Colorectal Cancer Screening

Evaluating approaches to increase colorectal cancer screening


Colorectal cancer (CRC) is the second leading cause of cancer-related deaths among men and women in the U.S. It is recommended that individuals begin regular screenings for CRC at the age of 50. Screening can prevent cancer by discovering precancerous polyps that can be removed before they turn into cancer. It can also find CRC early when treatment can often lead to a cure. Patients have several options when it comes to completing screening. The most common are colonoscopy and fecal immunochemical test (FIT).

Unfortunately, millions of people in the U.S. are not getting screened for CRC.


We have run a series of pilots to identify strategies to improve CRC screening rates. To hone in on what might move the needle, we’ve tested behavioral economic approaches such as active choice, opt-out nudges, and incentives, experimented with how outreach and communication modalities are used, and explored which types of screening patients are most amenable to completing.


Key findings to date include the following:

  • A bidirectional, automated texting navigation program improved colonoscopy adherence rates as compared with usual care. Learn more.

  • The addition of a lottery-based incentive to a text messaging program that asks patients to opt-in to receive mailed FIT screening did not improve completion rates. Learn more.

  • Mailed CRC screening outreach providing an option to opt-out had significantly higher participation rates than opt-in messaging. Learn more.

  • Offering the choice of FIT reduced colonoscopy selection, and active choice resulted in an even lower colonoscopy rate compared with a sequential choice or colonoscopy alone. Learn more.

We’re currently scaling up our automated text navigation program to help patients through the colonoscopy preparation process. We’re also expanding outreach efforts - taking key findings and broadening our reach to other preventive health areas, including hepatitis C screening and hepatocellular carcinoma surveillance.


COVID-19 resulted in about a 90 percent decrease in CRC screening during the initial surge. Since then, our work on mailed outreach that does not require an in-person office visit has been utilized across the health system to increase screening rates.

Phase 2: It does work

Susan Day, MD, MPH
Carmen Guerra, MD, MSCE, FACP
Charles Orellana, MD
Chyke Doubeni, MD, MPH
Nadim Mahmud, MD, MS, MPH, MSCE

Innovation leads

Shivan Mehta, MD, MBA, MSHP
Cathy Reitz, MPH
Caitlin McDonald, MPH
Jessica Sung
Matt Van Der Tuyn, MA


The Family Practice and Counseling Network

Innovation Methods

Fake back end
It is essential to validate feasibility and understand user needs before investing in the design and development of a product or service.
A fake back end is a temporary, usually unsustainable, structure that presents as a real service to users but is not fully developed on the back end.
Fake back ends can help you answer the questions, "What happens if people use this?" and "Does this move the needle?"
As opposed to fake front ends, fake back ends can produce a real outcome for target users on a small scale. For example, suppose you pretend to be the automated back end of a two-way texting service during a pilot. In that case, the user will receive answers from the service, just ones generated by you instead of automation.
Fake back end

For the first phase of the automated texting pilot in colonoscopy preparation, we asked open-ended questions that were answered by a GI fellow.

This enabled us to learn more about the needs of patients quickly and at a low-cost. It also helped us identify portions of the support process that could be automated.