Screening for Colorectal Cancer on the Front Line

OBJECTIVE:The aim of this study was to assess knowledge, beliefs, and practices of primary care clinicians regarding colorectal cancer screening.METHODS:We surveyed 77 primary care providers in six clinics in central Massachusetts to evaluate several factors related to colorectal cancer screening.RESULTS:Most agreed with guidelines for fecal occult blood test (97%) and sigmoidoscopy (87%), which were reported commonly as usual practice. Although the majority (86%) recommended colonoscopy as a colorectal cancer screening test, it was infrequently reported as usual practice. Also, 36% considered barium enema a colorectal cancer screening option, and it was rarely reported as usual practice. Despite lack of evidence supporting effectiveness, digital rectal examinations and in-office fecal occult blood test were commonly reported as usual practice. However, these were usually reported in combination with a guideline-endorsed testing option. Although only 10% reported that fecal occult blood test/home was frequently refused, 60% reported sigmoidoscopy was. Frequently cited patient barriers to sigmoidoscopy compliance included fear the procedure would hurt and that patients assume symptoms occur if there is a problem. Perceptions of health systems barriers to sigmoidoscopy were less strong.CONCLUSIONS:Most providers recommended guideline-endorsed colorectal cancer screening. However, patient refusal for sigmoidoscopy was common. Results indicate that multiple levels of intervention, including patient and provider education and systems strategies, may help increase prevalence.

[1]  D. Lieberman,et al.  Use of colonoscopy to screen asymptomatic adults for colorectal cancer. Veterans Affairs Cooperative Study Group 380. , 2000, The New England journal of medicine.

[2]  A. Detsky.  Screening for colon cancer--can we afford colonoscopy? , 2001, The New England journal of medicine.

[3]  R. Luckmann,et al.  Periodic health evaluation of adults: a survey of family physicians. , 1995, The Journal of family practice.

[4]  L. Solberg,et al.  Delivering clinical preventive services is a systems problem , 1997, Annals of behavioral medicine : a publication of the Society of Behavioral Medicine.

[5]  R Wender,et al.  American Cancer Society Guidelines for the Early Detection of Cancer: Update of Early Detection Guidelines for Prostate, Colorectal, and Endometrial Cancers: ALSO: Update 2001—Testing for Early Lung Cancer Detection , 2001, CA: a cancer journal for clinicians.

[6]  S. Woolf.  The best screening test for colorectal cancer--a personal choice. , 2000, The New England journal of medicine.

[7]  R. Fletcher.  Diet for fecal occult blood test screening: help or harm? , 2001, Effective clinical practice : ECP.

[8]  C. Beeker,et al.  Colorectal Cancer Screening in Older Men and Women: Qualitative Research Findings and Implications for Intervention , 2000, Journal of Community Health.

[9]  J Lomas,et al.  Evidence of self-report bias in assessing adherence to guidelines. , 1999, International journal for quality in health care : journal of the International Society for Quality in Health Care.

[10]  G. Chejfec,et al.  Fecal occult blood screening for colorectal cancer in a Veterans Administration Hospital. , 1983, American journal of surgery.

[11]  B. Levin,et al.  Colorectal cancer screening by primary care physicians in two medical care organizations. , 2001, Cancer detection and prevention.

[12]  G. Harewood,et al.  A Videotape-Based Decision Aid for Colon Cancer Screening , 2000, Annals of Internal Medicine.

[13]  B. Rimer,et al.  The impact of tailored interventions on a community health center population. , 1999, Patient education and counseling.

[14]  S. Lemon,et al.  Colorectal cancer screening participation: comparisons with mammography and prostate-specific antigen screening. , 2001, American journal of public health.

[15]  F. V. von Eyben,et al.  Colorectal cancer screening: clinical guidelines and rationale. , 1997, Gastroenterology.

[16]  Gavin Harewood,et al.  Videotape-Based Decision Aid for Colon Cancer Screening , 2001, Annals of Internal Medicine.

[17]  Making "time" for preventive services. , 1994, Mayo Clinic proceedings.

[18]  J. Mandelblatt,et al.  Effectiveness of interventions to improve follow-up after abnormal cervical cancer screening. , 2000, Preventive medicine.

[19]  Carol Carr,et al.  Meta-analysis of dietary restriction during fecal occult blood testing. , 2001, Effective clinical practice : ECP.

[20]  E. Bini,et al.  The findings and impact of nonrehydrated guaiac examination of the rectum (FINGER) study: a comparison of 2 methods of screening for colorectal cancer in asymptomatic average-risk patients. , 1999, Archives of internal medicine.

[21]  L. Goebel,et al.  A peer review feedback method of promoting compliance with preventive care guidelines in a resident ambulatory care clinic. , 1997, The Joint Commission journal on quality improvement.

[22]  E. Weitzman,et al.  Risk and reluctance: understanding impediments to colorectal cancer screening. , 2001, Preventive medicine.

[23]  S. Vernon,et al.  A survey of physician beliefs and self-reported practices concerning screening for early detection of cancer. , 1994, Social science & medicine.

[24]  L. Metsch,et al.  The role of the physician as an information source on mammography. , 1998, Cancer practice.

[25]  C. Skinner,et al.  Cost-effectiveness comparison of five interventions to increase mammography screening. , 1999, Preventive medicine.

[26]  S. Fletcher,et al.  Prompting physicians for preventive procedures: a five-year study of manual and computer reminders. , 1990, American journal of preventive medicine.

[27]  Peter Dews,et al.  The effect of patient and physician reminders on use of screening mammography in a health maintenance organization: Results of a randomized controlled trial , 1996, Cancer.

[28]  E. Perez-stable,et al.  Colon cancer screening in the ambulatory setting. , 2002, Preventive medicine.

[29]  J E Rodnick,et al.  Promoting cancer prevention activities by primary care physicians. Results of a randomized, controlled trial. , 1991, JAMA.

[30]  B. Rimer,et al.  Using the telephone to improve health behavior and health service delivery. , 1999, Patient education and counseling.

[31]  J W Peabody,et al.  Comparison of vignettes, standardized patients, and chart abstraction: a prospective validation study of 3 methods for measuring quality. , 2000, JAMA.

[32]  C. Tse,et al.  Increasing compliance with mammography recommendations: health assessment forms. , 1993, The Journal of family practice.

[33]  R. Kelly,et al.  Adherence to Screening Flexible Sigmoidoscopy in Asymptomatic Patients , 1992, Medical care.

[34]  D A Redelmeier,et al.  Screening for colorectal cancer. , 1995, The New England journal of medicine.

[35]  H. Juon,et al.  Cancer screening behaviors among Korean-American women. , 2000, Cancer detection and prevention.

[36]  T. Heeren,et al.  Implementation of on-site screening sigmoidoscopy positively influences utilization by primary care providers. , 1999, Gastroenterology.

[37]  Hermann Brenner,et al.  Cost-effectiveness of colonoscopy in screening for colorectal cancer. , 2002, Archives of internal medicine.

[38]  L. Solberg,et al.  Smoking screening and management in primary care practices. , 1997, Archives of family medicine.

[39]  E. Paskett,et al.  Predictors of stage of adoption for colorectal cancer screening. , 2000, Preventive medicine.

[40]  L. Solberg,et al.  Primary Care, Process Improvement, and Turmoil , 1997, The Journal of ambulatory care management.

[41]  A. Neale,et al.  Compliance with colorectal cancer screening in a high-risk occupational group. , 1989, Journal of occupational medicine. : official publication of the Industrial Medical Association.

[42]  D. Gregorio,et al.  Ongoing physician guidance to achieve periodic mammography of women at an urban health center. , 1998, Connecticut medicine.

[43]  J. Selby.  Colorectal cancer screening: keeping the options open. , 2001, Effective clinical practice : ECP.

[44]  R. Fortinsky,et al.  Factors associated with the use of flexible sigmoidoscopy as a screening test for the detection of colorectal carcinoma by primary care physicians , 1998, Cancer.

[45]  J. Olynyk,et al.  Flexible sigmoidoscopy screening for colorectal cancer in average‐risk subjects: a community‐based pilot project , 1996, The Medical journal of Australia.

[46]  C. Messina,et al.  A systems model of clinical preventive care: the case of breast cancer screening among older women. For the NCI Breast Cancer Screening Consortium. , 2000, Preventive medicine.

[47]  Colorectal cancer prevention 2000: screening recommendations of the American College of Gastroenterology , 2000 .

[48]  S. Erban,et al.  Colorectal cancer screening in Massachusetts: measuring compliance with current guidelines. , 2001, Effective clinical practice : ECP.

[49]  T. Clarkson.  Principles of Risk Assessment , 1992, Advances in dental research.

[50]  Taylor Murray,et al.  Cancer Statistics, 2001 , 2001, CA: a cancer journal for clinicians.

[51]  Trends in screening for colorectal cancer--United States, 1997 and 1999. , 2001, MMWR. Morbidity and mortality weekly report.

[52]  F. D'Amico,et al.  Five-Year Follow-Up Of A Nurse-Initiated Intervention To Improve Mammography Recommendation , 1995, The Journal of the American Board of Family Medicine.

[53]  J. Ramsdell,et al.  Effect of medical records' checklists on implementation of periodic health measures. , 1987, The American journal of medicine.

[54]  K. Stange,et al.  How do family physicians prioritize delivery of multiple preventive services? , 1994, The Journal of family practice.

[55]  D. Blumenthal,et al.  Physician response to patient insurance status in ambulatory care clinical decision-making. Implications for quality of care. , 1996, Medical care.

[56]  T. Heeren,et al.  Utilization of colorectal cancer screening tests: a 1997 survey of Massachusetts internists. , 2001, Preventive medicine.

[57]  K. Burns,et al.  Prescription of physical activity by adult nurse practitioners: a national survey. , 2000, Nursing outlook.

[58]  A. Neugut,et al.  Cancer screening and prevention practices of inner-city physicians. , 2000, American journal of preventive medicine.

[59]  S. Vernon,et al.  Participation in colorectal cancer screening: a review. , 1997, Journal of the National Cancer Institute.

[60]  S. Mcphee,et al.  A Systems Model of Clinical Preventive Care: An Analysis of Factors Influencing Patient and Physician , 1992, Health education quarterly.

[61]  W. Phillips,et al.  Cancer screening by primary care physicians: a comparison of rates obtained from physician self-report, patient survey, and chart audit. , 1995, American journal of public health.

[62]  R. Hawkins,et al.  Effect of medical record audit and feedback on residents' compliance with preventive health care guidelines , 1998, Academic medicine : journal of the Association of American Medical Colleges.

[63]  J. Wardle,et al.  Acceptability of flexible sigmoidoscopy screening in older adults in the United Kingdom , 2000, Journal of medical screening.