Reducing the growing disparity of colorectal cancer screening among underserved populations in rural health clinics: The PRIME-CRC trial

Abstract Introduction: Colorectal cancer (CRC), the third leading cause of cancer death in the United States, can be significantly reduced if it is detected early. Although overall CRC screening rates have increased significantly, disparities persist among low-income individuals, adults with low literacy and those living in rural areas. These groups all have screening completion rates below 50%. Purpose of Study: To assess the effectiveness of a patient-centered, shared decision making, health literacy strategy to promote longer-term adherence to colorectal cancer (CRC) screening in resource-limited, rural health clinics via colonoscopy or annual fecal immunochemical test (FIT). Methods Used: A two-arm randomized control trial implemented in 6 rural community clinics. Clinics reported CRC baseline screening rates of 17% to 38%. Eligible patients, age 45-75, who were not up to date on CRC screening were recruited. Clinic based RAs screened and consented patients. They collected baseline data and then recommended screening and gave brief literacy and culturally appropriate education using a pamphlet developed by the authors (4th grade level). The RA used shared decision-making techniques to aid patients in selecting the test they prefer and that met their needs – colonoscopy or FIT. All patients who selected the FIT kit were given simplified instructions (3rd grade level) and a demonstration of how to use it and those who chose colonoscopy were given simplified colonoscopy prep instructions and had a referral made to GI clinic. Patients were randomized into intervention (INT) arm or enhanced usual care (EUC) arm. Those in INT who selected the FIT (and had not returned it) at 4, 8 and 12 weeks received an automated follow-up call or text from a provider at their clinic using plain language and motivational messages encouraging patients to complete the FIT (colonoscopy INT patients received reminder calls prior to appointment to remind them about prepping for procedure and their appointment). Summary of Results: 734 patients have been enrolled to date: 361 in INT arm and 373 in EUC arm; 64.1% are African American, 60.3% women; 38% have limited literacy; 71.8% highest level of education completed was high school or less; only 5.6% have annual incomes > $50,000. 72.4% of patients had heard of tests to screen for CRC and 75.4% had a doctor or nurse recommend screening for CRC in the past. With regard to screening tests, 5.6% of patients have chosen a colonoscopy and 94.4% have selected a FIT. Screening to date in Year 1: 56.0% completed screening by FIT in INT arm versus 54.2% in EUC arm; only 20% have completed screening by colonoscopy to date. Conclusions: Simplified instructions accompanied by a face-to-face demonstration of FIT, use of “teach back” to confirm understanding with a follow-up automated text message or call if needed, facilitated completion rates of all patients, particularly those with limited literacy. This has not been effective to date with colonoscopy. Citation Format: Connie L. Arnold, Joseph Dean, James Morris, Elise Reed, Laura Curtis, Terry Davis. Reducing the growing disparity of colorectal cancer screening among underserved populations in rural health clinics: The PRIME-CRC trial [abstract]. In: Proceedings of the 16th AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2023 Sep 29-Oct 2;Orlando, FL. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2023;32(12 Suppl):Abstract nr A016.