Posted by Kate Murphy on September 7th, 2007
Screening all men and women over the age of 50 for polyps would prevent a majority of colon and rectal cancers. In addition, finding colorectal cancer early significantly reduces the risk of dying from the disease. Despite the recommendations, less than half of Americans are up-to-date with colorectal cancer screening.
Researchers at the University of Iowa examined patient charts for fifteen randomly chosen family practice doctors in rural Iowa, identifying patients who were screened and those who were not. For each doctor in the study they selected 6 patients at random, 3 who had been screened and 3 who had not.
Focusing on those specific patients, they asked the doctors why the individual had been screened or why not. Reasons for about half of those who were not screened were due to no discussion by the physician, another forty percent due to the patient refusing the doctor’s recommendation.
Reason that the doctor didn’t offer patients colorectal screening included:
- lack of opportunity — limited time, patients who only came to the doctor for acute illness
- doctor’s assessment that cost would be prohibitive
- distraction by patient’s acute health problems or life issues
- physician forgetfulness — lack of reminder systems
- expectation that patient would refuse
Reasons that patients refused included:
- cost
- lack of interest
- distraction by health problems or other life issues
- fear of screening exam
- lack of symptoms
Among the patients who were up-to-date with screening, half were tested because they had symptoms of colon or rectal cancer, and were not really screened.
The words doctors used made a difference in whether the patient accepted the screening recommendation or not. Language ranged from discouraging to neutral personal to strongly championing screening.
Discouraging: “On the other hand, you probably don’t have colon cancer and, therefore, there’s a real good chance that doing this screening test won’t benefit you in any way other than giving you the peace of mind that you don’t have something that you weren’t even suspicious of.”
Championing: “‘The lifetime incidence of colon cancer approaches 8% in this country. If you were to cross the street and get run over 1 out of 10 times, which is essentially the same [risk], you would consider that a significant risk, so I think we ought to take a look [and do a colonoscopy].’ And sometimes I tell them that my father and my grandmother had colon cancer and that I’m an evangelist on the subject.”
The researchers wrote,
We found evidence that the words physicians use to present their recommendation for screening potentially impacts whether patients follow through with testing, based on higher physician-specific screening rates among physicians whose narratives demonstrated they were more adamant about screening and lower rates when physicians used terms like “they recommend” or “organization X recommends.”
Reasons for patients without symptoms who were up-to-date on their screening included:
- Doctor recommendation
- Patient’s own awareness of screening and interest in it
- Patients with other cancers
- Family history of colorectal cancer
- Multiple factors including doctor recommendation, family history, personal patient awareness.
Barcey T. Levy, PhD, MD, and colleagues concluded,
Reasons many patients remain unscreened for CRC include (1) factors related to the health care system, patient, and physician that impede or prevent discussion; (2) patient refusal; and (3) the focus on diagnostic testing. Strategies to improve screening might include patient and physician education about the rationale for screening, universal coverage for health maintenance exams, and development of effective tracking and reminder systems. The words physicians choose to frame their recommendations are important and should be explored further.
SOURCE: Levy et al, The Journal of the American Board of Family Medicine, Volume 20, Number 5, pages 458-468, September- October 2007
