Wednesday, March 29, 2023
| Characteristic | Primary care cliniciansb (n = 814) | Gastroenterologists (n = 159) |
|---|---|---|
| Age, yc | ||
| 27–39 | 107 (13.1) | 41 (25.8) |
| 40–49 | 254 (31.2) | 42 (26.4) |
| 50–59 | 236 (29.0) | 45 (28.3) |
| ≥60 | 217 (26.7) | 31 (19.5) |
| Sexd | ||
| Male | 586 (72.2) | 131 (82.9) |
| Female | 226 (27.8) | 27 (17.1) |
| Race and ethnicitye | ||
| Hispanic | 26 (3.2) | 10 (6.3) |
| Non-Hispanic Asian/Pacific Islander | 193 (23.7) | 42 (26.4) |
| Non-Hispanic Black | 19 (2.3) | 4 (2.5) |
| Non-Hispanic otherf/multiple race | 42 (5.2) | 15 (9.4) |
| Non-Hispanic White | 534 (65.6) | 88 (55.4) |
| Annual household income, $ | ||
| <74,999 | 43 (5.3) | 4 (2.5) |
| 75,000–124,999 | 104 (12.8) | 9 (5.7) |
| 125,000–174,999 | 115 (14.1) | 12 (7.6) |
| 175,000–199,999 | 86 (10.6) | 16 (10.1) |
| ≥200,000 | 466 (57.2) | 118 (74.2) |
| Board certification | ||
| Internal medicine | 427 (52.5) | 0 |
| Family medicine | 387 (47.5) | 0 |
| Gastroenterology | 0 | 159 (100.0) |
| No. of years practicing medicine after residency | ||
| 0–9 | 116 (14.3) | 42 (26.4) |
| 10–19 | 277 (34.0) | 53 (33.3) |
| 20–29 | 271 (33.3) | 45 (28.3) |
| ≥30 | 150 (18.4) | 19 (12.0) |
| Average no. of patients seen on typical day | ||
| 0–15 | 163 (20.0) | 41 (25.8) |
| 16–20 | 291 (35.7) | 49 (30.8) |
| 21–25 | 188 (23.1) | 30 (18.9) |
| >25 | 172 (21.1) | 39 (24.5) |
| No. of clinicians in practice | ||
| 1–5 | 344 (42.3) | 49 (30.8) |
| 6–15 | 247 (30.3) | 54 (34.0) |
| ≥16 | 223 (27.4) | 56 (35.2) |
| Clinician-reported characterization of practice location | ||
| Urban | 262 (32.2) | 81 (50.9) |
| Suburban | 447 (54.9) | 69 (43.4) |
| Rural | 105 (12.9) | 9 (5.7) |
Table 1. Clinician and Practice Characteristics of Participants, by Clinical Specialty, in a Survey on Factors Associated With Clinician Recommendations for Colorectal Cancer Screening Among Average-Risk Patients, United States, November–December 2019a
a All values presented are number (percentage). The study population included practicing primary care clinicians (PCCs) and practicing gastroenterologists (GIs) in the US in 2019. Information about other clinician or practice characteristics of the study population were not publicly available at the time of the study.
b Includes internal medicine and family medicine practitioners.
c In 2019, 53.6% of PCCs and 50.5% of GIs in the US were aged <55 years [26].
d In 2019, 60% of PCCs and 81.1% of GIs were male [25]. Data on sex were missing for 2 primary care clinicians and 1 gastroenterologist.
e In 2018, 50.8% of PCCs and 49.8% of GIs were non-Hispanic White, 18.4% of PCCs and 23.5% of GIs were Asian, 6.2% of PCCs and 5.6% of GIs were Hispanic (alone or with any race), 6.0% of PCCs and 3.7% of GIs were Black or African American, 0.4% of PCCs and 0.1% of GIs were American Indian/Alaska Native, 0.1% of PCCs and 0.1% of GIs were Native Hawaiian/Other Pacific Islander, 0.8% of PCCs and 1% of GIs were non-Hispanic multirace, 0.9% of PCCs and 0.8% of GIs were “other” race or ethnicity, and the race and ethnicity of 16.4% of PCCs and 15.5% of GIs were unknown [27].
f Any race not listed above.
| Item | Screening method | |||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| gFOBT | FIT | mt-sDNA (Cologuard) | Colonoscopy | CT colonography | Flexible sigmoidoscopy | Flexible sigmoidoscopy with FIT | ||||||||
| PCC | GI | PCC | GI | PCC | GI | PCC | GI | PCC | GI | PCC | GI | PCC | GI | |
| No. of clinicians who routinely recommend the method | 693 (85.1) | 120 (75.5) | 650 (79.9) | 124 (78.0) | 628 (77.1) | 124 (78.0) | 805 (98.9) | 159 (100.0) | 213 (26.2) | 65 (40.9) | 282 (34.6) | 48 (30.2) | 225 (27.6) | 47 (29.6) |
| P valuec | .009 | .73 | .82 | .43 | .001 | .49 | .73 | |||||||
| Recommended screening interval is consistent with guidelineb | 487 (70.3) | 86 (71.7) | 370 (56.9) | 72 (58.1) | 472 (75.2) | 96 (77.4) | 605 (75.2) | 135 (84.9) | 109 (51.2) | 46 (70.8) | 222 (78.7) | 31 (64.6) | 171 (76.0) | 28 (59.6) |
| P valuec | .81 | .81 | .81 | .03 | .03 | .06 | .049 | |||||||
| Age to stop screening, yd | ||||||||||||||
| <75 | 23 (3.3) | 2 (1.7) | 21 (3.2) | 2 (1.6) | 25 (4.0) | 0 | 40 (5.0) | 2 (1.3) | 9 (4.2) | 0 | 18 (6.4) | 1 (2.1) | 9 (4.0) | 1 (2.1) |
| 75 | 178 (25.7) | 42 (35.0) | 165 (25.4) | 45 (36.3) | 159 (25.3) | 45 (36.3) | 266 (33.0) | 56 (35.2) | 46 (21.6) | 28 (43.1) | 75 (26.6) | 17 (35.4) | 55 (24.4) | 19 (40.4) |
| 76–85 | 200 (28.9) | 42 (35.0) | 184 (28.3) | 43 (34.7) | 177 (28.2) | 47 (37.9) | 258 (32.0) | 73 (45.9) | 54 (25.4) | 19 (29.2) | 58 (20.6) | 12 (25.0) | 52 (23.1) | 12 (25.5) |
| >85 | 18 (2.6) | 3 (2.5) | 11 (1.7) | 1 (0.8) | 13 (2.1) | 1 (0.8) | 18 (2.2) | 2 (1.3) | 4 (1.9) | 1 (1.5) | 9 (3.2) | 0 | 5 (2.2) | 0 |
| No upper age limit | 274 (39.5) | 31 (25.8) | 269 (41.4) | 33 (26.6) | 254 (40.4) | 31 (25.0) | 223 (27.7) | 26 (16.4) | 100 (46.9) | 17 (26.2) | 122 (43.3) | 18 (37.5) | 104 (46.2) | 15 (31.9) |
| P valuec | .03 | .01 | .001 | .001 | <.001 | .001 | .01 | |||||||
Table 2. Clinicians’ Recommended Screening Interval and Age to Stop Screening for CRC, by Clinical Specialty, Among Clinicians Who Routinely Recommend These Methods to Asymptomatic, Average-Risk Patients, United States, November–December 2019a
Abbreviations: CRC, colorectal cancer; CT, computed tomography; FIT, fecal immunochemical test; FOBT, fecal occult blood test; gFOBT, guaiac FOBT; GI, gastroenterologist; mt-sDNA, multitarget stool DNA; PCC, primary care clinician.
a Clinicians were surveyed on factors associated with clinician recommendations for CRC screening among patients at average risk of CRC, November–December 2019. PCCs (n = 814) include internal medicine and family medicine practitioners; 159 GIs participated in survey. All values presented are number (percentage) unless otherwise indicated.
b Recommended screening interval was measured with the following question: “Please share the recommendations you typically make for CRC screening to asymptomatic, average-risk patients for each of the items presented below. Recommended frequency of testing, in years (fill-in-the-blank response). Answers coded as consistent with 2018 American Cancer Society, 2017 Multi-Society Task Force, 2016 US Preventive Services Task Force, or 2009 American College of Gastroenterology CRC screening guidelines if answered gFOBT/FIT every year, mt-sDNA every 1 to 3 years, colonoscopy every 10 years, CT colonography every 5 years, flexible sigmoidoscopy every 5 to 10 years, or flexible sigmoidoscopy every 5 to 10 years with annual FIT.
c P values obtained from χ2 test or Fisher exact test and adjusted for multiple testing by using the Benjamini–Hochberg procedure; P < .05 considered significant.
d Age at which the clinician no longer recommends screening was measured with the following question: “Is there an age at which you no longer recommend screening? If yes, what age?”
| Item | Screening method | ||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| gFOBT | FIT | Mt-sDNA (Cologuard) | Colonoscopyb | CT colonography | Flexible sigmoidoscopy | Flexible sigmoidoscopy with FIT | |||||||
| PCC | GI | PCC | GI | PCC | GI | PCC | PCC | GI | PCC | GI | PCC | GI | |
| No. of clinicians who do not routinely recommend the method | 121 | 39 | 164 | 35 | 186 | 35 | 9 | 601 | 94 | 532 | 111 | 589 | 112 |
| Barrierc | |||||||||||||
| Inadequate sensitivity (too many false negatives) | 79 (65.3) | 31 (79.5) | 55 (33.5) | 18 (51.4) | 28 (15.1) | 13 (37.1) | 1 (11.1) | 101 (16.8) | 26 (27.7) | 230 (43.2) | 56 (50.5) | 122 (20.7) | 42 (37.5) |
| P valued | .38 | .09 | .006 | —e | .02f | .20 | <.001 | ||||||
| Inadequate specificity (too many false positives) | 75 (62.0) | 25 (64.1) | 49 (29.9) | 13 (37.1) | 25 (13.4) | 15 (42.9) | 1 (11.1) | 85 (14.1) | 24 (25.5) | 52 (9.8) | 13 (11.7) | 47 (8.0) | 15 (13.4) |
| P valued | .81 | .48 | <.001 | —e | .01f | .54 | .06 | ||||||
| Poor insurance coverage | 5 (4.1) | 1 (2.6) | 30 (18.3) | 1 (2.9) | 75 (40.3) | 12 (34.3) | 1 (11.1) | 297 (49.4) | 44 (46.8) | 74 (13.9) | 5 (4.5) | 98 (16.6) | 6 (5.4) |
| P valued | — | .07 | .60 | —e | .64 | .009 | .003 | ||||||
| Poor patient adherence | 18 (14.9) | 7 (17.9) | 30 (18.3) | 7 (20.0) | 24 (12.9) | 4 (11.4) | 4 (44.4) | 134 (22.3) | 18 (19.1) | 193 (36.3) | 23 (20.7) | 210 (35.7) | 26 (23.2) |
| P valued | .81 | .81 | .80 | —e | .59 | .004 | .01f | ||||||
| Preference for visual inspection | 52 (43.0) | 21 (53.8) | 58 (35.4) | 17 (48.6) | 53 (28.5) | 17 (48.6) | 2 (22.2) | 112 (18.6) | 29 (30.9) | 67 (12.6) | 29 (26.1) | 67 (11.4) | 32 (28.6) |
| P valued | .47 | .22 | .03 | —e | .01f | .002 | <.001 | ||||||
| Lack of experience with this method | 3 (2.5) | 0 | 54 (32.9) | 1 (2.9) | 73 (39.2) | 5 (14.3) | 1 (11.1) | 231 (38.4) | 13 (13.8) | 69 (13.0) | 3 (2.7) | 162 (27.5) | 10 (8.9) |
| P valued | — | .002 | .009 | —e | <.001 | .004 | <.001 | ||||||
Table 3. Clinician-Reported Barriers to Recommending Each CRC Screening Method Among Clinicians Who Do Not Routinely Recommend These Methods to Asymptomatic, Average-Risk Patients, United States, November–December, 2019a
Abbreviations: CRC, colorectal cancer; CT, computed tomography; FIT, fecal immunochemical test; FOBT, fecal occult blood test; gFOBT, guaiac FOBT; GI, gastroenterologist; mt-sDNA, multitarget stool DNA; PCC, primary care clinician.
a Clinicians were surveyed on factors associated with clinician recommendations for colorectal cancer screening among patients at average risk of CRC, November–December 2019. PCCs were internal medicine and family medicine practitioners. All values presented are number (percentage) unless otherwise indicated.
b All GIs reported routinely recommending colonoscopy for CRC screening.
c Barrier to each method was measured with the following question: “For each of the following CRC screening options, please identify any factors that prevent you from recommending that method to asymptomatic, average-risk patients age 50 and older. Please select all that apply.”
d P values obtained from χ2 test or Fisher exact test and adjusted for multiple testing by using the Benjamini–Hochberg procedure.
e Analysis not conducted because outcome was rare.
f Statistical test did not have 80% power to detect this difference.
| Item | Rated as very influential, no. (%) | P valueb | |
|---|---|---|---|
| Primary care clinicians (n = 814) | Gastroenterologists (n = 159) | ||
| CRC screening clinical practice guidelinesc | |||
| American Cancer Society Colorectal Cancer Screening Guideline (5) | 451 (57.8) | 82 (51.6) | .23 |
| US Preventive Services Task Force Colorectal Cancer Screening Guideline (22) | 478 (61.4) | 86 (54.4) | .21 |
| American College of Gastroenterology Colorectal Cancer Screening Guideline (23) | 349 (46.1) | 115 (72.3) | <.001 |
| Multi-Society Task Force Colorectal Cancer Screening Guideline (24) | 245 (35.9) | 77 (50.3) | .005 |
| Method-specific factorsd | |||
| Published clinical evidence | 557 (69.5) | 124 (78.5) | .07 |
| Inclusion in clinical practice guidelines | 428 (53.0) | 103 (65.2) | .02 |
| Ease of use in practice | 363 (45.0) | 81 (51.3) | .23 |
| Support among peer groups and professional societies/networks | 244 (30.3) | 62 (39.0) | .08 |
| Patient satisfaction with recommended method | 380 (46.9) | 65 (41.4) | .27 |
| Patient likelihood to comply with recommendation | 383 (47.6) | 72 (45.3) | .60 |
| Patient request for specific method | 308 (38.0) | 53 (33.5) | .34 |
| Patient insurance coverage | 303 (37.6) | 64 (40.5) | .54 |
Table 4. Influence of Guidelines and Method-Specific Factors on Clinician CRC Screening Recommendation to Asymptomatic, Average-Risk Patients, by Provider Specialty, United States, November–December 2019a
Abbreviation: CRC, colorectal cancer.
a Clinicians were surveyed on factors associated with clinician recommendations for colorectal cancer screening among patients at average risk of CRC, November–December 2019. Primary care clinicians include internal medicine and family medicine practitioners. All values presented are number (percentage) unless otherwise indicated.
b P values obtained from χ2 test or Fisher exact test and adjusted for multiple testing by using the Benjamini–Hochberg procedure.
c Influence of the guidelines was measured with the following question: “Please rate the following CRC screening clinical practice guidelines based on how much they influence your recommendation of specific CRC screening methods. Please use a scale from 1 to 5, where 1 is not at all influential and 5 is very influential.” Clinicians who reported not knowing the guidelines were excluded (American Cancer Society guidelines, 34 primary care physicians; US Preventive Services Task Force guidelines, 35 primary care physicians and 1 gastroenterologist; American College of Gastroenterology guidelines, 57 primary care physicians; Multi-Society Task Force guidelines, 131 primary care physicians and 6 gastroenterologists).
d Influence of the method-specific factors was measured with the following question: “Please rate the level of influence the following method-specific factors have on your recommendation of specific CRC screening methods. Please use a scale from 1 to 5, where 1 is not at all influential and 5 is very influential.” Not all physicians answered this question; missingness for each question ranged from 4 to 12 among primary care physicians and 0 to 2 among gastroenterologists; denominators for percentages vary.
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Colorectal cancer (CRC) screening among average-risk patients is underused in the US. Clinician recommendation is strongly associated with CRC screening completion. To inform interventions that improve CRC screening uptake among average-risk patients, we examined clinicians’ routine recommendations of 7 guideline-recommended screening methods and factors associated with these recommendations.
We conducted an online survey in November and December 2019 among a sample of primary care clinicians (PCCs) and gastroenterologists (GIs) from a panel of US clinicians. Clinicians reported whether they routinely recommend each screening method, screening method intervals, and patient age at which they stop recommending screening. We also measured the influence of various factors on screening recommendations.
Nearly all 814 PCCs (99%) and all 159 GIs (100%) reported that they routinely recommend colonoscopy for average-risk patients, followed by stool-based tests (more than two-thirds of PCCs and GIs). Recommendation of other visualization-based methods was less frequent (PCCs, 26%–35%; GIs, 30%–41%). A sizable proportion of clinicians reported guideline-discordant screening intervals and age to stop screening. Guidelines and clinical evidence were most frequently reported as very influential to clinician recommendations. Factors associated with routine recommendation of each screening method included clinician-perceived effectiveness of the method, clinician familiarity with the method, Medicare coverage, clinical capacity, and patient adherence.
Clinician education is needed to improve knowledge, familiarity, and experience with guideline-recommended screening methods with the goal of effectively engaging patients in informed decision making for CRC screening.
