Informed Decision Making Changes Test Preferences for Colorectal Cancer Screening in a Diverse Population

Navkiran K. Shokar; Carol A. Carlson; Susan C. Weller

doi:10.1370/afm.1054

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The challenges of informed decision-making for colorectal cancer screening
Richard M. Hoffman

Published on: 05 April 2010
Preference Clarification and Decision Making in Colorectal Canncer Screening
Ronald E. Myers

Published on: 25 March 2010
Further support for variation in colon cancer screening preferences
Sarah T Hawley

Published on: 11 March 2010
Patient preferences for colorectal cancer screening
Michael Pignone

Published on: 11 March 2010
Preferences for colorectal cancer screening
K. Allen Greiner

Published on: 09 March 2010

Published on: (5 April 2010)
Page navigation anchor for The challenges of informed decision-making for colorectal cancer screening
The challenges of informed decision-making for colorectal cancer screening
Richard M. Hoffman, Albuquerque, NM, USA
Other Contributors:
Shokar and colleagues elegantly demonstrate the value of eliciting patient preferences for colorectal cancer screening tests given the complex tradeoffs between effectiveness, diagnostic accuracy, testing burdens and risks (1). The article also indirectly highlights the challenges to achieving informed decision-making given evolving guidelines, new evidence, and changing practice patterns. Many of the testing options...
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Shokar and colleagues elegantly demonstrate the value of eliciting patient preferences for colorectal cancer screening tests given the complex tradeoffs between effectiveness, diagnostic accuracy, testing burdens and risks (1). The article also indirectly highlights the challenges to achieving informed decision-making given evolving guidelines, new evidence, and changing practice patterns. Many of the testing options and attributes presented to subjects in the Shokar study are no longer even current. Recent U.S. Preventive Services Task Force guidelines recommend fecal immunochemical tests over the guaiac-based FOBT because of higher accuracy and not needing to alter diet and medication; the guidelines also no longer recommend screening with barium enemas (2). We now have better evidence that colonoscopy reduces risk of death from colorectal cancer, though the failure to prevent right-sided deaths suggests that the benefit of examining the entire colon may be overestimated (3). Flexible sigmoidoscopy and barium enema are increasingly impractical options given their limited availability. While CT colonography has generated enthusiasm, the potential harms from radiation exposure and finding extra-colonic pathology are poorly characterized, and Medicare will not reimburse these procedures.
The authors note the challenge of presenting comprehensive, objective, and current information on colorectal cancer screening to patients—especially within the time constraints of an office visit. Patient navigators and health educators have been shown to increase screening rates and the authors suggest that decision aids may be a useful strategy to facilitate decision-making. Decision aids, which can be written, oral, video, or web-based, are interventions designed to help patients make decisions by providing disease information, presenting alternative testing strategies, describing possible outcomes, and helping patients clarify their values (4). Providing patients with decision aids can increase colorectal cancer screening rates and increase knowledge and agreement between patient values and choice (5). Utilizing some combination of patient navigators, health educators, and/or decision aids may be an efficient approach to help patients achieve informed decisions and to increase colorectal cancer screening rates in primary care practices.
However, a point to consider about informed decision-making is that a very appropriate decision may be to forego screening. While we have high- quality evidence that screening reduces colorectal cancer mortality, we have to recognize that the absolute benefit is quite small—a cumulative decrease of about 3 deaths per 1,000 (6). Cancer screening may be less of a priority for patients with serious comorbidities.
References
1. Shokar NK, Carlson CA, Weller SC. Informed decision making changes test preferences for colorectal cancer screening in a diverse population. Ann Fam Med;8(2):141-50.
2. Screening for colorectal cancer: U.S. Preventive Services Task Force recommendation statement. Ann Intern Med. 2008;149(9):627-37.
3. Baxter NN, Goldwasser MA, Paszat LF, Saskin R, Urbach DR, Rabeneck L. Association of colonoscopy and death from colorectal cancer. Ann Intern Med. 2009;150(1):1-8.
4. Rimer BK, Briss PA, Zeller PK, Chan EC, Woolf SH. Informed decision making: what is its role in cancer screening? Cancer. 2004;101(5 Suppl):1214-28.
5. O'Connor AM, Bennett CL, Stacey D, et al. Decision aids for people facing health treatment or screening decisions. Cochrane Database Syst Rev. 2009(3):CD001431.
6. Mandel JS, Bond JH, Church TR, et al. Reducing mortality from colorectal cancer by screening for fecal occult blood. Minnesota Colon Cancer Control Study. N Engl J Med. 1993;328(19):1365-71.
Competing interests: None declared
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Competing Interests: None declared.
Published on: (25 March 2010)
Page navigation anchor for Preference Clarification and Decision Making in Colorectal Canncer Screening
Preference Clarification and Decision Making in Colorectal Canncer Screening
Ronald E. Myers, Philadelphia, USA
I recently read the paper by Shokar and colleagues with great interest. This article makes an important contribution to the growing number of reports in the literature that address patient preference in cancer screening. In brief, the authors guided a diverse sample of patients through the following multi-step process: (1) patients reviewed brief descriptions of colorectal cancer (CRC) screening tests and ranked the t...
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I recently read the paper by Shokar and colleagues with great interest. This article makes an important contribution to the growing number of reports in the literature that address patient preference in cancer screening. In brief, the authors guided a diverse sample of patients through the following multi-step process: (1) patients reviewed brief descriptions of colorectal cancer (CRC) screening tests and ranked the tests in terms of four levels of personal preference; (2) patients reviewed test attributes and ranked the attributes in terms of four levels of personal importance; (3) patient reviewed test attributes and ranked them using a “feeling thermometer”; and (4) patients reviewed more detailed descriptions of the tests and ranked them again in terms of personal preference. At the beginning of this intensive experience, participants expressed a preference for fecal occult blood testing (FOBT), followed by colonoscopy (COL), flexible sigmoidoscopy (FS), and double contrast barium enema (DCBE), in that order. At the end, the observed ordering of preferred tests was as follows: COL, FOBT, FS, and DCBE. Thus, it appears that as patients became more familiar with the tests recommended in current guidelines and specific attributes of the tests, personal preference shifted from FOBT to COL, the two tests with the highest preference scores. Findings reported here suggest that patients have different levels of preference for recommended CRC screening tests, and that test preference may change when patients are engaged in a systematic process of considering test attributes. Going forward, it would be useful to develop a relatively simple set of procedures to engage patients in preference clarification and decision making about performance of the preferred test. Making decision aids available to patients may help to clarify what test is preferred on the basis of information on hand at a given point in time. Involvement in the process of considering what is involved in test performance, however, may be help to crystallize personal test preference at a more fundamental level and set the stage for taking action. In primary care, individuals trained to help patients make and implement screening decisions (e.g., patient navigators) could help to move patients through test preference clarification to actual test performance.
Competing interests: None declared
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Competing Interests: None declared.
Published on: (11 March 2010)
Page navigation anchor for Further support for variation in colon cancer screening preferences
Further support for variation in colon cancer screening preferences
Sarah T Hawley, Ann Arbor, MI
The paper by Shokar and colleagues adds to the growing research on colon cancer screening preferences and confirms that variation in test preferences exists. A key contribution of the work is the inclusion of 64% minority participants, as prior studies have often not obtained such significant participation by non-white patients. In addition, the methodology of assessing test preferences before and after collecting reacti...
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The paper by Shokar and colleagues adds to the growing research on colon cancer screening preferences and confirms that variation in test preferences exists. A key contribution of the work is the inclusion of 64% minority participants, as prior studies have often not obtained such significant participation by non-white patients. In addition, the methodology of assessing test preferences before and after collecting reactions to test attributes is a unique feature. The authors also included attributes not formerly evaluated in the research, such as the degree of scientific evidence for the tests. The results were consistent with other studies showing that patients tend to prefer the least invasive test (FOBT) or the most accurate test (Colonoscopy). The results from Shokar and colleagues suggest that a single screening approach may not work, as noted by the authors, even for smaller subgroups. The authors contend that their results support the need for clinicians to discuss the full range of CRC screening choices with their patients. Yet these results are in opposition to the increasing trend in primary care to recommend colonoscopy. The paper by Shokar and colleagues, together with the work of others, underscores the need for providers to acknowledge that there is variation in CRC screening preferences. Incorporating these preferences into medical discussions may result in patients feeling more informed and, ultimately, may translate into better adherence.
Competing interests: None declared
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Competing Interests: None declared.
Published on: (11 March 2010)
Page navigation anchor for Patient preferences for colorectal cancer screening
Patient preferences for colorectal cancer screening
Michael Pignone, Chapel Hill, NC
Shokar and colleagues are to be commended for designing and carrying out a very interesting study of patient preferences for colorectal cancer screening. They essentially performed a single group, pre-post experiment that evaluated the effect of considering and ranking a detailed list of test attributes on patient preferences for CRC screening (fecal occult blood testing (FOBT), sigmoidoscopy (SIG), colonoscopy (COL), an...
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Shokar and colleagues are to be commended for designing and carrying out a very interesting study of patient preferences for colorectal cancer screening. They essentially performed a single group, pre-post experiment that evaluated the effect of considering and ranking a detailed list of test attributes on patient preferences for CRC screening (fecal occult blood testing (FOBT), sigmoidoscopy (SIG), colonoscopy (COL), and barium enema (BE).
Although not emphasized in their results, they actually found quite a bit of change between initial preferences and preferences elicited after the ranking exercise: at least 33% of participants changed their test preference after the ranking exercise. Whether this change is a result of the ranking itself, or simply due to the information provided in the long descriptions, cannot be determined. Nonetheless, this 33% represents quite a bit of movement, and should not be interpreted as “stable” preferences, in my opinion.
The net movement seen was away from FOBT (-33%) and in favor of other tests. Several features of the design may have influenced the direction of the results. First, it is unclear whether the attributes are meant to apply to a single use of a test, or a program of testing over some time period- it appears they are a mixture of both. Secondly, the use of a large number (13) of attributes may seem to provide comprehensiveness, but it comes at a cost of substantial overlap. For example, test accuracy and “amount of colon examined” are really the same construct, leading to double counting. Another problem is seen in the frequency rankings: a more frequent test was rated higher than a less frequent test, meaning that respondents are mapping another concept (accuracy) onto this construct, as patients should generally prefer a less frequent test if every other attribute, including accuracy over time, is held constant. Finally, the use of ranking rather than a combination of rating and ranking or a discrete choice experiment may have produced measurement error; studies comparing different techniques for this purpose are needed.
Despite these few limitations, Shokar and colleagues make an important point in their conclusions: differences in preferences by demographic group are not strong enough to change the clinical approach to CRC screening. Patients should be given information to allow them to make a preference-concordant decision. How much information is required, and how many options (FOBT and COL only?)to offer require additional study.
Competing interests: Dr. Pignone has developed decision aids for colorectal cancer screening.
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Competing Interests: None declared.
Published on: (9 March 2010)
Page navigation anchor for Preferences for colorectal cancer screening
Preferences for colorectal cancer screening
K. Allen Greiner, Kansas City, KS USA
This important and well constructed study by Drs. Shokar and colleagues adds to the literature on patient preferences among colorectal screening tests. The work supplements important prior projects by Ling (2001) and Pignone (1999) and results may be useful should clinicians begin to re-evaluate the overwhelming push towards colonoscopy for screning that has occurred over the last 10 years. Health care reform and debate...
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This important and well constructed study by Drs. Shokar and colleagues adds to the literature on patient preferences among colorectal screening tests. The work supplements important prior projects by Ling (2001) and Pignone (1999) and results may be useful should clinicians begin to re-evaluate the overwhelming push towards colonoscopy for screning that has occurred over the last 10 years. Health care reform and debates over the risk/ benefit calculations for other cancer screening procedures, such as those for prostate and breast cancer, which seem to be gaining traction, may spill over to discussions of colorectal screening.
Should this occur, it's noteworthy that many primary care patient groups, and especially those from diverse racial/ethnic or socioeconomic backgrounds, may prefer non-invasive colorectal screening methods such as immunochemical stool blood testing at rates near 50%. Our prior work (Greiner, JGIM 2005 and Prev Med 2005) found similar results and has been consistent into our current ongoing safety-net clinic based trials.
Studies on physician-patient communication around colorectal screening continue to show sub-optimal communication (see Wolf JGIM 2007, Ling Med Care 2008, or McQueen JGIM 2009) and close attention to longstanding patient preference trends will be important as attempts are initiated to present balanced test attribute information to patients given primary care's "competing demands". These demands and related time constraints make it crucial that providers have a sense of community-wide opinions and preferences about screening and health care utilization to maximize health outcomes and "opportunistic" intervention and prevention in the most effective and efficient ways.
Competing interests: None declared
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Competing Interests: None declared.