Colorectal cancer screening rates did not significantly increase among patients who were offered the option of fecal immunochemical testing compared with colonoscopy only, according to study results published in JAMA Network Open.

Investigators conducted a 3-arm pragmatic randomized clinical trial ( Identifier, NCT03246438) to study response rates among individuals who were offered colonoscopy only compared with either colonoscopy followed by fecal immunochemical testing (sequential choice) or colonoscopy or fecal immunochemical testing (active choice) through mailed outreach.

A total of 438 participants (mean age, 56 years; 55.0% women) were randomly assigned to 1 of 3 outreach cohorts with the following options: a direct phone number to call for scheduling a colonoscopy only, a direct phone number to call for colonoscopy and a mailed fecal immunochemical testing kit if participants do not respond within 4 weeks (sequential choice), or a direct phone number to call for colonoscopy and a mailed kit offered simultaneously (active choice).

The main outcome was the completion of colorectal cancer screening with fecal immunochemical testing or colonoscopy within 4 months of first outreach.

Four months following initial outreach, colorectal screening completion rates for the colonoscopy-only group, the sequential choice group, and active choice group were 14.4%, 17.1%, and 19.9%, respectively. Screening rates among participants in the choice groups were not statistically significantly greater than those in the colonoscopy-only group.

Among participants who completed screening, 90.5% chose colonoscopy in the colonoscopy-only group; however, 52.0% of sequential choice and 37.9% of active choice participants chose colonoscopy as their screening option.

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“Making colonoscopy the only or first choice implied to patients that it is the default option,” the authors noted.  

“Our findings demonstrate that preference for the default option can also apply to choices between difference screening options,” continued the investigators.


Mehta SJ, Induru V, Santos D, et al. Effect of sequential or active choice for colorectal cancer screening outreach: a randomized clinical trial. JAMA Netw Open. 2019;(8):e1910305.