Colorectal cancer screening: practices and opinions of primary care physicians
Introduction
Four randomized clinical trials (RCTs) [1], [2], [3], [4], [5], [6], [7] and one meta-analysis [8] provide evidence that screening with fecal occult blood testing (FOBT) can reduce colorectal cancer (CRC) mortality, with relative risk reductions ranging from 15% to 33%. Evidence supporting the use of other screening modalities including flexible sigmoidoscopy, colonoscopy, and air-contrast barium enema (ACBE) comes from observational studies rather than RCTs. Several published models [9], [10], [11], [12], [13] and a recent review [14] of United States (US) cost-effectiveness studies concluded that all commonly recommended screening strategies for adults aged 50 and above will reduce CRC mortality at a cost of US$10,000–25,000 per life-year saved. However, it was not clear from the analysis whether one particular strategy was superior.
Several professional societies, organizations, and cancer agencies recommend screening average-risk adults for colorectal cancer [15], [16], [17], [18], [19], [20]. The Canadian Task Force on Preventive Health Care (CTFPHC) concluded, in 2001, that there is good evidence to include annual or biennial FOB testing and fair evidence to include flexible sigmoidoscopy in the periodic health examination of asymptomatic people more than 50 years of age [15]. This recommendation was based on a systematic review of the evidence [21] and graded based on the quality of published medical evidence [22]. The recommendation was widely disseminated to Canadian primary care physicians [15], [23].
Guidelines in the US take a different approach by recommending a variety of screening options and suggesting that the physician, together with the patient, determines the appropriate test strategy [16], [20]. The rationale for offering multiple screening options reflects both the lack of evidence suggesting a single test is of unequivocal superiority and the belief that allowing patients to make an informed choice that incorporates their personal preferences will increase the likelihood of screening [24].
Screening rates for CRC have changed very little [25] since the introduction of guidelines, and screening rates for CRC lag behind other, more established cancer screening tests [26], [27], [28]. Indeed, a recent US National Cancer Institute workshop identified research to address barriers to the implementation of routine CRC screening as one of the primary challenges facing cancer researchers [29].
Primary care physicians must play a key role in screening for colorectal cancer. Physician recommendation is a strong predictor of acceptance of colorectal [30], [31] and other cancer screening tests [32], [33], [34]. However, little is known about primary care physicians' attitudes towards CRC screening. The purpose of this study was to determine primary care physicians' current screening practices, familiarity with the newly released guideline, and opinions about, and key perceived barriers to CRC screening of average-risk patients.
Section snippets
Methods
We conducted a mailed survey from June to December 2002, of 2010 Alberta primary care physicians (family physicians and general practitioners) selected randomly from the registry of the College of Physicians and Surgeons of Alberta. Each physician was sent a questionnaire on demographic and practice characteristics, CRC screening practices, and knowledge and opinions about CRC screening. Definitions of average risk and screening FOB tests were provided.
The Clinical Practice Guideline (CPG)
Results
The response rate was 58.0% (965/1664) after excluding those who were unreachable (n = 38, 1.9%), retired or deceased (n = 64, 3.2%), or for whom the topic was not relevant (n = 244, 12.1%). Of the returned and completed surveys, 861 (51.7%) were the full survey and 104 (6.2%) were the abbreviated survey. The characteristics of the final sample are shown in Table 1. Comparison of respondents and nonrespondents showed that respondents were representative of Alberta primary care physicians in
Discussion
We found that relatively few primary care physicians offered CRC screening to the majority of their average-risk patients despite considering screening to be beneficial. In general, the physicians' screening practices were consistent with prevailing guidelines [15], [16], [17], [18], [19], [20] in terms of the types and timing of testing. The most commonly recommended testing intervals were consistent with CPGs except for colonoscopy where the majority of physicians (56.2%) recommended a 5-year
Acknowledgements
This research was funded by grant R-493 from the Alberta Cancer Foundation. S. Elizabeth McGregor and Robert J. Hilsden were supported by Population Health Investigator awards from the Alberta Heritage Foundation for Medical Research.
References (57)
- et al.
Randomised controlled trial of faecal-occult-blood screening for colorectal cancer
Lancet
(1996) - et al.
Randomised study of screening for colorectal cancer with faecal-occult-blood test
Lancet
(1996) Cost-effectiveness model for colon cancer screening
Gastroenterology
(1995)- et al.
Screening for colorectal cancer in a high-risk population. Results of a mathematical model
Gastroenterology
(1987) - et al.
Colorectal cancer screening: clinical guidelines and rationale
Gastroenterology
(1997) - et al.
Colorectal cancer screening and surveillance: clinical guidelines and rationale: update based on new evidence
Gastroenterology
(2003) - et al.
Are people being screened for colorectal cancer as recommended? Results from the National Health Interview Survey
Prev. Med.
(2002) - et al.
Colorectal cancer screening participation by older women
Am. J. Prev. Med.
(2000) - et al.
Utilization of colorectal cancer screening tests: a 1997 survey of Massachusetts internists
Prev. Med.
(2001) - et al.
Primary care physicians' awareness and implementation of screening guidelines for colorectal cancer
Prev. Med.
(2002)
Physician response to surveys. A review of the literature
Am. J. Prev. Med.
Average-risk screening: is public policy compatible with individual needs?
Surg. Oncol. Clin. N. Am.
Reducing mortality from colorectal cancer by screening for fecal occult blood. Minnesota Colon Cancer Control Study
N. Engl. J. Med.
Follow-up after screening for colorectal neoplasms with fecal occult blood testing in a controlled trial
Dis. Colon Rectum
Colorectal cancer mortality: effectiveness of biennial screening for fecal occult blood
J. Natl. Cancer Inst.
A randomised study of screening for colorectal cancer using faecal occult blood testing: results after 13 years and seven biennial screening rounds
Gut
Effect of faecal occult blood screening on mortality from colorectal cancer: results from a randomised controlled trial
Gut
A systematic review of the effects of screening for colorectal cancer using the faecal occult blood test, hemoccult
BMJ
Cost-effectiveness of colorectal cancer screening in average-risk adults
Screening for colorectal cancer
Ann. Intern. Med.
Cost effectiveness of colorectal cancer screening in the elderly
Ann. Intern. Med.
Cost-effectiveness analyses of colorectal cancer screening: a systematic review for the U.S. Preventive Services Task Force
Ann. Intern. Med.
Colorectal cancer screening. Recommendation statement from the Canadian Task Force on Preventive Health Care
CMAJ
U.S. Preventive Services Task Force. Screening for colorectal cancer: recommendation and rationale
Ann. Intern. Med.
Screening for colorectal cancer. American College of Radiology. ACR appropriateness criteria
Radiology
Colorectal cancer screening: final report of the Ontario Expert Panel
Screening strategies for colorectal cancer: a systematic review of the evidence
Can. J. Gastroenterol.
New grades for recommendations from the Canadian Task Force on Preventive Health Care
CMAJ
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