Physician-related Barriers to Colorectal Cancer Screening in Missouri 

Dayna S. Early, M.D., Steve Ristvedt, Ph.D. and Mario Schootman, Ph.D.

Project Overview:
Colorectal cancer (CRC) is a leading cause of cancer death in the U.S. Studies have shown that all currently recommended means of colorectal cancer screening (flexible sigmoidoscopy, fecal occult blood testing and colonoscopy) are effective in reducing mortality rates. Less than half of eligible patients, however, participate in colorectal cancer screening (CRCS) programs. 

Reasons for non-participation, also referred to as “barriers” to CRCS, are often divided into provider-specific barriers(issues that prevent providers from recommending screening) and patient-specific barriers (issues which prevent patients from participating in screening). Identifying barriers to CRCS is vital in order to develop and shape educational efforts and community interventions designed to increase participation in CRCS programs and thereby reduce CRC incidence and mortality. 

We will be conducting focus groups of primary care practitioners in St. Louis City and County. There are three major aims of the focus groups. The first is to identify barriers to colorectal cancer screening (as perceived by practitioners in Missouri) so that we can subsequently collect more specific data about their barriers and plan interventions that we anticipate will lead to increased utilization of CRCS services. Secondly, since family history of CRC is the most common risk factor for developing CRC, we will inquire about practitioners’ methods of obtaining family history of CRC. Finally, we are exploring the possibility of developing a Practice-Based Research Network (PBRN) in Missouri and eastern Illinois. The level of interest in our focus groups will allow us to predict the level of interest for establishing a PBRN. The investigators have existing affiliations with primary practitioners in BJC clinics and with Washington University family medicine teaching preceptors. The Siteman Cancer Center also has a well-established physician outreach program. We intend to use these existing relationships to identify physicians wishing to participate in focus groups. 

We intend for the information obtained from this study to be viewed as preliminary data to be used in the development of future project/grant submissions. The National Institutes of Health has posted a program announcement entitled Colorectal Cancer Screening in Primary Care (PAR-020042). This announcement is designed to encourage applications for exploratory/developmental grants (R21) designed to improve the delivery and uptake and evaluate the short-term outcomes of colorectal cancer screening in primary care practice. The study investigators are focused on this Program Announcement and intend for the information gathered from our focus group of physicians to allow us to collect more specific information about provider-related barriers, and subsequently define specific interventions to improve delivery and uptake of colon cancer screening that may be studied among primary care providers. 

Data to be gathered: 
Topics for focus groups will include the following: 

  • In what situations do you currently recommend colorectal cancer screening? 
  • What do you perceive as barriers to recommending screening to your patients? 
  • What do you think patients perceive as barriers to screening? 
  • What method, if any, do you have to gather information about family history, and how is it documented in the medical record? 
  • Do you use family history when making decisions about recommendations for CRCS to your patients? 
  • What processes do you have in place to facilitate performing or referring patients for CRCS? Could this be improved, and if so, how?
  • What studies would you be willing to have conducted in your own office, assuming that the demands on your own personnel are sufficiently constrained or reimbursed? 

Approaches to Gathering Data:
We will use the above mentioned mechanisms to identify primary care providers. The study investigators will contact providers to invite participation in the focus groups and will arrange dinner meetings in locations convenient for the practitioners. We anticipate conducting 5 focus group dinner meetings. Participants will be encouraged to not only respond to issues raised by the investigators but also to put forth issues of concern to them as regards improving participation in colorectal cancer screening. The study investigators will analyze responses and information obtained at the focus group meetings. In particular, we plan to identify barriers to screening for which an intervention is available to overcome the barrier (e.g. access to screening, knowledge about screening recommendations, education about risks/benefits of screening tests). Additionally, we intend to identify gaps in gathering family history data and use this information to develop tools to enhance practitioners’ use of family history to make decisions about screening recommendations.

Final Report:
Colorectal cancer screening (CRCS) utilization is poor, despite evidence demonstrating efficacy in reducing colorectal cancer (CRC) incidence and mortality. Patients have identified physician recommendation, or lack of, as an important influence determining CRCS utilization. We sought to understand barriers to CRCS delivery and utilization in our community ...  Read the full Final Report.