Randomized Trial of Sequential Testing Versus Multiple Choices for CRC Screening

Douglas K. Rex, MD, FASGE reviewing Mehta SJ, et al. JAMA Netw Open 2019 Aug 30.

Many guidelines on colorectal cancer (CRC) screening advocate that the choice of screening tests should be based on a discussion between the provider and patient about the endorsed options. An alternative approach that has been endorsed in GI specialty guidelines is sequential testing, in which colonoscopy is offered first, and if patients decline colonoscopy, a second test (usually a fecal immunochemical test [FIT]) is offered. Previous randomized trials have found that sequential testing results in overall screening rates that are as high as those when multiple options are offered; however, colonoscopy was not tested first in one of the arms. 

In a randomized trial, 438 patients received one of the following outreach mailings: a direct phone number to call for scheduling colonoscopy (colonoscopy only), a direct phone number to call for colonoscopy scheduling and a mailed FIT if there was no response within 4 weeks (sequential), or the direct phone number to call for colonoscopy and a mailed FIT kit at the same time (multiple options). 

At 4 months, the rates of completing CRC screening in the colonoscopy-only, sequential choice, and active choice arms were 14.4%, 17.1%, and 19.9%, respectively. The percentages of patients who completed screening with colonoscopy in each arm were 90.5%, 52%, and 37.9%, respectively.

This is an important trial because it again suggests that sequential testing at least approaches multiple options as an effective approach to screening and results in more patients getting the better test, namely colonoscopy. The differences in the arms were numerical rather than statistical, except that a higher percentage of patients in the colonoscopy-only arm received colonoscopy. These data support sequential testing with colonoscopy offered first as an appropriate approach to screening, but a larger trial would be useful.

Douglas K. Rex, MD, FASGE
Bio and Disclosures

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Mehta SJ, Induru V, Santos D, et al. Effect of sequential or active choice for colorectal cancer screening outreach: a randomized clinical trial. JAMA Netw Open 2019;2:e1910305. (https://doi.org/10.1001/jamanetworkopen.2019.10305)