From guideline to practice: New shared decision‐making tools for colorectal cancer screening from the American Cancer Society

The goal of the American Cancer Society (ACS) 2018 guideline update for colorectal cancer (CRC) screening is to reduce the incidence of and deaths from CRC for average-risk adults aged 45 years and older through the use of screening tests that are selected to align with a patient’s preferences and test availability. Beginning screening at age 45 years is a qualified recommendation, and regular screening of adults aged 50 years and older is a strong recommendation. The basis for the grading of these recommendations is described in the guideline update. For adults in good health with at least a 10-year life expectancy, screening should continue to age 75 years, whereas the decision to screen individuals ages 76 through 85 years should be individualized based on patient preferences, life expectancy, health status, and prior screening history (qualified recommendation). Clinicians should discourage individuals older than 85 years from continuing screening (qualified recommendation). The updated guideline includes details about the process for developing and rating the recommendations. In the updated guideline, the ACS Guideline Development Group placed greater emphasis on the importance of patient preferences and choice in selecting a screening test, with the goal of increasing CRC screening uptake and adherence. Six screening options are included in the new guideline, including 3 stool-based tests (fecal immunochemical test [FIT]; high-sensitivity guaiac-based fecal occult blood test [HSgFOBT]; and multitarget stool DNA test [mt-sDNA]) and 3 structural (visual) examinations (colonoscopy, computed tomography colonography [CTC], and flexible sigmoidoscopy [FS]). Each option is associated with unique operational and performance attributes as well as demands on patients, and there is an extensive literature demonstrating variability in how patients value the attributes of CRC screening options. These attributes, which include the frequency of testing, test procedures, and required preparation, alone or in combination, can impact a patient’s preference for CRC screening tests. Provider recommendations also strongly influence the uptake of screening and choice of test. Decision making about CRC screening therefore involves the patient weighing the importance of the test attributes when making a decision with a health care provider about which test is right for them. In the absence of the provider’s assessment of patient preferences, screening may not take place if the test offered is judged by the patient to be undesirable. There is evidence that screening intentions are higher among patients who are offered an option that is consonant with their preferences. The updated guideline emphasizes the importance of communication about CRC screening between health care providers and patients to improve CRC screening utilization. Shared decision making is a collaborative process that allows patients and their health care providers to make decisions together, accounting for the best scientific evidence available as well as the values and preferences of the patient. With the release of its updated CRC screening guideline, the ACS has developed decision support tools to engage patients and health care providers in making shared decisions about screening (cancer.org/health-care-professionals/ colon-md.html). Here, we introduce these new tools for supporting shared decision Professor, Department of Health Services Research, The University of Texas MD Anderson Cancer Center, Houston, TX; Program Manager, Department of Health Services Research, The University of Texas MD Anderson Cancer Center, Houston, TX; Project Manager, Department of Health Services Research, The University of Texas MD Anderson Cancer Center, Houston, TX; Associate Professor of Medicine, Department of Medicine, University of Virginia School of Medicine, Charlottesville, VA; Vice President, Cancer Control Interventions, Prevention, and Early Detection, American Cancer Society, Atlanta, GA; Chief Cancer Control Officer, American Cancer Society, Atlanta, GA; Professor, Department of Family and Community Medicine, Thomas Jefferson University, Philadelphia, PA; Vice President, Cancer Screening, Cancer Control Department, American Cancer Society, Atlanta, GA.