Patient Navigation After Positive Fecal Immunochemical Test Results Increases Diagnostic Colonoscopy and Highlights Multilevel Barriers to Follow-Up

Abstract

Background

The fecal immunochemical test (FIT) is a common colorectal cancer screening modality in the USA but often is not followed by diagnostic colonoscopy.

Aims

We investigated the efficacy of patient navigation to increase diagnostic colonoscopy after positive FIT results and determined persistent barriers to follow-up despite navigation in a large, academic healthcare system.

Methods

The study cohort included all health system outpatients with an assigned primary care provider, a positive FIT result between 12/01/2016 and 06/01/2019, and no documentation of colonoscopy after positive FIT. Two non-clinical patient navigators engaged patients and providers to encourage follow-up, offer solutions to barriers, and assist with colonoscopy scheduling. The primary intervention endpoint was completion of colonoscopy within 6 months of navigation. We documented reasons for persistent barriers to colonoscopy despite navigation and determined predictors of successful follow-up after navigation.

Results

There were 119 patients who received intervention. Of these, 37 (31.1%) patients completed colonoscopy at 6 months. In 41/119 (34.5%) cases, the PCP did not recommend colonoscopy, most commonly due to a normal colonoscopy prior to the positive FIT (19, 46.3%). There were 41/119 patients (34.5%) that declined colonoscopy despite the patient navigator and the PCP order. Male sex and younger age were significant predictors of follow-up (aOR = 2.91, 95%CI, 1.18-7.13; aOR = 0.92, 95%CI, 0.87-0.99).

Conclusions

After implementation of patient navigation, diagnostic colonoscopy was completed for 31.1% of patients with a positive FIT result. However, navigation also highlighted persistent multilevel barriers to follow-up. Future work will develop targeted solutions for these barriers to further increase FIT follow-up rates in our health system.

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References

  1. 1.

    Meester RG, Zauber AG, Doubeni CA, et al. Consequences of increasing time to colonoscopy examination after positive result from fecal colorectal cancer screening test. Clin Gastroenterol Hepatol Off Clin Pract J Am Gastroenterol Assoc. 2016;14:1445-51.e8. https://doi.org/10.1016/j.cgh.2016.05.017.

    Article  Google Scholar 

  2. 2.

    US Preventive Services Task Force, Bibbins-Domingo K, Grossman DC, et al. Screening for colorectal cancer: US preventive services task force recommendation statement. JAMA. 2016;315:2564–2575. https://doi.org/10.1001/jama.2016.5989.

    CAS  Article  Google Scholar 

  3. 3.

    Rex DK, Boland CR, Dominitz JA, et al. Colorectal cancer screening: recommendations for physicians and patients from the us multi-society task force on colorectal cancer. Am J Gastroenterol. 2017;112:1016–1030. https://doi.org/10.1038/ajg.2017.174.

    Article  PubMed  Google Scholar 

  4. 4.

    Robertson DJ, Lee JK, Boland CR, et al. Recommendations on fecal immunochemical testing to screen for colorectal neoplasia: a consensus statement by the US multi-society task force on colorectal cancer. Gastroenterology. 2017;152:1217-37.e3. https://doi.org/10.1053/j.gastro.2016.08.053.

    Article  Google Scholar 

  5. 5.

    Flugelman AA, Stein N, Segol O, Lavi I, Keinan-Boker L. Delayed colonoscopy following a positive fecal test result and cancer mortality. JNCI Cancer Spectr. 2019;3:pkz024. https://doi.org/10.1093/jncics/pkz024.

    Article  PubMed  PubMed Central  Google Scholar 

  6. 6.

    Lee YC, Li-Sheng Chen S, Ming-Fang Yen A, et al. Association between colorectal cancer mortality and gradient fecal hemoglobin concentration in colonoscopy noncompliers. J Natl Cancer Inst. 2017;. https://doi.org/10.1093/jnci/djw269.

    Article  PubMed  PubMed Central  Google Scholar 

  7. 7.

    Corley DA, Jensen CD, Quinn VP, et al. Association between time to colonoscopy after a positive fecal test result and risk of colorectal cancer and cancer stage at diagnosis. JAMA. 2017;317:1631–1641. https://doi.org/10.1001/jama.2017.3634.

    Article  PubMed  PubMed Central  Google Scholar 

  8. 8.

    Lee YC, Fann JC, Chiang TH, et al. Time to colonoscopy and risk of colorectal cancer in patients with positive results from fecal immunochemical tests. Clin Gastroenterol Hepatol Off Clin Pract J Am Gastroenterol Assoc. 2019;17:1332-40.e3. https://doi.org/10.1016/j.cgh.2018.10.041.

    Article  Google Scholar 

  9. 9.

    Heavener T, Jaeger V, Stephenson K, McStay F, Sing T. Diagnostic colonoscopy following abnormal FIT results: a quality improvement analysis. J Clin Oncol. 2018;36:568–569. https://doi.org/10.1200/jco.2018.36.4_suppl.568.

    Article  Google Scholar 

  10. 10.

    Issaka RB, Singh MH, Oshima SM, et al. Inadequate utilization of diagnostic colonoscopy following abnormal FIT results in an integrated safety-net system. Am J Gastroenterol. 2016;112:375. https://doi.org/10.1038/ajg.2016.555.

    Article  PubMed  PubMed Central  Google Scholar 

  11. 11.

    Partin MR, Gravely AA, Burgess JF Jr, et al. Contribution of patient, physician, and environmental factors to demographic and health variation in colonoscopy follow-up for abnormal colorectal cancer screening test results. Cancer. 2017;123:3502–3512. https://doi.org/10.1002/cncr.30765.

    Article  PubMed  PubMed Central  Google Scholar 

  12. 12.

    Cusumano VT, May FP. Making FIT count: maximizing appropriate use of the fecal immunochemical test for colorectal cancer screening programs. J Gen Intern Med. 2020;. https://doi.org/10.1007/s11606-020-05728-y.

    Article  PubMed  Google Scholar 

  13. 13.

    May FP, Yano EM, Provenzale D, et al. Barriers to follow-up colonoscopies for patients with positive results from fecal immunochemical tests during colorectal cancer screening. Clin Gastroenterol Hepatol Off Clin Pract J Am Gastroenterol Assoc. 2019;17:469–476. https://doi.org/10.1016/j.cgh.2018.05.022.

    Article  Google Scholar 

  14. 14.

    Martin J, Halm EA, Tiro JA, et al. Reasons for lack of diagnostic colonoscopy after positive result on fecal immunochemical test in a safety-net health system. Am J Med. 2017;130:93. https://doi.org/10.1016/j.amjmed.2016.07.028.

    Article  PubMed  Google Scholar 

  15. 15.

    Llovet D, Serenity M, Conn LG, et al. Reasons for lack of follow-up colonoscopy among persons with a positive fecal occult blood test result: a qualitative study. Am J Gastroenterol. 2018;113:1872–1880. https://doi.org/10.1038/s41395-018-0381-4.

    Article  PubMed  PubMed Central  Google Scholar 

  16. 16.

    Wells KJ, Battaglia TA, Dudley DJ, et al. Patient navigation: state of the art or is it science? Cancer. 2008;113:1999–2010. https://doi.org/10.1002/cncr.23815.

    Article  PubMed  PubMed Central  Google Scholar 

  17. 17.

    Freeman HP, Rodriguez RL. History and principles of patient navigation. Cancer. 2011;117:3537–3540. https://doi.org/10.1002/cncr.26262.

    Article  Google Scholar 

  18. 18.

    Freeman HP, Muth BJ, Kerner JF. Expanding access to cancer screening and clinical follow-up among the medically underserved. Cancer Pract. 1995;3:19–30.

    CAS  PubMed  Google Scholar 

  19. 19.

    Oluwole SF, Ali AO, Adu A, et al. Impact of a cancer screening program on breast cancer stage at diagnosis in a medically underserved urban community. J Am Coll Surg. 2003;196:180–188. https://doi.org/10.1016/s1072-7515(02)01765-9.

    Article  PubMed  Google Scholar 

  20. 20.

    Wells KJ, Lee JH, Calcano ER, et al. A cluster randomized trial evaluating the efficacy of patient navigation in improving quality of diagnostic care for patients with breast or colorectal cancer abnormalities. Cancer Epidemiol Biomark Prev Publ Am Assoc Cancer Res. 2012;21:1664–1672. https://doi.org/10.1158/1055-9965.Epi-12-0448.

    Article  Google Scholar 

  21. 21.

    Percac-Lima S, Grant RW, Green AR, et al. A culturally tailored navigator program for colorectal cancer screening in a community health center: a randomized, controlled trial. J Gen Intern Med. 2009;24:211–217. https://doi.org/10.1007/s11606-008-0864-x.

    Article  PubMed  Google Scholar 

  22. 22.

    Lasser KE, Murillo J, Medlin E, et al. A multilevel intervention to promote colorectal cancer screening among community health center patients: results of a pilot study. BMC Fam Pract.. 2009;10:37. https://doi.org/10.1186/1471-2296-10-37.

    Article  PubMed  PubMed Central  Google Scholar 

  23. 23.

    Christie J, Itzkowitz S, Lihau-Nkanza I, Castillo A, Redd W, Jandorf L. A randomized controlled trial using patient navigation to increase colonoscopy screening among low-income minorities. J Natl Med Assoc. 2008;100:278–284. https://doi.org/10.1016/s0027-9684(15)31240-2.

    Article  PubMed  Google Scholar 

  24. 24.

    Clark CR, Baril N, Kunicki M, et al. Addressing social determinants of health to improve access to early breast cancer detection: results of the Boston REACH 2010 Breast and Cervical Cancer Coalition Women’s Health Demonstration Project. J Womens Health (Larchmt). 2009;18:677–690. https://doi.org/10.1089/jwh.2008.0972.

    Article  Google Scholar 

  25. 25.

    Lebwohl B, Neugut AI, Stavsky E, et al. Effect of a patient navigator program on the volume and quality of colonoscopy. J Clin Gastroenterol. 2011;45:e47–e53. https://doi.org/10.1097/MCG.0b013e3181f595c3.

    Article  PubMed  PubMed Central  Google Scholar 

  26. 26.

    Chen LA, Santos S, Jandorf L, et al. A program to enhance completion of screening colonoscopy among urban minorities. Clin Gastroenterol Hepatol Off Clin Pract J Am Gastroenterol Assoc. 2008;6:443–450. https://doi.org/10.1016/j.cgh.2007.12.009.

    Article  Google Scholar 

  27. 27.

    Nash D, Azeez S, Vlahov D, Schori M. Evaluation of an intervention to increase screening colonoscopy in an urban public hospital setting. J Urban Health. 2006;83:231–243. https://doi.org/10.1007/s11524-006-9029-6.

    Article  PubMed  PubMed Central  Google Scholar 

  28. 28.

    Lamanna A, Sheaffer H, Guerra C, Kochman M. Colorectal cancer screening navigation for the underserved: experience of an urban program. Gastroenterol Hepatol. 2016;12:547–551.

    Google Scholar 

  29. 29.

    Selby K, Baumgartner C, Levin TR, et al. Interventions to improve follow-up of positive results on fecal blood tests: a systematic review. Ann Intern Med. 2017;167:565–575. https://doi.org/10.7326/m17-1361.

    Article  PubMed  PubMed Central  Google Scholar 

  30. 30.

    Beydoun HA, Beydoun MA. Predictors of colorectal cancer screening behaviors among average-risk older adults in the United States. Cancer Causes Control CCC. 2008;19:339–359. https://doi.org/10.1007/s10552-007-9100-y.

    Article  PubMed  Google Scholar 

  31. 31.

    Modiri A, Makipour K, Gomez J, Friedenberg F. Predictors of colorectal cancer testing using the California Health Inventory Survey. World J Gastroenterol. 2013;19:1247–1255. https://doi.org/10.3748/wjg.v19.i8.1247.

    Article  PubMed  PubMed Central  Google Scholar 

  32. 32.

    Siegel RL, Miller KD, Goding Sauer A, et al. Colorectal cancer statistics, 2020. CA Cancer J Clin. 2020;. https://doi.org/10.3322/caac.21601.

    Article  PubMed  Google Scholar 

  33. 33.

    Bakhai S, Ahluwalia G, Nallapeta N, Mangat A, Reynolds JL. Faecal immunochemical testing implementation to increase colorectal cancer screening in primary care. BMJ Open Qual. 2018;7:e000400. https://doi.org/10.1136/bmjoq-2018-000400.

    Article  PubMed  PubMed Central  Google Scholar 

  34. 34.

    Raich PC, Whitley EM, Thorland W, Valverde P, Fairclough D. Patient navigation improves cancer diagnostic resolution: an individually randomized clinical trial in an underserved population. Cancer Epidemiol Biomark Prev. 2012;21:1629–1638. https://doi.org/10.1158/1055-9965.epi-12-0513.

    Article  Google Scholar 

  35. 35.

    Singh H, Kadiyala H, Bhagwath G, et al. Using a multifaceted approach to improve the follow-up of positive fecal occult blood test results. Am J Gastroenterol. 2009;104:942–952. https://doi.org/10.1038/ajg.2009.55.

    Article  PubMed  PubMed Central  Google Scholar 

  36. 36.

    Green BB, Anderson ML, Wang CY, et al. Results of nurse navigator follow-up after positive colorectal cancer screening test: a randomized trial. J Am Board Family Med JABFM. 2014;27:789–795. https://doi.org/10.3122/jabfm.2014.06.140125.

    Article  Google Scholar 

  37. 37.

    Phillips-Angeles E, Song L, Hannon PA, et al. Fostering partnerships and program success. Cancer. 2013;119:2884–2893. https://doi.org/10.1002/cncr.28157.

    Article  PubMed  Google Scholar 

  38. 38.

    Selby K, Jensen CD, Zhao WK, et al. Strategies to Improve Follow-up After Positive Fecal Immunochemical Tests in a Community-Based Setting: a Mixed-Methods Study. Clin Transl Gastroenterol. 2019;10:e00010. https://doi.org/10.14309/ctg.0000000000000010.

    Article  PubMed  PubMed Central  Google Scholar 

  39. 39.

    Plumb AA, Ghanouni A, Rainbow S, et al. Patient factors associated with non-attendance at colonoscopy after a positive screening faecal occult blood test. J Med Screen. 2017;24:12–19. https://doi.org/10.1177/0969141316645629.

    Article  PubMed  Google Scholar 

  40. 40.

    Beshara A, Ahoroni M, Comanester D, et al. Association between time to colonoscopy after a positive guaiac fecal test result and risk of colorectal cancer and advanced stage disease at diagnosis. Int J Cancer. 2020;146:1532–1540. https://doi.org/10.1002/ijc.32497.

    CAS  Article  PubMed  Google Scholar 

  41. 41.

    Kim NH, Jung YS, Lim JW, Park JH, Park DI, Sohn CI. Yield of repeat colonoscopy in asymptomatic individuals with a positive fecal immunochemical test and recent colonoscopy. Gastrointest Endosc. 2019;89:1037–1043. https://doi.org/10.1016/j.gie.2019.01.012.

    Article  PubMed  Google Scholar 

  42. 42.

    Nadel MR, Berkowitz Z, Klabunde CN, Smith RA, Coughlin SS, White MC. Fecal occult blood testing beliefs and practices of U.S. primary care physicians: serious deviations from evidence-based recommendations. J Gen Intern Med. 2010;25:833–839. https://doi.org/10.1007/s11606-010-1328-7.

    Article  PubMed  PubMed Central  Google Scholar 

  43. 43.

    Jimbo M, Myers RE, Meyer B, et al. Reasons patients with a positive fecal occult blood test result do not undergo complete diagnostic evaluation. Ann Family Med. 2009;7:11–16. https://doi.org/10.1370/afm.906.

    Article  Google Scholar 

  44. 44.

    Cossu G, Saba L, Minerba L, Mascalchi M. Colorectal cancer screening: the role of psychological, social and background factors in decision-making process. Clin Pract Epidemiol Ment Health. 2018;14:63–69. https://doi.org/10.2174/1745017901814010063.

    Article  PubMed  PubMed Central  Google Scholar 

  45. 45.

    Zorzi M, Hassan C, Selby K, Rugge M. Do not leave FIT positives alone! Am J Gastroenterol. 2018;113:913. https://doi.org/10.1038/s41395-018-0019-6.

    Article  PubMed  Google Scholar 

  46. 46.

    Chubak J, Garcia MP, Burnett-Hartman AN, et al. Time to colonoscopy after positive fecal blood test in four US health care systems. Cancer Epidemiol Biomark Prev. 2016;25:344–350. https://doi.org/10.1158/1055-9965.epi-15-0470.

    Article  Google Scholar 

  47. 47.

    Myers RE, Balshem AM, Wolf TA, Ross EA, Millner L. Screening for colorectal neoplasia: physicians’ adherence to complete diagnostic evaluation. Am J Public Health. 1993;83:1620–1622.

    CAS  Article  Google Scholar 

  48. 48.

    Chauvin P, Josselin JM, Heresbach D. The influence of waiting times on cost-effectiveness: a case study of colorectal cancer mass screening. Eur J Health Econ HEPAC Health Econ Prev Care. 2014;15:801–812. https://doi.org/10.1007/s10198-013-0525-9.

    Article  Google Scholar 

  49. 49.

    Gellad ZF, Almirall D, Provenzale D, Fisher DA. Time from positive screening fecal occult blood test to colonoscopy and risk of neoplasia. Dig Dis Sci. 2009;54:2497–2502. https://doi.org/10.1007/s10620-008-0653-8.

    Article  PubMed  Google Scholar 

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Funding

This study was funded by the UCLA Melvin and Bren Simon Gastroenterology Quality Improvement Program.

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Correspondence to Folasade P. May.

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The authors declare that they have no conflict of interest.

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All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki Declaration and its later amendments or comparable ethical standards.

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Informed consent was obtained from all individual participants included in the study.

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Cusumano, V.T., Myint, A., Corona, E. et al. Patient Navigation After Positive Fecal Immunochemical Test Results Increases Diagnostic Colonoscopy and Highlights Multilevel Barriers to Follow-Up. Dig Dis Sci (2021). https://doi.org/10.1007/s10620-021-06866-x

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Keywords

  • Colorectal cancer
  • Stool-based test
  • Cancer screening
  • Prevention