Monday, December 20, 2010

Why screening for colorectal cancer shouldn't be a hard sell

Breast and prostate cancer screening tests may dominate headlines, but in terms of the quality of the scientific evidence that early detection saves lives, there are no better cancer screening tests than those for colorectal cancer, or cancer of the large intestine. One in 20 adults will develop colorectal cancer during his or her lifetime, and detecting it before symptoms occur substantially improves a patient’s chances of survival. Nevertheless, 57,000 people in the United States still die from colorectal cancer every year; in fact, more men under age 75 will lose their lives this year to colorectal cancer than to prostate cancer.

Given these facts, I am often perplexed at why colorectal cancer screening is such a hard sell to my patients in practice. Women and men over 50 who diligently come back for annual mammograms and PSA tests politely decline when I bring up three effective and widely available colorectal cancer tests: yearly fecal occult blood testing (checking for microscopic evidence of blood in stool samples); flexible sigmoidoscopy (visualizing the lower third of the large intestine) every five years; or colonoscopy (visualizing the entire large intestine, a procedure typically performed under anesthesia) every 10 years. Nationally, other family doctors encounter similar resistance. The Centers for Disease Control and Prevention estimates that about two in five adults older than 50 is overdue for a colorectal cancer screening. As a result, patients may suffer and die needlessly from advanced cancers that, having spread to other organs, offer little hope of survival.

Why the resistance? One problem may be that patients are confused by having to choose between more than one colorectal screening test, each of which has pros and cons that are difficult to explain in a five-minute conversation. Another issue is that many patients who have had rectal examinations in doctor's offices as part of physical exams are misled into thinking that's all they need. (According to a recent national survey whose results were published in the Journal of General Internal Medicine, nearly a quarter of primary care clinicians are unaware that testing a single stool sample obtained during a rectal exam misses 95 percent of colorectal cancers and precancerous polyps.) And there's no denying that at least some of the resistance to testing stems from the "ick" factor and fears about pain, which apparently weren't completely overcome by the example of former Today show host Katie Couric, who got a colonoscopy on national television after her husband died of colorectal cancer.

The problem of low adherence to colorectal cancer screening recommendations was concerning enough that the National Institutes of Health organized a state-of-the-science conference in February to recommend ways to ramp up the use of these tests. An expert panel reviewed the available evidence and concluded that effective strategies to increase screening rates include improving patients' access to the tests, one-on-one counseling sessions with physicians or health educators, and sending reminders to patients who are due for screenings.

Two studies recently published online in the Archives of Internal Medicine provide additional proof that reminders and targeted messages can prod reluctant patients into complying. The first study, led by researchers at Harvard Medical School and Washington University School of Medicine in St. Louis, tested the effectiveness of sending an electronic reminder message via a Web-based personal health record to patients who were overdue for a colorectal cancer screening. Those who received the reminder were provided with a link to an online tool that allowed them to calculate their personal colorectal cancer risk. After one month, patients who received the message were statistically more likely to have gotten screened than patients who did not; however, by 4 months there was no difference between the two groups.

The second study was done by researchers at Northwestern University's Feinberg School of Medicine. Patients who'd been advised to get a colonoscopy but hadn't followed up within three months of the order being placed in their electronic health record were randomly assigned to either receive a personal reminder letter from their physician and an educational brochure and DVD, or usual care. Patients who received the letter were statistically more likely than patients who did not to undergo screening three and six months later, though the effect was small; even after six months, more than four out of five patients in both groups hadn't gotten a screening test.

As I mentioned in a previous blog post, electronic health records will only improve outcomes for patients if doctors use them to make patients aware when their healthcare isn't meeting proven guidelines. Even though the interventions in these two studies produced less-than-dramatic improvements in screening rates, they illustrate the importance of doctors having systems in place to identify who is or isn't up-to-date on screening. If your doctor doesn't have an easy and/or automated way to figure out if you need a test, you probably won't know, either. So the next time you visit your family doctor, consider asking him or her what tools the practice uses to communicate with patients outside of office visits about preventive health needs. Receiving these important messages could mean the difference between getting—or skipping—a test that could save your life.


The above post was first published on my Healthcare Headaches blog at