Colorectal Cancer Screening

Colorectal cancer (CRC) is the third most common form of cancer in the U.S. and has the third highest mortality rate, and screening clearly reduces mortality. In 2001, only 53% of those eligible had undergone fecal occult blood testing (FOBT) within the preceding year or lower endoscopy within the past 10 years.¹ In a recent systematic assessment of the value of clinical preventive services, which are recommended for average risk individuals by the U.S. Preventive Services Task Force (USPSTF), preventive services were ranked based on burden of disease prevented by the service and cost effectiveness. Screening for CRC was one of the highest ranked services (score of 7+ on a scale of 2 to 10) with the lowest delivery rate (<50% nationally) and it was concluded that it should be a national priority to increase rates of CRC screening.²

The provision and receipt of preventive care is complex and takes place within the patient-physician interaction (Figure 1). The patient and the physician are each influenced by predisposing factors (e.g., sociodemographics, health beliefs, and attitudes), enabling factors (skills and resources), and reinforcing factors (such as social support) and that each is also affected by health care system factors and by certain cues to action (such as symptoms or reminders).³ All of these factors influence the patient and/or the physician and influence whether or not the preventive activity occurs. Barriers can occur at any level including the patient, the physician, the system, and cues to action.

Figure 1.

The systems model of clinical preventive care.

PATIENT BARRIERS

Many patient barriers to CRC screening have been described. In a telephone survey of 775 community-dwelling individuals, barriers which were commonly reported included thinking that the tests would be uncomfortable, thinking that the preparation is too complicated, and concern that the test is embarrassing.⁴ Additional reasons include practical reasons such as being too busy, conflict with work or family commitments, not having any current health problems and not wanting to know about health problems, and being unaware that screening was due.

PROVIDER BARRIERS

Provider barriers include uncertainty about conflicting recommendations, medical records not being organized in a way that clearly indicate when screening is due, and distraction by multiple other health issues and time. Time is an extremely important barrier; although it is a barrier for the provision of any preventive service in the context of a routine medical visit, it is particularly a challenge for CRC screening. Because there are several screening options available, determining the participant's current understanding of the available screening options and discussing the available screening options takes much longer than telling the participant that she needs breast cancer screening, where mammography is the only currently recommended option.

SYSTEMS BARRIERS

Often times the health care system is not organized in a way as to facilitate screening. In a recent meta-analysis of interventions to increase the use of adult immunization and cancer screening services, rates of cancer screening were most likely to improve when some type of organizational change, which often involved taking some of the responsibility for the preventive activity out of the hands of the physician or simplify the physician's task, occurred.⁵

CUES TO ACTION

Screening will not happen if the patient and the physician do not think about it. Cues to action include reminding the patient and/or the provider that the patient is due for screening, education about the importance of CRC screening and publicity about CRC screening such as in magazines, newspapers, or television. When television celebrity Katie Couric underwent a colonoscopy on television, this “cue to action” resulted in an increase in colonoscopy screening in 2 different data sets.⁶

Three studies in the current issue of JGIM address colorectal cancer screening—2 address patient barriers to colorectal cancer screening and 1 study is an intervention targeting the system designed to improve rates of colorectal cancer screening.

Although many studies have addressed barriers to colorectal cancer screening, these 2 studies address issues that have not been previously extensively studied. Although the biggest factor influencing whether or not a patient is screened is physician recommendation, physician recommendation is not enough. Few studies have addressed what happens after a recommendation for CRC screening is made. Denberg et al.,⁷ address the question of what factors predict nonadherence to colonoscopy after it has been recommended by the physician. In a large retrospective analysis, they found that female sex, younger age, and insurance status predicted nonadherence. The more interesting part of the study is the qualitative component, which explored reasons why patients who are already referred do not get screening. These patients described many barriers, which include cognitive/emotional barriers such as fear of pain, fear of the preparation, and not believing they were at risk for colorectal cancer. Logistical obstacles such as being too busy and system barriers such as problems with referral paperwork or having to talk to too many people to schedule the procedure were also common. Although the small numbers of participants and the convenience nature of the sample do not allow formal ranking or quantitative analysis of the barriers, these results show that even after the physician makes the referral and hence assumes the patient is going to comply, there are still patient barriers to completion of the screening tests.

In the second article in this issue to address patient colorectal cancer screening barriers, Greiner et al.,⁸ conduct a series of focus groups with African-American individuals to explore knowledge, attitudes, barriers, and preferences about colorectal cancer screening. Again, this was a qualitative study using a convenience sample of participants, but important barriers to screening were identified. These included fear, fatalism, lack of knowledge, and mistrust. Lack of knowledge was a major barrier to screening, although as many of the participants were less than 50, knowledge may have been artificially low. Fear was also one of the most commonly stated barriers, suggesting that future interventions that focus on overcoming fear will be critical. Fatalism has been seen previously in both the African-American and Latino communities and encompasses beliefs that cancer is inevitable and that there is no point in screening.^9–11 In a previous study of elderly African Americans, fatalism was a negative predictor of receipt of FOBT.⁹ One interesting finding in the current study was the fear that surgery would cause cancer to spread, and hence there was a fear of screening because it might lead to surgery. Familiarity with these unique barriers will be particularly important in developing interventions to increase rates of CRC screening in the African-American population.

The main reason to understand barriers to colorectal cancer screening is so that we can work to overcome those barriers and increase rates of colorectal cancer screening. Based on what we know about barriers to CRC screening and interventions that work for promoting other cancer screening, successful interventions would address patient and physician barriers, would use systems changes to simplify the screening process and would include reminders or cues to action.

The third study of colorectal cancer screening in this issue of JGIM is an intervention designed to improve CRC screening. Miller and colleagues conducted a randomized, controlled trial comparing an educational multimedia computer program to teach patients about FOBT testing with usual nurse counseling. This intervention targeted patient (providing knowledge), the physician (saving time) and the system (taking the education/counseling out of the hands of the nurse and thus changing the system). In the educational multimedia program, graphics, video clips, and audio segments were used and patients could proceed at their own pace. They found that this educational intervention was as good as nurse counseling (62% vs 63%) in achieving adherence to FOBT screening. We might have expected that this multimedia intervention would be better than the standard of nurse counseling. However, why was it not better than nurse counseling? Rates of FOBT return did increase in both groups compared with baseline (49%) so it is possible there was some effect from just being in the study. However, other interventions targeting patients have also shown that it is difficult to improve rates of screening. A recent study which utilized a video intervention only showed modest improvements in sigmoidoscopy screening rates, but no effects on other outcomes among patients in primary care practices.¹²

There are many challenges ahead as we try to increase rates of colorectal cancer screening. Interventions must target all types of barriers—physician, patient, system and “cues to action.” Interventions targeting more than one barrier are most likely to be successful. As we continue our efforts toward education and public awareness (e.g., the American Cancer Society is currently devoting many efforts toward increasing public awareness of the importance of colorectal cancer screening), we cannot assume that “one size fits all,” therefore we must also develop “tailored” approaches for particular patient groups. Tailoring is defined as “the adaptation of the intervention and/or total redesign to best fit the needs and characteristics of a target audience.”¹³ For example, identifying barriers in particular subgroups (e.g., African Americans) allows us to tailor interventions that focus on those barriers most important in the group. Approaches can potentially be tailored to ethnic groups, can be gender specific or can be tailored to patient preferences. Physician-focused interventions must overcome barriers such as lack of time, confusion about the recommendations, and inadequate reminders. Very importantly, any intervention that will make a difference must include the system in which the patient and the physician interact and must incorporate system changes. Examples include direct access endoscopy, automatic reminder systems, and transferring some of the preventive care responsibilities to someone other than the physician. Although it is important to continue to elucidate CRC screening barriers, now is the time to intervene to increase rates of CRC screening. Although much discussion is currently devoted to which CRC screening test is the “best” test, perhaps our energies would be better channeled toward ensuring that all eligible individuals receive some type of CRC screening test—any screening is better than no screening at all.