Risk assessment and clinical decision making for colorectal cancer screening

Abstract

Background Shared decision-making (SDM) related to test preference has been advocated as a potentially effective strategy for increasing adherence to colorectal cancer screening yet primary care providers (PCPs) are often reluctant to comply with patient preferences if they differ from their own. Risk stratification advanced colorectal neoplasia (ACN) provides a rational strategy for reconciling these differences. Objective To assess the importance of risk stratification in PCP decision-making related to test preference for average-risk patients and receptivity to use of an electronic risk assessment tool for ACN to facilitate SDM. Design Mixed-methods, including qualitative key informant interviews and a cross-sectional survey. Participants PCPs at an urban, academic safety-net institution. Main Measures Screening preferences, factors influencing patient recommendations, and receptivity to use of a risk stratification tool Key Results Nine PCPs participated in interviews and 57 completed the survey. Despite an overwhelming preference for colonoscopy by 95% of respondents, patient risk (67%) and patient preferences (63%) were more influential in their decision-making than patient comorbidities (31%; P<0.001). Age was the single most influential risk factor (excluding family history), with <20% of respondents choosing factors other than age. Most respondents reported that they would be likely to use a risk stratification tool in their practice either “often” (43%) or sometimes (53%). Conclusions Risk stratification was perceived to be important in clinical decision-making yet few providers considered risk factors other than age for average-risk patients. Providers were receptive to the use of a risk assessment tool for ACN when recommending an appropriate screening test for select patients.

A Risk Prediction Index for Advanced Colorectal Neoplasia at Screening Colonoscopy

“…Conceptually, providers who prefer colonoscopy may be more willing to comply with patient preferences for tests other than colonoscopy for individuals at low risk; alternatively, patients who prefer tests other than colonoscopy may be more receptive to colonoscopy if informed that they are increased risk. We have previously reported that most primary care providers were willing to use such a tool, assuming that it minimized disruptions to workflow, was easy to use and required minimal time to complete (25). The ACNI’s simple scoring algorithm using readily available clinical information satisfies these prerequisites, especially if adapted into an electronic format and automated within electronic health records.…”

“…Adjusted 95% confidence intervals for the rate of ACN were generated for each risk category using the bootstrap methods described above. The actual cut-point was optimized to insure that: (1) the prevalence of ACN in the low-risk group was sufficiently low (range, 2–3% (25)) to influence provider decision-making, and (2) the proportion of patients categorized as low-risk was large enough to be clinically relevant, recognizing that approximately 30 to 60% of patients may prefer tests other than colonoscopy (8, 26, 27). …”

Gut microbiome identifies risk for colorectal polyps

“…Widespread screening for CRC results in earlier diagnosis (when the disease is more easily treated) and primary prevention,6 yet remains underused. An affordable, non-invasive or minimally invasive tool for risk assessment for the presence of polyps would have the potential to increase acceptability of colonoscopy by individuals categorised as high risk for CRC,48 that in turn could have a salient effect on CRC morbidity and mortality. Such a tool would have the additional benefit of reducing healthcare costs by avoiding screening colonoscopies in individuals without polyps.…”

Risk Stratification and Shared Decision Making for Colorectal Cancer Screening

“…From our previous work, we assumed that: (1) approximately one-third of patients would prefer a test other than colonoscopy: (2) 45% of patients would be classified as low risk; and (3) concordance in the control group would be approximately 51%. 10,20 Based on these assumptions, we estimated that a sample size of 180 patients per group would give >80% power of detecting a 15% increase in concordance from 51% in the control group to 66% in the risk assessment group at the P <0.05 level.…”

“…25 The index represents a prototype version of the Advanced Colorectal Neoplasia Index (ACNI). 20 The final version substitutes a height variable for NSAID use and an interaction term for sex and race/ ethnicity. Discrimination, as defined by the area under the receiver operator characteristic curve (C statistic), was similar for the 2 versions (prototype, C = 0.68; final, C = 0.69).…”