Presentation
PS2 - Barriers to Accessible and Effective Colorectal Cancer Screening (CRCS): Patient and Provider Shared Decision-Making (SDM) Perspectives on Colonoscopies and Fecal Immunochemical Tests (FITs)
SessionPoster Session 2
DescriptionBackground:
Colorectal cancer (CRC) is the second leading cause of cancer death in the United States (Siegel et al., 2023). Colorectal cancer screening (CRCS) is a critical component of preventive healthcare, offering the ability to significantly reduce CRC incidence and mortality through early detection (Chetroiu et al., 2021). However, CRCS rates remain low (American Cancer Society, 2024a), compromising patient safety by increasing the likelihood that CRC is identified at a later stage. The effectiveness of CRCS is contingent upon overcoming various barriers faced by patients and providers when selecting appropriate screening modalities.
There are two common categories of CRCS that patients and providers must decide upon: visual (structural) exams (i.e., colonoscopy) and stool-blood tests, each with unique barriers. Colonoscopy is the most widely used visual exam, allowing doctors to examine the entire colon and rectum for pre-cancerous polyps (American Cancer Society, 2024b). This procedure requires bowel preparation for optimal viewing (American Cancer Society, 2024b). In contrast, the fecal immunochemical test (FIT) is less invasive and more convenient, requiring minimal preparation and allowing patients to complete it at home. The FIT detects occult blood in the stool (American Cancer Society, 2024b). A colonoscopy is the gold standard for CRCS, with sensitivity ranging from 75% to 93% for detecting advanced adenomas, while the FIT has a sensitivity of 25% to 56% for the same (Lin et al., 2021; Collins et al., 2005 & Kumar et al., 2024).
Shared decision-making (SDM) plays a vital role in allowing patients and providers to collaboratively navigate factors such as family history to determine the most suitable screening method. However, time constraints for providers often hinder effective SDM, limiting meaningful engagement with patients. Both screening options present unique barriers. Understanding and addressing the barriers to CRCS can enhance accessibility and effectiveness, strengthen SDM, and increase patient adherence, thereby improving patient safety and ultimately improving outcomes in CRC prevention.
Method:
We conducted semi-structured interviews with providers and patients to investigate current CRCS procedures and the dynamics of teamwork between clinical teams and patients. To be eligible to participate, (1) patients between the ages of 45 and 75 must have undergone CRCS (either FIT or colonoscopy) within the past year at an academically-affiliated network of Federally Qualified Health Centers (FQHCs) in the Midwestern United States, and (2) providers must have been employed by the participating FQHC. Patients received information on the study via email, phone call, and mail. Clinicians received study information via email and in-person clinic presentations. Interested patients were scheduled for 30-minute Zoom interviews and received consent documentation via email. Interested clinicians who responded to an eligibility screening survey via REDCap were also scheduled for 30-minute Zoom interviews. Visa gift cards ($65 for medical providers, $30 for patient navigators & support personnel, and $20 for patients) were used to reimburse participants who completed interviews. Recordings were transcribed verbatim and stripped of identifying information before analysis. Transcripts were uploaded to Atlas.ti. A mixed inductive-deductive coding approach was used, with two independent coders per transcript and complete consensus resolution. Salas’s Heuristic Critical Considerations for Teamwork (also known as the “C’s of Teamwork”) guided the deductive codes (Salas et al., 2015). The qualitative team iteratively reviewed coded excerpts to identify emergent themes, including but not limited to barriers to CRCS.
Results:
Twenty-five semi-structured interviews were conducted, including 9 clinicians and 16 patients. The interviews revealed several key barriers to CRCS that compromise patient safety by hindering adherence, accessibility, and the overall effectiveness of both screening processes. For colonoscopy, these included: (1) coordinating transportation with someone else, as patients cannot drive themselves to or from the procedure, along with the need for both parties to take time off work, (2) cultural embarrassment, (3) scheduling difficulties, (4) long wait times, (5) patient hesitancy to undergo preparation, (6) the time required for providers to explain the procedure, (7) insurance and cost concerns, and (8) past negative experiences with colonoscopy or anesthesia. Conversely, the FIT had unique barriers, including (1) the time needed for providers to discuss the test with patients, educating them on how to properly complete and return the FIT, (2) logistical issues with patients needing to return the completed FIT kit during business hours, (3) returned FIT kits getting “lost”, (4) supply issues, and (5) human error in completing the test or obtaining a viable sample. Example quotations for some themes are below; additional quotations for every theme will be provided in the presentation.
Patient hesitancy to undergo preparation (for colonoscopy):
“And I believe one of the biggest barriers for some people, is yes, how to actually take the prep. When they’re told ‘don’t eat,’ and you find a lot of people getting up that morning and actually eating a full breakfast, and then they'll say, oh, they didn't eat, but then the prep was not a good prep. And happens with a lot of elderly people because some of them are on medications and they say that ‘if I don't eat this, I can't take this medication.’ So that's one of the barriers that I, lot of people run into. That you forget, oh, I got up and ate that morning and said, oh crap, I can't do this test now because I ate and now, I need to cancel this appointment and a [sic?] appointment constantly gets cancelled to where they never actually do the task. Until something serious arises.” [Patient 1]
Logistical issues with patients needing to return the completed FIT kit during business hours:
“Because currently we ask the patient to come back [to return the FIT]. Which you know for the most part, is during business hours, which is difficult for people that work, or have, you know, take care of children to like take another day out of their, you know, hour or two out of their day to return something to a clinic.” [Provider 1]
Discussion:
The barriers identified in this study reinforce the critical need to continually examine and understand the challenges associated with CRCS, particularly for colonoscopies and FITs. Addressing these barriers is crucial, as they not only hinder patient adherence but also compromise safety and the overall effectiveness of screening methods. For instance, patient hesitancy regarding colonoscopy preparation can lead to appointment cancellations, delaying essential screenings and increasing the risk of advanced disease, all at a detriment to patient safety. Similarly, logistical issues with returning FIT kits during business hours create additional obstacles for patients. By effectively addressing these barriers across all CRCS methods, we can enhance accessibility, SDM, and ultimately improve patient adherence. This proactive approach is vital for ensuring patient safety and achieving better outcomes in CRC prevention.
Colorectal cancer (CRC) is the second leading cause of cancer death in the United States (Siegel et al., 2023). Colorectal cancer screening (CRCS) is a critical component of preventive healthcare, offering the ability to significantly reduce CRC incidence and mortality through early detection (Chetroiu et al., 2021). However, CRCS rates remain low (American Cancer Society, 2024a), compromising patient safety by increasing the likelihood that CRC is identified at a later stage. The effectiveness of CRCS is contingent upon overcoming various barriers faced by patients and providers when selecting appropriate screening modalities.
There are two common categories of CRCS that patients and providers must decide upon: visual (structural) exams (i.e., colonoscopy) and stool-blood tests, each with unique barriers. Colonoscopy is the most widely used visual exam, allowing doctors to examine the entire colon and rectum for pre-cancerous polyps (American Cancer Society, 2024b). This procedure requires bowel preparation for optimal viewing (American Cancer Society, 2024b). In contrast, the fecal immunochemical test (FIT) is less invasive and more convenient, requiring minimal preparation and allowing patients to complete it at home. The FIT detects occult blood in the stool (American Cancer Society, 2024b). A colonoscopy is the gold standard for CRCS, with sensitivity ranging from 75% to 93% for detecting advanced adenomas, while the FIT has a sensitivity of 25% to 56% for the same (Lin et al., 2021; Collins et al., 2005 & Kumar et al., 2024).
Shared decision-making (SDM) plays a vital role in allowing patients and providers to collaboratively navigate factors such as family history to determine the most suitable screening method. However, time constraints for providers often hinder effective SDM, limiting meaningful engagement with patients. Both screening options present unique barriers. Understanding and addressing the barriers to CRCS can enhance accessibility and effectiveness, strengthen SDM, and increase patient adherence, thereby improving patient safety and ultimately improving outcomes in CRC prevention.
Method:
We conducted semi-structured interviews with providers and patients to investigate current CRCS procedures and the dynamics of teamwork between clinical teams and patients. To be eligible to participate, (1) patients between the ages of 45 and 75 must have undergone CRCS (either FIT or colonoscopy) within the past year at an academically-affiliated network of Federally Qualified Health Centers (FQHCs) in the Midwestern United States, and (2) providers must have been employed by the participating FQHC. Patients received information on the study via email, phone call, and mail. Clinicians received study information via email and in-person clinic presentations. Interested patients were scheduled for 30-minute Zoom interviews and received consent documentation via email. Interested clinicians who responded to an eligibility screening survey via REDCap were also scheduled for 30-minute Zoom interviews. Visa gift cards ($65 for medical providers, $30 for patient navigators & support personnel, and $20 for patients) were used to reimburse participants who completed interviews. Recordings were transcribed verbatim and stripped of identifying information before analysis. Transcripts were uploaded to Atlas.ti. A mixed inductive-deductive coding approach was used, with two independent coders per transcript and complete consensus resolution. Salas’s Heuristic Critical Considerations for Teamwork (also known as the “C’s of Teamwork”) guided the deductive codes (Salas et al., 2015). The qualitative team iteratively reviewed coded excerpts to identify emergent themes, including but not limited to barriers to CRCS.
Results:
Twenty-five semi-structured interviews were conducted, including 9 clinicians and 16 patients. The interviews revealed several key barriers to CRCS that compromise patient safety by hindering adherence, accessibility, and the overall effectiveness of both screening processes. For colonoscopy, these included: (1) coordinating transportation with someone else, as patients cannot drive themselves to or from the procedure, along with the need for both parties to take time off work, (2) cultural embarrassment, (3) scheduling difficulties, (4) long wait times, (5) patient hesitancy to undergo preparation, (6) the time required for providers to explain the procedure, (7) insurance and cost concerns, and (8) past negative experiences with colonoscopy or anesthesia. Conversely, the FIT had unique barriers, including (1) the time needed for providers to discuss the test with patients, educating them on how to properly complete and return the FIT, (2) logistical issues with patients needing to return the completed FIT kit during business hours, (3) returned FIT kits getting “lost”, (4) supply issues, and (5) human error in completing the test or obtaining a viable sample. Example quotations for some themes are below; additional quotations for every theme will be provided in the presentation.
Patient hesitancy to undergo preparation (for colonoscopy):
“And I believe one of the biggest barriers for some people, is yes, how to actually take the prep. When they’re told ‘don’t eat,’ and you find a lot of people getting up that morning and actually eating a full breakfast, and then they'll say, oh, they didn't eat, but then the prep was not a good prep. And happens with a lot of elderly people because some of them are on medications and they say that ‘if I don't eat this, I can't take this medication.’ So that's one of the barriers that I, lot of people run into. That you forget, oh, I got up and ate that morning and said, oh crap, I can't do this test now because I ate and now, I need to cancel this appointment and a [sic?] appointment constantly gets cancelled to where they never actually do the task. Until something serious arises.” [Patient 1]
Logistical issues with patients needing to return the completed FIT kit during business hours:
“Because currently we ask the patient to come back [to return the FIT]. Which you know for the most part, is during business hours, which is difficult for people that work, or have, you know, take care of children to like take another day out of their, you know, hour or two out of their day to return something to a clinic.” [Provider 1]
Discussion:
The barriers identified in this study reinforce the critical need to continually examine and understand the challenges associated with CRCS, particularly for colonoscopies and FITs. Addressing these barriers is crucial, as they not only hinder patient adherence but also compromise safety and the overall effectiveness of screening methods. For instance, patient hesitancy regarding colonoscopy preparation can lead to appointment cancellations, delaying essential screenings and increasing the risk of advanced disease, all at a detriment to patient safety. Similarly, logistical issues with returning FIT kits during business hours create additional obstacles for patients. By effectively addressing these barriers across all CRCS methods, we can enhance accessibility, SDM, and ultimately improve patient adherence. This proactive approach is vital for ensuring patient safety and achieving better outcomes in CRC prevention.
Authors
Event Type
Poster Presentation
TimeTuesday, April 14:45pm - 6:15pm EDT
LocationFrontenac Foyer