Offering Annual Fecal Occult Blood Tests at Annual Flu Shot Clinics Increases Colorectal Cancer Screening Rates

Potter and colleagues achieved an impressive increase in colorectal cancer screening rates with a creative intervention to offer patients FOBT test kits when they came for flu shots. Intervening in their study population was particularly challenging given the need to develop educational material about colorectal cancer screening in 5 languages and the relatively high proportion of uninsured patients. A number of factors contributed to the study’s success, including an electronic medical record that identified patients eligible for colorectal cancer screening in advance of their flu shot clinic visit, sufficient non-physician personnel to offer screening and to follow up patients who did not promptly return stool test kits, and resources to ensure that patients testing positive had access to diagnostic evaluations. However, perhaps the most important feature of the study was designing an intervention that did not require a primary care clinic visit. Expecting preventive services to be consistently delivered during clinic visits is increasingly unrealistic. Even offering the relatively limited number of interventions recommended by the U.S. Preventive Services Task Force would consume many hours a day of primary care time. The need to also address a multitude of competing medical and psychosocial problems, especially with an inefficient screening test reminder and tracking system, further undermines a clinician’s ability to effectively deliver preventive care. With the dwindling number of trainees entering primary care, non-visit based care provided by non-physicians will become an increasingly important strategy for delivering preventive care. Integrating this strategy with a comprehensive electronic health record may allow a health care system to more effectively and efficiently deliver preventive services to its entire population of eligible patients.

Competing interests:   None declared

I appreciate these supportive comments. While the presence or absence of a doctor's recommendation within the context of a clinical office visit is frequently cited as the most important determinant of colorectal cancer screening behavior, we believe that there is much that can be done outside the context of physician visits to facilitate screening. In fact, given that FOBT and FIT are home tests that must be done annually to achieve maximal benefit, it is likely that, in order to maximize screening rates in diverse clinical settings, multiple strategies may need to be employed, including: (1) promotion by clinicians in the context of an office visit; (2) promotion by non-physician staff who interact with patients before or after doctor visits, (3) routine mailing of kits to patients who are due; and (4) at other times when patients come into contact with the medical system, such as when they are coming in for an annual flu shot. We believe that offering FOBT or FIT at the time of flu shots reinforces other efforts to achieve annual screening, and it has the potential to create new community norms through the message that, just like flu shots, for patients who are not already up to date with other methods of colorectal cancer screening, FOBT/FIT saves lives and should be done every year after age 50.

Competing interests:   None declared