Colorectal Cancer Screening Discussions Research Articles

Abstract B107: Colorectal cancer (CRC) screening: What is discussed with patients in a federally qualified health center?

Abstract Purpose: To assess the quality of CRC screening discussions based on elements of informed decision making (IDM). Methods: Audio tapes of average-risk patients’ medical visits occurred as part of a patient-level CRC screening education intervention that activated patients to ask their providers for a CRC screening test. Audiotapes were coded by two independent trained reviewers for the presence of a CRC screening discussion. CRC screening discussions were coded for key elements of IDM. Fifteen percent of the audiotapes were randomly selected and coded by the reviewers twice to calculate inter- and intra-observer reliability. Results: This study was part of a randomized controlled trial of two patient educational programs conducted among 269 average-risk patients and 8 providers at a federally qualified health center (FQHC). Patient characteristics included: 72% African American; 61% with annual household incomes of less than $20,000; 56% with no health insurance; 28% with less than a high school education; and 54% who read ≤8th grade level (10% ≤6th grade level). In addition, 84% of the patients reported that they preferred to have some level of input into the decision about what medical tests they undergo. Forty-five percent of the patients allowed their medical visit to be audio taped (106 visits were audio taped but 103 were reviewed because of tape recorder malfunction in 3 visits). Near the end of the study, one provider no longer allowed audio taping (n=34 patients) of the medical visits. The rate of patient agreement to be audio taped was a reflection of the different research assistants (range of acceptance by research assistants: 23% to 67%). Both reviewers documented that there was a CRC discussion in 50 of the 103 (48.5%) visits. The patient initiated the screening discussion in 39 (78%) of the 50 visits, however, four patients only mentioned it to the medical assistant who met with them prior to seeing the provider. Although CRC screening was mentioned in 50 visits, no discussion occurred in 14 of these visits. There was a low occurrence of IDM elements in the CRC screening discussions. The most common elements raised by providers were: the nature of the decision (e.g. need for screening because of age): (n=19); patient's understanding: (n=3) [assistants checked for understanding: (n=7)]; and patient test preference: (n=2). IDM elements raised by patients were: nature of the decision: (n=5); test preference: (n=4); understanding: (n=3); and uncertainties and alternatives (n=1). There was no mention of African Americans having higher CRC incidence and mortality rates in any of the visits. Two patients told the provider that by watching the video they realized that they had incorrectly completed the FOBT in past. Conclusions: Although patients reported wanting some role in making decisions about medical tests they receive, elements of informed decision making were not consistently addressed in patients’ medical visits. This finding suggests that communication skills training for patients and providers about CRC screening is needed to reduce CRC disparities that exist among underserved populations. Citation Information: Cancer Epidemiol Biomarkers Prev 2010;19(10 Suppl):B107.

Systematic Review: Enhancing the Use and Quality of Colorectal Cancer Screening

National guideline groups recommend screening and discussion of screening options for persons at average risk for colorectal cancer (CRC). However, emerging evidence suggests that CRC screening is simultaneously underused, overused, and misused and that adequate patient-provider discussions about screening are infrequent. To summarize evidence on factors that influence CRC screening and strategies that increase the appropriate use and quality of CRC screening and CRC screening discussions. MEDLINE, the Cochrane Library, and the Cochrane Central Register of Controlled Trials were searched for English-language publications describing studies conducted in the United States from January 1998 through September 2009. Two reviewers independently selected studies that addressed the study questions and met eligibility criteria. Information on study design, setting, intervention, outcomes, and quality were extracted by one reviewer and double-checked by another. Reviewers assigned a strength-of-evidence grade for intervention categories by using criteria plus a consensus process. Reviewers found evidence of simultaneous underuse, overuse, and misuse of CRC screening as well as inadequate clinical discussions about CRC screening. Several patient-level factors were independently associated with lower screening rates, including having low income or less education, being uninsured, being Hispanic or Asian, being less acculturated into the United States, or having limited access to care. Evidence that interventions that included patient reminders or one-on-one interactions (that is, between patients and nonphysician clinic staff), eliminated structural barriers (for example, simplifying access to fecal occult blood test cards), or made system-level changes (for example, using systematic screening as opposed to opportunistic screening) were effective in enhancing use of CRC screening was strong. Evidence on how best to enhance discussions about CRC screening options is limited. No studies focused on reducing overuse, and very few focused on misuse. Reporting and publication bias may have affected our findings. The independent effect of individual elements of multicomponent interventions was often uncertain. Although CRC screening is underused overall, important problems of overuse and misuse also exist. System- and policy-level interventions that target vulnerable populations are needed to reduce underuse. Interventions aimed at reducing barriers by making the screening process easier are likely to be effective. Studies aimed at reducing overuse and misuse and at enhancing the quality and frequency of discussions about CRC screening options are needed. Agency for Healthcare Research and Quality.

Efficacy Expectations for Colorectal Cancer Screening in Primary Care: Identifying Barriers and Facilitators for Patients and Clinicians

Physicians (MDs), nurse practitioners (NPs), and physician assistants (PAs) in primary care (PC) specialties, as well as patients, participated in a series of peer-level focus groups to explore how colorectal cancer (CRC) screening is approached in PC. Twenty-seven focus groups were conducted, including 8 groups composed of MDs (n = 56), 7 with NP/PAs (n = 47), and 12 with patients (n = 103). Clinicians (MDs, NPs, PAs) reported discussing CRC screening during well visits and were alerted to patients in need of screening through flow sheets, chart reminders (paper, electronic) or by office personnel, and cited lack of time, patient reluctance, and challenges related to scheduling colonoscopy as barriers to screening. Clinicians identified communication skills and the convenience of office-based screening procedures as facilitators of CRC screening. Patients recalled discussing CRC screening during PC office visits and most commonly identified colonoscopy and fecal occult blood test as common CRC screening tests. Physician recommendation and knowing someone who has/had cancer were the most common factors motivating patients' decision to complete CRC screening. Results are framed according to patient and clinician perceptions of self-efficacy related to CRC screening.

Use of focus group data to develop recommendations for demographically segmented colorectal cancer educational strategies

Screening is available and effective in colorectal cancer (CRC) control, but underutilized. The purpose of this study was to use focus group data to develop recommendations for the development of educational interventions to increase CRC screening, using an audience segmentation strategy. Demographic segments were based on urban-rural residence, race (African-American, White) and sex. One hundred and sixty-five participants age 50+, with no history of CRC participated in 17 focus groups in Alabama urban and rural communities. Transcripts were examined by independent coders. Knowledge among participants was limited regarding age to begin screening, insurance coverage and risk factors for CRC. Perceived barriers to screening included lack of physician recommendation, cost/lack of insurance coverage, pain/discomfort and embarrassment. African-American men reported postponement in seeing their physicians. White women were proactive at initiating discussion of CRC screening with their providers while African-American women felt that providers should drive the process. No urban-rural differences were identified. This study identified cultural and gender characteristics and perceptions that can be used in the development of demographically segmented health communication interventions to increase CRC awareness and screening.

A multimedia patient education program on colorectal cancer screening increases knowledge and willingness to consider screening among Hispanic/Latino patients

Objective To test a multimedia patient education program on colorectal cancer (CRC) screening that was designed specifically for the Hispanic/Latino community, and developed with input from community members. Methods A total of 270 Hispanic/Latino adults, age 50–80 years, participated in Spanish for all phases of this pretest–posttest design. Patients were randomly assigned to a version of the multimedia program that opened with either a positive or negative introductory appeal. Structured interviews assessed screening relevant knowledge (anatomy and key terms, screening options, and risk information), past screening behavior, willingness to consider screening options, intention to discuss CRC screening with the doctor, and reactions to the multimedia patient education program. Results The multimedia program significantly increased knowledge of anatomy and key terms (e.g., polyp), primary screening options (FOBT, flexible sigmoidoscopy, colonoscopy), and risk information as well as willingness to consider screening ( p < .001 for all). No significant differences emerged between positive and negative introductory appeals on these measures, intention to discuss CRC screening with their doctor, or rating the multimedia program. Conclusion Multimedia tools developed with community input that are designed to present important health messages using graphics and audio can reach Hispanic/Latino adults across literacy levels and ethnic backgrounds. Additional research is needed to determine effects on actual screening behavior. Practice implications Despite promising results for engaging a difficult-to-reach audience, the multimedia program should not be considered a stand-alone intervention or a substitute for communication with physicians. Rather, it is a priming mechanism intended to prepare patients for productive discussions of CRC screening.

Perceptions of Iowa Family Physicians Regarding Colorectal Cancer Screening

Fewer than half of Americans have been screened for colorectal cancer (CRC), a largely preventable disease. All physician members (n = 1030) of the Iowa Academy of Family Physicians were mailed a 3-page investigator-developed survey about their attitudes, barriers, and practices regarding CRC screening. The usable response rate was 29%. Forty-three percent practiced in rural settings. Ninety-five percent felt that they were well informed about American Cancer Society guidelines and 90% tried to follow the guidelines. Most doctors (88%) disagreed with the statement that there was "no time to adequately discuss screening," but they would like more time to discuss screening. Only 40% felt their medical records were organized to easily determine screening status, 40% encouraged office staff to participate in screening, and 16% had a written policy regarding CRC screening. Physicians estimated that they recommend screening to 78% of their patients and that 54% of their patients were actually up-to-date. Discussion of CRC screening was strongly dependent on visit type, with physicians estimating that CRC screening is discussed at 11% of acute visits, 42% of chronic visits, and 87% of health maintenance visits. Several office system factors were associated with a recommendation for screening in a multivariable linear regression model (R = 0.33). Although nearly all physicians felt that they were well informed about American Cancer Society guidelines and tried to follow guidelines for CRC screening, few had office systems to facilitate screening. Physicians would like more time to discuss screening. Office systems likely have the most potential to improve CRC screening among patients attending primary care practices.

Informed Decision-Making and Colorectal Cancer Screening

Current recommendations advise patients to participate in the decision-making for selecting a colorectal cancer (CRC) screening option. The degree to which providers communicate the information necessary to prepare patients for participation in this process is not known. To assess the level of informed decision-making occurring during actual patient-provider communications on CRC screening and test for the association between informed decision-making and screening behavior. Observational study of audiotaped clinic visits between patients and their providers in the primary care clinic at a Veterans Administration Medical Center. Male patients, age 50-74 years, presenting to a primary care visit at the study site. The Informed Decision-Making (IDM) Model was used to code the audiotapes for 9 elements of communication that should occur to prepare patients for participation in decision-making. The primary outcome is completion of CRC screening during the study period. The analytic cohort consisted of 91 patients due for CRC screening who had a test ordered at the visit. Six of the 9 IDM elements occurred in < or =20% of the visits with none addressed in > or =50%. CRC screening occurred less frequently for those discussing "pros and cons" (12% vs. 46%, P = 0.01) and "patient preferences" (6% vs. 47%, P = 0.001) compared with those who did not. We found that a lack of informed decision-making occurred during CRC screening discussions and that particular elements of the process were negatively associated with screening. Further research is needed to better understand the effects of informed decision-making on screening behavior.

Colorectal Cancer Screening in Gynecology Patients

Objective: Gynecologists are essential primary care providers for female patients. Therefore, colorectal cancer (CRC) screening should be a part of their routine preventive practices. The purpose of our study is to evaluate CRC screening adherence in this population. Methods: A questionnaire was administered to a prospective cohort of female patients awaiting health maintenance exams at six academic and private gynecology offices. Patients reported demographic characteristics, CRC/breast/cervical screening compliance, previous CRC screening recommendations, and future likelihood of CRC screening. Results: 422 women aged 50 years and older completed the questionnaire. 91% were Caucasian with an average age of 58 years. 69% were seen by gynecologists with remaining patients seen by nurse practitioners (NP). 21% of subjects identified their gynecologist as their primary care provider (PCP). 75% of all respondents were compliant with one or more CRC screening modalities compared to 94% and 86% for breast and cervical cancer screening. Participants were more compliant with CRC screening in the academic setting (76%) vs. the private setting (62%). 76% of patients reported previous CRC screening recommendations from any physician. Gynecologists/NPs recommended CRC screening in 44% of patients (49% private, 40% academic). Colonoscopy was the most frequently utilized modality (55%). 65% of respondents were planning to undergo future CRC screening. On multivariable analysis, patient characteristics associated with previous CRC screening in the both settings included (odds ratio, 95% confidence interval) older age (1.1, 1.0-1.2), previous mammography (8.4, 2.8-24.7), PCP recommendation (4.3, 2.6-7.1) and family history (FH) of CRC (1.64, 1.3-4.5). Factors predicting future CRC screening included insurance status (4.7, 1.0-21), previous mammography (6.5, 2.9-6.2) PCP recommendation (3.9, 2.4-6.2) and FH of CRC and polyps (4.0, 2.1-7.5). Only older patients were less likely to undergo future CRC screening (0.96, 0.93-0.99). Patients in the academic setting were 60% more likely than those in non-academic settings to have previously undergone any CRC screening modality (1.64, 1.0-2.7), but they were not more likely to plan on having CRC screening. Conclusion: CRC screening adherence continues to lag behind breast and cervical cancer in gynecology patients. Strategies must be in place to prompt gynecologists and nurse practitioners to discuss CRC screening in eligible patients.

Patient–Physician Colorectal Cancer Screening Discussions and Screening Use

Little is known about patient-physician colorectal cancer (CRC) screening discussions or how discussion content affects screening use. Analyses conducted in 2004-2005 of patient-physician CRC screening discussion content and its association with screening use are described. A mailed survey and retrospective claims data were used to compile information on insured, primary care patients aged 50 to 70 years (n = 4966). The survey collected information on patient-physician CRC screening discussion content (including the 5A's: assess, advise, agree, assist, and arrange). Survey responses were linked with 5-year retrospective claims data (ending December 31, 2003) on CRC screening use. Among patients reporting screening discussions, generalized estimating equation approaches were used to estimate the association of discussion content with screening use. Among those reporting discussion information (n = 2463), 80% reported discussing CRC screening with their physician. The content of these discussions varied, and only 54% used CRC screening. Multivariable model results indicated that the likelihood of screening was greater among patients reporting help scheduling an appointment (assist) (odds ratio [OR] = 2.69, 95% confidence interval [CI] = 1.95-3.72) and those reporting a discussion of results or follow-up (arrange) (OR = 1.63, 95% CI = 1.18-2.24), and lower among patients offered a choice among screening modalities (agree) (OR = 0.57, 95% CI = 0.37-0.86) as well as among those who wanted more screening information (OR = 0.65, 95% CI = 0.43-0.97). Not all patient-physician CRC screening discussions result in CRC screening use. It is important to understand which aspects of shared decision making and discussion content are likely to increase informed and value-concordant decisions to participate in recommended evidence-based CRC screening.

Promoting Community Awareness of the Need for Colorectal Cancer Screening

The purpose of this pilot study was to determine if a community education program based on the Health Belief Model effectively promotes awareness of the need for colorectal cancer (CRC) prevention and screening. An education program was given to 20 employees of an accounting firm in a midwestern city. A survey evaluated the participants' beliefs about CRC, before and after the presentation. The results support a significant increase in the belief that CRC is preventable, and in 5 of 6 screening factors from the Health Belief Model. Participants were encouraged to share what they learned and reported that they anticipate sharing with at least 31 others. A screening questionnaire was distributed as a "cue to action" to discuss CRC screening with their physicians. Participants' intention to discuss CRC with their physicians also increased. The actual effectiveness will be evaluated with 11 participants who volunteered for a 1-year follow-up study. This community education concept had several advantages, including simultaneous access to many participants who share personal testimonials and who invite peers to become screened. The program was effective in increasing awareness of the need for CRC prevention and screening, even beyond those in attendance. The results of the 1-year follow-up study may provide more insight to what education factors promote screening most effectively.

Barriers to Colorectal Cancer Screening

Barriers to colorectal cancer (CRC) screening are not well understood. We sought to compare barriers to CRC screening reported by primary care physicians (PCPs) and by average-risk adults, and to examine characteristics of average-risk adults who identified lack of provider recommendation as a major barrier to CRC screening. This was a comparative study using data from the 1999-2000 Survey of Colorectal Cancer Screening Practices and the 2000 National Health Interview Survey (NHIS). We recruited nationally representative samples of PCPs (n= 1235) from the SCCSP and average-risk adults (n = 6497) from the NHIS. We measured barriers to CRC screening identified by PCPs and average-risk adults who were not current with screening. Both PCPs and average-risk adults identified lack of patient awareness and physician recommendation as key barriers to obtaining CRC screening. PCPs also frequently cited patient embarrassment/anxiety about testing and test cost/lack of insurance coverage, but few adults identified these as major barriers. Of adults not current with testing, those who had visited a doctor in the past year or had health insurance were more likely to report lack of physician recommendation as the main reason they were not up-to-date compared with their counterparts with no doctor visit or health insurance. Only 10% of adults not current with testing and who had a doctor visit in the past year reported receiving a screening recommendation. A need exists for continued efforts to educate the public about CRC and the important role of screening in preventing this disease. Practice-based strategies to systematically prompt health care providers to discuss CRC screening with eligible patients also are required.

Identifying opportunities for improved colorectal cancer screening in primary care

Background. Although current recommendations advocate screening persons 50 years of age or older for colorectal cancer (CRC), actual screening practice is highly variable among primary care physicians (PCPs). Knowledge of the factors that influence whether or not screening is offered during a clinic visit is essential to develop effective screening strategies. Methods. A cross-sectional telephone survey of one in four randomly selected patients aged 50 years or older ( n = 400) attending a primary care clinic within an integrated health care system in central Texas was conducted. A survey of all PCPs ( n = 32) at the practice sites was also administered. Results. The visit type was an important determinant of whether CRC screening was discussed, with most discussion occurring during visits for physicals ( P < 0.0001). This finding was corroborated by the physician survey. Patient age and education were also associated with a higher likelihood of having been offered CRC screening ( P = 0.009 and 0.014, respectively). Patient race, gender, primary language, PCP, or clinics attended were not significantly associated with the discussion of CRC screening. Conclusions. Discussions regarding CRC screening are most likely to occur during preventive care visits. Thus, facilitating preventive visits especially for the elderly represents an opportunity to improve CRC screening rates in primary care practice.

Barriers to colorectal cancer screening in rural primary care

Background. Residents of rural communities may face unique barriers to obtaining colorectal cancer (CRC) screening, including reduced access to services. This study assessed the impact of patient, physician, and practice characteristics on rural primary care patient receipt of CRC screening. Methods. We surveyed patients ( N = 801) over 50 years of age and primary care physicians ( N = 36) in rural practices. Medical students administered surveys to assess patient demographics, self-reported CRC screening, practice features, local availability of endoscopy, and physician screening test preferences. We used multivariable logistic regression analyses to investigate associations between independent variables, and (1) patient CRC screening status and (2) adequacy of CRC discussions between physicians and patients. Results. Fifty-seven percent of patients reported being up-to-date with colorectal cancer screening and most in this group had received FOBT and endoscopy. A minority of patients (39%) reported adequate time to discuss CRC screening, and this was positively associated with being up-to-date with CRC screening in a multivariable analysis. Endoscopy was available in 58% of the practices and 44% of the practices had local gastroenterologists available on at least a monthly basis. The availability of endoscopic procedures and gastroenterological services were not associated with CRC screening or with use of endoscopy as a screening method. Conclusions. CRC screening among rural primary care patients is related to adequacy of physician CRC screening discussions but not access to endoscopic procedures. Efforts to improve CRC screening should focus on improving physician–patient discussions of CRC.

Relatives of colorectal cancer patients: Factors associated with screening behavior

Background The purpose of this study was to identify whether decisions regarding colorectal cancer (CRC) screening by relatives of CRC patients are influenced by social interactions with family members, friends, and physicians or by public awareness campaigns. Methods Screened ( n=236) and nonscreened ( n=132) relatives of CRC patients were interviewed in 2001. A socioecologic model was used as the framework for the interview variables, which included interactions with relatives, medical professionals, and social groups, as well as perceived benefits and barriers to screening and perceived susceptibility. Results Physician encouragement, fewer barriers to screening, strong CRC family history, encouragement from relatives, advice from a surgeon, and discussion of CRC screening with social groups were all associated with ever having been screened. Having been encouraged by a physician was the strongest correlate of screening behavior. Perceived susceptibility to CRC, advice from family members, and exposure to public awareness information were not associated with screening. Conclusions The socioecologic framework is a good explanatory model of CRC screening in increased-risk relatives, as variables from each level were associated with screening. These findings can guide interventions aimed at increasing screening uptake, particularly those involving physicians.