Colorectal cancer screening: How to help patients comply

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Original Research

Colorectal cancer screening: How to help patients comply

J Fam Pract. 2008 July;57(7):E2-E6

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References

1. Myers RE, Ross EA, Wolf FA, et al. Behavioral interventions to increase adherence in colorectal cancer screening. Med Care. 1991;29:1039-1050.

2. Weitzman ER, Zapka J, Estabrook B, et al. Risk and reluctance: understanding impediments to colorectal cancer screening. Prev Med. 2001;32:502-513.

3. Codori AM, Petersen GM, Miglioretti DL, et al. Health beliefs and endoscopic screening for colorectal cancer: potential for cancer prevention. Prev Med. 2001;33:128-136.

4. Coronado G, Thompson B. Rural Mexican American men’s attitudes and beliefs about cancer screening. J Cancer Educ. 2000;15:41-45.

5. Borum ML. Childhood sexual trauma as a potential factor for noncompliance with endoscopic procedures. Gen Hosp Psychiatry. 1998;20:381-382.

6. Morgan DL, Krueger RA. The Focus Group Kit. Thousand Oaks, CA: Sage Press; 1998.

7. Resnicow KA, Schorow M, Bloom HG, et al. Obstacles to family practitioners’ use of screening tests: determinants of practice? Prev Med. 1989-18:101-112.

8. Baier M, Calonge N, Cutter G, et al. Validity of self-reported colorectal cancer screening behavior. Cancer Epidemiol Biomarkers Prev. 2000;9:229-232.

9. Leider HL. Influencing physicians: the three critical elements of a successful strategy. Am J Manag Care. 1998;4:583-588.

10. Harris R, Pignone M. Colorectal Cancer Screening videotape. University of North Carolina, 1998.

11. Screening for Colon Cancer: An Easy Step to Save Your Life. Bethesda, Md: Foundation for Digestive Health and Nutrition; 1999.

12. American Cancer Society. Screening Guidelines for Colorectal Cancer Screening, ACS. 2005.

13. Davis TC, Crouch MA, Long SW, et al. Rapid assessment of literacy levels of adult primary care patients. Fam Med. 1991;23:433-435.

14. Leider HL. Influencing physicians: the three critical elements of a successful strategy. Am J Manag Care. 1998;4:583-588.

15. Clark N, Becker MH. Theoretical models and strategies for improving adherence and disease management. In Shumaker SA, Schron EB, Ockene JK, McBee WL, eds. The Handbook of Health Behavior Change. New York, NY: Springer Publishing Co; 1998:5-32.

16. Denberg TD, Wong S, Beattie A. Women’s misconceptions about cancer screening: implications for informed decision making. Patient Educ Counsel. 2005;57:280-285.

17. Stewart M. What is a successful doctor-patient interview? A study of interactions and outcomes. Soc Sci Med. 1984;19:167-175.

18. Meade CD, McKinney WP, Barnas GP. Educating patients with limited literacy skills: the effectiveness of printed and videotaped materials about colon cancer. Am J Public Health. 1994;84:119-121.

19. Pignone M, Harris R, Kinsinger L. Videotape-based decision aid for colon cancer screening. A randomized, controlled trial. Ann Intern Med. 2000;;133:761-769.

20. Green LW, Eriksen MP, Schor EL. Preventive practices by physicians: behavioral determinants and potential interventions. Am J Prev Med. 1988;4(suppl):101-107.

21. Brenes GA, Paskett ED. Predictors of stage of adoption for colorectal cancer screening. Prev Med. 2000;31:410-416.

Find a way to address the above concerns. Participants suggested that if a doctor’s time is limited, then someone else in the office (a nurse or even a clinic staff member) ought to speak with patients—preferably someone who has undergone endoscopy screening and can talk about what it was like in “real terms we can understand.”

TABLE
How to improve CRC screening rates—focus group recommendations by theme

Strategies, other than physician communications, that could improve CRC screening rates
Most common responses in order of frequency: Videotape on CRC screening similar to the ones shown to focus groups Print handouts on CRC screening Advice of friends and family
Family physician communications that could improve CRC screening
Most common responses in order of frequency (and typical comments): Delivery of advice to be screened: use a clear and forceful recommendation. Emphasize that CRC screening is a routine part of preventive care. Address patient psychological barriers and concerns. *Address barriers to access to care.*
Preferred communication strategy for learning about the importance of CRC screening
Most common responses based on frequency (and typical comments): Communication directly from the physician Videotape viewing before seeing the doctor Written materials in the doctor’s office Written materials sent to the patient’s home from the doctor’s office Someone in the medical office discusses endoscopy with the patient, including their own experience with the test

Discussion

Many factors keep the CRC screening rate lower than it ought to be. Physicians do not uniformly follow screening guidelines.^7,14 Limited practice time, difficulty in identifying patients needing preventive services, and little financial incentive to provide preventive care in the ambulatory setting all hinder the effort to increase screening. And even when CRC screening is advised, patients are often reluctant to comply because of the reasons already discussed.

FAST TRACK

Let patients know they can opt for less expensive screening

Effective communication between patients and physicians therefore becomes ever more important.¹⁵ Informed decision making about cancer screening is difficult for many patients to grasp, as evidenced by inaccuracies, distortions, and oversimplification of cancer-related beliefs.¹⁶ Patient-centered communications can give the physician a clearer understanding of the patient’s perspective and influence health-seeking behavior.¹⁷

The suggestions offered by this study’s participants can help family physicians improve communication about CRC screening, which should encourage more patients to opt for screening.

Participants unanimously recommended that physicians speak directly to well-known patient concerns about endoscopy, even if the patient does not bring them up during a visit.

Though participants spoke mainly about ways physicians could improve doctor/patient communications about CRC screening, they also expressed high regard for videotapes in patient education. The videos they watched taught them that CRC could be prevented or cured if discovered early, and they felt this message was not conveyed by their physicians. The value of video-based patient education observed in our study is consistent with the results of other studies.^18,19 Given that primary care physicians often have insufficient time to educate patients fully, using a videotape may be well received by patients and prove an efficient way to augment advice about CRC screening.

FAST TRACK

“My doctor did something really smart. He told me of his personal experience [with CRC screening]. I appreciated him doing that.”

Shared decision making has many advocates these days, but the focus group population in this context preferred that physicians be more assertive in promoting CRC screening. Patients may more readily comply with screening recommendations if physicians convey a message that is persuasive rather than factual but emotionally neutral.

This study confirmed the findings of others: fear, lack of information, cost of testing, and the physician’s failure to recommend CRC screening are all potential barriers to increasing screening rates.^1,2,20,21 The study also showed the importance of physicians asking patients to clarify the origin of their fears about CRC testing.

Of the 10 focus group members who had not been screened for CRC, fully half said they would now consider screening given what they learned in the focus group. This encouraging finding implies that giving patients accurate information can improve screening rates. The remaining members of the focus group were still uncertain as to whether they would accept CRC screening if offered, and they did not give reasons for their indecision.

Limitations

The focus group participants may have been more assertive than most of the general population, given their willingness to freely express their feelings in front of others.

A sample of convenience was selected and most participants were women, despite efforts to recruit an equal number of men and women. Thus, our findings should be interpreted with caution for the male population.