News Release
An open mailbox filled with letters.

PHILADELPHIA— Liver cancer screening among patients with cirrhosis almost doubled when they were mailed a signed order from their specialist, according to a new study from the Perelman School of Medicine at the University of Pennsylvania. However, when researchers added an incentive of $20 to the mailed orders, it made no difference in whether patients completed their screenings. The work was published this week in Hepatology Communications.

“Our findings show that an approach like this can meaningfully increase liver cancer surveillance, which is particularly important in a group of patients who are high risk for liver cancer,” said Shivan Mehta, MD, MBA, an associate professor of Gastroenterology and the associate chief innovation officer at Penn Medicine.

The study’s intervention took place across three different time periods stretching across 2020 and 2021 and involved a diverse cohort of more than 500 patients. When patients were mailed the order to get an abdominal ultrasound, approximately 55 percent completed their screening within six months of the letter going out. In the arm that received the usual care—being offered the screening by a gastroenterologist or hepatologist during routine office visits—just 27 percent of the patients got their ultrasound.

Letters mailed with the screening orders to patients included information on why the ultrasounds were important for patients with cirrhosis: Chiefly, those with the condition are at particular risk for hepatocellular carcinoma, a major cause of cancer deaths worldwide.

“It is so important to screen patients with cirrhosis for liver cancer since early detection improves survival,” said study lead author Kenneth Rothstein, MD, a 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 being screened correctly, which results in many early and unnecessary deaths from liver cancer.”

By using mailed orders and the letters explaining the risk, the researchers hoped to make the right decision—getting a screening ultrasound—the easiest for patients. It follows the principle of “nudging,” a behavioral science technique meant to subtly and easily move people toward making positive decisions.

To that end, the researchers added a third arm of the study that not just included mailing orders for screening, but also offered an unconditional $20 incentive just for opening the mail. Yet, the rate of patients who completed their screening in that arm of the study was nearly identical to the regular, non-incentive mailed order arm: 54.1 percent in the incentive group versus 54.5 percent in the non-incentive.

“There is mixed data on the effectiveness of financial incentives for preventive health activities,” Mehta explained. “It may not be something that patients are used to getting from their clinicians through direct mail, so they were not sure about the context. Also, perhaps larger incentives or a conditional incentive—such as only receiving the cash if the screening is complete—may be more effective.”

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

An additional recent study by Mehta also found mail to be effective compared to electronic messaging when patients were reminded to get screened for hepatitis C.

As such, mail appears to have a particular advantage over some other methods of communication with patients.

“While more of our patients have access to internet, smartphones, and text messaging, there is still differential access,” said Mehta. “However, most patients are able to receive mailings. Ultimately, our goal is to communicate with patients through the method that they choose or have the best access to.”

This study was funded mostly by the National Institute of Aging (5P30AG03456-10) and partly by the National Cancer Institute (K08CA234326).


Penn Medicine is one of the world’s leading academic medical centers, dedicated to the related missions of medical education, biomedical research, excellence in patient care, and community service. The organization consists of the University of Pennsylvania Health System and Penn’s Raymond and Ruth Perelman School of Medicine, founded in 1765 as the nation’s first medical school.

The Perelman School of Medicine is consistently among the nation's top recipients of funding from the National Institutes of Health, with $550 million awarded in the 2022 fiscal year. Home to a proud history of “firsts” in medicine, Penn Medicine teams have pioneered discoveries and innovations that have shaped modern medicine, including recent breakthroughs such as CAR T cell therapy for cancer and the mRNA technology used in COVID-19 vaccines.

The University of Pennsylvania Health System’s patient care facilities stretch from the Susquehanna River in Pennsylvania to the New Jersey shore. These include the Hospital of the University of Pennsylvania, Penn Presbyterian Medical Center, Chester County Hospital, Lancaster General Health, Penn Medicine Princeton Health, and Pennsylvania Hospital—the nation’s first hospital, founded in 1751. Additional facilities and enterprises include Good Shepherd Penn Partners, Penn Medicine at Home, Lancaster Behavioral Health Hospital, and Princeton House Behavioral Health, among others.

Penn Medicine is an $11.1 billion enterprise powered by more than 49,000 talented faculty and staff.

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