Although Physicians Prefer Colonoscopy, Many Are Implementing Shared Decision-Making With Patients in Colon Cancer Screening

Both primary care clinicians (PCCs) and gastroenterologists (GIs) tended to choose colonoscopies as the preferred colorectal cancer (CRC) screening method for their patients, according to recent research. However, health care providers showed a willingness to adjust their recommendations based on each patient’s individual needs or characteristics.

In a study published in Mayo Clinic Proceedings, researchers analyzed the factors affecting CRC screening knowledge, attitudes and behavior among health care providers. They looked at provider, clinical practice and patient characteristics associated with screening preferences and practices.

“Our findings suggest that although clinicians may oftentimes default to recommending colonoscopy, they recognize the need to tailor their recommendations to the needs and preferences of their patients,” said lead study author Lila Rutten, a health services researcher at the Mayo Clinic, during an interview with CURE®. “It is frequently said that the best screening test is the one patients are willing to complete.”

CRC screening rates currently fall well below the national goals outlined by organizations like the National Colorectal Cancer Roundtable, with almost one-third of eligible adults in the United States reported to not be up to date with screening recommendations.

It has become a topic of concern among researchers as rates of early-onset CRC have risen in recent years due to unknown reasons and obstacles like the pandemic have affected screening rates. Additionally, among certain population subgroups such as certain racial or ethnic groups, lower socioeconomic status and younger people, screening rates are even lower.

The current U.S. Preventive Services Task Force recommended screening age for an average-risk patient is 45 years — a recent change from the previous recommendation of 50 years.

Read more: Additional Efforts Necessary to Implement New Recommended Age Range for Colorectal Cancer Screenings

The researchers in the Mayo Clinic study developed a survey to assess the screening factors including knowledge, skills, social/professional role and identity, beliefs about capabilities, optimism, beliefs about consequences, intentions, memory, attention and decision processes, environmental context and resources as well as social influences.

They collected the data through a web survey from Nov. 6, 2019 to Dec. 6, 2019. They drew a validated panel of 779 primary care clinicians and 159 gastroenterologists from U.S. national databases and professional organizations.

The survey found that health care providers preferred colonoscopy for average-risk patients, with 96.9% of GIs and 75.7% of PCCs electing for this option. Among the remaining PCCs, 12.2% preferred a multi-target stool DNA (mt-sDNA), 7.3% chose the fecal immunochemical test (FIT) and 4.8% selected the guaiac-based fecal occult blood test (gFOBT).

Rutten explained that the tests fall into two categories: direct visualization (colonoscopy) and stool-based (FIT, mt-sDNA, gFOBT).

“The colorectal cancer screening tests that are currently recommended by the U.S. Preventive Services Task Force vary with regard to effectiveness, safety, convenience, cost and importantly with regard to patient acceptability, which underscores the importance of endorsing multiple screening options,” she added.

When patients were unable to undergo an invasive procedure, both PCCs and GIs in the survey leaned in the direction of noninvasive screening options. Typical reasons for being unable to undergo an invasive procedure included concern about time off from work, being unconvinced about the need for screening or refusing other screening options.

“Stool-based tests do not require bowel preparation, sedation and insertion of a scope. These tests can be performed at home and are less disruptive for patients,” Rutten said. “However, if results of a stool-based screening test are positive, patients are likely to need additional screening, like colonoscopy.”

With a colonoscopy, providers can also remove and sample any abnormal tissue found during the procedure, providing an advantage for those who utilize this option.

PCC preference for mt-sDNA over FIT and gFOBT was less frequent in larger practices when compared with smaller clinical practices. A preference for mt-sDNA over FIT was more likely for PCCs who had longer clinical experience, higher patient volumes (more than 25 per day) and practice locations in suburban and rural settings.

In considering the financial barriers a patient may face, Rutten explained that the Affordable Care Act requires health plans that started on or after Sept. 23, 2010 to cover the cost of colorectal cancer screening.

“In most cases there should be no out-of-pocket costs for these tests,” she said. “However, the definition of what qualifies as a ‘screening’ test can be unclear and may vary by insurance provider. It is therefore important for patients to review the details of their insurance plan and to ask their health insurance providers what it might mean if a colonoscopy is needed as a result of a positive stool test, and whether they would be responsible for out-of-pocket expenses.”

To further the findings in this area, Rutten and fellow researchers are currently launching a multi-site trial to evaluate the impact of an intervention to improve informed decision making among patients about their CRC screening options.

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