96 Quick summary: A study involving over 5,000 participants at community health centres reveals that providing newer stool-based screening tests with manufacturer-led outreach can increase colorectal cancer screening rates among medically underserved and Hispanic populations. While these interventions successfully reduce administrative burdens for under-resourced clinics, the notably low rate of follow-up colonoscopies at 36% highlights a critical gap in the healthcare continuum that public policy must address to prevent avoidable deaths. Healthcare providers and policymakers should focus resources on removing structural barriers to diagnostic procedures towards ensuring that early detection leads to the effective treatment and long-term well-being of at-risk patients. Colorectal cancer (CRC) is the second most common cause of cancer death in the US and disproportionately impacts people who receive care in under-resourced settings. Fortunately, several effective screening tests are available to detect cancer early when it is most treatable. In partnership with community health centres (CHCs), investigators from Mass General Brigham and UCLA Health mailed one of two stool-based screening tests to more than 5,000 participants from CHCs in Boston and Los Angeles. Researchers found that participants were more likely to complete screening if they received a newer stool-based screening test, but follow-up colonoscopy rates remained low for those with abnormal results. Findings are published in JAMA Internal Medicine. “Rates of colorectal cancer are rising, but many eligible people are unscreened, especially in Community Health Centres,” said corresponding author Jennifer Haas, MD, of the Division of Internal Medicine in the Mass General Brigham Department of Medicine. “CHCs are an important source of care in the US, especially for under- or uninsured people. Since many CHCs are under-resourced, the goal of our research was to help design an intervention to specifically benefit people who receive care in these settings.” Haas and colleagues are members of the Stand Up To Cancer (SU2C) Colorectal Cancer Health Equity Dream Team that brings together leading researchers, patient advocates, community leaders and clinicians to accomplish several goals, including improving colorectal cancer screening in medically underserved communities. In previous studies, mailing stool-based tests to patients increased CRC screening at CHCs, but with multiple mail-in tests now available, it was unclear which test and which forms of patient outreach were most effective. In the current study, researchers compared completion rates for participants who received either a mailed faecal immunochemical test (FIT) or FIT-DNA kit. Both are non-invasive, at-home tests that detect blood in the stool. However, the newer FIT-DNA test also identifies abnormal DNA indicative of cancer or precancerous polyps and is repeated every three years rather than every year. Whereas CHCs bear the costs of mailing FIT tests and conducting patient outreach, the manufacturer of FIT-DNA coordinates mailing for these tests and offers a wrap-around assistance programme to support patients through screening test completion. Participants in the randomised study included adults aged 45–75 years at eight CHCs in Boston and LA who were due for CRC screening. Patients were predominantly Hispanic (75%) and on Medicaid (50%). Ultimately, 28% of patients who received FIT-DNA kits completed screening after 90 days, which was significantly higher than the completion rate in those who received FIT kits and automated English or Spanish text-message reminders (23%). The researchers suggest that FIT-DNA screening may have had a higher completion rate due to stronger outreach support through the patient assistance programme and the potential for reduced testing frequency. In a separate associated study in a tribal site in South Dakota, FIT-DNA kits were associated with an increase in participation in CRC screening. Improving screening is especially important in Native American populations due to their high CRC incidence and low screening rates. The researchers emphasise the urgency of improving access to diagnostic colonoscopy, which is necessary after a positive stool or blood test. In this study, despite participants with abnormal stool tests receiving phone calls to help educate them about and schedule their colonoscopy, completion rates were only 36% in both the FIT and FIT-DNA groups and were lower in LA than in Boston, perhaps related to access to colonoscopy or differences in insurance coverage. “Effective screening is essential because it allows us to catch and treat cancer early,” Haas said. “There are evidence-backed, preventive interventions for CRC, but they need to be implemented systematically in a way that addresses barriers for both the CHCs and the patients they are serving. The best screening test will always be the one that people are able to complete.”