Research articleThe Relative Importance of Patient-Reported Barriers to Colorectal Cancer Screening
Introduction
Colorectal cancer (CRC) is the second-leading cause of cancer deaths in the U.S.1 Early detection can reduce CRC mortality by 15%–33%,2 and screening is widely recommended for average-risk adults beginning at age 50 years.3, 4 Since the mid-1990s, the U.S. Preventive Services Task Force, American Cancer Society, and other groups have recommended four modalities for screening: fecal occult blood testing (FOBT), flexible sigmoidoscopy, colonoscopy, and barium enema. In recent years, some groups have also proposed newer screening technologies, such as stool DNA and computed tomographic colonography.3 However, as of 2006, only 60.8% of U.S. adults aged ≥50 years reported having received recent CRC screening.5
Uptake of CRC screening is limited by many factors, including barriers faced by health systems, clinicians, and patients. Patients' barriers include: failure of a physician to recommend screening, scheduling difficulties, cost, lack of access to healthcare or insurance coverage, gaps in knowledge, disinterest, fear, embarrassment, perceived pain, and a lack of current symptoms or health problems.6, 7, 8, 9, 10, 11, 12, 13, 14 Knowledge of what barriers matter most is helpful to prioritize strategies to improve screening rates. However, the relative importance patients assign to CRC screening barriers, in general or to specific recommended tests, has not been adequately studied.
Most studies do not quantify the relative importance of barriers to patients.7, 8, 9, 15, 16, 17, 18, 19, 20, 21, 22, 23 To our knowledge, no study has asked patients to review an extensive list of potential barriers to all recommended modalities and to rate the importance of each. Some studies have taken this systematic approach, but with a narrow focus, examining a limited number of barriers, focusing on a particular test (e.g., FOBT or sigmoidoscopy), or examining barriers to CRC screening generally without alluding to specific tests. Few studies have involved diverse populations17, 21, 22, 24, 25, 26 or individuals with different past experience with CRC screening tests.24, 25, 27, 28
The present study addresses this gap in the literature by systematically measuring the factors that a diverse group of primary care patients identified for not being screened for CRC and the relative importance. In a sample of patients with heterogeneous CRC screening experiences and a robust representation of minorities and older adults, the following questions were addressed: (1) What are the leading patient-reported barriers for four recommended CRC screening modalities (FOBT, flexible sigmoidoscopy, colonoscopy, and barium enema)? Specifically, what is the relative importance that patients assign to (1a) barriers that are common to all four tests and to (1b) test-specific barriers given item mean scores? (2) Do the barriers differ for patients with different screening histories (i.e., never-screened, up-to-date, overdue)?
Section snippets
Study Population
Twelve family medicine practices affiliated with the Virginia Ambulatory Care Outcomes Research Network, a practice-based research network, participated in the current study. The practices were located in rural, suburban, and urban areas of Central Virginia, the Shenandoah Valley, and Northern Virginia. The study was approved by the IRBs of Virginia Commonwealth University and Riverside Medical Center.
A sampling frame of 26,032 patients who were in the target age group for screening (50–75
Results
A total of 3357 patients (55%) completed the questionnaire (51% among residents in concentrated African-American ZIP codes and 62% among residents of less-concentrated areas). Respondents were likely to be older, to be female, and to be white, but 30% were African-American (Table 1). More than one third reported no education beyond high school, and 22% reported an annual household income under $20,000. More than 90% reported some type of health insurance coverage. About half reported having
Discussion
Consistent with other research,5, 6, 7, 11, 16, 19, 21, 24, 25, 26, 27, 28, 37, 38 the current study found that patients' most important global reasons for not undergoing CRC screening were the failure of clinicians to suggest testing and patients' lack of knowledge that testing is necessary. Similarly, lack of a physician recommendation was among the top five barriers for all modalities except colonoscopy.
Interestingly, in formative research to develop the questionnaire (the open-ended
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