Why Hasn't This Patient Been Screened for Colon Cancer? An Iowa Research Network Study

Barcey T. Levy; Terri Nordin; Suzanne Sinift; Marcy Rosenbaum; Paul A. James

doi:10.3122/jabfm.2007.05.070058

Article Figures & Data

Tables

View popup

Table 1.

Physicians’ Reasons for Specific Patients Being Up to Date With CRC Guidelines

Reasons	Illustrative Quotation
Reasons for diagnostic testing
Symptoms suggestive of possible CRC	He did have one episode of bleeding and I worked on him for about 2 years to have a colonoscopy.
Previous pathology within the colon	He actually had had rectal bleeding back in 1993, and I did a flex sig …, and I found a polyp … So actually what got him started on the trail of lower GI endoscopy was symptoms more than anything else, and he's just followed through as he was instructed with surveillance scopes.
Reasons for asymptomatic screening
Physician recommendation to be screened	She actually presented for a health maintenance examination in 2002 and [we] … actually recommended that she be screened for colon cancer. She accepted the recommendations and then chose the colonoscopy as the method of choice.
Patient awareness of and interest in screening and health maintenance	[She] did have a screening test because she understands the importance of it.
	[He] has been a long-time patient who has been interested in regular health supervision examinations and chronicity of care examinations.
Patient has/had a type of cancer other than CRC	[She] had had breast cancer times two. I advised her there was an association between breast cancer and colon cancer and I personally had two cases where this was the case, and this was the motivation for her to move forward with the colonoscopy.
Family history of CRC	During [his] well care we discussed risk factors… . He had a positive family history of colon cancer.
Multiple factors (family history, physician recommendation, patient awareness)	Basically, her mom had colon cancer, and she actually is clever enough to figure out what we mean when we talk about screening tests. I think she basically just took my advice and decided to go ahead and have a screening test.

CRC, colorectal cancer; GI, gastrointestinal.

View popup

Table 2.

Physicians’ Reasons for Specific Patients Not Being Up to Date With CRC Guidelines

Reason	Illustrative Quotation
Factors that hindered screening discussions
Lack of opportunity to discuss screening
Patients came in only for acute visits or problems	[The patient] has always been a very acute care oriented patient and probably has only come to see me on maybe 3 occasions over the past 15 years. Hence, again, his inconsistent seeking of health care has led to failure to screen for colorectal cancer.
Patients came in sporadically or saw other providers for health maintenance care	He gets his physicals at the VA hospital, so I really haven't considered myself in the position to offer him screening [since] I don't do [his] routine physicals, [which] is when I bring up this subject.
No tracking system	She generally presents for acute care, and honestly with … the intermittent few times I see her, I forgot to even bring up colorectal cancer screening. And so, I would put her down as an office system issue with no reminder tracking system.
Not enough time during appointments	I think the reason that he wasn't screened, and probably several other [patients], was just a matter of time in not getting everything done.
Physician forgetfulness	See quote above for “no tracking system”
Assessment that cost or lack of insurance would be prohibitive to patient	Anyway, the bottom line is he doesn't have any insurance and he doesn't have any money, and he's a truck driver kinda just barely scraping by.
Patient had life issues or other health problems that distracted from screening	So, basically, we're distracted and he's distracted by other [health] problems. I don't believe I've ever really pushed getting colon cancer screening.
Expected patient refusal and/or lack of interest	He has no complaints, and I would suspect that he doesn't think that it is necessary, and he's not one that reads papers or talks about health care. I don't believe I've ever really pushed getting colon cancer screening 'cause I didn't think he would probably be real keen on it.
When CRC screening was discussed, but patient declined
Cost of screening tests	[She] won't do it because she doesn't have the finances and doesn't have insurance [that] will pay for the procedure.
Lack of interest in screening	I think basically he's just your proverbial older rural Iowa retired farmer guy who kind of likes to leave things well enough alone … and so I'm not too surprised if he doesn't do everything that I tell him to do. [He] has not been screened because he has no interest in health prevention.
Patient autonomy	His father actually died of colon cancer. I discussed this with him during a visit in 3/02, and he personally refused to undergo any type of screening. He's a clinical psychologist which means that he's actually given more latitude in running his own health care under the assumption that he has more inside information about health care, which may or may not actually be very true. The plan for him is to bring up colon cancer screening again in the future when he is here for an unrelated visit or perhaps a health maintenance visit.
Patients had life issues or other health problems	Her husband had recently died. She had a depressive reaction associated with it and did not think it was necessary to do the screening.
Fear of screening test procedure	She was not screened and … is resistant to have the colonoscopy due to the fear of the procedure.
No symptoms or family history of CRC	[He] has not been screened because he has no interest in … having a colonoscopy done unless he was having some symptoms that would require it.

CRC, colorectal cancer.

View popup

Table 3.

Overall Patterns of CRC Screening Discussions

Descriptor	Illustrative Quotation
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.
Neutral recommendation/ outside influence	If the patient is 50 years old or more, I just simply suggest that the American Cancer Society and the American Society of Gastroenterologists suggest that all patients at 50 years of age or older should be screened for colorectal cancer.
Personal recommendation	We would recommend, after the age of 50 … you be screened for colon cancer.
Champion	I'd say, ‘It's imperative that a screening colonoscopy be done …’ I tell patients myself that I believe in this and when I turn 50 … I myself will have a colonoscopy.
	‘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.