LAUSR

The use of patient navigation (PN) improves colorectal cancer (CRC) screening participation. When it comes to screening colonoscopy completion, PN is particularly important due to the complexity of scheduling, preparing, and obtaining the procedure. For example, DeGroff reported in a randomized control trial that colonoscopy completion was significantly higher in the group that received navigation compared with patients who received usual care [1]. Effectiveness of PN is increased when using culturally tailored materials including language concordance with the target population [2]. PN can also increase compliance with screening colonoscopies among urban minorities, leading to the detection of clinically significant pathology [3]. Most studies using PN interventions have targeted patients who are screening naïve; few have studied patients who have already started their screening process with a noninvasive test, such as fecal immunochemical test (FIT). When offered a choice, many patients choose a noninvasive stool-based screening test in preference to colonoscopy. Yet, if such patients test positive and do not then undergo colonoscopy in a timely fashion, clinically important pathology is often overlooked. Though it has often been assumed that PN may not be needed for performing FIT testing, coordinating a timely diagnostic colonoscopy subsequent to a positive FIT can be as complex as getting a screening colonoscopy yet additionally imperative given the abnormal result. In this issue of Digestive Diseases and Sciences, Cusumano et al. [4] report on the use of PN for follow-up of a positive FIT in a large urban healthcare system. The aim of the study was to investigate if PN increased the rate of diagnostic colonoscopy after a positive FIT and to report the barriers to follow-up despite navigation. A novelty of the study was the use of non-clinical patient navigators—individuals with college degrees who worked part-time in this program—who contacted patients via telephone to schedule the diagnostic colonoscopy. Of note, the time from the positive FIT test to the start of the PN process was 326 days. Their efforts resulted in 31% of FIT-positive patients completing their colonoscopy within 6 months. Though male gender and younger age were significant predictors of successful follow-up, overall 35% of patients declined diagnostic colonoscopy. Perhaps of even greater concern, in 35% of cases, the primary care provider declined to refer the patient for the diagnostic colonoscopy. The authors concluded that there were multilevel barriers to follow-up that persisted despite the implementation of PN. Successful completion of any CRC screening test is fraught with patient and provider barriers. The patient barriers cited in this study included: concerns for increased procedural risk due to comorbidities, having a general hesitation about undergoing colonoscopy, low perceived priority or perceived lack of time to undergo the procedure, avoidance or fear of colonic preparation, inability to secure transportation, and perceived excessive costs. Although these barriers are similar to the barriers to colonoscopic CRC screening initiation [5], this study emphasizes that barriers to invasive testing are uncovered further along the screening continuum if left unaddressed. This highlights the need to reinforce to patients, even before they perform the FIT, that a colonoscopy is mandatory should the test be positive. The physician barriers underscored the gap between guideline recommendations and clinical practice. The most commonly cited reason was that many patients had a normal colonoscopy prior to the positive FIT. While this raises the question as to why FIT was even offered to those who had a recent colonoscopy, it is worth noting that the last colonoscopy occurred an average of 143–1686 days prior to the positive FIT test (mean 726 days). It also highlights that if a FIT is used as an interval exam between colonoscopies, physicians should realize that a positive FIT in this context warrants a repeat colonoscopy. Similar gaffes in screening algorithms can be seen in other studies, which have also reported missed opportunities for referrals to diagnostic colonoscopy by physicians [6]. * Steven H. Itzkowitz [email protected]