Patient–Physician Colorectal Cancer Screening Discussions

Delivery of the 5A's in Practice


      The U.S. Preventive Services Task Force advocates use of a 5A's framework (assess, advise, agree, assist, and arrange) for preventive health recommendations.


      To describe 5A content of patient–physician colorectal cancer (CRC) screening discussions and physician-recommended screening modality and to test if these vary by whether patient previously received screening recommendation.


      Direct observation of periodic health examinations in 2007–2009 among average-risk primary care patients aged 50–80 years due for screening. Qualitative content analyses conducted 2008–2010 used to code office visit audio-recordings for 5A and other discussion content.


      Among study-eligible visits (N=415), 59% contained assistance (i.e., help scheduling colonoscopy or delivery of stool cards), but the assess, advise, and agree steps were rarely comprehensively provided (1%–21%), and only 3% included the last step, arrange follow-up. Almost all physicians endorsed screening via colonoscopy (99%), either alone (69%) or in combination with other tests (30%). Patients nonadherent to a prior physician screening recommendation (31%) were less likely to have the reason(s) for screening discussed (37% vs 65%) or be told the endoscopy clinic would call them for scheduling (19% vs 27%), and more likely to have fecal occult blood testing (FOBT) alone (34% vs 25%) or FOBT and colonoscopy recommended (24% vs 14%), and a screening plan negotiated (21% vs 14%). Significance level is p<0.05 for all contrasts.


      Most patients due for CRC screening discuss screening with their physician, but with limited application of the 5A's approach. Opportunities to improve CRC screening decision-making are great, particularly among patients who are nonadherent to a prior recommendation from a physician.
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        • Guessous I.
        • Dash C.
        • Lapin P.
        • Doroshenk M.
        • Smith R.A.
        • Klabunde C.N.
        Colorectal cancer screening barriers and facilitators in older persons.
        Prev Med. 2010; 50: 3-10
        • Beydoun H.A.
        • Beydoun M.A.
        Predictors of colorectal cancer screening behaviors among average-risk older adults in the U.S..
        Cancer Causes Control. 2008; 19: 339-359
        • Sheridan S.L.
        • Harris R.P.
        • Woolf S.H.
        Shared Decision-Making Workgroup of the U.S. Preventive Services Task Force. Shared decision making about screening and chemoprevention: a suggested approach from the U.S. Preventive Services Task Force.
        Am J Prev Med. 2004; 26: 56-66
        • Pignone M.
        • Rich M.
        • Teutsch S.M.
        • Berg A.O.
        • Lohr K.N.
        Screening for colorectal cancer in adults at average risk: a summary of the evidence for the U.S. Preventive Services Task Force.
        Ann Intern Med. 2002; 137: 132-141
        • Smith R.A.
        • Cokkinides V.
        • Eyre H.J.
        American Cancer Society guidelines for the early detection of cancer, 2005.
        CA Cancer J Clin. 2005; 55 (quiz 55–6): 31-44
        • Winawer S.
        • Fletcher R.
        • Rex D.
        • et al.
        Colorectal cancer screening and surveillance: clinical guidelines and rationale—update based on new evidence.
        Gastroenterology. 2003; 124: 544-560
        • Lafata J.E.
        • Divine G.
        • Moon C.
        • Williams L.K.
        Patient–physician colorectal cancer screening discussions and screening use.
        Am J Prev Med. 2006; 31: 202-209
        • McQueen A.
        • Bartholomew L.K.
        • Greisinger A.J.
        • et al.
        Behind closed doors: physician–patient discussions about colorectal cancer screening.
        J Gen Intern Med. 2009; 24: 1228-1235
        • Ling B.S.
        • Trauth J.M.
        • Fine M.J.
        • et al.
        Informed decision-making and colorectal cancer screening: is it occurring in primary care?.
        Med Care. 2008; 46: S23-S29
        • Wunderlich T.
        • Cooper G.
        • Divine G.
        • et al.
        Inconsistencies in patient perceptions and observer ratings of shared decision making: the case of colorectal cancer screening.
        Patient Educ Couns. 2010; 80: 358-363
        • Vernon S.W.
        • Myers R.E.
        • Tilley B.C.
        Development and validation of an instrument to measure factors related to colorectal cancer screening adherence.
        Cancer Epidemiol Biomarkers Prev. 1997; 6: 825-832
        • Pinsky P.F.
        • Kramer B.S.
        • Reding D.
        • Buys S.
        Reported family history of cancer in the prostate, lung, colorectal, and ovarian cancer screening trial.
        Am J Epidemiol. 2003; 157: 792-799
        • Kroenke K.
        • Spitzer R.L.
        • Williams J.B.
        The Patient Health Questionnaire-2: validity of a two-item depression screener.
        Med Care. 2003; 41: 1284-1292
        • Flocke S.A.
        Measuring attributes of primary care: development of a new instrument.
        J Fam Pract. 1997; 45: 64-74
      1. 2nd ed. Assessing alcohol problems: a guide for clinicians and researchers. National Institute of Alcohol Abuse and Alcoholism/DHHS/Public Health Service/NIH, Rockville MD2003
        • Stange K.C.
        • Flocke S.A.
        • Goodwin M.A.
        • Kelly R.B.
        • Zyzanski S.J.
        Direct observation of rates of preventive service delivery in community family practice.
        Prev Med. 2000; 31: 167-176
        • Turner B.J.
        • Weiner M.
        • Yang C.
        • TenHave T.
        Predicting adherence to colonoscopy or flexible sigmoidoscopy on the basis of physician appointment-keeping behavior.
        Ann Intern Med. 2004; 140: 528-532
        • Charles C.
        • Gafni A.
        • Whelan T.
        Decision-making in the physician–patient encounter: revisiting the shared treatment decision-making model.
        Soc Sci Med. 1997; 49: 651-661
        • Schroy 3rd, P.C.
        • Emmons K.
        • Peters E.
        • et al.
        The impact of a novel computer-based decision aid on shared decision making for colorectal cancer screening: a randomized trial.
        Med Decis Making. 2011; 31: 93-107
        • Epstein R.M.
        • Street Jr, R.L.
        Patient-centered communication in cancer care: promoting healing and reducing suffering.
        National Cancer Institute, Bethesda MD2007 ([NIH Publication No. 07-6225])
        • Coulter A.
        Partnerships with patients: the pros and cons of shared clinical decision-making.
        J Health Serv Res Policy. 1997; 2: 112-121
        • Hawley S.T.
        • Volk R.J.
        • Krishnamurthy P.
        • Jibaja-Weiss M.
        • Vernon S.W.
        • Kneuper S.
        Preferences for colorectal cancer screening among racially/ethnically diverse primary care patients.
        Med Care. 2008; 46: S10-S16
        • Ling B.S.
        • Moskowitz M.A.
        • Wachs D.
        • Pearson B.
        • Schroy P.C.
        Attitudes toward colorectal cancer screening tests.
        J Gen Intern Med. 2001; 16: 822-830
        • Leard L.E.
        • Savides T.J.
        • Ganiats T.G.
        Patient preferences for colorectal cancer screening.
        J Fam Pract. 1997; 45: 211-218
        • Klabunde C.N.
        • Frame P.S.
        • Meadow A.
        • Jones E.
        • Nadel M.
        • Vernon S.W.
        A national survey of primary care physicians' colorectal cancer screening recommendations and practices.
        Prev Med. 2003; 36: 352-362
        • Ram P.
        • Grol R.
        • Rethans J.J.
        • Schouten B.
        • van der Vleuten C.
        • Kester A.
        Assessment of general practitioners by video observation of communicative and medical performance in daily practice: issues of validity, reliability and feasibility.
        Med Educ. 1999; 33: 447-454
        • Cargill V.A.
        • Conti M.
        • Neuhauser D.
        • McClish D.
        Improving the effectiveness of screening for colorectal cancer by involving nurse clinicians.
        Med Care. 1991; 29: 1-5