Major Finding: Patients who were allowed to choose their colorectal screening method were significantly more likely to follow through with the test, with an adherence rate of 70%, than were those referred to only one method (adherence of 38% or 67%, depending on method).
Data Source: A randomized trial of 1,000 patients who were diverse in terms of language and race/ethnicity.
Disclosures: None reported.
NEW ORLEANS — Patients given a choice between different screening methods are significantly more likely to follow through on colorectal cancer screening than are those told to undergo either colonoscopy or fecal occult blood testing.
“We usually assume that the presence of choices can paralyze people into indecision, and instead of making the choice, they defer,” Dr. John M. Inadomi said at the annual Digestive Disease Week. “We were concerned that, in the case of colorectal screening, giving a choice of screening methods might actually lead to noncompliance.”
Dr. Inadomi of the University of California, San Francisco, and his colleagues found just the opposite when they conducted a randomized trial on the issue with 1,000 patients at an average risk of colorectal cancer. The participants were randomized to one of three screening recommendations: fecal occult blood testing (FOBT), colonoscopy, or the individual patient's choice between the two. The investigators then followed each group for 12 months to evaluate compliance with the screening.
The study was conducted in San Francisco, and the participants reflected the city's diverse population: 34% were Latino, 30% were Asian, 18% were black, 15% were white, and 3% were other; a total of 53% were women. The investigators tried to remove as many barriers to health care adherence as possible by reducing or eliminating cost, providing rides, giving instructions for preparation in the patient's preferred language, allowing direct screening access without a gastroenterology referral, and limiting wait time to 2 weeks.
Overall, 65% of patients followed through on their recommended screening. But there were significant differences in adherence between the groups. Patients referred to colonoscopy alone had the lowest rate of adherence (38%), followed by those referred to fecal occult blood testing (67%). The highest rate of adherence, 70%, was found for patients given a choice between colonoscopy and FOBT.
“Even though significantly more patients followed through on the fecal occult blood testing [compared with colonoscopy], the number was still significantly less than the 70% who were given the choice between the two methods,” Dr. Inadomi said.
At baseline, patients also filled out a survey about their health beliefs. The investigators found that fears of the test results, procedure complications, the preparation and procedure, and of cancer in general significantly reduced adherence to screening. Patients were significantly more likely to follow through on screening if they had good self-perceived health and believed that colorectal cancer screening could prevent cancer.
Dr. Inadomi noted that race/ethnicity and language also had an apparent impact on adherence. Asians and Latinos had significantly higher rates of compliance overall (73% and 70%, respectively) than did whites and blacks (55% and 56%). Different groups seemed to prefer different methods, he said. “Asians and Latinos assigned to fecal occult blood testing adhered more frequently than did whites and blacks. Conversely, whites seemed to prefer colonoscopy,” with a 52% adherence rate, compared with 27% in the nonwhite groups.
Language was a factor as well. “Patients with limited English proficiency actually had greater adherence,” as they received their instructions in their native language. “In a multivariate model, race and ethnicity fell out, and language was the only significant factor that remained,” Dr. Inadomi said. “In a system where access is provided and language is not a barrier, we see that immigrants have the tools to access the health care system in the same way they would in their own country.”