Serial SMS Reminders and an Opt-out Mailed FIT Kits to Improve Colorectal Screening Participation: A Single Center RCT

It is estimated that colorectal cancer (CRC) screening can reduce the risk of dying from
bowel cancer by approximately 15%. Yet despite this, the national participation rate is only
approximately 62.9%, highlighting that the national target of 70.5% set out in the Healthy
People 2020 Objectives remains well out of reach. The US Preventative Task Force (USPSTF)
recommends colorectal screening for adults aged 50-75 years through either annual fecal
occult blood testing (FOBT), flexible sigmoidoscopy every 5 years or colonoscopy every 10
years. However, many service providers rely on the opportunistic offer of screening at
existing health touch-points. This requires the patient to see their healthcare provider,
usually for a different clinical reason, the provider to recognize that the patient is
overdue for CRC screening and the provider to recommend and book the patient for CRC
screening. This process identifies a number of barriers encountered at the system, provider
and patient level, to completing a screening test regularly. Furthermore, much evidence
indicates that public participation in colorectal screening is heavily influences by
socioeconomic factors. Lower participation rates are seen in individuals without health
insurance, without a medical home, who are more deprived and from ethnic minority groups.
These individuals are more likely to present with later stage disease and experience poorer
outcomes. Fecal immunochemistry testing (FIT) is a stool sample based test kit that uses
antibodies to detect the human haemoglobin protein in the stool sample and can be completed
in the privacy of the home. Research has showed that mailed home test kits such as FOBT or
FIT kits can improve CRC participation by reducing the effort required to see a provider in
order to arrange CRC screening. Evidence has also shown that text message reminders can
improve participation in cancer screening. Furthermore, the message content of text messages
can differentially change behavior, for example reducing the 'did not attend rate' in
hospital outpatient appointments but also in the context of participation in cervical cancer
screening. Therefore this trial will test a multimodal outreach approach, which uses serial
SMS reminders with different word contents and mailed FIT kits on the participation rates of
CRC screening.

Inclusion Criteria:

1. aged 50-74

2. at least 1 clinic visit to the FPCN within the previous 12 months

3. due or overdue for colorectal screening

4. Asymptomatic for bowel cancer

5. mobile phone number available

Exclusion Criteria:

1. Has had prior colonoscopy within 10 years, sigmoidoscopy within 5 years, and FOBT/FIT
within twelve months of the chart review (We will exclude patients who self-report
undergoing any of the above procedures)

2. Has a history of CRC

3. Has a history of other GI cancer

4. Has history of confirmed Inflammatory Bowel Disease (IBD) (e.g. Crohns disease,
ulcerative colitis) Irritable bowel syndrome does not exclude patients.

5. Has history of colitis other than Crohns disease or ulcerative colitis

6. Has had a colectomy

7. Has been diagnosed with Lynch Syndrome (i.e. HNPCC)

8. Has been diagnosed with Familial Adenomatous Polyposis (FAP)

9. Has metastatic (Stage IV) blood or solid tumor cancer

10. Has end stage renal disease

11. Has dementia

12. Has liver cirrhosis

13. Has any other condition that, in the opinion of the investigator, excludes the patient
from participating in this study.