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Some patients delay colonoscopy after positive fecal test

Kaiser Permanente study finds 7.4% of patients who had a positive fecal blood test had a second test rather than a colonoscopy

A new Kaiser Permanente study found that some patients repeat fecal testing rather than have a colonoscopy — the procedure recommended following a positive fecal test. Moreover, among those patients who repeated the fecal test, over half did not have a colonoscopy within a year.

The study, published in the Journal of General Internal Medicine, examined data from hundreds of thousands of medical records. The research team also interviewed dozens of patients between the ages of 50 and 89 who had positive fecal tests between 2010 and 2018 at 4 different health systems: Kaiser Permanente Southern California, Kaiser Permanente Northern California, Kaiser Permanente Washington, and Parkland Health in Texas. Researchers also interviewed physicians.

TR Levin in blue shirt with colorful tie
Theodore R. Levin, MD

“The fecal immunochemical test is an efficient and highly effective way to screen for colorectal cancer,” said senior author Theodore R. Levin, MD, a research scientist at the Kaiser Permanente Division of Research and a gastroenterologist with The Permanente Medical Group. “But if patients with an abnormal test do not receive a colonoscopy, there is no benefit for them in terms of reduced colorectal cancer incidence or mortality.”

The study found that only 41% of the patients who had 2 positive fecal tests had a colonoscopy within a year of their initial positive fecal test. In addition, those with an initial positive test followed by a negative second test were significantly less likely to have a colonoscopy than those with 2 positive tests. Patients ages 65 to 89 who had a greater number of chronic conditions were significantly more likely to do a repeat fecal test than go for a colonoscopy.

Erin Hahn wearing a white shirt under a suit jacket
Erin E. Hahn, PhD

“The good news is that the majority of patients in our study received a recommended colonoscopy after a positive result from a home test, which is the absolute best way we have to catch colorectal cancer early and get it treated,” said lead author Erin E. Hahn, PhD, of the Kaiser Permanente Southern California Department of Research & Evaluation and the Kaiser Permanente Bernard J. Tyson School of Medicine, both in Pasadena, Calif.  “What is worrisome is we did see that some patients repeated the home tests instead of immediately getting a colonoscopy.”

Colorectal cancer is the second most common cancer-related cause of death in the U.S. Colorectal cancer screening with an annual fecal blood test is associated with reductions in colorectal cancer related deaths. A fecal blood test is done at home and then mailed to a laboratory for processing. A positive test result should be followed by a colonoscopy. Long time intervals between a positive fecal test and a colonoscopy, which is necessary to diagnose colorectal cancer, are associated with poorer outcomes.

If patients with an abnormal test do not receive a colonoscopy, there is no benefit for them in terms of reduced colorectal cancer incidence or mortality.

— Theodore R. Levin, MD

The research team interviewed patients who had had a second test rather than a colonoscopy after to learn more about their decision-making process. Some patients said they did the second test to avoid or delay the colonoscopy, or because they thought it would help rule out other health conditions. Others said they felt a second test was important to confirm the results.

“Our study found repeat testing after an abnormal test was driven by patient reluctance,” said Levin. “As physicians and a health care system, we need to find better ways to encourage and reassure our patients that they should not have a second test but should proceed with a colonoscopy as soon as they can.”

The research team said their findings highlight the importance of patient-provider communication about colorectal cancer screening. “If a patient is hesitant about getting a colonoscopy after a positive FIT, it’s critical to talk to them about what the FIT results really mean: there is blood in the stool that might indicate colorectal cancer,” said Hahn. “Even if the patient has a negative result the next week, the cancer could still be there. It’s so important to find these cancers early so we can treat them effectively.”

The study was supported by the National Cancer Institute’s Population-based Research to Optimize the Screening Process II (PROSPR II) consortium.

Co-authors included Corrine E. Munoz-Plaza, MPH, Nirupa R. Ghai, PhD, Katherine Pak, MS, Britta I. Amundsen, MA, Richard Contreras, MS,  and Nancy Cannizzaro, PhD, of the Department of Research & Evaluation; Christopher D. Jensen, PhD, of the Division of Research; Jessica Chubak, PhD, and  Beverly B. Green, MD, of Kaiser Permanente Washington Health Research Institute; Celette Sugg Skinner, PhD, of the University of Texas; Ethan A. Halm, MD, of the Rutgers Robert Wood Johnson Medical School; and Joanne E. Schottinger, MD, of the Kaiser Permanente School of Medicine.

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About the Kaiser Permanente Division of Research

The Kaiser Permanente Division of Research conducts, publishes and disseminates epidemiologic and health services research to improve the health and medical care of Kaiser Permanente members and society at large. It seeks to understand the determinants of illness and well-being, and to improve the quality and cost-effectiveness of health care. Currently, DOR’s 600-plus staff is working on more than 450 epidemiological and health services research projects. For more information, visit or follow us @KPDOR.


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