Informed Decision Making Changes Test Preferences for Colorectal Cancer Screening in a Diverse Population

Abstract

PURPOSE We wanted to better understand patient preferences and decision making about options for colorectal cancer screening. Consistency in patient preferences could improve patient-clinician communication about tests by simplifying and focusing discussions. METHODSIn a cross-sectional sample of primary care patients, cognitive ranking tasks were used to estimate patient preferences for fecal occult blood testing, fl exible sigmoidoscopy, colonoscopy, and double-contrast barium enema before and after consideration of 13 test attributes, such as accuracy and scientifi c evidence. Patients also ranked the 13 test attributes and attribute descriptions in terms of importance. Friedman's nonparametric test was used to measure overall discrimination among items, and the average Pearson correlation coeffi cient (r ) among participants was used to measure the degree of consistency in choices.RESULTS Participants (n = 168) averaged 62.1 years of age, and 64.3% were of minority racial ethnicity. For test-specifi c attributes, preferences were for high test accuracy (r = 0.63, P <.001), amount of colon examined (r = 0.64, P <.001), strong scientifi c evidence for effi cacy (r = 0.59, P <.001), minimum discomfort (r = 0.50, P <.001), and low risk of complications (r = 0.38, P <.001). When all 13 attributes were considered together, agreement dropped (r = 0.13, P <.001), but attributes considered most important for decision making were test accuracy, scientifi c evidence for effi cacy, amount of colon examined, and need for sedation. Test preferences showed moderate agreement (r = 0.20, P <.001), and choices were fairly consistent before and after exposure to test-specifi c attributes (κ = 0.17, P = .007). Initially the modal choice was fecal occult blood testing (59%); however, after exposure to test specifi c attributes, the modal choice was colonoscopy (54%).CONCLUSION Participants were clear about the attributes that they prefer, but no single test has those attributes. Preferences were varied across participants and were not predictable; clinicians should discuss the full range of recommended tests for colorectal cancer with all patients. 2 Professional organizations have widely endorsed screening for colorectal cancer 3-5 because of evidence of its effectiveness [6][7][8][9][10][11] and because screening could prevent 18,800 deaths per year.12 Screening remains underutilized, [13][14][15][16][17][18] however, with the lowest rates in African Americans and Hispanics. [19][20][21][22] Discussing colorectal cancer screening is challenging because multiple tests are recommended for screening, the tests are quite different and 142 INF OR MED DECISION M A K ING A ND T ES T PR EFER ENC EScomplex, patients lack familiarity with them, physicians have limited time to explain all the tests, and physicians have misconceptions about patient preferences regarding the tests and their attributes. [23][24][25][26] These problems have further been compounded by the continuing evolution of guidelines for colorectal cancer scree...

Patient–Provider Discussions about Colorectal Cancer Screening: Who Initiates Elements of Informed Decision Making?

“…Interventions using decision aids to improve patients' decision making about CRC screening have demonstrated improved CRC knowledge and risk perception, have increased intention to be screened, and there are mixed results for improving CRC screening behaviors. [18][19][20][21][22][23][24][25][26] In addition, decision aids have demonstrated that CRC screening test preferences vary by screening test attributes. 22 Patients making informed decisions about CRC screening should have information including: 1) the nature of the clinical decision; 2) the patient's role; 3) alternatives; 4) pros and cons of alternatives; 5) uncertainties associated with the decision; 6) patient's understanding; and 7) patient's preferences.…”

“…[18][19][20][21][22][23][24][25][26] In addition, decision aids have demonstrated that CRC screening test preferences vary by screening test attributes. 22 Patients making informed decisions about CRC screening should have information including: 1) the nature of the clinical decision; 2) the patient's role; 3) alternatives; 4) pros and cons of alternatives; 5) uncertainties associated with the decision; 6) patient's understanding; and 7) patient's preferences. 16,17 In addition, the patients' desire for input from trusted others should be considered in the CRC screening informed decision making (IDM) process.…”

Conjoint Analysis Versus Rating and Ranking for Values Elicitation and Clarification in Colorectal Cancer Screening

“…24 Although we are not aware of other published studies that have compared different methods of values elicitation for CRC screening, several have used explicit techniques to assess key decisional attributes. 13,[25][26][27][28] (Details of these studies are provided in Appendix 5-available online) Most studies have found test accuracy (ability to detect cancer and polyps) to be the most common most important attribute, but the order of importance of other attributes has varied considerably across studies.…”

Improving survival in colorectal cancer: what role for general practice?

“…10 Further, misunderstandings abound in cancer screening, highlighting an important educational role for primary care; addressing, for example, beliefs that negative test results mean bowel symptoms are less of a concern, or that taking a screening test is an appropriate response to a symptom. There is a recognised role for primary care in promoting informed choice in cancer screening; 11 ideally individuals should make their screening decisions based on the best available information.…”