Patient Attitudes Toward Individualized Recommendations to Stop Low-Value Colorectal Cancer Screening

Abstract

Importance: Guidelines for colorectal cancer (CRC) screening recommend an individualized approach in older adults that is informed by consideration of life expectancy and cancer risk. However, little is known about how patients perceive individualized screening recommendations.

Objective: To assess veterans' attitudes toward and comfort with cessation of low-value CRC screening (defined as screening in a patient for whom the benefit is expected to be small based on quantitative estimates from hypothetical risk calculators).

Design, setting, and participants: This survey study included patients older than 50 years who had undergone prior screening colonoscopy with normal results at the Veterans Affairs Ann Arbor Healthcare System. A total of 1500 surveys were mailed to potential participants from November 1, 2010, to January 1, 2012. Survey data were analyzed from January 1, 2016, to December 31, 2017.

Main outcomes and measures: Response to the question, "If you personally had serious health problems that were likely to shorten your life and your doctor did not think screening would be of much benefit based on the calculator, how comfortable would you be with not getting any more screening colonoscopies?"

Results: Of the 1500 surveys mailed, 85 were returned to sender, leaving 1415 potential respondents; 1054 of these respondents (median age range, 60-69 years; 884 [85.9%] white and 965 [94.2%] male) completed the survey (response rate, 74.5%). A total of 300 (28.7%) were not at all comfortable with cessation of low-value CRC screening, and 509 (49.3%) thought that age should never be used to decide when to stop screening. In addition, 332 (31.7%) thought it was not at all reasonable to use life expectancy calculators, and 255 (24.3%) thought it was not at all reasonable to use CRC risk calculators to guide these decisions. In ordered logistic regression analysis, factors associated with more comfort with screening cessation were (1) higher trust in physician (odds ratio [OR], 1.19; 95% CI, 1.07-1.32), (2) higher perceived health status (OR, 1.41; 95% CI, 1.23-1.61), and (3) higher barriers to screening (OR, 1.20; 95% CI, 1.11-1.30). Factors that were associated with less comfort with screening cessation included (1) greater perceived effectiveness of screening (OR, 0.86; 95% CI, 0.80-0.94) and (2) greater perceived threat of CRC (OR, 0.81; 95% CI, 0.73-0.89).

Conclusions and relevance: The findings suggest that many veterans have strong preferences against screening cessation even when given detailed information about why the benefit may be low. Efforts to tailor screening recommendations may be met by resistance unless they are accompanied by efforts to address underlying perceptions about the benefit of screening.

Figure 1.. Attitudes Toward Use of Age to Decide When to Start and Stop Colorectal Cancer Screening

Proportion of patients’ responses about whether age should be used by physicians to decide when to start and stop screening. Scores were measured on a Likert-type scale with 1 indicating not at all and 7 indicating extremely.

Figure 2.. Attitudes Toward Use of Risk Calculators to Inform Colorectal Cancer Screening Decisions

Proportion of patients’ responses about whether a life-expectancy calculator or colon cancer risk calculator should be used by physicians to decide when to stop screening. Scores were measured on a Likert-type scale with 1 indicating not at all and 7 indicating extremely.

Figure 3.. Attitudes Toward Stopping Low-Value Colorectal Cancer Screening and Likelihood of Following Recommendations to Stop Colorectal Cancer Screening

Proportion of patients’ responses about comfort with a physician’s decision to stop screening because of the lack of benefit based on the life expectancy calculator and whether the patient would follow the physician’s recommendation to stop screening. Scores were measured on a Likert-type scale with 1 indicating not at all and 7 indicating extremely.