Colorectal cancer screening: physicians' knowledge of risk assessment and guidelines, practice, and description of barriers and facilitators

Knowledge, Attitude, Practice, and Perceived Barriers Regarding Colorectal Cancer Screening Practices Among Healthcare Practitioners: A Systematic Review

The recommendations of medical professionals play a significant role in colorectal cancer (CRC) screening. This study aims to systematically review knowledge, attitude, practice, and perceived barriers regarding CRC screening practices among healthcare practitioners (HCPs). From January 2023 to December 2023, a comprehensive literature search was conducted using online databases, including Web of Science, PubMed, Scopus, and Research Gate, by using the following keywords in combination: "knowledge," "attitude," "practice," "perceived barriers," "colorectal cancer," and "health practitioners." The researchers screened and examined the retrieved literature. A total of 21 studies were considered relevant for the current review. Among these studies, eight assessed the level of knowledge, attitude, practices, and perceived barriers toward CRC screening among various health practitioners. Three studies assessed knowledge and attitudes toward CRC screening among health practitioners. The remaining ten studies assessed awareness, perceived barriers, or only knowledge of CRC screening among HCPs. In addition, all the included studies employed a cross-sectional design. The review shows that many healthcare providers need more fundamental knowledge of CRC screening. Healthcare procedures must be improved to enhance the knowledge, attitudes, and practices of healthcare professionals regarding CRC screening and their understanding of the associated barriers.

Colorectal Cancer Screening Knowledge and Practices Among Practicing Obstetrician-Gynecologists and Residents

BACKGROUND

Colorectal cancer (CRC) is the second leading cause of cancer death in the US, the third most diagnosed cancer in women, and the second leading cause of cancer death in women. The aims of our study are to (1) investigate knowledge of and adherence to CRC screening guidelines by obstetrician-gynecologists (Ob/Gyns) and (2) assess whether this knowledge/adherence vary by demographic and practice characteristics.

METHODS

An anonymous cross-sectional survey was distributed to a convenience sample of 142 practicing Obs/Gyns drawn from National Medical Association section members/conference attendees and hospital Ob/Gyn department members.

RESULTS

Most respondents (80.3%) viewed colorectal screening within the scope of Ob/Gyn practice, and 71.8% used the American College of Obstetricians and Gynecologists guidelines for screening. Most respondents were knowledgeable regarding CRC screening but not in all areas. On average they only identified half of the 10 risk factors listed and only one-quarter correctly identified the age when screening can stop. Residents were somewhat more knowledgeable about screening guidelines and risk factors than attendings. More than half of respondents (57.8%) reported always initiating CRC screening for the appropriate age and risk factors. Respondents identified education and awareness (56.3%) and patients' unwillingness to undergo an invasive procedure (75.4%) as barriers to screening.

CONCLUSIONS

Knowledge regarding CRC screening was less than optimal and differed by attending/resident status. Greater emphasis should be placed on CRC screening and guidelines training for primary care providers like Ob/Gyns. Some of this could be accomplished through maintenance of certification and continued integration into residency education.

Colorectal Dysplasia and Cancer Surveillance in Ulcerative Colitis

Ulcerative colitis (UC) is a risk factor for the development of inflammation-associated dysplasia or colitis-associated neoplasia (CAN). This transformation results from chronic inflammation, which induces changes in epithelial proliferation, survival, and migration via the induction of chemokines and cytokines. There are notable differences in genetic mutation profiles between CAN in UC patients and sporadic colorectal cancer in the general population. Colonoscopy is the cornerstone for surveillance and management of dysplasia in these patients. There are several modalities to augment the quality of endoscopy for the better detection of dysplastic or neoplastic lesions, including the use of high-definition white-light exam and image-enhanced colonoscopy, which are described in this review. Clinical practice guidelines regarding surveillance strategies in UC have been put forth by various GI societies, and overall, there is agreement between them except for some differences, which we highlight in this article. These guidelines recommend that endoscopically detected dysplasia, if feasible, should be resected endoscopically. Advanced newer techniques, such as endoscopic mucosal resection and endoscopic submucosal dissection, have been utilized in the treatment of CAN. Surgery has traditionally been the mainstay of treating such advanced lesions, and in cases where endoscopic resection is not feasible, a proctocolectomy, followed by ileal pouch-anal anastomosis, is generally recommended. In this review we summarize the approach to surveillance for cancer and dysplasia in UC. We also highlight management strategies if dysplasia is detected.

Trainees' knowledge and application of guideline recommendations for colorectal cancer screening and surveillance

BACKGROUND

Data shows that practicing physicians don't recommend colorectal (CRC) screening and surveillance as suggested by guidelines. We assessed knowledge of CRC guidelines in medical trainees.

METHODS

A survey assessing confidence and knowledge of published CRC guidelines was emailed to program directors (PDs) of Accreditation Council of Graduate Medical Education approved training programs in the United States. PDs were requested to forward it to trainees. We analyzed trainees' knowledge by answers to clinical vignettes and identification of factors required by guidelines for screening and post polypectomy colonoscopy interval. We compared confidence and knowledge by specialty.

RESULTS

586 trainees in internal medicine (159), family medicine and primary care (147), gastroenterology (114), general surgery (51), ob/gyn (78), urology (13), and colorectal surgery (13) responded. 97% reported following guidelines. 68% and 50% stated confidence recalling screening and surveillance guidelines, respectively. 16% and 8% correctly identified all factors and answered corresponding vignettes for screening and surveillance, respectively. Overall accuracy of screening ranged between 11-23% and was not different between specialties (p = 0.11) while significant differences were noted between specialties in surveillance knowledge (0-39%, p < 0.001).

CONCLUSIONS

United States trainees' CRC screening and surveillance knowledge is poor. Measures are needed to enhance knowledge of CRC guidelines.

The Jordanian primary healthcare practitioner in cancer control

Aim To measure the knowledge, perceptions, and practices of Jordanian primary healthcare practitioners (PHCPs) (physicians, nurses, midwives, and nurse aids) employed in Jordanian Ministry of Health (MoH) primary health clinics with respect to counseling on cancer (cancer screening, the signs and symptoms of cancer, and referral for specialized care).

BACKGROUND

Integration of oncology services within primary care is a means of enhancing cancer early detection, and requires involvement of skilled. In the Middle East, little is known about PHCPs' potential to be providers of such services.

METHODS

A questionnaire measuring PHCP perceptions and practices related to counseling on cancer screening and diagnosis was distributed to PHCPs across MoH clinics covering the main regions of Jordan. Findings A total of 322 practitioners responded (75.1% response). Across most activities involving cancer detection, no more than 30% reported performing activities. Roughly half of PHCPs expressed discomfort at providing cancer-related counseling and at least 43% of non-physicians expressed limited confidence in cancer-related counseling. Confidence was a consistent predictor of provision of counseling and confidence in turn was associated with having greater knowledge, having positive a valuation of counseling, and being a physician. Results reveal points where educational efforts can strengthen PHCPs' provision of cancer control-related services.

Knowledge, attitude, and practices of primary health care physicians toward colorectal cancer screening

BACKGROUND/AIM

Early diagnosis of chronic illnesses and cancers mainly occurs at primary health care centers (PHCs) by primary health care physicians (PHPs). The incidence of colorectal cancer (CRC) in the Kingdom of Saudi Arabia (KSA) is rising and this has been attributed to many factors. The increasing incidence of CRC is compounded by nonadherence to screening recommendations. Therefore, evaluating PHPs knowledge, attitudes, and practices of screening for CRC is clinically important. We aimed to evaluate the knowledge, attitudes, and practices of PHPs regarding CRC screening and to identify the factors associated with nonadherence of PHPs to screening recommendations.

MATERIALS AND METHODS

PHPs working at three tertiary care centers and PHCs across the city of Jeddah were randomly recruited. Participants were surveyed using a comprehensive questionnaire that recorded data on demographics, qualifications, and knowledge of various modalities and guidelines related to CRC screening. Perspectives about effectiveness of, or adherence to, factors that influence physicians' perspectives or recommendations for CRC screening were also assessed. Logistic regression analysis was used to identify physician characteristics associated with PHPs perspectives and nonadherence to CRC screening.

RESULTS

A total of 127 PHPs were recruited. The average age of participants was 34 (±8.4) years, 86.6% were native Saudi's and 56.7% were females. The majority of surveys (66.9%) were completed at 24 PHCs and the remaining at hospital-based family medicine clinics. Most of the PHPs (55%) had a bachelor's degree and 31.5% were board-certified or carried a PhD in family medicine; 95% of participants believed that CRC screening in general was effective, but as much as 55% reported that they did not practice screening. The male physicians [odds ratio (OR) = 0.44, 95% confidence interval (CI) = 0.19-0.99, P = 0.048)] and PHPs with only a bachelor degree or less (OR = 0.72, 95% CI = 0.55-0.93, P = 0.011) were less likely to recommend screening for CRC.

CONCLUSIONS

A considerable proportion of PHPs do not adhere to CRC screening recommendations despite a wide belief that screening is effective. Male PHPs with lower qualifications appear to be less likely to recommend screening.

Racial minorities are more likely than whites to report lack of provider recommendation for colon cancer screening

OBJECTIVES

Although screening for colorectal cancer (CRC) is recommended for all adults aged 50 to 75 years in the United States, there are racial and ethnic disparities in who receives screening. Individuals lacking appropriate CRC screening cite various reasons for nonadherence, including lack of provider recommendation for screening. The purpose of this study is to evaluate the association between patient race and lack of provider recommendation for CRC screening as the primary reason for screening nonadherence.

METHODS

We conducted a cross-sectional observational study of individuals aged 50 to 75 years from the 2009 California Health Interview Survey who reported nonadherence to 2008 United States Preventive Service Task Force CRC screening guidelines. The outcome was self-report that the main reason for not undergoing CRC screening was lack of a physician recommendation ("non-recommendation") for screening. We performed logistic regression to determine significant predictors of non-recommendation, with particular attention to the role of race.

RESULTS

The study cohort included 5,793 unscreened subjects. Of the subjects, 19.1% reported that lack of a provider recommendation was the main reason for CRC nonscreening. African Americans (adjusted odds ratio (adj. OR) 1.46, 95% confidence interval (CI) 1.03-2.05) and English-speaking Asians (adj. OR 1.65, 95% CI 1.24-2.20) were more likely than whites to report physician non-recommendation as the main reason for lack of screening. Asian non-English speakers, however, were less likely to report physician non-recommendation (adj. OR 0.31, 95% CI 0.11-0.91).

CONCLUSION

Racial minorities are less likely than whites to receive a physician recommendation for CRC screening. Future research should evaluate why race appears to influence provider recommendations to pursue CRC screening; this is an important step to reduce disparities in CRC screening and lessen the burden of CRC in the United States.

Colorectal cancer screening at community health centers: A survey of clinicians' attitudes, practices, and perceived barriers

Objective

Colorectal cancer (CRC) screening rates remain lower among some racial/ethnic groups and individuals with low income or educational attainment who are often cared for within community health centers (CHCs). We surveyed clinicians in a network of CHCs to understand their attitudes, practice patterns, and perceived barriers to CRC screening.

Methods

A clinician survey was conducted in 2013 within the Community Health Applied Research Network (CHARN).

Results

180 clinicians completed the survey (47.9% response rate). Participants had an average of 11.5 (SD: 9.8) years in practice, 62% were female, and 57% were physicians. The majority of respondents somewhat agreed (30.2%) or strongly agreed (57.5%) that colonoscopy was the best screening test. However, only 15.8% of respondents strongly agreed and 32.2% somewhat agreed that colonoscopy was readily available for their patients. Fecal immunochemical testing (FIT), a type of fecal occult blood test (FOBT), was viewed less favorably; 24.6% rated FIT as very effective.

Conclusions

Although there are no data showing that screening colonoscopy is superior to FIT, CHC clinicians believe colonoscopy is the best CRC screening test for their patients, despite the high prevalence of financial barriers to colonoscopy. These attitudes could be due to lack of knowledge about the evidence supporting long-term benefits of fecal occult blood testing (FOBT), lack of awareness about the improved test characteristics of FIT compared to older guaiac-based FOBT, or the absence of systems to ensure adherence to regular FOBT screening. Interventions to improve CRC screening at CHCs must address clinicians' negative attitudes towards FIT.

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We surveyed primary care clinicians in a nationwide network of Community Health Centers.

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The vast majority believed that colonoscopy was the best screening test for colorectal cancer.

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However, less than half agreed that colonoscopy was readily available for their patients.

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Fecal occult blood testing was viewed far less favorably than colonoscopy.

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These attitudes and barriers must be overcome to improve screening and reduce disparities.

Feasibility of a call-in centre to deliver colorectal cancer screening in primary care

OBJECTIVE

To evaluate the feasibility of a call-in centre to deliver colorectal cancer (CRC) screening in primary care through self-administered fecal occult blood testing (FOBT).

DESIGN

Four-month intervention study (September 2010 to January 2011) with randomly selected follow-up interviews.

SETTING

The family medicine clinics of 3 hospitals in Montreal, Que.

PARTICIPANTS

Letters from doctors invited their patients to contact the call-in centre (N = 761). Eligible patients agreeing to FOBT were sent testing kits that could be returned by mail (N = 100). Randomly selected patients (N = 36) were interviewed to explore the reasons why they did not contact the call-in centre, or why they did or did not adhere to FOBT.

MAIN OUTCOME MEASURES

Feasibility was assessed by the proportions of patients who contacted the call-in centre, who were eligible for FOBT, and who adhered to FOBT; and by the time between invitation mail-out and contact with the call-in centre, initial telephone contact and receipt of the signed consent form, and FOBT kit mail-out and receipt of the kit by the laboratory. Hierarchical logistic regression evaluated the effect of patient characteristics on feasibility indicators, adjusting for clustering by physician and centre.

RESULTS

Of 761 patients (61.6% female, mean age 61.0 years), 250 (32.9%) contacted the call-in centre, of whom 100 (40.0%) were eligible for and consented to FOBT; 62 (62.0%) of these patients adhered to FOBT. Median (interquartile range) time from invitation mail-out to call-in centre contact was 21 (7 to 29) days, from initial telephone contact to receipt of the signed consent form was 24 (10 to 38) days, and from FOBT kit mail-out to receipt at the laboratory was 23 (18 to 32) days. With the exception of previous cancer diagnosis, patient characteristics were not associated with feasibility indicators. Of the 115 (46.0%) patients determined to be ineligible for FOBT screening, 111 (96.5%) were up to date with or already scheduled for screening.

CONCLUSION

Feasibility of the call-in centre was demonstrated. Targeting screening-eligible individuals or coupling a call-in service with another evidence-based CRC screening improvement strategy might further improve uptake of fecal testing.

Colorectal cancer screening among underserved minority population: discrepancy between physicians' recommended, scheduled, and completed tests

OBJECTIVE

This study examines the correlates of: (1) health care provider recommendation of CRC testing; (2) provider scheduling for recommended CRC testing using sigmoidoscopy, colonoscopy, or double-contrast barium enema; and (3) adherence to CRC scheduling among underserved minority populations.

METHODS

Medical record and schedule logbook reviews and interviewer-administered surveys.

SETTING

Large urban safety-net, outpatient primary care setting in Los Angeles County.

PARTICIPANTS

306 African-American and Latino patients aged 50 years and older.

RESULTS

A vast majority of minority patients do not receive standard CRC testing in urban safety-net primary care settings. Of those patients who were actually scheduled for sigmoidoscopy or colonoscopy, almost half completed the procedure. Completing CRC testing was associated with marital status, co-morbid chronic physical conditions, number of risk factors for colorectal cancer, and lower perceived barriers to CRC testing.

CONCLUSION

Effective interventions to reduce CRC mortality among underserved minority populations require an integrated approach that engages patients, providers, and health care systems.

PRACTICE IMPLICATIONS

Designing interventions that (1) increase physician-patient communications for removing patients' perceived barriers for CRC testing and (2) promote a non-physician-based navigator system that reinforces physicians' recommendation are strongly recommended.

Adherence to colorectal cancer screening guidelines in Canada

BACKGROUND

To identify correlates of adherence to colorectal cancer (CRC) screening guidelines in average-risk Canadians.

METHODS

2003 Canadian Community Health Survey Cycle 2.1 respondents who were at least 50 years old, without past or present CRC and living in Ontario, Newfoundland, Saskatchewan, and British Columbia were included. Outcomes, defined according to current CRC screening guidelines, included adherence to: i) fecal occult blood test (FOBT) (in prior 2 years), ii) endoscopy (colonoscopy/sigmoidoscopy) (prior 10 years), and iii) adherence to CRC screening guidelines, defined as either (i) or (ii). Generalized estimating equations regression was employed to identify correlates of the study outcomes.

RESULTS

Of the 17,498 respondents, 70% were non-adherent CRC screening to guidelines. Specifically, 85% and 79% were non-adherent to FOBT and endoscopy, respectively. Correlates for all outcomes were: having a regular physician (OR = (i) 2.68; (ii) 1.91; (iii) 2.39), getting a flu shot (OR = (i) 1.59; (ii) 1.51; (iii) 1.55), and having a chronic condition (OR = (i) 1.32; (ii) 1.48; (iii) 1.43). Greater physical activity, higher consumption of fruits and vegetables and smoking cessation were each associated with at least 1 outcome. Self-perceived stress was modestly associated with increased odds of adherence to endoscopy and to CRC screening guidelines (OR = (ii) 1.07; (iii) 1.06, respectively).

CONCLUSION

Healthy lifestyle behaviors and factors that motivate people to seek health care were associated with adherence, implying that invitations for CRC screening should come from sources that are independent of physicians, such as the government, in order to reduce disparities in CRC screening.