Screening rates increase even more when doctors discuss details of screening tests, Kaiser Permanente study finds

Patients who visited their doctor for any reason were nearly six times more likely to be screened for colon cancer compared to those who didn't visit their doctor, according to a study funded by the National Cancer Institute and published online today in the American Journal of Managed Care.

The study was conducted in an integrated health system that uses automated phone calls to remind patients when they are overdue for screening. The patients also are reminded again if they visit their doctor's office.

"Just going to the doctor increases the odds that patients will screen for colon cancer, but what the doctor says about screening is also important," said David Mosen, PhD, MPH, lead author and researcher with Kaiser Permanente Center for Health Research in Portland, Ore.

"Doctors should explain how each screening test is done, how often it needs to be done, and perhaps most importantly, they should make sure patients understand their options for screening," Mosen added.

This study was conducted among 883 Kaiser Permanente members in Washington and Oregon who were overdue for screening and had received an automated call during the spring or summer of 2009. Nine months after the automated calls, researchers examined the members' medical records to see if they had completed screening either by sigmoidoscopy, colonoscopy, or the fecal immunochemical (FIT) test -- a one-time, at-home test of a stool sample. More than 28 percent of the members completed screening, most of them with the FIT test.

Members who had visited their primary-care office between the time of the automated reminder call and their screening test were nearly six times more likely to complete screening compared to those who had no primary-care visit. As part of the study, members were asked if their health care provider had talked to them about any of the following factors during the last two years:

• Benefits of colon cancer screening.
• How often each screening test should be done.
• Information on how to do various tests.
• Accuracy of each screening test.
• Potential complications from screening tests.
• If the patient understood or had any questions about screening.
• If the patient had the information he or she wanted about screening.

Patients who said their providers discussed all seven items were 1.5 times more likely to screen, compared to patients who said their doctors discussed none of the topics.

"This may seem like a lot to include in a short discussion, but if you know the material, you can explain it in a few minutes," said Elizabeth Liles, MD, MCR, a physician at Kaiser Permanente Northwest and a co-author of the paper, who makes a point of having this discussion with her eligible patients.

According to the American Cancer Society, colorectal cancer is the third most common cancer and second leading cause of cancer death in the United States.

The U.S. Preventive Services Task Force recommends that colorectal cancer screening start at age 50 for patients of average risk. Patients can:

• Take a fecal occult blood test (for example, a FIT test) every year
• Have a flexible sigmoidoscopy (examination of lower colon) every five years, along with the fecal occult blood test every three years
• Have a colonoscopy (examination of the entire colon) every 10 years.

Despite this range of options, the Centers for Disease Control and Prevention says about a third of adults, or 22 million people, are not up to date on screening. People give various reasons for not screening, including fear that the screening will reveal cancer, concerns that the procedure will be too invasive, and lack of communication or advice from their clinician regarding screening.

"Screening for colon cancer saves lives, and now the new at-home screening tests are simple and easy to use," added Dr. Liles. "They don't require any dietary or medication restrictions and they can be completed in just a few minutes."

Kaiser Permanente has an organized reminder program to alert patients that they are overdue for screening. Some patients receive automated reminder phone calls; others automatically receive test kits in the mail. When patients come into their doctor's office for any reason, there is an alert in their medical record that prompts doctors and the medical staff to remind patients that they are overdue.

Study authors say primary-care physicians are often pressed for time during office visits, and they suggest that other members of the health care team -- such as nurses, care managers, or health educators -- could start the discussion with patients about colon cancer screening.

Study authors include David M. Mosen, PhD, MPH, Nancy Perrin, PhD, A. Gabriela Rosales, MS, David H. Smith, RPh, PhD, and Jennifer L. Schneider, MPH, from the Kaiser Permanente Center for Health Research in Portland, Ore.; Adrianne C. Feldstein, MD, MS, and Elizabeth G. Liles, MD, MCR, from the Kaiser Permanente Center for Health Research and Kaiser Permanente Northwest in Portland, Ore.; Ronald E. Myers, PhD, from Thomas Jefferson University in Philadelphia; and Jennifer Elston-Lafata, PhD, from Virginia Commonwealth University in Richmond, Va.