Introduction

Colorectal cancer (CRC) is a significant cause of cancer deaths in the U.S., ranking third nationwide and second in Texas. Up to 90% of CRC deaths can be avoided through CRC screening (CRCS), which detects and treats precancerous polyps and early-stage CRC, significantly improving survival rates. However, Texas has relatively low CRCS rates, with only 39% of cases diagnosed early. The Alliance for Colorectal Cancer Testing 3.0, renamed Project 80%, aims to achieve an 80% CRCS rate among eligible individuals in Texas by addressing barriers such as cost and lack of insurance. The project serves priority populations in 64 counties through Federally Qualified Health Centers (FQHCs) and community clinics. MD Anderson supports the implementation of evidence-based interventions to enhance CRCS effectiveness, striving to reduce disparities and prevent needless suffering and death from CRC in Texas.

Methods

Program component interventions are based on those described by the Community Guide to Preventive Services, RTIPS, USPSTF and the ACS. These may include patient reminders, small media, group and one-on-one education, provider reminders, provider feedback and assessment, reducing structural barriers, and reducing out-of-pocket costs.

FIT-based screening is offered annually to asymptomatic average risk individuals ages 45 to 75 followed by optical colonoscopy to evaluate positive findings. Individuals at increased risk are offered initial colonoscopy and may initiate screening at an earlier age as per recommendations of the U.S. Multi-Society Task Force (USMSTF). Project 80% staff provide clinic teams with education screening recommendation and addressing common patient concerns. Clinical champions are identified at each FQHC or community clinic to facilitate implementation of the project and ensure that each clinic site adheres to the project processes. MD Anderson project staff instruct clinic teams to track the distribution of FITs to their patients, verify results and ensure patients testing positive are referred to a community gastroenterologist for colonoscopy, providing navigation as needed. Follow-up surveillance colonoscopy is provided in accordance with USMSTF recommendations. UT Health Science Center faculty will evaluate Project 80% to assess CRC FIT screening completion, colonoscopy adherence, diagnostic follow-up, and navigation of patients.

Results

Project 80% implemented CRCS processes at community clinics, including assessing patient eligibility, providing guidance on completing the FIT at home to address health literacy, establishing capacity for CRCS lab orders, creating patient lab requests, notifying patients of FIT results, and facilitating referrals for those with positive results. Qualitative data indicate barriers and challenges to the implementation of FIT screening include high turnover at organizations, non-systematic use of screening recommendations, and updates to electronic health record integration that impact provider reminders.

Between 2015 and 2023, 93,773 FITs were completed, with 6,404 (6.8%) yielding positive results. Throughout the program, 4,101 patients had one or more polyps (some patients may have had multiple screenings), resulting in the identification of 1,317 polyps and 270 colorectal cancer diagnoses. Additionally, 8,670 colonoscopies were completed during this period.

Conclusion

Coordinated clinic-level interventions boost FQHC CRC screening rates through FIT. Project 80% continues to enhance FIT reach and integration at FQHCs, especially in underserved areas. Integrating EBIs improves FIT distribution, data collection, and outcomes to enhance CRCS in Texas clinical settings serving underinsured and higher-risk patients.