Maintaining Equitable Follow-Up After Positive Stool-Based Colorectal Cancer Screening in Rural Populations

Background Colorectal cancer (CRC) remains a leading cause of cancer-related mortality in the United States. Although screening colonoscopy is effective, access barriers and long wait times limit its use. Stool-based fecal occult blood testing (FOBT) has emerged as an alternative screening strategy for average-risk patients. Rural populations often experience worse health care outcomes, making it important to evaluate whether implementation of stool-based screening affects follow-up care in these patients. Methods Retrospective single-institution observational study evaluating patients ≥18 years old who had a positive stool-based test between January and December 2024. Patients were categorized as rural or non-rural based on Rural-Urban Commuting Area codes derived from home ZIP codes. Primary outcomes included follow-up colonoscopy rates, time to diagnostic colonoscopy, and colonoscopy findings. Results A total of 688 patients met inclusion criteria, including 494 (72%) non-rural and 194 (28%) rural patients. Follow-up colonoscopy rates were 92% non-rural vs 88% rural, P = 0.1002. Median time from the positive stool-based test to colonoscopy was similar between groups (53 days vs 44 days, P = 0.10). Rural patients were more likely to undergo colonoscopy at an outside facility (12% vs 5%, P = 0.008). Overall polyp detection rates were comparable (91% vs 92%, P = 0.87), with similar rates of tubular and tubulovillous adenomas. Conclusions Implementation of a stool-based CRC screening strategy was successful without causing delays for rural patients, with high rates of follow-up for both rural and non-rural patients. These findings suggest that stool-based screening can reasonably implemented without increasing health care barriers for rural patients.