Opportunity 

Colorectal cancer (CRC) is the second leading cause of cancer-related deaths among men and women in the United States. Regular screening can prevent cancer by discovering precancerous polyps that can be removed before they turn into cancer. It can also find CRC early when treatment often leads to a cure.  

Patients have several options when it comes to completing screening. The most common are colonoscopy and FIT (fecal immunochemical test).  

Unfortunately, millions of people in the United States are not getting screened for CRC. Offering a choice of screening methods could increase participation by accommodating varying patient preferences and signaling respect by offering autonomy in decision-making.

Intervention  

We conducted several clinical trials to explore the effect of active choice on CRC screening rates.

In a 2018 study, we sent Penn Medicine patients mailed outreach offering CRC screenings in one of three ways: 1) colonoscopy only, 2) colonoscopy at first and, if they did not schedule or complete a colonoscopy, FIT (sequential), or 3) active choice of colonoscopy or FIT (simultaneous). 

In 2022, we conducted a clinical trial with patients at Community Health and Dental Care, a community health center in southeastern Pennsylvania. We mailed each participant a letter urging them to get screened via either 1) colonoscopy, with a referral provided, 2) FIT screening, with an at-home FIT kit included in the mailing, or 3) their choice of colonoscopy or FIT, with a referral and FIT kit provided.
 

Impact  

In the 2018 study with sequential and simultaneous choice, we observed no significant difference in CRC screening among the three groups. However, the rate of completed screenings via colonoscopy was much lower in the choice arms – 52 percent for sequential and 38 percent for active – than in the colonoscopy-only arm.

In the 2022 study testing active choice versus no choice of screening method, we found that patients who received a choice had a CRC screening rate (12.8 percent) more than double that of patients in the colonoscopy-only group (5.6 percent). Patients in the FIT-only group completed screenings at 11.3 percent, which was also significantly higher than the colonoscopy-only group's rate. The vast majority of patients who completed screenings in the active choice arm used FIT.

These results indicate that framing choices affects patients’ health care decisions. In particular, active choice may boost screening in populations with a low screening rate, as was the case among patients of the community health center, who may have less access to care.