Informed choice in bowel cancer screening: a qualitative study to explore how adults with lower education use decision aids

Background Offering informed choice in screening is increasingly advocated, but little is known about how evidence‐based information about the benefits and harms of screening influences understanding and participation in screening. Objective We aimed to explore how a bowel cancer screening decision aid influenced decision making and screening behaviour among adults with lower education and literacy. Methods Twenty‐one men and women aged 55–64 years with lower education levels were interviewed about using a decision aid to make their screening decision. Participants were purposively selected to include those who had and had not made an informed choice. Results Understanding the purpose of the decision aid was an important factor in whether participants made an informed choice about screening. Participants varied in how they understood and integrated quantitative risk information about the benefits and harms of screening into their decision making; some read it carefully and used it to justify their screening decision, whereas others dismissed it because they were sceptical of it or lacked confidence in their own numeracy ability. Participants’ prior knowledge and beliefs about screening influenced how they made sense of the information. Discussion and conclusions Participants valued information that offered them a choice in a non‐directive way, but were concerned that it would deter people from screening. Healthcare providers need to be aware that people respond to screening information in diverse ways involving a range of literacy skills and cognitive processes.     

Blood‐based screening for bowel cancer may not resolve suboptimal screening participation in Australia

Objective: Emerging blood‐based screening technologies for bowel cancer may improve screening participation compared to at‐home stool sampling. This study assessed the impact of different screening delivery scenarios with increasing health system interactions on sampling preferences and likelihood of screening participation. Methods: N=1,561 persons aged 45 to 74 years completed a behavioural survey measuring demographics, readiness to screen, overall collection method preference, and proposed participation in stool and blood methods across four screening scenarios differing in terms of the number of required health system interactions. Results: Overall, respondents preferred a blood test (79.6%) compared to a stool test (20.4%). However, increasing health system interactions had a strong impact on the likelihood of participating in either sampling method (p<0.001). Moreover, likelihood of participating in each of the four blood‐screening scenarios was significantly lower than the current at‐home stool sampling approach (all p<0.001). Conclusions: Blood‐based screening methods require increased contact with the health system but these interactions have negative impact on screening likelihood. All blood‐based scenarios showed lower screening likelihood ratings than the current at‐home FIT approach. Thus, blood‐based screening may not resolve suboptimal screening participation rates in Australia.     

Responses to procedural information about colorectal cancer screening using faecal occult blood testing: the role of consideration of future consequences

Background Colorectal cancer (CRC) screening participation is low despite its effectiveness in reducing CRC mortality. Identifying benefits and barriers requires consideration of specific characteristics of screening modalities. Aims and Research Questions To monitor the impact of providing information about CRC screening via faecal occult blood testing (FOBt) on intentions to participate. To investigate moderation by individual differences in consideration of future consequences (CFC). Design, setting and participants A total of 211 healthy adults (aged 45–59) with no experience of CRC screening were presented with eight consecutive statements about FOBt‐based screening in a web survey. Participants completed measures of i) intention (after each statement), ii) CFC and iii) the importance of screening practicalities (e.g. unpleasantness of completing the test) and benefits (e.g. early detection of cancer). Results An 8 (information) × 2 (CFC) mixed ancova showed that intentions varied across the eight statements. (P < 0.001): increasing after information about FOBt being completed at home (P < 0.001) before subsequently decreasing after information about the requirement to collect faecal samples (P < 0.001) in a plastic tub (P < 0.01) on three occasions (P < 0.01) with the low CFC group generally being less inclined to complete the test (P < 0.01). Two between‐group anovas demonstrated that the low CFC group attributed greater importance to practicalities of screening than the high CFC group while the opposite was found for the importance of benefits (both P’s < 0.001). Conclusion Deconstructing FOBt‐based screening pointed to specific benefits and barriers which can advance research into public preferences of screening and educational materials.     

Cost savings in mass population screening for colorectal cancer resulting from the early detection and excision of adenomas.

The widely-accepted hypothesis of a development sequence from colorectal adenoma to carcinoma is felt by clinicians to legitimate adenoma excision during routine colonoscopic investigation. Using published data on adenoma development, and adenoma prevalence data derived from the Nottingham colorectal cancer screening trial, the number of carcinomas prevented by early excision as a result of screening is predicted. The cost-effectiveness of early excision is then evaluated with reference to the expected treatment costs saved. These cost savings are found to represent a discount on the overall costs of mass population screening for colorectal cancer.     

Testing the effectiveness of a general practice intervention to improve uptake of colorectal cancer screening: a randomised controlled trial

Objective : Uptake of screening through the Australian National Bowel Cancer Screening Program remains low. General practice guidelines support the general practitioners’ role to offer CRC screening. This study tests the effect that an intervention including point‐of‐care FOBT provision, printed screening advice and GP endorsement has on self‐reported FOBT uptake. Methods : A multisite, 1:1 parallel‐arm, cluster‐randomised controlled trial. Participants aged 50–74, at average risk of CRC and overdue for screening were recruited from four general practices in New South Wales, Australia, from September 2016 to May 2017. Self‐report of FOBT up to eight weeks post baseline. Results : A total of 336 participants consented to complete a baseline survey (64% consent rate), of which 123 were recruited into the trial (28 usual care days and 26 intervention days). Follow‐up data was collected for 114 participants (65 usual care and 49 intervention). Those receiving the intervention had ten times greater odds of completing screening compared to usual care (39% vs. 6%; OR 10.24; 95%CI 2.9‐36.6, p=0.0006). Conclusions : A multicomponent intervention delivered in general practice significantly increased self‐reported FOBT uptake in those at average risk of CRC. Implications for public health : General practice interventions could serve as an important adjunct to the Australian National Bowel Cancer Screening Program to boost plateauing screening rates.     

Cost-effectiveness analysis of two strategies for mass screening for colorectal cancer in France

The implementation of colorectal cancer mass screening is a high public health priority in France, as in most other industrialised countries. Despite evidences that screening using guaiac fecal occult blood test may reduce colorectal cancer mortality, no European country has organised widespread mass screening with this test. The low sensitivity of this test constitutes its main limitation. Immunological tests, which provide higher sensitivity than the guaiac test, may constitute a satisfactory alternative. This study was carried out to compare the costs and the effectiveness of 20 years of biennial colorectal cancer (CRC) screening with an automated reading immunological test (Magstream) with those obtained with a guaiac stool test (Haemoccult). The model used to estimate the costs and effectiveness of successive biennial CRC screening campaigns was a transitional probabilistic model. The parameters used in this model concerning costs and CRC epidemiological data were calculated from results obtained in the screening program run in Calvados or from published results of foreign studies because of the lack of French studies. The use of Magstream for 20 years of biennial screening costs 59 euros more than Haemoccult per target individual, and should lead to a mean increase in individual life expectancy of 0.0198 years (i.e. about one week), which corresponds to an incremental cost-effectiveness ratio of 2980 euros per years of life saved. Our results suggest that using an immunological test could increase the effectiveness of CRC screening at a reasonable cost for society.     

Faecal occult blood test: current practice in a rural Queensland community

ABSTRACT: The findings of a recent telephone survey of 604 residents (50–74 years of age) in a rural community in Queensland are presented. The survey focused on the participants' knowledge concerning the faecal occult blood test (FOBT) and their previous testing history. Responses were analysed in terms of gender, age and education differences. More than half of all participants were aware of the FOBT, and 109 (18%) had undergone FOBT in the past. Fewer understood the importance of 'health checks without symptoms' than the 'advantage of early treatment'. The most common reasons to use FOBT were: 'prevention' and 'I want to know if I have cancer'. A person's gender, age and education were shown to be associated with their knowledge and beliefs. These results suggest an increase in the use of the FOBT with time (in relation to previous surveys), but a poor understanding of its place in promoting health.     

Risk and reluctance: understanding impediments to colorectal cancer screening

PURPOSE: Screening to detect and prevent colorectal cancer (CRC) is well below optimal, contributing to needless CRC-related morbidity and mortality. Little detailed information exists explaining why screening technologies are underutilized and why screening adherence rates are low. Prior to the design of an intervention study, we assessed knowledge about CRC among adult women and men with access to health care. We also investigated patterns of perceived risk for CRC, barriers and facilitators to screening, and experience and intentions with regard to both fecal occult blood testing and flexible sigmoidoscopy. METHODS: We analyzed data from semistructured focus group interviews with a small, nonrepresentative sample (n = 39) of community-dwelling adult men and women ages 50 to 64 and 65 plus. RESULTS: CRC-related knowledge is low, and misperceptions are common. Provider practices reinforce low levels of perceived risk. Multiple barriers to screening exist, of which many are remediable. CONCLUSIONS: We are at an early stage in the diffusion of information about CRC. Screening utilization may be improved through development of appropriate public health awareness campaigns and by addressing service factors. Recommendations are provided.     

Use of a patient navigator to increase colorectal cancer screening in an urban neighborhood health clinic

Colorectal cancer (CRC) is the second leading cause of cancer-related deaths in the United States. Racial disparities in CRC incidence and mortality have been well documented. In addition, lower rates of CRC screening among ethnic minorities have been reported. Therefore, we tested the effectiveness of a patient navigator (PN) in increasing compliance with CRC screening in a minority community health setting. Men and women aged 50 or older attending a primary care practice were enrolled if they had not had a fecal occult blood test within the past year, a sigmoidoscopy or barium enema within the past 3–5 years, or a colonoscopy within the past 10 years. Participants were randomly assigned either to receive navigator services (PN+) or not to receive navigator services (PN−). There were no demographic differences between the two groups. Within 6 months of physician recommendation, 15.8% in the PN+ group had complied with an endoscopic examination, compared with only 5% in the PN− group (P=.019). The PN+ groups also demonstrated higher rates of fecal occult blood test completion (42.1% vs. 25%, P=.086). Thus, a PN system successfully increases CRC screening rates among a predominantly minority population of low socioeconomic status.     

大肠癌筛查现况与展望

目的 探讨大肠癌筛查相关知信行、健康素养等因素与肠镜检查顺应性的相关性,为改善居民肠镜顺应性提出针对性的建议。 方法 结合上海市重大公共卫生项目大肠癌筛查,对2015 — 2016年参加大肠癌筛查且初筛判定为阳性的1 959名居民采用大肠癌筛查知信行问卷、健康素养量表进行综合评估,并追踪其肠镜检查情况。 结果 大肠癌筛查初筛阳性居民的健康素养量表的总分为109.44分,各维度平均得分差异有统计学意义（P < 0.001）;大肠癌知信行问卷条目的总体平均得分为61.55分,态度和信念的平均得分高于知识得分（P < 0.001）。健康素养得分与大肠癌筛查相关知信行得分之间存在线性相关,相关系数为0.410（P < 0.001）,肠镜检查组与未进行肠镜检查组居民健康素养总得分和大肠癌筛查知信行总得分的差异有统计学意义,总得分越高,肠镜顺应性越高。 结论 健康素养总得分、大肠癌筛查知信行总得分与肠镜检查顺应性存在相关,提高居民健康素养以及大肠癌筛查相关知识是改善肠镜顺应性低的有效手段。     

Decision-making role preferences and information needs: a comparison of colorectal and breast cancer

Objective  An exploratory study has been carried out to examine decision-making role preferences and information needs for a sample of people with colorectal cancer ( n =48). The work replicated a larger study carried out for women with breast cancer ( n =150), and this paper compares and contrasts findings for both disease groups.
Design  A cross-sectional design was employed, involving structured interviews. The main variables investigated were decision-making preference (using a decisional role preference card sort), perceived decisional role and information need (using an information needs questionnaire).
Results  The majority (78%) of the colorectal cancer patients preferred to play a passive role in decision making, in contrast to 52% of women with breast cancer in previous work. Eighty per cent of the colorectal sample and 61% of the women with breast cancer perceived that the doctor had made treatment decisions. Priority information needs for both groups related to cure, spread of disease and treatment options.
Conclusions  The two most striking findings from the comparison between the two disease groups relate to the differences in decision-making role preferences and the similarities in information needs. The process of involving people with colorectal cancer in treatment decision making warrants further investigation. The similarity in information needs of the two disease groups has implications for health care professionals providing information to people with cancer.     

Program to improve colorectal cancer screening in a low-income, racially diverse population: a randomized controlled trial

PURPOSE More effective strategies are needed to improve rates of colorectal cancer screening, particularly among the poor, racial and ethnic minorities, and individuals with limited English proficiency. We examined whether the direct mailing of fecal occult blood testing (FOBT) kits to patients overdue for such screening is an effective way to improve screening in this population. METHODS All adults aged 50 to 80 years who did not have documentation of being up to date with colorectal cancer screening as of December 31, 2009, and who had had at least 2 visits to the community health center in the prior 18 months were randomized to the outreach intervention or usual care. Patients in the outreach group were mailed a colorectal cancer fact sheet and FOBT kit. Patients in the usual care group could be referred for screening during usual clinician visits. The primary outcome was completion of colorectal cancer screening (by FOBT, sigmoidoscopy, or colonoscopy) 4 months after initiation of the outreach protocol. Outcome measures were compared using the Fisher exact test. RESULTS Analyses were based on 104 patients assigned to the outreach intervention and 98 patients assigned to usual care. In all, 30% of patients in the outreach group completed colorectal cancer screening during the study period, compared with 5% of patients in the usual care group (P <.001). Nearly all of the screenings were by FOBT. The groups did not differ significantly with respect to the percentage of patients making a clinician visit or the percentage for whom a clinician placed an order for a screening test. CONCLUSIONS The mailing of FOBT kits directly to patients was efficacious for promoting colorectal cancer screening among a population with high levels of poverty, limited English proficiency, and racial and ethnic diversity. Non-visit-based outreach to patients may be an important strategy to address suboptimal rates of colorectal cancer screening among populations most at risk for not being screened.     

Risk assessment and clinical decision making for colorectal cancer screening

Background

Shared decision making (SDM) related to test preference has been advocated as a potentially effective strategy for increasing adherence to colorectal cancer (CRC) screening, yet primary care providers (PCPs) are often reluctant to comply with patient preferences if they differ from their own. Risk stratification advanced colorectal neoplasia (ACN) provides a rational strategy for reconciling these differences.

Objective

To assess the importance of risk stratification in PCP decision making related to test preference for average‐risk patients and receptivity to use of an electronic risk assessment tool for ACN to facilitate SDM.

Design

Mixed methods, including qualitative key informant interviews and a cross‐sectional survey.

Participants

PCPs at an urban, academic safety‐net institution.

Main Measures

Screening preferences, factors influencing patient recommendations and receptivity to use of a risk stratification tool.

Key Results

Nine PCPs participated in interviews and 57 completed the survey. Despite an overwhelming preference for colonoscopy by 95% of respondents, patient risk (67%) and patient preferences (63%) were more influential in their decision making than patient comorbidities (31%; P < 0.001). Age was the single most influential risk factor (excluding family history), with <20% of respondents choosing factors other than age. Most respondents reported that they would be likely to use a risk stratification tool in their practice either ‘often’ (43%) or sometimes (53%).

Conclusions

Risk stratification was perceived to be important in clinical decision making, yet few providers considered risk factors other than age for average‐risk patients. Providers were receptive to the use of a risk assessment tool for ACN when recommending an appropriate screening test for select patients.     

How do people interpret information about colorectal cancer screening: observations from a think‐aloud study

Background

The English NHS Bowel Cancer Screening Programme biennially invites individuals aged 60–74 to participate in screening. The booklet, ‘Bowel Cancer Screening: The Facts'' accompanies this invitation. Its primary aim is to inform potential participants about the aims, advantages and disadvantages of colorectal cancer screening.

Objective

To provide detailed commentary on how individuals process the information contained within ‘The Facts’ booklet.

Design, setting and participants

This study comprised of 18 interviews with individuals aged 45–60 and used a ‘think‐aloud’ paradigm in which participants read aloud the booklet. Participant utterances (verbal statements made in response to researcher‐led prompts) were transcribed and analysed using a combination of content and thematic analysis.

Results

A total of 776 coded utterances were analysed (mean = 43.1 per person; range = 8–95). While overall comprehension was satisfactory, several problem areas were identified such as the use of complex unfamiliar terminology and the presentation of numerical information. Specific sections such as colonoscopy risk information evoked negative emotional responses. Participants made several suggestions for ways in which comprehension might be improved.

Conclusion

Public perceptions of the NHS Bowel Cancer Screening Programme information materials indicated that specific aspects of the booklet were difficult to process. These materials may be an appropriate target to improve public understanding of the aims, benefits and disadvantages of colorectal cancer screening. These findings will contribute to a broader NIHR‐funded project that aims to design a supplementary ‘gist‐based’ information leaflet suitable for low literacy populations.     

国外结直肠癌筛查指南更新进展及对我国人群筛查工作的启示

目的了解国外结直肠癌(colorectal cancer,CRC)筛查指南更新进展,为我国人群结直肠癌筛查工作提供借鉴。方法采用文献综述的方法分析国外CRC筛查指南更新进展。检索以下数据库:Pubmed、Ovid EBMR、EBSCO MEDLINE、Springe For Hospital&Health。检索词为"colorectal cancer""guideline""recommendations""consensus"。文献发表时间为2009年1月至2019年7月,语言为英语并可获得全文文献者。结果共纳入5个指南及共识:美国预防服务工作组CRC筛查建议(2016)、美国结直肠癌多学会工作组筛查指南(2017)、加拿大卫生保健预防工作组CRC筛查指南(2016)、欧盟CRC筛查指南工作组指南(2010)、亚太地区CRC筛查共识(2015)。多数指南推荐筛查人群的年龄为50～75岁,筛查方法为粪隐血试验(化学法和免疫法)、乙状结肠镜检查和结肠镜检查,但推荐的优选试验和间隔时间不同。结论对CRC普通风险人群应于50-75岁间进行CRC筛查,筛查方法可依据所在地区的CRC流行...     

Trust,choice and obligation: a qualitative study of enablers of colorectal cancer screening in South Australia

Colorectal cancer (CRC) has the second highest cancer prevalence and mortality rates in Australia. The Australian National Bowel Cancer Screening Program (NBCSP) aims to increase early detection of CRC by offering free faecal occult blood testing. The NBCSP aims to offer choice to consumers about whether or not to participate in screening. This article presents data on trust, choice and perceived obligation to participate in the NBCSP by population groups with low uptake. A qualitative study was undertaken in South Australia. We interviewed 94 people from four culturally distinct groups: Greek, Iranian, Anglo‐Australian and Indigenous peoples. This article demonstrates the complexity of factors shaping the choice, or lack thereof, to participate in the NBCSP. Informed choice is based on adequate knowledge, although this varied among our participants, highlighting the need for more health education in appropriate languages. An obligation to participate was found in the Iranian and Anglo‐Australian groups and resulted from an established personal relationship with the doctor, a sense of duty, the acknowledgement of government investment and appreciation. Overall, this article makes a link between trust, choice and obligation, adding to literature on the sociology of trust and medical screening and highlighting important issues in the need of a policy and practice to improve CRC screening rates.     

癌症早诊早治工作评价指标的探讨

  目的  通过对北京市大兴区农村地区居民进行结直肠癌筛查,比较问卷和便潜血检测2种筛查工具效果。  方法  采用多阶段整群随机抽样方法,在2018年11月 — 2019年5月,对北京市大兴区农村居民进行结直肠癌筛查,采用问卷评估和便潜血检测2种筛查方式。纳入本研究的对象共有12 042人,其中男性5 508人,女性6 534人。问卷评估为高危或（和）粪便潜血阳性即为高危人群,并对结果进行分析。  结果  单因素分析结果显示,吸烟、饮酒、久坐办公室等是问卷及便潜血检测评估结直肠癌高危的危险因素（P < 0.05）。logistics回归分析结果显示,溃疡性结肠炎、痔疮等均为问卷高危和便潜血阳性的危险因素（P < 0.05）。  结论  在结直肠癌筛查中使用风险问卷评估和便潜血检测2种筛查工具,能明确结直肠癌高危人群,对于降低结直肠癌的发病率和死亡率具有重要意义。