Factors Associated With Clinician Recommendations for Colorectal Cancer Screening Among Average-Risk Patients: Data From a National Survey

Introduction

Colorectal cancer (CRC) screening among average-risk patients is underused in the US. Clinician recommendation is strongly associated with CRC screening completion. To inform interventions that improve CRC screening uptake among average-risk patients, we examined clinicians’ routine recommendations of 7 guideline-recommended screening methods and factors associated with these recommendations.

Methods

We conducted an online survey in November and December 2019 among a sample of primary care clinicians (PCCs) and gastroenterologists (GIs) from a panel of US clinicians. Clinicians reported whether they routinely recommend each screening method, screening method intervals, and patient age at which they stop recommending screening. We also measured the influence of various factors on screening recommendations.

Results

Nearly all 814 PCCs (99%) and all 159 GIs (100%) reported that they routinely recommend colonoscopy for average-risk patients, followed by stool-based tests (more than two-thirds of PCCs and GIs). Recommendation of other visualization-based methods was less frequent (PCCs, 26%–35%; GIs, 30%–41%). A sizable proportion of clinicians reported guideline-discordant screening intervals and age to stop screening. Guidelines and clinical evidence were most frequently reported as very influential to clinician recommendations. Factors associated with routine recommendation of each screening method included clinician-perceived effectiveness of the method, clinician familiarity with the method, Medicare coverage, clinical capacity, and patient adherence.

Conclusion

Clinician education is needed to improve knowledge, familiarity, and experience with guideline-recommended screening methods with the goal of effectively engaging patients in informed decision making for CRC screening.

Patient preferences on general health and colorectal cancer screening decision-making: Results from a national survey

OBJECTIVE

We examined patient preferences regarding colorectal cancer (CRC) screening decision-making and factors associated with these preferences among screening-eligible US adults.

METHODS

Through a national survey of 1595 US adults ages 40-75 (response rate: 31.3%), we measured general medical decision-making and CRC screening decision-making preferences (0-100, 100 = highest desire for involvement) and preferred control level over three CRC screening decisions (whether to screen, what method to use, and when to screen). Analyses focused on respondents aged 45-75 at average CRC risk (N = 1062).

RESULTS

Respondents expressed strong desire for involvement in general medical decision-making and CRC screening decision-making (Mean = 68.1, 64.4). Over half of respondents reported preferring having equal control as their providers over whether to screen, what method to use, and when to screen. Women and people with higher education expressed higher desire for involvement in general medical decision-making. For CRC screening decision-making, variations exist in preferred level of involvement and control by race/ethnicity, educational attainment, insurance status, and recency of routine checkup.

CONCLUSION

Most respondents preferred a collaborative process of CRC screening decision-making, while variations existed across subgroups.

PRACTICE IMPLICATIONS

Providers should assess patients' values and preferences and involve them in CRC screening decision-making at a level they are comfortable with.

Provider-perceived barriers to patient adherence to colorectal cancer screening

Background

Average-risk colorectal cancer (CRC) screening remains underutilized in the US. Provider recommendation is strongly associated with CRC screening completion. To inform interventions aimed at improving screening uptake, we examined providers’ perspectives on patient and health system barriers to CRC screening adherence, along with associated system-level interventions to improve uptake.

Methods

We conducted an online survey between November and December 2019 with a sample of primary care clinicians (PCCs) and gastroenterologists (GIs) from a validated panel of US clinicians (814 PCCs, 159 GIs; completion rates: 25.3% for PCCs, 29.6% for GIs). Clinicians rated the extent to which each patient and health system factor interferes with patient adherence with CRC screening recommendations and the availability of practice interventions to improve screening rates.

Results

Provider-reported top barriers to CRC screening included patient discomfort with offered screening method (66%), cost (62–64%), and perceived low importance of screening (62%). Additional barriers included providers prioritizing urgent health concerns over screening (45–48%), not offering a choice of screening options (42–48%), lacking time to educate patients about screening (38–45%), and lacking education about available screening options (37–40%). Most frequently reported system-level interventions to improve CRC screening rates included patient education materials (57–62%) and point of care prompts (56–61%). Other interventions were less frequently reported, although variations existed by clinical specialty regarding barriers and interventions.

Conclusions

Addressing barriers to CRC screening requires system-level interventions, including provider training on shared decision-making, automated scheduling and reminder processes, and policies to increase clinician time for preventive screening consultations.

Health Care Provider Characteristics Associated With Colorectal Cancer Screening Preferences and Use

OBJECTIVE

To assess health care provider (HCP) preferences related to colorectal cancer (CRC) screening overall, and by HCP and patient characteristics.

PARTICIPANTS AND METHODS

We developed a survey based on the Theoretical Domains Framework to assess factors associated with CRC screening preferences in clinical practice. The survey was administered online November 6 through December 6, 2019, to a validated panel of HCPs drawn from US national databases and professional organizations. The final analysis sample included 779 primary care clinicians (PCCs) and 159 gastroenterologists (GIs).

RESULTS

HCPs chose colonoscopy as their preferred screening method for average-risk patients (96.9% (154/159) for GIs, 75.7% (590/779) for PCCs). Among PCCs, 12.2% (95/779) preferred multi-target stool DNA (mt-sDNA), followed by fecal immunochemical test (FIT), (7.3%; 57/779) and guaiac-based fecal occult blood test (gFOBT) (4.8%; 37/779). Preference among PCCs and GIs generally shifted toward noninvasive screening options for patients who were unable to undergo invasive procedures; concerned about taking time from work; unconvinced about need for screening; and refusing other screening recommendations. Among PCCs, preference for mt-sDNA over FIT and gFOBT was less frequent in larger compared with smaller clinical practices. Additionally, preference for mt-sDNA over FIT was more likely among PCCs with more years of clinical experience, higher patient volumes (> 25/day), and practice locations in suburban and rural settings (compared to urban).

CONCLUSION

Both PCCs and GIs preferred colonoscopy for CRC screening of average-risk patients, although PCCs did so less frequently and with approximately a quarter preferring stool-based tests (particularly mt-sDNA). PCCs' preference varied by provider and patient characteristics. Our findings underscore the importance of informed choice and shared decision-making about CRC screening options.

Barriers to utilization of three colorectal cancer screening options - Data from a national survey

Colorectal cancer (CRC) screening continues to be underutilized in the United States. A better understanding of existing barriers is critical for improving uptake of, and adherence to, CRC screening. Using data from a population-based panel survey, we examined barriers to utilization of three commonly used screening options (FIT/gFOBT, mt-sDNA, and screening colonoscopy) and assessed differences by socio-demographic characteristics, healthcare access, and health status. Data were obtained from a questionnaire developed by the authors and implemented through a U.S. national panel survey conducted in November 2019. Among 5,097 invited panelists, 1,595 completed the survey (31.3%). Analyses were focused on individuals ages 50-75 at average risk for CRC. Results showed that among respondents who reported no prior CRC screening with FIT/gFOBT, mt-sDNA, or colonoscopy, the top barriers were lack of knowledge (FIT/gFOBT: 42.1%, mt-sDNA: 44.9%, colonoscopy: 34.7%), lack of provider recommendation (FIT/gFOBT: 32.1%, mt-sDNA: 27.3%, colonoscopy: 18.6%), and suboptimal access (FIT/gFOBT: 20.8%, mt-sDNA: 17.8%, colonoscopy: 26%). Among participants who had used one or two of the screening options, the top barriers to FIT/gFOBT and mt-sDNA were lack of provider recommendation (31.6% & 37.5%) and lack of knowledge (24.6% & 25.6%), while for colonoscopy top barriers were psychosocial barriers (31%) and lack of provider recommendation (22.7%). Differences by sex, race/ethnicity, income level, and health status were observed. Our research identified primary barriers to the utilization of three endorsed CRC screening options and differences by patient characteristics, highlighting the importance of improving CRC screening education and considering patient preferences in screening recommendations.

Initial validation of a self-report questionnaire based on the Theoretical Domains Framework: determinants of clinician adoption of a novel colorectal cancer screening strategy

BACKGROUND

Colorectal cancer (CRC) screening for average risk adults age 45 and older continues to be underutilized in the USA. One factor consistently associated with CRC screening completion is clinician recommendation. Understanding the barriers and facilitators of clinical adoption of emerging CRC screening strategies is important in developing effective intervention strategies to improve CRC screening rates. We aimed to develop a questionnaire based on the Theoretical Domains Framework (TDF) to assess determinants of clinical adoption of novel CRC screening strategies, using the multi-target stool DNA test (mt-sDNA; Cologuard®) as an example, and test the psychometric properties of this questionnaire on a sample of US clinicians.

METHODS

A web survey was administered between November and December 2019 to a national panel of clinicians including primary care clinicians (PCCs) and gastroenterologists (GIs) to assess 10 TDF constructs with 55 items. Confirmatory factor analysis (CFA) was used to examine whether the a priori domain structure was supported by the data. Discriminant validity of domains was tested with Heterotrait-Monotrait ratio (HTMT). Internal consistency for each scale was assessed using Cronbach's alpha. Criterion validity was assessed with self-reported mt-sDNA use and mt-sDNA recommendation as the outcomes.

RESULTS

Complete surveys were received from 814 PCCs and 159 GIs (completion rate, 24.7% of 3299 PCCs and 29.6% of 538 GIs). Providers were excluded from analysis if they indicated not recommending CRC screening to average-risk patients (final N = 973). The final questionnaire consisted of 38 items covering 5 domains: (1) knowledge; (2) skills; (3) identity and social influence; (4) optimism, beliefs about consequences, and intentions; and (5) environmental context and resources. CFA results confirmed a reasonable fit (CFI = 0.948, SRMR = 0.057, RMSEA = 0.080). The domains showed sufficient discriminant validity (HTMT < 0.85), good internal consistency (McDonald's omega > 0.76), and successfully differentiated providers who reported they had ordered mt-sDNA from those who never ordered mt-sDNA and differentiated providers who reported routinely recommending mt-sDNA from those who reported not recommending mt-sDNA.

CONCLUSIONS

Findings provide initial evidence for the validity and internal consistency of this TDF-based questionnaire in measuring potential determinants of mt-sDNA adoption for average-risk CRC screening. Further investigation of validity and reliability is needed when adapting this questionnaire to other novel CRC screening strategy contexts.

National Survey of Patient Factors Associated with Colorectal Cancer Screening Preferences

Recommended colorectal cancer screening modalities vary with respect to safety, efficacy, and cost. Better understanding of the factors that influence patient preference is, therefore, critical for improving population adherence to colorectal cancer screening. To address this knowledge gap, we conducted a panel survey focused on three commonly utilized colorectal cancer screening options [fecal immunochemical test or guaiac-based fecal occult blood test (FIT/gFOBT), multi-target stool DNA (mt-sDNA) test, and colonoscopy] with a national sample of U.S. adults, ages 40-75 years and at average risk of colorectal cancer, in November 2019. Of 5,097 panelists invited to participate, 1,595 completed the survey (completion rate, 31.3%). Our results showed that when presented a choice between two colorectal cancer screening modalities, more respondents preferred mt-sDNA (65.4%) over colonoscopy, FIT/gFOBT (61%) over colonoscopy, and mt-sDNA (66.9%) over FIT/gFOBT. Certain demographic characteristics and awareness of and/or experience with various screening modalities influenced preferences. For example, uninsured people were more likely to prefer stool-based tests over colonoscopy [OR, 2.53; 95% confidence interval (CI), 1.22-5.65 and OR, 2.73; 95% CI, 1.13-7.47]. People who had heard of stool-based screening were more likely to prefer mt-sDNA over FIT/gFOBT (OR, 2.07; 95% CI, 1.26-3.40). People who previously had a stool-based test were more likely to prefer FIT/gFOBT over colonoscopy (OR, 2.75; 95% CI, 1.74-4.41), while people who previously had a colonoscopy were less likely to prefer mt-sDNA or FIT/gFOBT over colonoscopy (OR, 0.39; 95% CI, 0.24-0.63 and OR, 0.40; 95% CI, 0.26-0.62). Our survey demonstrated broad patient preference for stool-based tests over colonoscopy, contrasting the heavy reliance on colonoscopy for colorectal cancer screening in clinical practice and highlighting the importance of considering patient preference in colorectal cancer screening recommendations. PREVENTION RELEVANCE: Our national survey demonstrated broad patient preference for stool-based tests over colonoscopy, contrasting the heavy reliance on colonoscopy for colorectal cancer screening in clinical practice and highlighting the importance of considering patient preference in colorectal screening recommendations.

An examination of socioeconomic and racial/ethnic disparities in the awareness, knowledge and utilization of three colorectal cancer screening modalities

While colorectal cancer (CRC) mortality rates have been decreasing, disparities by socioeconomic status (SES) and race/ethnicity persist. CRC screening rates remain suboptimal among low SES and racial/ethnic minority populations, despite the availability of multiple screening modalities. Understanding awareness, knowledge, and utilization of common screening modalities within different racial/ethnic and SES groups is critical to inform efforts to improve population screening uptake and reduce disparities in CRC-related health outcomes. Through the theoretical lenses of diffusion of innovation and fundamental cause theory, we examined the associations of race/ethnicity and SES with awareness, knowledge, and utilization of three guideline recommended CRC screening strategies among individuals at average risk for CRC. Data were obtained from a survey of a nationally representative panel of US adults conducted in November 2019. The survey was completed by 31.3% of invited panelists (1595 of 5097). Analyses were focused on individuals at average risk for CRC, aged 45–75 for awareness and knowledge outcomes (n = 1062) and aged 50–75 for utilization outcomes (n = 858). Analyses revealed racial/ethnic and SES disparities among the three CRC screening modalities, with more racial/ethnic and SES differences observed in the awareness, knowledge, and utilization of screening colonoscopy and mt-sDNA than FIT/gFOBT. Patterns of disparities are consistent with previous research showing that inequities in social and economic resources are associated with an imbalanced adoption of medical innovations. Our findings demonstrate a need to increase awareness, knowledge, and access of various CRC screening modalities in specific populations defined by race/ethnicity or SES indicators. Efforts to increase CRC screening should be tailored to the needs and social-cultural context of populations. Interventions addressing inequalities in social and economic resources are also needed to achieve more equitable adoption of CRC screening modalities and reduce disparities in CRC-related health outcomes.

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Socioeconomic status linked to screening method awareness gap, notably mt-sDNA.

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Screening modalities with low demand on patient resources more likely to be adopted.

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Screening education needs to emphasize uniform starting age for all modalities.

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Tailoring education to low resource communities may improve screening uptake.

Colorectal cancer screening completion: An examination of differences by screening modality

Average-risk colorectal cancer (CRC) screening is broadly recommended, using one of several endorsed test options. However, CRC screening participation rates remain below national goals. To gain further insights regarding recent, population-based patterns in overall and test-specific CRC screening participation, we conducted a retrospective study of adults, ages 50-75 years, utilizing comprehensive data resources from the Rochester Epidemiology Project (REP). Among residents of Olmsted County, MN eligible and due for CRC screening, we identified 5818 residents across three annual cohorts who completed screening between 1/1/2016 and 12/31/2018. We summarized CRC screening rates as incidence per 1000 population and used Poisson regression to test for overall and mode-specific CRC trends. We also analyzed rates of follow-up colonoscopy within 6-months after a positive stool-based screening result. While no significant differences over time were observed in overall CRC screening incidence rates among those due for screening, we observed a statistically significant increase in mt-sDNA test and statistically significant decreases in screening colonoscopy and FIT/FOBT test completion rates; differences in screening overall and by modality were observed by age, sex, and race/ethnicity. The diagnostic colonoscopy follow-up rate within six months after a positive stool-based test was significantly higher following mt-sDNA (84.9%) compared to FIT/FOBT (42.6%). In this retrospective, population-based study, overall CRC screening incidence rates remained stable from 2016 to 2018, while test-specific rates for mt-sDNA significantly increased and decreased for colonoscopy and FIT/FOBT. Adherence with follow-up colonoscopy after a positive stool-based test was significantly higher among patients who underwent mt-sDNA screening compared to FIT/FOBT.

Invasive central venous monitoring during hepatic resection: unnecessary for most patients

BACKGROUND

Low central venous pressure (LCVP) anesthesia reduces blood loss during hepatic resection and historically has required a central venous catheter (CVC) for intra-operative monitoring. The aim of this study was to assess the effect of an evolution of practice to CVP monitoring without CVC on the perioperative outcomes after liver resection.

METHODS

A retrospective study of partial hepatectomy patients from 2007 to 2016 who were over 18 years of age was performed.

RESULTS

Of 3903 patients having partial hepatectomy, 2445 (62%) met inclusion criteria, and 404 (16%) had a CVC. Overall morbidity (33% non-CVC vs 38% CVC P = 0.076), major morbidity (16% vs 20% P = 0.067), and infective complications (superficial wound infection) 3% vs 4% P = 0.429; deep wound infection (5% vs 6% P = 0.720) did not differ between the two groups. In multivariate analysis, superficial wound infection, deep wound infection, and major complications were not associated with the presence of a CVC. All-cause mortality at 90 days was associated with CVC presence (OR 3.45, CI 1.74-6.85, P = 0.001) and age (OR 1.05, CI 1.02-1.08, P < 0.001).

CONCLUSION

Since the adoption of non-invasive CVP monitoring, there has been no increase in adverse peri-operative outcomes.

Cross-sectional adherence with the multi-target stool DNA test for colorectal cancer screening: Real-world data from a large cohort of older adults

Objective

To determine cross-sectional adherence with the multi-target stool DNA test used for colorectal cancer screening in a large, fully insured Medicare population.

Methods

All patients aged 65–85 with a valid multi-target stool DNA test order from 1 September 2016 to 31 August 2017 identified from the Exact Sciences Laboratories (Madison, WI; sole-source national multi-target stool DNA test provider) database were evaluated for test adherence. Cross-sectional adherence, defined as multi-target stool DNA test completion within 365 days from order date, was analyzed overall and by time to adherence, as well as by available patient (age, sex, test order date, Medicare coverage type) and provider (specialty, year of first multi-target stool DNA test order, multi-target stool DNA test order frequency, and practice location) factors.

Results

Among 368,494 Medicare beneficiaries (64% female), overall cross-sectional adherence was 71%. Cumulative adherence rates increased more rapidly at 30 (44%) and 60 (65%) days, followed by more gradual increases at 90 (67%), 180 (70%), and 365 (71%) days. By provider specialty, primary care clinicians represented a higher percentage of multi-target stool DNA orders than gastroenterologists (88% vs. 6%), but had a lower associated patient adherence rate (71% vs. 78%).

Conclusions

In this large, national sample of Medicare insured older adults, nearly three-quarters of patients adhered with a multi-target stool DNA order for colorectal cancer screening. These real-world data should inform further clinical and population health applications, reimbursement model simulations, and guideline-endorsed colorectal cancer screening strategies adherence.

Healthcare Provider Perspectives on Lowering Colorectal Cancer Screening Initiation Age to 45 Years: Results From a Survey of Clinicians in the U.S

We conducted a survey of primary care clinicians and gastroenterologists (n = 938) between 11/06/19-12/06/19 to assess knowledge and attitudes regarding colorectal cancer screening. We assessed clinicians' attitudes toward lowering the colorectal cancer screening initiation age to 45 years, a topic of current debate. We also evaluated provider and practice characteristics associated with agreement. Only 38.1% of primary care clinicians endorsed colorectal cancer screening initiation at age 45 years, compared to 75.5% of gastroenterologists (p < .0001). Gastroenterologists were over 5 times more likely than primary care clinicians to endorse lowering the screening initiation age (OR = 5.30, 3.54-7.93). Other factors found to be independently associated with agreement with colorectal cancer screening initiation at age 45 years included seeing more than 25 patients per day (vs. fewer) and suburban (vs. urban) location. Results emphasize the need for collaboration between primary care clinicians and gastroenterologists to ensure that patients receive consistent messaging and evidence-based care.

Reduced hepatic growth hormone (GH) receptor gene expression and increased plasma GH binding protein in experimental uremia

In uremia, reduced longitudinal growth and decreased hepatic insulin-like growth factor-I (IGF-I) secretion despite elevated GH serum levels point to an insensitivity to the action of GH. The molecular basis that accounts for this insensitivity could comprise decreased GH receptor expression in the target organs for GH or binding of GH in the circulation to substances that compete with the receptor. To address this hypothesis, the abundance of hepatic GH receptor mRNA was measured by solution hybridization RNase protection assay in uremic female Sprague-Dawley rats, following two-stage 5/6 nephrectomy, and in pair-fed and in ad libitum-fed sham-operated controls; rat GH binding protein (GHBP) plasma concentration was measured by a sensitive direct RIA. Uremia was associated with a 50% decrease of hepatic GH receptor expression compared to pair-fed controls, which themselves showed a 25% reduction of hepatic GH receptor mRNA abundance when compared to ad libitum-fed controls. Plasma GHBP levels in uremia were markedly higher than in both control groups. Treatment with recombinant human GH (rhGH) (10 IU/kg body wt per day s.c. for 10 days) led to a comparable induction of IGF-I plasma levels and weight gain in uremia and pair-fed controls, indicating that the insensitivity to GH in uremia can be overcome by large rhGH doses. Subcutaneous rhGH injections did not significantly alter the hepatic GH receptor transcript abundance or plasma GHBP levels in any of the groups.(ABSTRACT TRUNCATED AT 250 WORDS)

Nonsquamous cancer of the vagina

This report retrospectively analyzes 48 cases of primary vaginal cancer treated at Walter Reed Army Medical Center and the Naval Hospital, Bethesda, from 1962 through 1983. There was an unusually high number of uncommon histologic types. Nine patients had an adenocarcinoma, 5 had a sarcoma, 3 had a melanoma, 2 had an adenosquamous carcinoma, 1 had a lymphoma, and 1 had a carcinoid tumor. The remaining 27 patients had a squamous cell carcinoma. This represents a 43% prevalence of nonsquamous lesions. Nonsquamous cancer of the vagina occurred in patients at an earlier age than squamous cell carcinoma. Presenting symptoms, the location of the tumor within the vagina, and survival rates were similar for both groups. The clinical characteristics and treatment of the patients with nonsquamous tumors are discussed.

The treatment of retroperitoneal fibromatosis with medroxyprogesterone acetate

Wide excision is the recommended primary therapy for retroperitoneal fibromatosis. Radiation therapy and a variety of medications have been used to treat patients with recurrent tumors, but the response to these agents has not been uniform. The patient presented was successfully treated with medroxyprogesterone acetate for recurrent retroperitoneal fibromatosis that was refractory to multiple operative resections and radiation therapy.

Cardiotoxic effects of the venom of the burrowing asp, Atractaspis engaddensis (Atractaspididae, Ophidia)

The venom from the snake Atractaspis engaddensis has a very high lethal potency, with an i.v. LD50 of 0.06-0.075 micrograms per g body weight in mice. The action of the venom is rapid and death results from seemingly neurotoxic effects. However, even at high concentrations, the venom does not block contractions of skeletal muscles that are directly or indirectly stimulated. The most prominent action of the venom is seen in the function of the heart in anesthetized mice, with or without artificial respiration. The changes observed in the ECG are similar to those recorded in human victims and are the result of an A-V block that is caused by an apparent direct action of the venom on the heart.

Nonuniform biosynthesis of multiple hemoglobins in the adult rat and guinea pig

Separation of adult rat bone marrow cells by the method of thin layer countercurrent distribution permits the analyses of 59Fe-tagged erythroid cells for the various multiple hemoglobins and the assignment of such hemoglobins to erythroid cells at different stages of their development. Of the six adult red cell hemoglobins, hemoglobin 5 is synthesized most actively in the earliest erythroid cell whereas hemoglobin 4 (the major hemoglobin of the red cell) is synthesized most actively in the latest erythroid cells, e.g. the reticulocyte. Experimental evidence also indicates that maturation of the erythroid cell is accompanied by a decreased rate of synthesis of hemoglobin 5. The earliest erythroid cells of the marrow contain two hemoglobins, 7 and 8, which are absent in the adult red cell. Similar studies with the guinea pig confirm the nonuniform biosynthesis of its two hemoglobins and suggest that the phenomenon may be a general one among mammalian multiple hemoglobins.