Behind Closed Doors: Physician-Patient Discussions About Colorectal Cancer Screening

  • Amy McQueen
  • L. Kay Bartholomew
  • Anthony J. Greisinger
  • Gilda G. Medina
  • Sarah T. Hawley
  • Paul Haidet
  • Judith L. Bettencourt
  • Navkiran K. Shokar
  • Bruce S. Ling
  • Sally W. Vernon
Original Article

Abstract

BACKGROUND

Despite the availability of multiple effective screening tests for colorectal cancer, screening rates remain suboptimal. The literature documents patient preferences for different test types and recommends a shared decision-making approach for physician-patient colorectal cancer screening (CRCS) discussions, but it is unknown whether such communication about CRCS preferences and options actually occurs in busy primary-care settings.

OBJECTIVE

Describe physician-patient CRCS discussions during a wellness visit.

DESIGN

Cross-sectional; patients audio-recorded with physicians.

PARTICIPANTS

A subset of patients (N = 64) participating in a behavioral intervention trial designed to increase CRCS who completed a wellness visit during the trial with a participating physician (N = 8).

APPROACH

Transcripts were analyzed using qualitative methods.

RESULTS

Physicians in this sample consistently recommended CRCS, but focused on colonoscopy. Physicians did not offer a fecal occult blood test alone as a screening choice, which may have created missed opportunities for some patients to get screened. In this single visit, physicians’ communication processes generally precluded discussion of patients’ test preferences and did not facilitate shared decision-making. Patients’ questions indicated their interest in different CRCS test types and appeared to elicit more information from physicians. Some patients remained resistant to CRCS after discussing it with a physician.

CONCLUSION

If a preference for colonoscopy is widespread among primary-care physicians, the implications for intervention are either to prepare patients for this preference or to train physicians to offer options when recommending screening to patients.

KEY WORDS

colorectal cancer screening physician-patient communication shared decision-making qualitative research interventions 

References

  1. 1.
    Smith RA, Cokkinides V, Brawley OW. Cancer screening in the United States 2009: a review of current American Cancer Society guidelines and issues in cancer screening. CA Cancer J Clin. 2009;59:27–41.CrossRefPubMedGoogle Scholar
  2. 2.
    Meissner HI, Breen NL, Klabunde CN, Vernon SW. Patterns of colorectal cancer screening uptake among men and women in the US. Cancer Epidemiol Biomarkers Prev. 2006;15(2):389–94.CrossRefPubMedGoogle Scholar
  3. 3.
    Shapiro JA, Seeff LC, Thompson TD, Nadel MR, Klabunde CN, Vernon SW. Colorectal cancer test use from 2005 National Health Interview Study. Cancer Epidemiology Biomarkers and Prevention. 2008;17(7):1623–30.CrossRefGoogle Scholar
  4. 4.
    Levin B, Lieberman DA, McFarland B, Smith RA, Brooks D, Andrews KS, et al. Screening and surveillance for the early detection of colorectal cancer and adenomatous polyps, 2008: a joint guideline from the American Cancer Society, the US Multi-Society Task Force on Colorectal Cancer, and the American College of Radiology. CA Cancer J Clin. 2008 March 5, 2008.Google Scholar
  5. 5.
    U. S. Preventive Services Task Force. Screening for colorectal cancer: US Preventive Task Force recommendation. Ann Intern Med. 2008;149(9):627–37.Google Scholar
  6. 6.
    Klabunde CN, Frame PS, Meadow A, Jones E, Nadel MR, Vernon SW. A national survey of primary care physicians’ colorectal cancer screening recommendations and practices. Prev Med. 2003;36:352–62.CrossRefPubMedGoogle Scholar
  7. 7.
    Klabunde CN, Lanier D, Nadel MR, McLeod C, Yuan G, Vernon SW. U.S. primary care physicians’ colorectal cancer screening recommendations and practices, 2006–2007. Am J Prev Med. 2009;37(1):8–16.CrossRefPubMedGoogle Scholar
  8. 8.
    American Cancer Society. Cancer facts and figures, 2008. Atlanta, GA: American Cancer Society; 2008.Google Scholar
  9. 9.
    Walsh JME, Terdiman JP. Colorectal cancer screening. Clinical applications. Journal of the American Medical Association. 2003;289(10):1297–302.CrossRefPubMedGoogle Scholar
  10. 10.
    Leard LE, Savides TJ, Ganiats TG. Patient preferences for colorectal cancer screening. J Fam Pract. 1997;45(3):211–8.PubMedGoogle Scholar
  11. 11.
    Ling BS, Moskowitz MA, Wachs D, Pearson B, Schroy PC. Attitudes toward colorectal cancer screening tests. J Gen Intern Med. 2001;16:822–30.CrossRefPubMedGoogle Scholar
  12. 12.
    Hawley ST, Volk RJ, Krishnamurthy P, Jibaja-Weiss ML, Vernon SW, Kneuper S. Preferences for colorectal cancer screening among racially/ethnically diverse primary care patients. Med Care. 2008;46(9 (Suppl 1)):S5–9.Google Scholar
  13. 13.
    Pignone MP, Bucholtz D, Harris R. Patient interest and preferences for colon cancer screening. J Gen Intern Med. 1998;13(suppl 1):96.Google Scholar
  14. 14.
    Denberg TD, Coombes JM, Byers TE, Marcus AC, Feinberg LE, Steiner JF, et al. Effect of a mailed brochure on appointment-keeping for screening colonoscopy. Ann Intern Med. 2006;145(12):895–900.PubMedGoogle Scholar
  15. 15.
    Pignone MP, Harris RP, Kinsinger LS. Videotape-based decision aid for colon cancer screening: a randomized, controlled trial. Ann Intern Med. 2000;133(10):761–9.PubMedGoogle Scholar
  16. 16.
    Costanza ME, Luckmann R, Stoddard AM, White MJ, Stark JR, Avrunin JS, et al. Using tailored telephone counseling to accelerate the adoption of colorectal cancer screening. Cancer Detection & Prevention. 2007;31:191–8.CrossRefGoogle Scholar
  17. 17.
    Marcus AC, Mason M, Wolfe P, Rimer BK, Lipkus I, Strecher V, et al. The efficacy of tailored print materials in promoting colorectal cancer screening: results from a randomized trial involving callers to the National Cancer Institute’s Cancer Information Service. J Health Commun. 2005;10(Suppl 1):83–104.CrossRefPubMedGoogle Scholar
  18. 18.
    Myers RE, Sifri R, Hyslop T, Ronsenthal M, Vernon SW, Cocroft J, et al. A randomized controlled trial of the impact of targeted and tailored interventions on colorectal cancer screening. Cancer. 2007;110(9).Google Scholar
  19. 19.
    Rawl SM, Champion VL, Scott LL, Zhou H, Monahan PO, Ding Y, et al. A randomized trial of two print interventions to increase colon cancer screening among first-degree relatives. Patient Education & Counseling. 2008;71:215–27.CrossRefGoogle Scholar
  20. 20.
    Ferreira MR, Dolan NC, Fitzgibbon ML, Davis TC, Gorby N, Ladewski L, et al. Health care provider-directed intervention to increase colorectal cancer screening among veterans: results of a randomized controlled trial. J Clin Oncol. 2005;23(7):1548–54.CrossRefPubMedGoogle Scholar
  21. 21.
    Lane D, Messina C, Cavanagh M, Chen J. A provider intervention to improve colorectal cancer screening in county health centers. Med Care. 2008;46(9 (Suppl 1):S109–16.CrossRefPubMedGoogle Scholar
  22. 22.
    Ruffin MT, Gorenflo DW. Interventions fail to increase cancer screening rates in community-based primary care practices. Prev Med. 2004;39:435–40.CrossRefPubMedGoogle Scholar
  23. 23.
    Walsh JME, Salazar R, Terdiman JP, Gildengorin G, Perez-Stable EJ. Promoting use of colorectal cancer screening tests: can we change physician behavior. J Gen Intern Med. 2005;20:1097–101.CrossRefPubMedGoogle Scholar
  24. 24.
    Lafata JE, Divine G, Moon C, Williams K. Patient-physician colorectal cancer screening discussions and screening use. Am J Prev Med. 2006;31(3):202–9.CrossRefPubMedGoogle Scholar
  25. 25.
    Shokar NK, Carlson CA, Shokar GS. Physician and patient influences on the rate of colorectal cancer screening in a primary care clinic. J Cancer Educ. 2006;21:84–8.CrossRefPubMedGoogle Scholar
  26. 26.
    Canada RE, Turner BJ. Talking to patients about screening colonoscopy - where conversations fall short. The Journal of Family Practice. 2007;56(8):E1–9.PubMedGoogle Scholar
  27. 27.
    Wackerbarth SB, Tarasenko YN, Joyce JM, Haist SA. Physician colorectal cancer screening recommendations: an examination based on informed decision making. Patient Education & Counseling. 2007;66:43–50.CrossRefGoogle Scholar
  28. 28.
    Ling B, Trauth J, Fine M, Mor M, Resnick A, Braddock C, et al. Informed decision-making and colorectal cancer screening: is it occuring in primary care. Med Care. 2008;46(9 (suppl 1):S23–9.CrossRefPubMedGoogle Scholar
  29. 29.
    Wolf MS, Baker DW, Makoul G. Physician-patient communication about colorectal cancer screening. J Gen Intern Med. 2007;22(11):493–9.CrossRefGoogle Scholar
  30. 30.
    American Cancer Society. Cancer facts and figures, 2007. Atlanta, GA: American Cancer Society; 2007.Google Scholar
  31. 31.
    MacQueen KM, McLellan E, Kay K, Milstein B. Codebook development for team-based qualitative analysis. Cultural Anthropology Methods. 1998;10(2):31–6.Google Scholar
  32. 32.
    ATLAS.ti. Germany: Scientific Software Development; 2004.Google Scholar
  33. 33.
    Boyatzis RE. Transforming qualitative information: thematic analysis and code development. Thousand Oaks, CA: Sage Publications; 1998.Google Scholar
  34. 34.
    Fereday J, Muir-Cochrane E. Demonstrating rigor using thematic analysis: a hybrid approach of inductive and deductive coding and theme development. International Journal of Qualitative Methods. 2006;5(1):80–92.Google Scholar
  35. 35.
    Charmaz K. Grounded theory. In: Smith JA, Harre R, Van Langahove L, eds. Rethinking methods in psychology. London: Sage; 1995:27–49.Google Scholar
  36. 36.
    Henwood KL, Pidgeon NF. Qualitative research and psychological theorizing. Br J Psychol. 1992;83:97–111.PubMedGoogle Scholar
  37. 37.
    Esterberg KG. Qualitative research methods in social research. Boston: McGraw-Hill; 2002.Google Scholar
  38. 38.
    Collins JF, Lieberman DA, Durbin TE, Weiss DG. The Veterans Affairs Cooperative Study Group. Accuracy of screening for fecal occult blood on a single stool sample obtained by digital rectal examination: a comparison with recommended sampling practice. Ann Intern Med. 2005;142(2):81–6.PubMedGoogle Scholar
  39. 39.
    Sox HC Jr. Office-based testing for fecal occult blood: do only in case of emergency. Ann Intern Med. 2005;142(2):146–8.PubMedGoogle Scholar
  40. 40.
    Smith RA, Cokkinides V, Eyre HJ. Cancer Screening in the United States, 2007: a review of current guidelines, practices, and prospects. CA Cancer J Clin. 2007;57(2):90–104.CrossRefPubMedGoogle Scholar
  41. 41.
    U. S. Preventive Services Task Force. Screening for colorectal cancer: recommendations and rationale. Ann Intern Med. 2002;137:129–31.Google Scholar
  42. 42.
    Berg AO. The aftermath of efficacy. Ann Fam Med. 2009;7(1):3–4.CrossRefPubMedGoogle Scholar
  43. 43.
    Guerra CE, Schwartz JS, Armstrong K, Brown JS, Halbert CH, Shea JA. Barriers of and facilitators to physician recommendation of colorectal cancer screening. J Gen Intern Med. 2007;22(12):1681–8.CrossRefPubMedGoogle Scholar
  44. 44.
    Griffith KM, Lewis CL, Brenner ART, Pignone MP. The effect of offering different numbers of colorectal cancer screening test options in a decision aid: a pilot randomized trial. BMC Med Inform Decis Mak. 2008;8(4).Google Scholar
  45. 45.
    Lance P. Colorectal cancer screening: confusion reigns. Cancer Epidemiology Biomarkers and Prevention. 2008;17(9):2205–7.CrossRefGoogle Scholar
  46. 46.
    Achkar E. Colorectal cancer screening in primary care: the long and short of it. Am J Gastroenterol. 2004;99(5):837–8.CrossRefPubMedGoogle Scholar
  47. 47.
    Fenton JJ, Franks P, Reid RJ, Elmore JG, Baldwin LM. Continuity of care and cancer screening among health plan enrollees. Med Care. 2008;46(1):58–62.CrossRefPubMedGoogle Scholar
  48. 48.
    Zhu J, Davies J, Taira DA, Yamashita M. The impact of seeing physicians new to a patient on the response to screening reminders. Med Care. 2006;44(10):908–13.CrossRefPubMedGoogle Scholar
  49. 49.
    McQueen A, Vernon SW, Myers RE, Watts BG, Lee ES, Tilley BC. Correlates and predictors of colorectal cancer screening among male automotive workers. Cancer Epidemiol Biomarkers and Prevention. 2007;16(3):500–9.CrossRefGoogle Scholar
  50. 50.
    Hesse BW, Nelson DE, Kreps GL, Croyle RT, Arora NK, Rimer BK, et al. Trust and sources of health information: the impact of the Internet and its implications for health care providers: findings from the first Health Information National Trends Survey. Arch Intern Med. 2005;165(22):2618–24.CrossRefPubMedGoogle Scholar
  51. 51.
    Chapman S, Wong WL, Smith W. Self-exempting beliefs about smoking and health: differences between smokers and ex-smokers. Am J Public Health. 1993;83(2):215–9.CrossRefPubMedGoogle Scholar
  52. 52.
    Oakes W, Chapman S, Borland R, Balmford J, Trotter L. “Bulletproof skeptics in life’s jungle”: which self-exempting beliefs about smoking most predict lack of progression towards quitting? Prev Med. 2004;39:776–82.CrossRefPubMedGoogle Scholar
  53. 53.
    Briss PA, Rimer B, Reilley B, Coates RC, Lee NC, Dolan-Mullen PD, et al. Promoting informed decisions about cancer screening in communities and healthcare systems. Am J Prev Med. 2004;26(1):67–80.CrossRefPubMedGoogle Scholar
  54. 54.
    Wolf RL, Basch CE, Brouse CH, Shmukler C, Shea S. Patient preferences and adherence to colorectal cancer screening in an urban population. Am J Public Health. 2006;96(5):809–11.CrossRefPubMedGoogle Scholar
  55. 55.
    Winawer S, Fletcher RH, Rex DK, Bond J, Burt RW, Ferrucci JT, et al. Colorectal cancer screening and surveillance: clinical guidelines and rationale-update based on new evidence. Gastroenterology. 2003;124(2):544–60.CrossRefPubMedGoogle Scholar
  56. 56.
    Zauber AG, Lansdorp-Vogelaar I, Knudsen AB, Wilschut J, Van Ballegooijen M, Kuntz KM. Evaluating test strategies for colorectal cancer screening: a decision analysis for the U.S. Preventive Services Task Force. Ann Intern Med. 2008;149(9):659–69.PubMedGoogle Scholar
  57. 57.
    Holt CL, Schroy PCr. A new paradigm for increasing use of open-access screening colonoscopy. Clin Gastroenterol Hepatol. 2008;6(4):377–8.CrossRefPubMedGoogle Scholar
  58. 58.
    Denberg TD, Myers BA, Lin C, Levine J. Screening colonoscopy through telephone outreach without antecedent provider visits: a pilot study. Prev Med. 2009;48:91–3.CrossRefPubMedGoogle Scholar
  59. 59.
    Haskard KB, DiMatteo MR, Heritage J. Affective and instrumental communication in primary care interactions: predicting the satisfaction of nursing staff and patients. Health Communication. 2009;24(1):21–32.CrossRefPubMedGoogle Scholar
  60. 60.
    Themessl-Huber M, Humphris G, Dowell J, Macgillivray S, Rushmer R, Williams B. Audio-visual recording of patient-GP consultations for research purposes: a literature review on recruiting rates and strategies. Patient Educ Couns. 2008;71:157–68.CrossRefPubMedGoogle Scholar
  61. 61.
    Patton MQ. Qualitative evaluation and research methods. 2nd ed. Newbury Park, CA: Sage Publications; 1990.Google Scholar

Copyright information

© Society of General Internal Medicine 2009

Authors and Affiliations

  • Amy McQueen
    • 1
  • L. Kay Bartholomew
    • 2
  • Anthony J. Greisinger
    • 3
  • Gilda G. Medina
    • 2
  • Sarah T. Hawley
    • 4
  • Paul Haidet
    • 5
  • Judith L. Bettencourt
    • 2
  • Navkiran K. Shokar
    • 6
  • Bruce S. Ling
    • 7
  • Sally W. Vernon
    • 2
  1. 1.Division of Health Behavior ResearchWashington University, School of MedicineSt LouisUSA
  2. 2.School of Public HealthUniversity of Texas-HoustonHoustonUSA
  3. 3.Kelsey Research FoundationHoustonUSA
  4. 4.School of MedicineUniversity of MichiganAnn ArborUSA
  5. 5.The Houston Center for Quality of Care and Utilization Studies at the DeBakey VA Medical Center and Baylor College of MedicineHoustonUSA
  6. 6.University of Texas Medical BranchGalvestonUSA
  7. 7.School of MedicineUniversity of PittsburghPittsburghUSA

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