FIT-DNA Shows Modest Advantage Over FIT for CRC Screening in Community Health Centers

The fecal immunochemical test (FIT)-DNA modestly outperformed FIT in boosting colorectal cancer (CRC) screening in community health centers (CHCs), but overall uptake and follow-up remained low, according to a study recently published in JAMA Internal Medicine.¹

CRC Screening in CHCs: FIT vs FIT-DNA

CRC is the second most common cause of cancer death in the US, with screening rates continuing to fall short, particularly among underserved populations.² Community health centers (CHCs), which serve as the primary care backbone for millions of safety-net patients, face persistent structural barriers to CRC screening, including resource constraints, low health literacy, and inadequate clinician follow-through.¹

Stool-based screening tests, the most common being FIT and FIT-DNA, are often used in places such as CHCs where access to colonoscopy is limited. FIT is an inexpensive, annually administered test long used in CHCs. FIT-DNA, a more recently developed stool-based option typically performed every 3 years, is mailed directly to patients and accompanied by a robust manufacturer-administered patient assistance program.

Despite evidence that mailed screening outreach can dramatically improve uptake, few studies have directly compared FIT and FIT-DNA in the CHC setting. Researchers designed a study to fill that gap, hypothesizing that FIT-DNA might achieve better screening participation, particularly in populations facing multiple social and economic barriers to care, because it does not require CHC staff effort for outreach and carries higher sensitivity for advanced adenomas than FIT.

The Community Collaboration to Advance Racial/Ethnic Equity in Colorectal Cancer Screening study was a pragmatic, cluster-randomized clinical trial (RCT), with the primary outcome being CRC screening participation within 90 days. The RCT was conducted at 8 CHC sites, with 4 in both greater Boston and Los Angeles, between June and October 2023. Sites were randomized at the clinic level to minimize contamination.

Participants were eligible if they were aged 45 to 75 years, due for CRC screening, received primary care at a participating CHC, and spoke English or Spanish. Individuals assigned to FIT received a mailed kit with automated text message reminders on days 14 and 28. Those assigned to FIT-DNA received the manufacturer's kit along with scripted telephone calls, texts, and emails coordinated by Exact Sciences. Patients with abnormal results in Boston and Los Angeles were offered standardized phone navigation to support colonoscopy follow-up.

FIT vs FIT-DNA Screening Outcomes Across Sites, Subgroups

The final sample included 5127 participants, with 2435 in the FIT group and 2692 in the FIT-DNA group. The mean (SD) age was 54.5 (8.1) years, and 58.9% (n = 3018) were female. Nearly half were covered by Medicaid (49.5%; n = 2540), and 12% (n = 614) were uninsured.

The cohort was predominantly Hispanic (74.5%; n = 3818), with 65.6% (n = 3363) preferring Spanish. However, demographics differed meaningfully by region, as Los Angeles had a higher proportion of uninsured and Spanish-speaking patients, whereas Boston's population reflected Massachusetts' broader insurance coverage.

At 90 days, screening participation was significantly higher in the FIT-DNA group (27.9%) compared with the FIT group (22.6%; P = .02). Participation remained higher for FIT-DNA (31.7% vs. 26.7%) at 180 days, with time to screening completion also shorter in this cohort.

Screening participation at 90 days was higher in Boston (28.4%) than in Los Angeles (23.1%). Specifically, in Boston, the FIT and FIT-DNA groups had similar screening completion (29.1% vs 28.0%). Meanwhile, in Los Angeles, participation was significantly higher in the FIT-DNA group than the FIT cohort (27.8% vs 18.5%). The researchers noted that screening participation at 180 days followed similar patterns.

Across subgroups, screening participation was higher with FIT-DNA vs FIT among individuals aged 50 years or older (30.0% vs 21.8%) and those who were Hispanic (28.3% vs 21.0%), Spanish-speaking (29.4% vs 21.2%), on Medicaid (29.5% vs 21.1%), and uninsured (20.2% vs 12.9%).

Among the 1435 participants who completed screening, 100 (7.0%) had abnormal results. Of those, only 36 completed a follow-up colonoscopy within 180 days. By region, Boston had a higher colonoscopy completion rate (69.7%; 23 of 33) than Los Angeles (19.4%; 13 of 67).

Improving CRC Screening in Underserved Populations

The researchers acknowledged their limitations, including that the 2 regions used different FIT kit brands, which may have contributed to differing rates of abnormal results between Boston and Los Angeles. They noted that this complicates direct regional comparisons. Also, in practice, it underscores the importance of FIT brand selection in clinical practice, since higher false-positive rates increase the downstream burden of colonoscopy follow-up. Still, the researchers expressed confidence in their findings and identified areas for further research.

“While overall participation was modest, our findings are clinically important and inform future practice,” they concluded. “Given that CRC outcomes are often poorest among underserved populations receiving care in CHCs, evidence-based interventions to improve outcomes must be research and policy priorities.”

References

1. May FP, Brodney S, Tuan JJ, et al. Mailed outreach for colorectal cancer screening in community health centers: The CARES pragmatic cluster randomized clinical trial. JAMA Intern Med. Published online April 27, 2026. doi:10.1001/jamainternmed.2026.1170
2. Siegel RL, Wagle NS, Cercek A, Smith RA, Jemal A. Colorectal cancer statistics, 2023. CA Cancer J Clin. 2023;73(3):233-254. doi:10.3322/caac.21772