Physician‐patient communication regarding colorectal cancer screening is lacking
Authors: Mary Kay Barton
Journal: CA A Cancer Journal for Clinicians (2011)

A recent study evaluating physician-patient communication revealed that discussions of colorectal cancer (CRC) screening often do not include information that patients believe is important for making an informed decision (Cancer Epidemiol Biomarkers Prev [published online ahead of print August 3, 2011]. doi:10.1158/1055-9965. EPI-11-0281). “The public is now more aware about the need for colorectal cancer screening and it is becoming mainstream, just as mammography did 15 years ago. However, our study shows that the questions people ask their doctors are not what they said was important to them before the visit,” says coauthor Kurt Stange, MD, PhD, professor of family medicine at Case Western Reserve University in Cleveland, Ohio. Despite the fact that several major organizations such as the American Cancer Society (ACS) and the US Preventive Services Task Force support CRC screening, only approximately 60% of eligible patients in the United States undergo CRC screening within the recommended time frame (MMWR Surveill Summ. 2011;60(suppl): 42-48). Susan Flocke, PhD, associate professor of family medicine and epidemiology and biostatistics at Case Western Reserve University, and colleagues conducted a cross-sectional observational study in 26 clinics of an integrated health care organization in Michigan. Physicians were informed that the study was about physician-patient communications, but were not told the main study questions. Of 163 physicians approached, 77 chose to participate. Physicians were on average 48 years of age. In addition, 57% of respondents were female and 66% were internists. Patients were ages 50 to 80 years and were due to undergo CRC screening at the time of an annual physical examination. Participants were on average aged 59 years; 64% were female and 66% were white. Patients completed a previsit survey that assessed their demographic information and how they rated the importance of different types of information regarding screening tests. The physician visits were also audio-recorded. The recordings were analyzed by 3 research assistants who coded the discussion by the physician relating information about the CRC screening tests in general, screening test accuracy, test alternatives, the pros and cons of testing, and the testing process. Of 456 eligible visits analyzed, 415 included a discussion of CRC screening and were included in the analysis. In the previsit survey, the majority (77%-89%) of patients responded that information regarding the purpose of screening, test accuracy, test alternatives, the pros and cons of testing, and the testing process were very important for their decision-making process. When the audio recordings were analyzed, gaps in information provided by the physician were identified. Of those patients who rated information regarding test accuracy as very important in the previsit survey, only 7% actually received information about that topic from their physician. Similarly, physicians provided information concerning testing pros and cons and testing alternatives to 4% and 29%, respectively, of patients who rated these topics as very important. CRC screening discussions generally focused on colonoscopy, and alternatives were rarely discussed. The authors noted that the focus on colonoscopy only has been found in other studies as well. In a recent study, patients indicated that their physicians often do not give them information they believe is important for making a decision regarding colorectal cancer screening. Durado Brooks, MD, MPH, director of prostate and colorectal cancer for the ACS in Atlanta, Georgia, says this study demonstrates that, “Clinician discussions and recommendations regarding screening for colorectal cancer frequently fail to address factors that patients view as important in helping them make a decision about whether or not to be screened. This communication gap likely contributes to the continuing low rate of CRC screening in the US.” Physicians performed better in relating information about the purpose of screening and the testing process, with 58% and 100%, respectively, of patients who rated these topics as very important actually receiving this information. Furthermore, physicians only asked patients if they had questions in 5% of visits, but 49% of patients asked a question regarding CRC screening. Patients most frequently asked about testing logistics such as what the process is like and who to call to schedule an appointment. Few questions were asked about other topics that were rated as very important before the visit such as testing pros and cons, alternatives, and accuracy. In fact, not even one question regarding test accuracy was asked. CRC screening recommendations include several modalities, making screening decisions relatively complex. In the current study, the majority of patients did not receive the education they believed was important regarding CRC screening during an office visit to make an informed decision. According to Dr. Brooks, “Patient decision-making could be greatly enhanced through increased utilization of patient education tools and decision aids by primary care clinicians.” He encourages clinicians to take advantage of the CRC tools and decision aids available from the ACS (available at: www.cancer.org/colonmd) and other organizations. The current study illustrated that although the patients asked questions almost half the time, they for the most part did not address the topics they believed were important for their decision-making process. The researchers noted that past studies have shown that patients who believe they need more information regarding CRC screening but were not able to ask their physicians those questions were less likely to undergo screening. The research team concluded, therefore, that providing more information to patients on the topics they believe are important may increase patient uptake of CRC screening. Dr. Stange says he understands that at regular checkup visits clinicians have many competing demands on the time available, but he believes this study may help by making it easier to address CRC screening. “We can take the findings from this study and apply them to practice now by asking an opening question to find out what the patient needs to know so our discussion can be individualized and more productive,” Dr. Stange says. “This will help streamline our conversation, and potentially save time while being more effective.”