Simple mailing trick doubles liver cancer screening rates for high-risk patients

Screening for liver cancer among patients with cirrhosis nearly doubled when they were sent a signed order from their specialist, according to a new study from the Perelman School of Medicine at the University of Pennsylvania. However, when the researchers added a $20 incentive to the mail orders, it made no difference in whether patients completed their tests. The project was published this week on Hepatology Communications.

Our findings show that an approach like this can significantly increase liver cancer surveillance, which is particularly important in a group of patients at high risk for liver cancer.”

Shivan Mehta, MD, MBA, Associate Professor of Gastroenterology and Associate Chief Innovation Officer at Penn Medicine

The study intervention took place in three different time periods spanning 2020 and 2021 and included a diverse group of more than 500 patients. When patients were mailed the order for an abdominal ultrasound, about 55 percent completed the screening within six months of the letter being posted. In the usual care arm — offered the screening by a gastroenterologist or hepatologist during routine office visits — just 27 percent of patients had the ultrasound.

Letters sent with patient screening orders included information about why ultrasounds were important for patients with cirrhosis: Mainly, those with the condition are at particular risk for hepatocellular carcinoma. leading cause of cancer deaths worldwide.

“It is so important to screen patients with cirrhosis for liver cancer, as early detection improves survival,” said the study leader. Kenneth Rothstein, MD, professor of Gastroenterology and regional director of Hepatology at the University of Pennsylvania Health System. “Unfortunately, only 20 percent of people with cirrhosis in this country are properly screened, leading to many early and unnecessary deaths from liver cancer.”

Using the mail orders and letters explaining the risk, the researchers hoped to make the right decision – to do a control ultrasound – the easiest for patients. It follows the principle of “sudging,” a behavioral science technique intended to subtly and easily nudge people toward making positive decisions.

To that end, the researchers added a third arm of the study that not only included mail orders for screening, but also offered an unconditional $20 incentive just for opening the mail. However, the proportion of patients who completed screening in this arm of the study was almost the same as in the regular, unincentive mail-order arm: 54.1 percent in the incentivized group versus 54.5 percent in the no-incentive group.

“There are mixed data on the effectiveness of financial incentives for preventive health activities,” Mehta explained. “It might not be something that patients are used to getting from their doctors through direct mail, so they weren’t sure of the context. Also, maybe bigger incentives or a conditional incentive — like getting cash only if the test is completed — ;might be more effective.”

This latest study builds on similar data from a previous study Mehta helped lead, which showed that 29 percent of people who were late for screening mailed colon cancer screening kits that were sent to their homes. Then, too, the positive results were achieved regardless of the financial incentive.

An additional recent study by Mehta also found mail to be effective compared to e-mail when reminding patients to get tested for hepatitis C.

Therefore, mail appears to have a distinct advantage over some other methods of communicating with patients.

“While more of our patients have access to the Internet, smartphones and texting, there is still disparity in access,” Mehta said. “However, most patients can receive referrals. Ultimately, our goal is to communicate with patients through the method they choose or have the best access to.”

This study was funded primarily by the National Institute on Aging (5P30AG03456-10) and in part by the National Cancer Institute (K08CA234326).