Patient-doctor discussions about choices in colon cancer screening may encourage more people to follow through. (Vic Lawrence: Flickr)

Although about 50,000 people in the U.S. died from colorectal cancer (CRC) last year, as many as half of those deaths could have been prevented by routine screening. That’s 25,000 lives that could have been saved using tools that are already widely available.

The problem is getting people to undergo screening can be a bit of a challenge. The “ick” factor of colonoscopies, concerns about paying for them, and other barriers get in the way of adequate screenings. Alternatives do exist, such as the fecal occult blood test (FOBT) – a non-invasive test people can do at home and send into the lab. As reported here in the past, new tools are also being developed that use more advanced science to check for markers of cancer, though these are still gaining traction.

But now doctors are looking at the psychology of how they talk to patients to figure out what might get the most people to get on board with screening.

In a study published today in the Archives of Internal Medicine, researchers from three medical schools, including UCSF, focused on just colonoscopies and FOBT. The study was done in San Francisco through the Community Health Network, and randomized doctors into three study groups: one to recommend only FOBT, one to recommend only colonoscopy, and one to offer patients a choice between the two.

Researchers presumed that recommending just one or the other would send a clear signal and be more effective than giving patients a choice.

They were wrong.

What they found instead was that patients who were recommended to get a colonoscopy only followed through 38 percent of the time. Compare that to patients who got a recommendation for FOBT and got screened 67 percent of the time, or those given a choice between the two — who underwent screening 69 percent of the time.

As the researchers say, “Giving choices through shared decision making can improve adherence by increasing patient engagement and allowing for individual patient preferences.”

The finding was surprising because previous studies had suggested that talking to patients about the wide range of available options often led them to do nothing at all. As the study authors put it, “[E]vidence also illustrates that providing options of similar value and characteristics can sometimes have a negative impact on adherence due to people defaulting to inertia, presumably because of confusion or indecision between choices.”

Dr. Theodore Levin, who heads up Colon Cancer Screening for Kaiser Permanente in Northern California, wrote a commentary in response to the publication. In his words:

 “If having too many choices leads to confusion, the study by Inadomi et al. demonstrates that not having enough choice may lead to inaction when the only choice is colonoscopy … When it comes to CRC screening, providing an option other than colonoscopy for our patients is not overwhelming, but necessary.”

“What should physicians recommend when talking with patients about CRC? The psychology literature has noted that too much choice is a problem in current society. Patients may be overwhelmed by the options and feel that no option is perfect and therefore choose to do nothing out of confusion. However, every option for CRC screening has its own unique strengths and limitations. A patient-centered approach would take each patient’s perspective into account when designing a screening strategy.”

The study further looked at differences among groups of people to find barriers to screening. The authors wrote:

“Prior studies reported low CRC screening rates among racial/ethnic minorities, especially among Asians, Latinos, and African Americans. While the present study confirms the disparity among African Americans, we observed higher adherence among Asians and Latinos than for whites. Our population had established access to health care, which may have reduced these racial differences.”

The study authors also found that people who did their patient-doctor visits in Spanish, Cantonese, or Mandarin were more likely to get screened than people of the same race/ethnicity who chose to do their visits in English.

And, not surprisingly, patients with insurance (public or private) completed screening more often than those without insurance.

If the sight of a colonoscope like this one makes you shudder, there are other options for colorectal cancer screening.

Colorectal cancer is one of the five most common cancers in both men and women, and it kills more than 43,000 Americans each year. As we learned today, colonoscopy is a successful screening method–it cuts the death rate of colorectal cancer in half.

Still, getting a colonoscopy has a problem: the yuck factor. That’s why a study in today’s New England Journal of Medicine caught my eye. Researchers in Spain looked at colonoscopy versus “FIT,” a non-invasive test to screen for colorectal cancer. FIT–fecal immunochemical testing–looks for the presence of blood in the stool, a marker for benign polyps or cancer. Patients have either one colonoscopy during the ten years of the study or FIT every other year. (Note that the American Cancer Society has a great explainer of the different screening methods available and pros and cons of each).

In the meantime, some interesting factoids that hint at the yuck factor popped up in the breakdown of which patients participated in which screening. Fully 94 percent of patients who responded to an invitation to participate in the FIT trial completed the test. But in the colonoscopy group, the rate dropped to 67 percent. In addition, more than 20 percent of the people who were assigned to colonoscopy opted for FIT instead. Apparently, they weren’t so interested in having a colonoscopy. But they WERE interested in being screened.

For a little perspective on the study, I called Dr. Theodore Levin, who heads up Colon Cancer Screening for Kaiser Permanente in Northern California. “What’s clearly shown here,” he told me, “is that in order to get a large proportion of a population screened, you have to offer an alternative to colonoscopy.”

For the last several years, Kaiser Permanente has been making aggressive strides to screen its own patient population. Individual doctors may still continue to recommend colonoscopy to patients ages 50 to 75 — the recommended ages for colorectal cancer screening. But Levin says that Kaiser wanted something they could mail out — something that people could do at home, then mail back to the lab. Kaiser put in place an automated system of phone calls and reminder postcards to encourage people to complete the FIT test and send it in. Unlike the study in Spain, Kaiser recommends patients get a FIT test every year, instead of every other year.

The effort has been working. Levin says Kaiser has seen their colorectal cancer screening rates “march up.” In 2011, 80 percent of its members ages 50 to 75 had been screened, he says. About twice as many people had FIT as colonoscopy. And the screening appears to be leading to earlier diagnosis. “We’re diagnosing much earlier stage cancers and fewer of them,” Levin says. “Two hundred fewer colon cancer in 2010 than in 2009 across Northern California Kaiser, even with membership growth.”

Levin cautions that he is waiting for one more year of data to be sure Kaiser is on the right track. As for cost, Levin also believes the screening will save money. “Cost of treating advanced colon cancer keeps getting more expensive, so we think any way you can get people screened is a cost saving endeavor through the whole cycle of screening through treatment.”

Choice in screening also speaks to the importance of patient decision-making. “We’re definitely making a difference,” Levin says, “and we’ll be most effective in giving patients what they want, instead of telling them what they need.”

(Jason DeRusha: Flickr)

Right about now, you might be thinking you’ve heard enough of cancer screening. From mammography to prostate cancer, cancer screening tests have been much debated this fall. Should a 40 year old woman get a mammogram or not? Should men abandon the PSA test? Yet another study released this week looks at a surprisingly unexplored group–older Americans.

Researchers wanted to look at this group because of an “ambiguity of recommendations” for them. While it seems like there’s some ambiguity for the rest of us, the ambiguity here is particularly surprising since age is perhaps the most significant risk factor for many cancers.

The study, “Prevalence of Cancer Screening in Older, Racially Diverse Adults,” appears in the Archives of Internal Medicine and found that, among adults aged 75 to 79, the screening rates for colorectal, breast, cervical and prostate cancer were between 56 and 62 percent. Screening rates are lower for older adults who are not white.

But are these rates good or bad? Too high or too low? The major organizations that issue guidelines on screening are divided on age cutoffs, as are many doctors. Dr. Louise Walter of UC San Francisco’s Division of Geriatrics, captures that divide in a commentary that accompanies the published study:

“Some had advocated for high breast and colorectal cancer screening rates in healthy older adults because the incidence and mortality of these cancers increase with age. … Others have advocated for low cancer screening rates in persons older than 75 years because the benefit of continuing screening is uncertain and screening can cause substantial harm, especially in frail, older adults.”

In an interview, Walter spoke of experiences from her own practice. “I have 80-year-olds hiking in mountains … and likely to live a long time, and I have people who have serious medical issues, dementia and life limiting disease.” The types of preventive care she would recommend for these two patients, she says, is very different and not based on age, but on their overall health status.

The study also found that nearly one in ten patients with terminal cancer still received screening tests for breast, cervical or prostate cancer. Walter described cases of older women who have had a hysterectomy, including removal of the cervix, yet still receive Pap smears to test for cervical cancer.

“The thing I try to emphasis is let’s do thoughtful cancer screening. Let’s avoid cancer screening in someone without a cervix, someone who is in a nursing home, very frail.” While people often think of screening tests as fairly benign, a positive result can lead to more and more invasive procedures to confirm a diagnosis, invasive procedures that can be very difficult for frail patients to withstand.

This study underscores the need for doctors to talk with older patients about their overall prognosis. Walter pointed out that screening tests can become a “distraction” from someone’s overall health concerns. “If you had a recent heart attack, that’s your major problem. Any major problem should make you rethink, ‘Why am I looking for an asymptomatic problem that I probably don’t have?’”