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Cancer Screening: Reducing Structural Barriers for Clients – Colorectal Cancer by Fecal Occult Blood Testing (FOBT)


What the CPSTF Found

About The Systematic Review

The Task Force finding is based on evidence from a Community Guide systematic review published in 2008 (Baron et al., 7 studies, search period 1966-2004) combined with more recent evidence (5 studies, search period 2004-2008). The systematic review was conducted on behalf of the Task Force by a team of specialists in systematic review methods, and in research, practice, and policy related to cancer prevention and control. This finding updates and replaces the 2008 Task Force finding on Cancer Screening: Reducing Structural Barriers – Colorectal Cancer by Fecal Occult Blood Testing [PDF - 254 kB].


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Summary of Results

Results of the Previous Review

The original colorectal cancer screening review included seven studies.

  • Screening by fecal occult blood test (FOBT): median increase of 16.1 percentage points (IQI: 12.1 to 22.9 percentage points; 11 study arms)

Results of the Updated Review

Of the five additional studies that qualified for the review, four considered screening by FOBT.

  • Colorectal cancer screening by any test: median increase of 36.9 percentage points (range: 16.3 to 41.1 percentage points; 4 study arms)
  • The larger intervention effect during the update period may be at least partially due to differences in target populations, baseline rates of screening, and study designs.

Summary of Economic Evidence

Three studies qualified for the review. Monetary values are presented in 2009 U.S dollars.

  • Two studies measured the cost per additional screen by FOBT to be $63.20 and $424.67.
  • One study estimated a cost-effectiveness ratio of $3000 to $4000 per year of life saved.


  • The original review findings were applicable across a range of settings where target populations may have limited physical access to FOBT.
  • Evidence from the updated search period expands applicability to include diverse populations as the additional studies included some from another high-income economy and some samples included other populations (e.g., Native Hawaiians, Hispanics).

Evidence Gaps

Each Community Preventive Services Task Force (Task Force) review identifies critical evidence gaps—areas where information is lacking. Evidence gaps can exist whether or not a recommendation is made. In cases when the Task Force finds insufficient evidence to determine whether an intervention strategy works, evidence gaps encourage researchers and program evaluators to conduct more effectiveness studies. When the Task Force recommends an intervention, evidence gaps highlight missing information that would help users determine if the intervention could meet their particular needs. For example, evidence may be needed to determine where the intervention will work, with which populations, how much it will cost to implement, whether it will provide adequate return on investment, or how users should structure or deliver the intervention to ensure effectiveness. Finally, evidence may be missing for outcomes different from those on which the Task Force recommendation is based.

Identified Evidence Gaps

The following outlines evidence gaps for interventions to reduce structural barriers to increase breast, cervical, or colorectal cancer screening.

  • Are interventions effective for promoting colorectal cancer screening with methods other than FOBT?
  • Are interventions to promote colorectal cancer screening equally effective when addressing colorectal cancer screening more generally, as when specific to one type of test?
  • What are the incremental effects of adding intervention components to other interventions?
  • What influence do newer methods of communication (e.g., the Internet, e-mail, social media, automated interactive voice response, texting) have on intervention effectiveness?
  • What is the influence of health system factors on intervention effectiveness?

Study Characteristics

Following are characteristics of included studies from the updated search period.

  • Most evidence focused on approaches to reduce time and distance to completing screening (e.g., mailing FOBT cards to clients).
  • Studies were conducted in the U.S. and France and in medical care and community settings.
  • All studies enrolled men and women aged ≥50 years.
  • Specified racial/ethnic groups included whites, Hispanics/Latinos, African Americans, and Native Hawaiians.
  • Included populations also varied, from residents of urban communities to residents of a remote Hawaiian Island.
  • Outcomes were assessed by proportion of returned kits, self-report, and medical record review.