Transcript
Dr. Colbert:
You're listening to Clinician's Roundtable on ReachMD, and I'm Dr. Gates Colbert. On this episode, we'll hear from Dr. Sarina Schrager and Dr. Lashika Yogendran, who will be discussing their recent review, which focused on shared decision-making in colorectal cancer screening.
Dr. Schrager is a family medicine physician at the University of Wisconsin School of Medicine and Public Health, where she focuses on preventative care, women's care, and patient-centered decision-making. Dr. Schrager, thanks for being here.
Dr. Schrager:
Thanks for having me.
Dr. Colbert:
Dr. Yogendran is also a family medicine physician at UW Health and an Assistant Professor at the University of Wisconsin School of Medicine and Public Health, Department of Family Medicine and Community Health. Dr. Yogendran, welcome to the program.
Dr. Yogendran:
Thanks so much for having me. Happy to be here.
Dr. Colbert:
Let's start by taking a look at your review, Dr. Schrager. What were you hoping to better understand about shared decision-making and colorectal cancer screening? And based on that objective, how was the review conducted?
Dr. Schrager:
So, as you know, the rate of colorectal cancer is increasing in our population, and it’s actually increasing faster in younger people. Depending on the state that you live in, only 60 to 70 percent of eligible people are getting screened. As family physicians, we see, every day, people either declining screening or agreeing to screening and then not completing it.
And so what we really wanted to know is, based on our real-life experience, what are the factors that people look at when they're trying to decide, first, whether or not to get screened, and then second, what type of screening to obtain. So we decided to do a scoping review, which is like reviewing the evidence, but in a much more rigorous way than we normally do.
We worked with a librarian at the UW School of Medicine and Public Health, and we went through the specific process of a scoping review. So she did a review of four different databases and ended up sending us 5,672 potential papers. We were able to whittle it down to 28 that were really relevant to looking at how people made decisions about cancer screening and why they decided to get screened or not get screened. And it gave us some insight about what the factors were that affected their decisions about which screening test to use.
We looked at average-risk adults between 40 and 75 in the US and Canada, and we specifically excluded people who were high risk, meaning people with family history, inflammatory bowel disease, or a history of precancerous polyps, just because we wanted to get a sense of, in the general population, how people are making decisions.
Dr. Colbert:
Turning to the findings now, Dr. Yogendran, what were the most important themes that emerged from the literature regarding how patients make decisions about colorectal cancer screening?
Dr. Yogendran:
So we ended up identifying four different key themes in the literature.
The first was that patients want to know details about the different tests to help make their screening decision, which totally makes sense. Factors that came out in the literature included how accurate the different options for screening are—things like sensitivity and specificity of the various tests—as well as the logistics and descriptions of any procedures—as in, whether the screening test could be done at home or at a healthcare facility, what the test entails, et cetera. Patients prioritized tests that prevented cancer and that were accurate and sensitive.
The second theme was that patients place high value on what their primary care physician recommends for them. I think this goes to show the level of trust that a patient has with their primary care doctor and the significance of that relationship on their overall health.
The third theme was that patients had many strong emotions around the different testing or screening options, which may influence their decision. Getting a colonoscopy, for example, can cause a fair amount of anxiety, which could cause someone to avoid that screening modality.
The last theme impacting patient decisions were external factors like culture, socioeconomic status, and family input. Family experiences—whether positive or negative—regarding colorectal cancer screening could impact a patient's decision regarding that screening. For other patients, taking time away from work and having a driver for a colonoscopy due to the sedation used could be a barrier for choosing a colonoscopy as their screening option.
Dr. Colbert:
And now, based on these findings, Dr. Schrager, what are the key takeaways for clinicians who are looking to better support shared decision-making and improve screening uptake?
Dr. Schrager:
So true shared decision-making is focused on supporting the patient in making the right decision for themselves. So it really incorporates patient values and beliefs into the decision-making. In true shared decision-making, we wouldn't be wedded to a particular outcome. But in this case, we want our patients to get screened.
So I tend to look at it a little differently. Instead of just shared decision-making about whether or not to get screened, in this situation, I try to focus on what kind of screening works best with each individual patient. So, for example, if their priority is making sure they don't have cancer, for example—they want the most accurate test—then maybe colonoscopy is the right test for them.
However, if they can't take time off work, then maybe home-based stool testing would be the right thing. What this review tells me is that there are real barriers to people getting colorectal cancer screening, and that, for us as their primary care clinicians, to better support them, we need to acknowledge those real barriers and help them make the screening decision that's right for them.
Because ultimately, the best screening method is the one that's completed. So we can order lots of colonoscopies, but if people don't go and get them, then we're not making progress.
Dr. Colbert:
For those just tuning in, you're listening to Clinician's Roundtable on ReachMD. I'm Dr. Gates Colbert, and I'm speaking with Dr. Sarina Schrager and Dr. Lashika Yogendran about shared decision-making in colorectal cancer screening.
Let's take those findings and put them in the clinical setting. Based on your experience, Dr. Yogendran, how do emotional responses like fear, anxiety, or avoidance shape patients' willingness to engage in screening?
Dr. Yogendran:
Oh, I think they play a big role and can significantly influence decision-making. I've had patients flat out refuse to get a colonoscopy, because the process of undergoing a scope causes them fear. I've had patients have loved ones diagnosed with cancer, which may cause them anxiety and some degree of avoidance.
And so engaging those patients in conversations regarding colorectal cancer screening sometimes doesn't go anywhere at first. But I think that just goes to show the importance of continuing these conversations in a shared decision-making fashion.
Patients have experienced nervousness around the bowel cleanout and prep for colonoscopy, as well. Folks tend not to be very thrilled about that part of the screening process. And as a result, patients may delay or avoid screening altogether due to all these different emotional responses.
Dr. Colbert:
In addition to emotions, Dr. Yogendran, what real-world or external factors most influence a patient's screening decision, and how do these show up in clinical practice?
Dr. Yogendran:
I would say the biggest real-world factors influencing a patient screening decision that I see in practice are, for colonoscopies, needing time away from work, as well as patients needing a driver to take them home after the procedure. Many of my older patients live alone and may not have a trusted person to drive them home after the colonoscopy, which prevents them from being able to get it done. Patients also may not be able to afford taking time away from work for the procedure, or they work night shifts and can't do the bowel prep the night before.
Cost is another factor I encounter with patients. Patients worry about additional incurred costs if there are any findings like polyps on the screening colonoscopy requiring intervention. There can also be long wait times to actually get a colonoscopy done, and so patients can be lost to follow-up and not complete the screening procedure that their physician recommended for them.
I've also found family input to be another important factor influencing a patient's screening decision for colorectal cancer. If a family member feels strongly that a patient should be screened with a specific screening option, more often than not, the patient will agree.
Dr. Colbert:
Lastly, Dr. Schrager, given these factors, what approaches have you found most effective for helping patients navigate these emotional and practical barriers so they can move forward with screening?
Dr. Schrager:
So that's actually a great question. In the real world—in my practice, and I think in Dr. Yogendran's practice—we really focus on individualized decision-making. So we know our patients. We can bring up previous decisions they've made. We can bring up family history. Being able to put their decision-making in the context of their real lives can be really helpful in encouraging them to make a decision that they feel comfortable with and will then complete.
Like I said before, the best screening is one that gets completed, and so I actually never want to pressure somebody into doing something that they don't feel comfortable with. We know their family history. We know their family circumstances. We often know their work schedule, and can say, "Hey, it seems like a colonoscopy, logistically, might be hard for you. So, in that situation, how do you feel about doing a home-based stool test? Yes, there are the issues with having to handle your own stool, but we'll give you gloves. It's really not that big of a deal, and we can talk through the process."
So I think there's no one-size-fits-all opportunities, but the approach of really knowing your patients, being patient-centered, and letting them lead can be really successful in helping people choose the correct screening method for them.
Dr. Colbert:
And with those key takeaways in mind, I want to thank my guests, Dr. Sarina Schrager and Dr. Lashika Yogendran, for joining me to discuss shared decision-making in colorectal cancer screening.
With ReachMD, I'm Dr. Gates Colbert. To access this and other episodes in our series, visit Clinician's Roundtable on ReachMD.com, where you can Be Part of the Knowledge. Thanks for listening.
