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RESEARCH AND PRACTICE |
Randi L. Wolf is with the Department of Health and Behavior Studies, Teachers College, Columbia University, New York, NY. Charles E. Basch is with the Department of Health and Behavior Studies, Teachers College, Columbia University, and the Herbert Irving Comprehensive Cancer Center, New York, NY. Corey H. Brouse is with the Department of Health Promotion and Wellness, SUNY Oswego, Oswego, NY. Celia Shmukler is with the Disease Management and Wellness Program, New York. Steven Shea is with the Department of Medicine, Columbia University, College of Physicians and Surgeons, New York.
Correspondence: Requests for reprints should be sent to Randi L. Wolf, Associate Professor of Human Nutrition, Ella McCollum Vahlteich Endowment, Department of Health and Behavior Studies, Teachers College, Columbia University, 525 West 120th Street, Box 137, New York, NY 10027 (e-mail: wolf{at}tc.columbia.edu).
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ABSTRACT |
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 TOP ABSTRACT INTRODUCTIONMETHODSRESULTSDISCUSSIONReferences |
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We measured patient preferences for colorectal cancer (CRC) screening strategies and actual receipt of alternative CRC screening tests among an urban minority sample participating in an intervention study. The fecal occult blood test was the most preferred test, reportedly owing to its convenience and the noninvasive nature. For individuals who obtained a test that was other than their stated preference (41.1%), reasons for this discordance may be due to physician preferences that override patient preferences.
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INTRODUCTION |
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TOPABSTRACTINTRODUCTIONMETHODSRESULTSDISCUSSIONReferences |
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METHODS |
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TOPABSTRACTINTRODUCTIONMETHODSRESULTSDISCUSSIONReferences |
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The health educator presented participants with 3 screening options (a fecal occult blood test [FOBT] that would be done at home, flexible sigmoidoscopy, and colonoscopy), provided a description of each test, and established the participant’s preference. The health educator probed for reasons underlying subject’s preference and willingness to make a verbal commitment to obtain the preferred test. Reasons for preferences were coded into themes from the health educator’s handwritten notes by 1 of the investigators. Intrarater reliability for a random sample of 30 participants was 100% for preferences and 97% for reasons. Follow-up calls varied in frequency and duration among participants and emphasized positive reinforcement, enhancement of perceived self-efficacy to overcome barriers, and the message that there is support from scientists, medical doctors, and health organizations for recommended screening.
Six months after randomization, subjects were interviewed by telephone to inquire if they had a CRC screening test, and research staff, unaware of the subjects’ group assignment, verified self-reported CRC screening with medical claims data and medical records. We assumed that those who did not complete a 6-month follow-up survey (15 of the 216 [6.9%]) did not receive CRC screening. FOBT (defined as 2 samples from each of 3 consecutive bowel movements), flexible sigmoidoscopy, colonoscopy, or barium enema within 6 months postrandomization were considered acceptable outcome measures (a single stool test was not). We used SPSS (Chicago, Illinois) for statistical analysis.
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RESULTS |
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TOPABSTRACTINTRODUCTIONMETHODSRESULTSDISCUSSIONReferences |
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. There was a significant difference in preferences (
2=310.1; df=2; P<.0001), with the majority (n=194, 89.8%) preferring the FOBT. The remaining 10.2% preferred either the colonoscopy (n=12, 5.6%) or had no preference (n=10, 4.6%). FOBT was preferred over colonoscopy (2=160.8; df=1; P<.0001); and over no preference (2= 166.0; df=1; P<.0001). We found no association between test preference and demographic subgroups, except for income level. Although most preferred the FOBT in both income groups (
50K or >50K), participants with lower household income showed an even stronger preference toward the FOBT: 93% versus 78.8% (Fisher exact test, P=.007).
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shows reasons for choosing the preferred screening tests. Among the 194 participants who preferred FOBT, the main reason was convenience (76, 39.2%). Among the 12 preferring colonoscopy, 7 (58.3%) did so because they believed it was the most reliable and accurate test. Among the 10 participants who did not specify a test preference, 8 (80%) preferred to ask for their physician’s recommendation.
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We examined chart notes for possible reasons why 24 participants completed a CRC screening test that was different from the test they reportedly preferred. Among the 23 who preferred an FOBT, but received another test, most (73.9%, n = 17) reported it was because their physician referred them for either a colonoscopy or a flexible sigmoidoscopy after their inquiry about an FOBT. The 1 individual who preferred a colonoscopy, but received an FOBT, reported that it was a routine annual procedure of the physician’s office to give FOBT kits to its patients.
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DISCUSSION |
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TOPABSTRACTINTRODUCTIONMETHODSRESULTSDISCUSSIONReferences |
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Our study is not generalizable to other populations, especially those with no health insurance. Further, preference data are based only on the perspective of the participant at the initial conversations with the study health educator. We do not have information on the nature or content of the interpersonal communication between the patient and the physician at the time the CRC screening test was ordered. We speculate that the discordances may be because of: (1) the physician’s preference for colonoscopy; (2) other clinical findings that might have warranted a colonoscopy; (3) lack of office systems to track and follow-up FOBT; and (4) lack of reimbursement of physician time related to the FOBT mailing and tracking when done outside an office visit, despite reimbursement of the FOBT itself. These possibilities need further exploration.
We did not explore the extent to which physicians’ recommendations for tests other than those preferred by their patients might have contributed to the high rate of overall noncompliance (71.8%) for CRC screening. We speculate that it would. Further research is required to determine if this mismatch reduces test completion rates or patient satisfaction when seeking preventive care.
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Acknowledgments |
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Human Participation Protection
The study was approved by the institutional review boards of Teachers College, Columbia University, and the Columbia University Medical Center. Informed oral consent was obtained from all participants.
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Footnotes |
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Contributors
R. L. Wolf originated the study, supervised all aspects of its implementation, provided day-to-day leadership and management of the study and direct supervision of study personnel, conducted data analysis, interpreted the study findings, and led the writing of the article. C. E. Basch developed study protocols, supervised all aspects of the study implementation, and assisted with interpretation of findings and writing of the article. C. H. Brouse assisted with development and implementation of the intervention, data collection, and writing of the article. C. Shmukler assisted with development and implementation of study protocols and provided medical oversight. S. Shea assisted with the study design, development of study protocols, interpretation of study findings, and writing of the article.
Accepted for publication August 7, 2005.
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References |
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TOPABSTRACTINTRODUCTIONMETHODSRESULTSDISCUSSIONReferences |
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2. Winawer S, Fletcher R, Douglas R, et al. Colorectal cancer screening and surveillance: clinical guidelines and rationale—update based on new evidence. Gastroenterology. 2003;124:544–560.[CrossRef][ISI][Medline]
3. Rex DK, Johnson DA, Lieberman DA, Burt RW, Sonnenberg A. Colorectal cancer prevention 2000: screening recommendations of the American College of Gastroenterology. Am J Gastroenterol. 2000;95:868–877.[ISI][Medline]
4. Seeff LC, Nadel MR, Klabunde CN, et al. Patterns and predictors of colorectal cancer test use in the adult US population. Cancer. 2004;100:2093–2103.[CrossRef][ISI][Medline]
5. Pignone M, Rich M, Teutsch S, Berg AO, Lohr KN. Screening for colorectal cancer in adults at average risk: a summary of evidence for the US Preventive Services Task Force. Ann Intern Med. 2002;137(2):132–141.
6. Walsh JM, Terdiman JP. Colorectal cancer screening: clinical applications. JAMA. 2003;289:1297–1302.
7. Leard LE, Savides TJ, Ganias TG. Patient preferences for colorectal cancer screening. J Fam Pract. 1997;45:211–218.[ISI][Medline]
8. Dominitz JA, Provenzale D. Patient preferences and quality of life associated with colorectal cancer screening. Am J Gastroenterol. 1997;92:2171–2177.[ISI][Medline]
9. Pignone M, Bucholtz D, Harris R. Patient preferences for colon cancer screening. J Gen Intern Med. 1999;13:432–437.
10. Ling BS, Moskowitz MA, Wachs D, Pearson B, Schroy P. Attitudes toward colorectal cancer screening tests: a survey of patients and physicians. J Gen Intern Med. 2001;16:822–830.[CrossRef][ISI][Medline]
11. Basch CE, Wolf RL, Brouse CH, et al. A randomized trial to increase colorectal cancer screening in an urban minority population. Am J Public Health. In press.
12. Colorectal Cancer Awareness: Some Important Facts You Should Know about Colorectal Cancer! Washington, DC: Centers for Medicare and Medicaid Services, US Department of Health and Human Services; 2004. Available at: http://www.medicare.gov/health/awareness.asp. Accessed July 2, 2004.
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