Colorectal cancer screening: How to help patients comply

,

Original Research

Colorectal cancer screening: How to help patients comply

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

By

Geoffrey Goldsmith, MD, MPH

Strongly recommending that a patient be screened and addressing commonly held fears are among the 7 ways you may be able to improve compliance

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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.

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Practice recommendations

Be more assertive about the need for screening with patients at risk, and do not rely solely on patient-education materials to communicate the message.
Address key issues such as fear of pain from colonoscopy, costs and comparative benefits of different tests, and safety of procedures—even if patients don’t raise these issues.

Abstract

Purpose: We elicited patient opinions about how physicians can improve communications about colorectal cancer (CRC) screening.

Methods: We recruited 15 patients, ages 50 years and older, from an urban family medicine teaching clinic. All patients in the initial pool of candidates had been seen at the university of Arkansas for Medical Sciences Family Medical Center within the past 12 months. The recruits participated in 1 of 3 focus groups to discuss how to enhance the rate of CRC screening.

Participants watched a videotape that described the different approaches to CRC screening. We then asked them to comment on how patients could be encouraged to undergo CRC screening.

Results: using a qualitative analysis of focus group data, we determined the most common reasons participants had not undergone CRC screening: fear, lack of information, and failure of the physician to strongly recommend CRC screening. Participants offered 7 recommendations for how physicians could address their concerns. Participants emphasized the importance of strong physician endorsement of screening, of frank and informative dialogue about patient’s concerns, and of using educational materials to supplement personal advice.

Conclusion: A physician’s recommendation for screening is the most powerful motivator in patients’ decisions. However, other sources of information such as videotapes, written materials, and even endorsement of CRC screening by the clinic’s office staff can help patients decide to undergo screening.

It’s well known that patients may avoid colorectal cancer (CRC) screening for fear of pain, embarrassment, lack of awareness of the importance of CRC screening, misperceptions about screening effectiveness, or lack of resources.^1-5 But how well do physicians address these concerns and misgivings to help patients make a different choice? Equipped with an understanding of patients’ perspectives, physicians could reframe their counsel and likely increase the rate of CRC screening in their practices.

We conducted 3 in-depth focus group sessions to draw out details of patients’ concerns regarding CRC screening and to solicit their thoughts on how physicians could address and even resolve these issues.

Methods

Patients randomly selected for focus groups

Our initial pool of candidates was approximately 500 patients who were at least 50 years old and had been seen at our Family Medicine Center during the prior 12 months. We stratified this population into 4 ethnic/gender groups: African American males, African American females, Caucasian males, and Caucasian females. Sixty percent of the patients were female; 50% were African American, 48% were Caucasian, and 2% were Latino.

After creating a database that listed these patients by number and concealed their identities except for race and gender, we sequentially selected participants for groups of 8 patients (2 drawn from each of the ethnic/gender groups). Our random selection process avoided such biases as choosing patients by name or age or whether they had been seen more recently.

The first group of 8 patients received a letter asking them to participate in the project. The invitation included the offer of an honorarium. Invitations were mailed every 10 days until we had recruited 4 to 6 volunteers from each ethnic/gender group. After enlisting 20 participants, we were finally able to assemble 15 of them into 3 groups roughly balanced by gender and race. We also had 4 stand-by groups of 8 patients, in case any of the original participants chose to leave the study. All patients who volunteered were assured that if they chose not to participate, their continuing care would be unaffected.

Sessions thoroughly explored patients’ issues

The same experienced focus group leader (Caucasian, female) led all 3 sessions, adhering to a widely accepted structure for focus groups.⁶ This facilitator was familiar with the common barriers to CRC screening, as cited in the medical literature.^1,7-9 She first asked an open-ended question and then probed specifically to determine why some participants or their family members had not received CRC screening. She solicited input from all attendees, sought clarification on points of view, and polled participants about their reactions to statements made by other members of the group. Participants were encouraged to discuss their experiences and their talks with family physicians about CRC screening.

How the sessions unfolded

After receiving instruction about the purpose of the session, participants viewed 2 patient-education videotapes that discussed CRC screening in an average-risk population. They also read a brief patient-education booklet about CRC screening before the facilitator engaged them in dialogue.