Patient preferences for colorectal cancer screening: how does stool DNA testing fare?

OBJECTIVE: To assess patient preferences for 1 of the recommended colorectal cancer screening options or stool DNA testing (sDNA), a novel noninvasive screening test. STUDY DESIGN: Cross-sectional survey of ambulatory-care patients in the primary care setting. METHODS: A decision aid was administered to eligible subjects, using a trained interviewer format. The decision aid described the pros and cons of colonoscopy, fecal occult blood testing (FOBT), flexible sigmoidoscopy, flexible sigmoidoscopy plus FOBT, double-contrast barium enema, and sDNA. After reviewing the decision aid, subjects were asked to identify a preferred screening option, test features influencing their choice, and level of interest in decision making. RESULTS: A total of 263 subjects completed the study. Colonoscopy (50.6%), sDNA (28.1%), and FOBT (18.3%) were preferred over the other screening options. Preferences were associated with race and education but not age, sex, or prior FOBT. Subjects who preferred colonoscopy rated accuracy as the most influential test feature, whereas those who preferred sDNA or FOBT rated concerns about discomfort or frequency of testing highest. Most subjects preferred a shared (54%) or patient-dominant (34%) decision-making process. CONCLUSIONS: Colonoscopy was the most frequently preferred screening option for average risk individuals. Noninvasive stool-based tests, particularly sDNA, were identified by most individuals who preferred an alternative to colonoscopy. These findings affirm the need to elicit patient preferences when selecting a screening option and suggest that provider-patient decision making can be tailored to include fewer options.

Colorectal cancer screening in average risk individuals.

Colorectal cancer is the third leading type of cancer, and the second leading cause of cancer-related death in the United States. Prevention of colorectal cancer should be achievable by screening programs that detect adenomas in asymptomatic patients and lead to their removal. In this manuscript, we review the major screening modalities, the advantages and disadvantages of each approach, the data supporting their use, and various issues affecting the implementation of each test. Screening guidelines will be reviewed, and future techniques for colorectal cancer screening examined.

Deficiencies in knowledge and familial risk communication among colorectal adenoma patients.

GOALS: Our primary objectives were to assess knowledge about familial risk and risk communication among colorectal adenoma patients. BACKGROUND: The first-degree relatives (FDRs) of colorectal adenoma patients diagnosed before the age of 60 years may be at increased risk of colorectal cancer and should begin screening by the age of 40 years. Adherence to this recommendation requires effective risk communication between physicians, affected patients, and their at-risk relatives. STUDY: We conducted a telephone survey of 129 consecutive English-speaking adenoma patients younger than 60 years treated by 11 endoscopists at two medical centers. Information regarding patient demographics, awareness of familial risk, and risk communication was elicited. RESULTS: A total of 71 eligible subjects responded to the survey. Few responders (n = 25, 33%) were aware that their FDRs were at increased risk of colorectal cancer, and only 56% of knowledgeable patients identified a physician as the source of information. Awareness was strongly associated (P < or = 0.001) with patient-initiated information-seeking behavior. Most knowledgeable patients (n = 20, 80%) reported that they had informed > or = 1 FDRs about their diagnosis, and most (68%) felt that it was the patient's responsibility to notify at-risk relatives. CONCLUSIONS: Most colorectal adenoma patients younger than 60 years are unaware of the familial implications of their diagnosis and therefore unlikely to notify at-risk FDRs.

A national survey of flexible sigmoidoscopy training in primary care graduate and postgraduate education programs.

OBJECTIVES: Expanding the pool of primary care endoscopists to perform flexible sigmoidoscopy (FS) has been advocated as a strategy for building colorectal cancer screening capacity. The principal aim of this study was to evaluate the availability and structure of FS training among internal medicine (IM), family practice (FP), physician assistant (PA), and nurse practitioner (NP) training programs. METHODS: A postal survey of all accredited IM (n = 445), FP (n = 471), PA (n = 118), and NP (n = 149) training programs nationwide was conducted. The primary outcome was the proportion of programs offering or mandating FS training; and secondary outcomes, if applicable, were the number of participating trainees, the number of required procedures, the availability of instruction in endoscopic biopsy technique, mentors, and barriers. RESULTS: The overall response rate was 63%. Most IM (89%) and FP (99%) programs offered FS training versus only 12% of PA and 0% of NP programs. Family practice programs were more likely to offer training (p < 0.0001), require training (p < 0.0001), and teach biopsy techniques (p < 0.0001); Internal medicine programs were more likely to have minimum requirements (p < 0.0001) and required >/= 25 procedures per trainee (p < 0.0001). Physician assistant programs were less structured and often lacked minimum requirements. CONCLUSIONS: Flexible sigmoidoscopy training is widely available among FP and IM programs but more restricted or nonexistent among PA and NP programs. The lack of minimum standards for ensuring competency highlights the need for a standardized credentialing process.