patients. This prospective study enrolled health plan members of Kaiser Permanente Northern California.

In 2018, African American patients aged 45-50 years were randomly selected for participation in an early-screening FIT kit program. Patients with a prior history of CRC, prior colonoscopy, or a family history of CRC were excluded. Tailored outreach materials and FIT kits were mailed to participants along with detailed instructions for completion. FIT-positive respondents were contacted to schedule a follow-up colonoscopy. Patients who did not complete the FIT kit received reminder phone calls and postcards. The comparison group comprised previously unscreened African American, white, Hispanic, and Asian/Pacific Islander patients aged 51-56 years. The comparison group was mailed FIT kits and tailored outreach materials during the same time period. Logistic regression analyses were conducted to evaluate between-group differences in screening uptake, colonoscopy receipt, and test yield. Models were adjusted for sex.

Among 10,232 African Americans who were selected for early screening, 3390 (33.1%) completed a FIT kit, and 136 (4.0%) had a positive FIT result. The majority (85.3%) of patients with a positive FIT kit received a follow-up colonoscopy, among whom 57.8% had any adenoma, 33.6% had an advanced adenoma, and 2.6% were diagnosed with CRC. Patients in the early screening group were more likely to return their FIT kits than African American patients aged 51-56 years (odds ratio [OR], 1.71; 95% CI, 1.57-1.87), white patients aged 51-56 years (OR, 1.18; 95% CI, 1.12-1.24), and Hispanic patients aged 51-56 years (OR, 1.35; 95% CI, 1.27-1.43).

FIT kit positivity rates were not significantly different between groups (range, 3.8%-4.6%). Rates of adenoma, advanced adenoma, and CRC were relatively comparable between groups. However, patients in the early screening program were more likely to have an adenoma with advanced histology than Asian/Pacific Islander patients (OR, 2.67; 95% CI, 1.13-6.29) and more likely to have an advanced adenoma than Hispanic patients (OR, 1.99; 95% CI, 1.04-3.83). Rates of follow-up colonoscopy in patients with positive FIT kits were high, exceeding 74% in all groups. 

African American patients aged 45-50 years were not less likely to complete CRC screening kits than their counterparts of typical screening age (51-56 years). Additionally, follow-up colonoscopy rates were comparable between early screening patients and controls. 

As study limitations, investigators noted that the Kaiser Permanente Northern California system had an established FIT-based organization of CRC screening, which may have led to increased uptake among patients.

“We demonstrated that implementation of FIT-based CRC screening in African Americans ages 45-50 is feasible in a large integrated healthcare setting,” investigators wrote. “FIT positivity, colonoscopy follow-up after a positive FIT, and the detection of adenomas, advanced adenomas, and CRC in this population subgroup who completed screening [were]… comparable to that seen in other racial/ethnic groups 51-56 years of age.”

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Levin TR, Jensen CD, Chawla NM, et al. Early screening of African Americans (45-50 years old) in a fecal immunochemical test-based colorectal cancer screening program [published online July 15, 2020]. Gastroenterology. doi: 10.1053/j.gastro.2020.07.011