Colorectal Cancer is the second leading cause of cancer deaths in the United States, yet with early detection, it is also one of the most preventable cancers. With several tests available, tailoring the conversation to your patient’s unique needs, preferences, and risk factors is key to fostering informed decision-making and improving adherence.
Understanding Screening Options
Before engaging in a conversation with your patient, ensure you are well-versed in the different colorectal cancer screening methods. Screening options vary regarding patient burden and factors that can influence test selection and adherence. These factors include screening frequency, location, preparation, need for sedation, time and transportation needs, out-of-pocket costs, risk of complications, and test accuracy.
Patients will likely prefer one type of colorectal cancer screening test over others if given sufficient information regarding each test’s benefits, limitations, and suitability for various patients. The primary screening options include:
| Screening Type | Interval | Limitations | Patient Burden | Cost & Reimbursement |
| Fecal Immunochemical Test (FIT) | Annual | – High nonadherence – Less effective for advanced adenoma detection – Few available tests have published peer-reviewed performance data | – Done at home – Many brands require a single sample – No diet or medication restrictions | – Inexpensive compared with structural examinations and mt-sDNA – Follow-up colonoscopy for positive test may be subject to out-of-pocket cost |
| Guaiac Fecal Occult Blood Test (gFOBT) | Annual | – High nonadherence – Less effective for advanced adenoma detection – Difficulty in ascertaining test performance among FDA-cleared tests | – Done at home – Requires multiple samples – Requires dietary and medication restrictions – Higher false-positive rate than FIT | – Inexpensive compared with structural exams and mt-sDNA – Follow-up colonoscopy for positive test may be subject to out-of-pocket costs |
| sDNA (Cologuard) | 3 Years | – New test with limited data – Uncertainty in management of positive results followed by negative colonoscopy | – Done at home – No bowel prep, sedation, or transportation required | – More expensive than other stool-based tests – Follow-up colonoscopy for positive test may be subject to out-of-pocket costs |
| Colonoscopy | 10 Years | – Risk of bowel perforation/bleeding and cardiopulmonary complications of anesthesia – Performance is dependent upon various factors (adequacy of bowel prep, cecal intubation rate, withdrawal time, etc.) – Limited collection of quality data – Level of adherence is unknown – Lower sensitivity for neoplasia in the proximal than the distal colon | – Requires full bowel cleansing Requires time off and a chaperone | – Most expensive test, but reimbursable for those with insurance – Polypectomy and anesthesia may be subject to out-of-pocket costs |
| CT Colonography | 5 Years | – Incidental extracolonic findings may require workup – Exposure to low-dose radiation | – Requires full bowel prep – Colonoscopy required if test positive | – Expensive and may not be covered by insurance – Follow-up colonoscopy for positive test may be subject to out-of-pocket costs |
| Flexible Sigmoidoscopy | 5 Years | – Does not examine proximal colon – Concerns about lack of quality standards, limited availability, and failure to achieve complete exam | – Pain and discomfort – Requires enema before procedures – Abnormal findings require colonoscopy | – Follow-up colonoscopy for positive test may be subject to out-of-pocket costs |
Key Considerations When Discussing Options
- Assess Risk Factors: Begin the conversation by reviewing the patient’s risk factors. Patients with a family history of colorectal cancer, a personal history of polyps, or certain genetic conditions may benefit more from a colonoscopy.
- Understand Patient Preferences: Some patients may prioritize non-invasive options due to fear of sedation, discomfort, or logistical challenges. Discuss how each test aligns with the patient’s lifestyle and comfort level.
- Address Barriers: The most common barriers to screening include lack of recommendation or referral from PCP, fear, financial struggles, logistical issues, misconception that the test is unnecessary, discomfort, and lack of awareness of the need.
- Logistical Barriers: Discuss how to coordinate transportation or time off work if they choose a colonoscopy.
- Financial Concerns: Review insurance coverage and out-of-pocket costs for each test.
- Cultural or Emotional Factors: Be sensitive to potential stigma, fear, or misconceptions about screening tests.
- Educate on Effectiveness: Emphasize while tests like colonoscopies are comprehensive, any colorectal cancer screening is better than none. Encourage patients to choose a test they are most likely to complete. Unanswered questions can discourage a patient from choosing an option.
Framing the Conversation
Shared decision-making can help patients choose a screening option they can adhere to. There are 3 steps to implementing an effective, shared decision-making process:
- Discuss why a patient fits the criteria for a recommended preventive service
- Share the benefits of screening for cancer early
- Communicate available screening options and assess the patient’s preferences to find a test they agree to
- Deliver a strong screening recommendation, set patient expectations, and gain patient commitment for follow-through
Use shared decision-making to empower patients. Here’s an example of how to frame the discussion:
“There are several effective ways to screen for colorectal cancer. The right test for you depends on your preferences, risk factors, and how you feel about certain procedures. Let’s go over the options so we can choose the one that works best for you.”
Encourage Follow-Through
- Provide Clear Instructions: If the patient chooses a home-based test like FIT or a stool DNA test, explain the steps clearly and offer resources like videos or handouts.
- Set Reminders: Help patients set up reminders for annual tests or follow-up appointments.
- Address Questions: Be available to answer questions and alleviate concerns as the patient completes the process.
- Follow-up: Ensure results are viewed promptly and, if necessary, discuss next steps like a colonoscopy.
A provider’s guidance can make a significant difference in helping patients take crucial steps toward preventing colorectal cancer. By discussing screening options openly, addressing barriers, and providing support, providers can motivate their patients to make informed decisions. Remember: the best test is the one the patient is willing and able to complete.