Personalized risk messages may not increase colorectal cancer screening uptake

1. In this randomized controlled trial, using personalized risk messages and provider notifications did not significantly increase screening uptake overall. 2. However, one of the two health systems in the study reported higher uptake rates for stool testing when either patients received a personalized decision aid or providers received a personalized notification. Evidence Rating Level: 1 (Excellent) Study Rundown: Personalized approaches to reporting risk and screening for colorectal cancer (CRC) may improve screening rates and improve patient satisfaction. For example, knowing advanced colorectal neoplasia (ACN) risk may allow low-risk patients to be screened through less invasive methods while directing high-risk patients to colonoscopy. This study aimed to assess the effect on CRC screening uptake of informing patients and their providers about patient risk for ACN. Overall, approximately forty percent of participants completed CRC screening, but screening uptake was not significantly affected by the personalized decision aid or the personalized provider notification. Colonoscopies were completed by nearly twenty percent of participants, and similarly screening uptake was not significantly affected by the personalized decision aid or provider notification, both overall and among high-risk participants. Stool testing was completed by over twenty percent of participants, and screening uptake was not significantly affected by the personalized decision aid or provider notification. However, stool testing was moderated by 3 factors: health system, decision aid type, and provider notification type. In one health systems, participants who received the generic decision aid had higher uptake of stool tests if their provider was sent a personalized notification, and participants whose provider received a generic notification also had higher uptake if they were given a personalized decision aid. The generalizability of this study is limited by its 2-system design in a metropolitan area with few Hispanic or Asian patients, its recruitment of only English-speaking patients, and a low proportion of high-average-risk ACN participants. Nevertheless, this study suggests that including personalized risk for ACN in a decision aid or provider notification may have limited impact, although it may increase uptake of stool tests in specific conditions. Click to read this study in AIM Relevant Reading: Risk-stratified strategies in population screening for colorectal cancer In-Depth [randomized controlled trial]: This study aimed to assess whether personalized decision aids or notifications may improve screening uptake for CRC. Patients were recruited from 2 health care systems in the midwestern United States, with health system 1 being a county safety-net system and health system 2 being a large private system. Patients were eligible if they were aged 50 to 75 years, and were excluded if they had symptoms of CRC, had a diagnosis or family history showing elevated CRC risk, were told by their provider to avoid CRC screening, or had had a colonoscopy after 50 years of age. This study included 328 providers, 161 of whom were randomly assigned to receive personalized notifications and 167 to receive generic notifications. The study also enrolled 1111 patients, 552 of whom were randomly assigned the personalized decision aid and 559 the generic decision aid. Patients had a mean age of 56.5 years (standard deviation [SD], 6.2), and 88% were younger than 65 years. Patients were largely female (59.7%), White (65.1%), and non-Hispanic (96.7%). The ACN risk score was low for 63.0% (n = 683) of patients, intermediate for 31.9% (n = 346) of patients, and high-average for 5.1% (n = 55) of patients. Overall, 39.8% of patients completed CRC screening within 6 months. Uptake rates were not significantly affected by type of notification (41.5% for personalized provider notification versus 36.4% for generic notification; difference, 5.1 [95% CI, -1.6 to 11.8] percentage points; p = 0.135). Similarly, patients who were given a personalized decision aid had similar uptake compared to patients given a generic decision aid (36.8% versus 41.0%; difference, -4.1 [95% CI, -10.2 to 1.9] percentage points; p = 0.180). Colonoscopies were completed by 18.5% of participants (15.4% for personalized decision aid versus 19.4% for generic decision aid; difference, -4.1 [95% CI, -8.6 to 0.4] percentage points; p = 0.076). Stool tests were completed by 21.2% of participants. Stool test uptake was moderated by a combination of health system, decision aid type, and notification type. In health system 1, among patients who were sent the generic decision aid, those whose providers were given a personalized notification had higher uptake (predicted probabilities, 21.1% vs. 7.9%; difference, 13.2 [95% CI, 1.6 to 24.8] percentage points; p = 0.032); among patients whose providers were given a generic notification, those who were sent a personalized decision aid had higher uptake (predicted probabilities, 21.4% vs. 7.9%; difference, 13.5 [95% CI, 2.4 to 24.5] percentage points; p = 0.023). Overall, this study suggests that personalized ACN risk messages may not significantly increase screening uptake in general, although they may have a positive effect in some scenarios. Image: PD