Establish an Individualized Patient Education Program

Patients who are knowledgeable about guidelines for CRC screening are more likely to follow prescribed guidelines and proactively discuss issues or problems with their healthcare providers. However, experience in dealing with patients has shown that knowing what to do does not always equate with compliance. Even when the patient is motivated to comply, barriers (e.g., inadequate healthcare insurance, physical limitations making it difficult to perform adequate colon preparation, family factors) may impede patient follow-through with prescribed screening tests.

Key Points for Establishing an Individualized Patient Education Program

The office policy for CRC screening needs to be very clear. Since the approach to screening differs based on risk category, it will probably be more understandable if visually presented in the form of an algorithm or flow chart. Many of these resources can be found in How to Increase Colorectal Cancer Screening Rates in Practice: A Primary Care Clinician's Evidence-Based Toolbox and Guide.

  • Decide who in the office will be the CRC screening patient educator
  • Prior to initiating education, determine the patient's current knowledge of CRC screening and whether the patient has made any personal decisions about being screened
  • Tailor education to the patient's readiness for/decision about screening:
    • If unaware of CRC screening, provide information about risks of CRC and benefits of screening as well as options available to the patient
    • If aware of but not considering CRC screening, remind patient of CRC risks and the benefits of screening
    • If considering CRC screening, assist patient in selecting a screening option. Help identify any barriers and possible solutions
    • If patient has decided to do CRC screening, discuss options and logistics
    • If patient has decided against CRC screening, ask for reasons and address them
  • Barriers or limitations to helping patient reach a decision to have CRC screening include: patient's language, literacy, cultural background, physical limitations, and financial ability to pay or otherwise follow through with recommended care
  • Follow the office policy for CRC screening when recommending testing
  • If patient has a choice of screening procedures, review the pros and cons of each option that is available to the patient based on patient's risk and office policy using information found in the table below1

Tests That Detect Adenomatous Polyps and Cancers

Test

Interval

Advantage

Disadvantage

Flexible sigmoidoscopy

Every 5 years

  • Less expensive than colonoscopy
  • Less intensive bowel preparation
  • No sedation required
  • Only distal part of colon can be accessed and visualized
  • Performance is operator dependent
  • Procedure can be uncomfortable
  • Positive tests require follow-up colonoscopy
  • Small risk of perforation and bleeding

Colonoscopy

Every 10 years

  • Visualization of entire colon and rectum
  • Allows for biopsy and polypectomy in single procedure, if necessary
  • Complete bowel preparation required
  • Sedation is usually needed
  • Low risk of perforation and bleeding
  • More expensive on a one-time basis than other testing
  • Performance is operator dependent

Double contrast barium enema (DCBE)

Every 5 years

  • Can usually visualize entire colon
  • Relatively inexpensive
  • No sedation required
  • Complete bowel preparation required
  • Suboptimal preparation reduces sensitivity and specificity of test
  • Performance is operator dependent
  • Can be uncomfortable
  • Abnormal testing results requires follow-up colonoscopy
  • Rare cases of perforation reported
  • Theoretical risk from radiation exposure

Virtual colonoscopy

Every 5 years

  • Examines entire rectum and colon
  • No sedation needed
  • Complete bowel preparation required
  • May be uncomfortable
  • Performance operator dependent
  • Abnormal testing results require follow-up colonoscopy
  • Theoretical risk from radiation exposure

Tests That Detect Cancer Only*

Test

Interval

Advantage

Disadvantage

High sensitivity guaiac-based fecal occult blood test (gFOBT)

Annual

  • Does not require bowel preparation
  • Samples collected at home
  • Costs are lower than other screening tests
  • Does not detect polyps
  • Follow-up colonoscopy is indicated, if test is positive
  • Requires adequate sampling
  • May produce false positive
  • Dietary restrictions recommended to improve specificity and sensitivity

Fecal immunochemical test (FIT)

Annual

  • Non invasive
  • Does not require bowel preparation
  • Samples collected at home
  • Costs are lower than other screening tests except FOBT
  • Dietary restrictions are not necessary
  • Does not detect polyps
  • Follow-up colonoscopy is indicated, if test positive
  • May produce false positive results

Stool DNA (sDNA)

Optimal interval for follow-up of negative test unknown

  • Non invasive
  • Does not require bowel preparation
  • Samples collected at home
  • Test not dependent on occult blood for detection of CRC
  • Requires only single stool sample
  • Dietary restrictions not necessary
  • Does not detect polyps
  • Follow-up colonoscopy is indicated if test is positive
  • Costs currently higher than other stool tests
  • May produce false positive results

*Tests that detect cancers only are not preferred. If used for screening fecal tests combined with sigmoidoscopy, DCBE, or CTC are preferred over fecal tests alone.

Obtain high-quality patient education materials for the office. There are many resources for brochures, pamphlets, and posters available in a variety of languages. For additional information, see: How to Increase Colorectal Cancer Screening Rates in Practice: A Primary Care Clinician's Evidence-Based Toolbox and Guide


Resources

  1. Levin B, Lieberman DA, McFarland B, Smith RA, Brooks D, Andrews KS, et al. Screening and surveillance for the early detection of colorectal cancer and adenomatous polyps, 2008: a joint guideline from the American Cancer Society, the US Multi-Society Task Force on Colorectal Cancer, and the American College of Radiology. CA: A Cancer Journal for Clinicians. 134(5): 1570-1595.