The videotapes—”Colon Cancer Screening: What You Need to Know,” produced by Harris and Pignone10; and “Screening for Colorectal Cancer: An Easy Step to Save Your Life,” produced by the Foundation for Digestive Health and Nutrition11—gave all focus group members a common understanding of the rationale and importance of CRC screening. We chose these 2 tapes because of their widespread use in clinical practice, complementary messages, easy-to-read graphics, content aimed at a lay audience, good sound quality, and recommendations that followed the American Cancer Society guidelines for average-risk patients.12
After participants contemplated the information they had viewed and read, the facilitator asked, “What suggestions would you give to a doctor to encourage a patient to be screened for colorectal cancer?” This began approximately 1 hour of feedback from the focus group members.
All 3 sessions were videotaped, but due to technical problems, video was available for only 2 groups. All 3 sessions were audiotaped.
Data analyzed promptly and rigorously
We systematically gathered and analyzed the qualitative data. The focus group leader and Dr. Goldsmith (principle investigator) together categorized the data by themes, which were structured so as to reduce overlapping. Disagreements on categorization were resolved by referring to transcripts and videos. We reassembled this information using an axial coding approach.
Though body language, gestures, and voice tone are important indicators of intent in communication, we did not classify data according to these non-verbal cues. However, we did note such cues during review of the videotapes, and also took into account the frequency and extensiveness of remarks (eg, how many people made a similar comment). Rapid transcription of the sessions and prompt review of the transcripts minimized the inaccurate interpretation of data that can occur when review is delayed.
We used 2 means of assessing the educational level of attendees. Patients in the first 2 focus groups were given the Rapid Estimate of Adult Literacy in Medicine (REALM) test,13 and members of the third group were asked for the highest grade level they completed in school.
Results
The average age of participants was 56 years. Few men volunteered to begin with. So to replace patients who dropped out on short notice, only women were immediately available from the standby groups. Thus, 13 participants were women and 2 were men. Two were covered by Medicaid, 6 by Medicare, 5 had private insurance, and 2 had no insurance. Eleven of the insured participants reported their insurance would pay for CRC screening.
Seven participants were African American, 7 were Caucasian, and 1 was Latino. Each focus group had approximately an equal mix of subjects by ethnic group, but only 2 groups had an uninsured subject. One man was part of each of the first 2 groups.
Reasons for low screening rate
Of the 15 subjects, 5 (at least 1 in each group) had undergone some type of CRC screening: colonoscopy (3), flexible sigmoidoscopy (1), or fecal occult blood testing (1).
Of the 10 subjects not screened, medical records lacked evidence that their family physicians had discussed CRC screening. The facilitator asked them why they had not been screened. The primary reason given was failure of their physicians to recommend screening; although on further inquiry, 1 patient said, “If the doctor did mention it [CRC screening], it was done in a fashion that didn’t impress me enough to remember.” Several other unscreened patients nodded in agreement. Other reasons given were costs, psychological issues (fear and embarrassment), belief that screening was unnecessary, and difficult logistics (time off and transportation) (TABLE).
Patients offered 7 suggestions for physicians
Our focus-group participants offered 7 recommendations for addressing issues that can hinder patients’ decisions to be screened.
- Do not rely on educational materials alone. Though participants thought videotapes and written information were important, all of them strongly stated that the primary endorsement for CRC screening must come from their physicians. All 3 groups agreed that videos and written materials were helpful supplements to a physician’s advice.
- Address fear of pain. Anticipate patients’ fear of pain from colonoscopy, and explain what is done to minimize discomfort.
- Cite costs of tests. A common theme was the lack of knowledge about the costs of the CRC screening options. Let patients know they can opt for less expensive screening.
- Discuss pros and cons of each test. A strongly held belief was that colonoscopy is the best, if not the only, test to have. If a physician had frankly discussed both costs and benefits of the options, patients might have been reassured enough to proceed with a screening procedure, even if it was not colonoscopy.
- Challenge the “worst case” mindset. Focus group participants feared that if cancer is found, it may not be curable. They urged physicians to expect this apprehension and to counter it with a realistic assessment.
- Emphasize safety of testing. Several participants who had not been screened feared being disabled by the test itself and said physicians should spend time to counter this belief.
- Elicit concerns about logistics. Some group members had avoided colonoscopy because it required taking time off from work, which they could not afford to do. The solution is to match the screening test to a patient’s needs and preferences.