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Am Fam Physician. 2020;102(2):117

Clinical Question

Does mailing a fecal occult blood test to patients improve screening rates compared with usual care?

Bottom Line

Mailed outreach significantly increases rates of colorectal cancer screening, with four tests needing to be mailed to screen one person. Other countries take this approach, with screening managed by the public health service rather than relying on physician or patient memory and motivation. Health systems in the United States should adopt this approach and insurers should support these efforts. (Level of Evidence = 1a)


Mailed outreach includes mailing of a fecal occult blood test to patients and asking them to provide a sample and mail it back. The goal is to improve adherence to colorectal cancer screening, which is approximately 62% in the United States, by reducing barriers. This meta-analysis identified U.S. studies that randomized patients to one of four groups: (1) mailed outreach using a guaiac-based fecal occult blood test (gFOBT), (2) mailed outreach using a fecal immunochemical test (FIT), (3) mailed outreach using a combined FIT and multitarget DNA test, or (4) usual care based on opportunistic office-based screening. After a thorough search, the authors identified seven studies: four used gFOBT and three used FIT; three of the studies included a telephone reminder. The studies were judged to be at low (n = 3) or moderate (n = 4) risk of bias. The authors found a 28% absolute increase in screening rates, which did not differ for FIT vs. gFOBT or for telephone reminder vs. no telephone reminder. Although the authors describe moderate heterogeneity based on the I2 statistic, this is misleading with so few studies. Visual inspection of the forest plot shows good homogeneity among studies, with all CIs but one overlapping.

Study design: Meta-analysis (randomized controlled trials)

Funding source: Self-funded or unfunded

Setting: Population-based

Reference: Jager M, Demb J, Asghar A, et al. Mailed outreach is superior to usual care alone for colorectal cancer screening in the USA: a systematic review and meta-analysis. Dig Dis Sci. 2019;64(9):2489–2496.

Editor's Note: Dr. Ebell is deputy editor for evidence-based medicine for AFP and cofounder and editor-in-chief of Essential Evidence Plus, published by Wiley-Blackwell.

POEMs (patient-oriented evidence that matters) are provided by Essential Evidence Plus, a point-of-care clinical decision support system published by Wiley-Blackwell. For more information, see Copyright Wiley-Blackwell. Used with permission.

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