Original Research

Journal of General Internal Medicine

, Volume 28, Issue 1, pp 18-24

Variation in Primary Care Physicians’ Colorectal Cancer Screening Recommendations by Patient Age and Comorbidity

  • David A. HaggstromAffiliated withVA Health Services Research & Development Center of Excellence on Implementing Evidence-Based Practice, Richard L. Roudebush VA Medical CenterDivision of General Internal Medicine and Geriatrics, Department of Medicine, Indiana University School of MedicineIU Center for Health Services and Outcomes Research, Regenstrief Institute, Inc. Email author 
  • , Carrie N. KlabundeAffiliated withHealth Services and Economics Branch, Applied Research Program, Division of Cancer Control and Population Sciences, National Cancer Institute
  • , Judith Lee SmithAffiliated withDivision of Cancer Prevention and Control, Centers for Disease Control and Prevention
  • , Gigi YuanAffiliated withInformation Management Services, Inc.

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Abstract

BACKGROUND

Screening patterns among primary care physicians (PCPs) may be influenced by patient age and comorbidity. Colorectal cancer (CRC) screening has little benefit among patients with limited life expectancy.

OBJECTIVE

To characterize the extent to which PCPs modify their recommendations for CRC screening based upon patients’ increasing age and/or worsening comorbidity

DESIGN

Cross-sectional, nationally representative survey.

PARTICIPANTS

The study comprised primary care physicians (n = 1,266) including general internal medicine, family practice, and obstetrics-gynecology physicians.

MAIN MEASURES

Physician CRC screening recommendations among patients of varying age and comorbidity were measured based upon clinical vignettes. Independent variables in adjusted models included physician and practice characteristics.

KEY RESULTS

For an 80-year-old patient with unresectable non-small cell lung cancer (NSCLC), 25 % of PCPs recommended CRC screening. For an 80-year-old patient with ischemic cardiomyopathy (New York Heart Association, Class II), 71 % of PCPs recommended CRC screening. PCPs were more likely to recommend fecal occult blood testing than colonoscopy as the preferred screening modality for a healthy 80-year-old, compared to healthy 50- or 65-year-old patients (19 % vs. 5 % vs. 2 % p < 0.001). For an 80-year-old with unresectable NSCLC, PCPs who were an obstetrics-gynecology physician were more likely to recommend CRC screening, while those with a full electronic medical record were less likely to recommend screening.

CONCLUSIONS

PCPs consider comorbidity when screening older patients for CRC and may change the screening modality from colonoscopy to FOBT. However, a sizable proportion of PCPs would recommend screening for patients with advanced cancer who would not benefit. Understanding the mechanisms underlying these patterns will facilitate the design of future medical education and policy interventions to reduce unnecessary care.

KEY WORDS

cancer screening health services colorectal cancer primary care physicians