Research article
Colorectal Cancer Screening by Primary Care Physicians: Recommendations and Practices, 2006–2007

https://doi.org/10.1016/j.amepre.2009.03.008Get rights and content

Background

Primary care physicians (hereafter, physicians) play a critical role in the delivery of colorectal cancer (CRC) screening in the U.S. This study describes the CRC screening recommendations and practices of U.S. physicians and compares them to findings from a 1999–2000 national provider survey.

Methods

Data from 1266 physicians responding to the 2006–2007 National Survey of Primary Care Physicians' Recommendations and Practices for Breast, Cervical, Colorectal, and Lung Cancer Screening (cooperation rate=75%) were analyzed in 2008. Descriptive statistics were used to examine physicians' CRC screening recommendations and practices as well as the office systems used to support screening activities. Sample weights were applied in the analyses to obtain national estimates.

Results

Ninety-five percent of physicians routinely recommend screening colonoscopy to asymptomatic, average-risk patients; 80% recommend fecal occult blood testing (FOBT). Only a minority recommend sigmoidoscopy, double-contrast barium enema, computed tomographic colonography, or fecal DNA testing. Fifty-six percent recommend two screening modalities; 17% recommend one. Nearly all physicians who recommend endoscopy refer their patients for the procedure. Four percent perform sigmoidoscopy, a 25-percentage-point decline from 1999–2000. Although 61% of physicians reported that their practice had guidelines for CRC screening, only 30% use provider reminders; 15% use patient reminders.

Conclusions

Physicians' CRC screening recommendations and practices have changed substantially since 1999–2000. Colonoscopy is now the most frequently recommended test. Most physicians do not recommend the full menu of test options prescribed in national guidelines. Few perform sigmoidoscopy. Office systems to support CRC screening are lacking in many physicians' practices. Given ongoing changes in CRC screening technologies and guidelines, the continued monitoring of physicians' CRC screening recommendations and practices is imperative.

Introduction

Colorectal cancer (CRC) is the second leading cause of cancer death in the U.S.1 Screening for CRC is recommended by national expert groups for average-risk adults aged ≥50 years2, 3 and has been designated as a high-priority preventive service because of its substantial potential impact on disease burden and its cost effectiveness.4 Screening options recommended by the U.S. Preventive Services Task Force (USPSTF) include annual fecal occult blood testing (FOBT); sigmoidoscopy every 5 years; or colonoscopy every 10 years.3 In 2005, 50% of adults aged ≥50 years in the U.S. had been screened according to these recommendations.5 This rate is notably lower than that of other recommended adult preventive services.6, 7, 8

Most cancer screening in the U.S. occurs within routine medical practice, especially primary care. By recommending CRC screening tests, performing them, or referring patients for them, primary care physicians (hereafter, physicians) play a critical role in implementing guidelines and achieving public health targets for CRC screening. Accordingly, physician recommendation has been shown to be a strong correlate of whether or not patients undergo CRC screening.9, 10, 11 Practice-level systems to support the translation of physicians' recommendations into clinical delivery are also recognized as an important influence on the utilization of CRC screening.11, 12, 13

An earlier study14 used data from a nationally representative survey conducted in 1999–2000 to assess physicians' recommendations for and means of conducting CRC screening in their clinical practices. The study found that 98% of physicians recommended CRC screening to patients, most often with FOBT, flexible sigmoidoscopy, or both, and that many recommended screening at nonstandard starting ages or too-frequent intervals. Subsequent to that study, several major developments in national policies related to CRC screening occurred. These include the expansion of coverage by the Medicare program to include screening colonoscopy for average-risk beneficiaries in 2001,15 the addition of colonoscopy and double-contrast barium enema (DCBE) to updated guidelines by the USPSTF in 2002,16 and the adoption of CRC screening as a Health Plan Employer Data and Information Set performance measure by the National Committee for Quality Assurance17 in 2003. Physicians' CRC screening recommendations and practices may have been influenced, altered, or both, by these and other developments in the rapidly evolving CRC screening field.

To assess physicians' current knowledge, attitudes, recommendations, and practices regarding CRC and three other types of cancer screening, the National Cancer Institute (NCI)—in collaboration with the Agency for Healthcare Research and Quality and the CDC—fielded in 2006–2007 the National Survey of Primary Care Physicians' Recommendations and Practices for Breast, Cervical, Colorectal, and Lung Cancer Screening (healthservices.cancer.gov/surveys/screening_rp/). The current study uses data from the new survey to characterize U.S. physicians' CRC screening recommendations and practices. Results are compared to selected findings from the earlier, 1999–2000 survey.14 The practice-level systems that physicians report having in place to support CRC screening activities, about which there is limited information at the national level, are also described.

Section snippets

Sampling Methodology

Between September 2006 and May 2007, a nationally representative sample of physicians was surveyed. The American Medical Association's Physician Masterfile, which contains demographic and practice information on all allopathic and nearly all osteopathic physicians in the U.S., was used as the sampling frame. Eligible respondents were nonfederal, office-based family physicians, general practitioners, general internists, and obstetrician/gynecologists aged ≤75 years with patient care as their

Description of Respondents

A total of 1266 physicians responded to the survey. The absolute response rate was 69.3%. The cooperation rate, which excludes physicians lacking valid contact information, was 75%. Nearly half of the respondents were family physicians or general practitioners (Table 1). Approximately half were aged <50 years. The majority were men, non-Hispanic white, board-certified, graduates of U.S. medical schools, full or part owners of their practices, and without a medical school faculty appointment.

Discussion

This study used data from a nationally representative survey of physicians conducted in 2006–2007 and compared them to selected results from an earlier national survey14 to show that physicians' CRC screening recommendations and practices have changed substantially over a 7-year period. Colonoscopy is now the most frequently recommended test; in 1999–2000, it was FOBT. Moreover, despite national guidelines that list multiple test options for CRC screening and that promote the precept of patient

References (45)

  • D.A. Marshall et al.

    Measuring patient preferences for colorectal cancer screening using a choice-format survey

    Value Health

    (2007)
  • N.K. Janz et al.

    Determinants of colorectal cancer screening use, attempts, and non-use

    Prev Med

    (2007)
  • D.K. Rex et al.

    Colorectal cancer prevention 2000: screening recommendations of the American College of Gastroenterology

    Am J Gastroenterol

    (2000)
  • A.H. Krist et al.

    Timing of repeat colonoscopy: disparity between guidelines and endoscopists' recommendation

    Am J Prev Med

    (2007)
  • T. Vogt

    Improving CRC screening requires innovative approaches: can electronic medical records help?

    Am J Prev Med

    (2008)
  • Cancer facts and figures 2008

    (2008)
  • Screening for colorectal cancer: U.S. Preventive Services Task Force recommendation statement

    Ann Intern Med

    (2008)
  • J.A. Shapiro et al.

    Colorectal cancer test use from the 2005 National Health Interview Survey

    Cancer Epidemiol Biomarkers Prev

    (2008)
  • N. Breen et al.

    Reported drop in mammography: is this cause for concern?

    Cancer

    (2007)
  • D. Solomon et al.

    Cervical cancer screening in the U.S. and the potential impact of implementation of screening guidelines

    CA Cancer J Clin

    (2007)
  • M. Sarfaty et al.

    How to increase colorectal cancer screening rates in practice

    CA Cancer J Clin

    (2007)
  • Colorectal cancer screening: overview

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