Colorectal Cancer Screening in Vulnerable Patients

Promoting Informed and Shared Decisions


      Low-income, low-literacy, limited English–proficient populations have low colorectal cancer (CRC) screening rates and experience poor patient–provider communication and decision-making processes around screening. The purpose of this study was to test the effect of a CRC screening decision aid on screening-related communication and decision making in primary care visits.

      Study design

      RCT with data collected from patients at baseline and immediately after the provider encounter.


      Patients aged 50–75 years, due for CRC screening, were recruited from two safety net clinics in North Carolina and New Mexico (data collection, January 2014–September 2015; analysis, 2015).


      Participants viewed a CRC screening decision aid or a food safety (control) video immediately before their provider encounter.

      Main outcome measures

      CRC screening–related knowledge, discussion, intent, test preferences, and test ordering.


      The study population (N=262) had a mean age of 58.3 years and was 66% female, 61% Latino, 17% non-Latino black, and 16% non-Latino white. Among Latino participants, 71% preferred Spanish. Compared with controls, intervention participants had greater screening-related knowledge (on average 4.6 vs 2.8 of six knowledge items correct, adjusted difference [AD]=1.8, 95% CI=1.5, 2.1) and were more likely to report screening discussion (71.0% vs 45.0%, AD=26.1%, 95% CI=14.3%, 38.0%) and high screening intent (93.1% vs 84.7%, AD=9.0%, 95% CI=2.0%, 16.0%). Intervention participants were more likely to indicate a specific screening test preference (93.1% vs 68.0%, AD=26.5%, 95% CI=17.2%, 35.8%) and to report having a test ordered (56.5% vs 32.1%, AD=25.8%, 95% CI=14.4%, 37.2%).


      Viewing a CRC screening decision aid before a primary care encounter improves knowledge and shared decision making around screening in a racially, ethnically, and linguistically diverse safety net clinic population.

      Trial registration

      This study is registered at NCT02054598.
      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to American Journal of Preventive Medicine
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • Siegel R.L.
        • Miller K.D.
        • Jemal A.
        Cancer statistics, 2015.
        CA Cancer J Clin. 2015; 65: 5-29
      1. U.S. Preventive Services Task Force. Screening for colorectal cancer: U.S. Preventive Services Task Force recommendation statement. Ann Intern Med. 2008;149(9):627-637.

        • Rex D.K.
        • Johnson D.A.
        • Anderson J.C.
        • et al.
        American College of Gastroenterology guidelines for colorectal cancer screening 2009 [corrected].
        Am J Gastroenterol. 2009; 104: 739-750
        • Zauber A.G.
        • Lansdorp-Vogelaar I.
        • Knudsen A.B.
        • Wilschut J.
        • van Ballegooijen M.
        • Kuntz K.M.
        Evaluating test strategies for colorectal cancer screening: a decision analysis for the U.S. Preventive Services Task Force.
        Ann Intern Med. 2008; 149: 659-669
        • Joseph D.A.
        • King J.B.
        • Miller J.W.
        • Richardson L.C.
        CDC. Prevalence of colorectal cancer screening among adults— Behavioral Risk Factor Surveillance System, United States, 2010.
        MMWR Morb Mortal Wkly Rep. 2012; 61: 51-56
        • Klabunde C.N.
        • Cronin K.A.
        • Breen N.
        • Waldron W.R.
        • Ambs A.H.
        • Nadel M.R.
        Trends in colorectal cancer test use among vulnerable populations in the United States.
        Cancer Epidemiol Biomarkers Prev. 2011; 20: 1611-1621
        • Shapiro J.A.
        • Klabunde C.N.
        • Thompson T.D.
        • Nadel M.R.
        • Seeff L.C.
        • White A.
        Patterns of colorectal cancer test use, including CT colonography, in the 2010 National Health Interview Survey.
        Cancer Epidemiol Biomarkers Prev. 2012; 21: 895-904
        • Liss D.T.
        • Baker D.W.
        Understanding current racial/ethnic disparities in colorectal cancer screening in the United States: the contribution of socioeconomic status and access to care.
        Am J Prev Med. 2014; 46: 228-236
        • Diaz J.A.
        • Roberts M.B.
        • Goldman R.E.
        • Weitzen S.
        • Eaton C.B.
        Effect of language on colorectal cancer screening among Latinos and non-Latinos.
        Cancer Epidemiol Biomarkers Prev. 2008; 17: 2169-2173
      2. American Cancer Society. Cancer prevention & early detection facts & figures 2013. Accessed June 27, 2014.

        • Gupta S.
        • Brenner A.T.
        • Ratanawongsa N.
        • Inadomi J.M.
        Patient trust in physician influences colorectal cancer screening in low-income patients.
        Am J Prev Med. 2014; 47: 417-423
        • Shokar N.K.
        • Carlson C.A.
        • Weller S.C.
        Factors associated with racial/ethnic differences in colorectal cancer screening.
        J Am Board Fam Med. 2008; 21: 414-426
        • Yepes-Rios M.
        • Reimann J.O.F.
        • Talavera A.C.
        • Ruiz de Esparza A.
        • Talavera G.A.
        Colorectal cancer screening among Mexican Americans at a community clinic.
        Am J Prev Med. 2006; 30: 204-210
        • Holden D.
        • Harris R.
        • Porterfield D.S.
        • et al.
        Enhancing the Use and Quality of Colorectal Cancer Screening.
        Agency for Healthcare Research and Quality, Rockville, MD2010
        • 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(9): S10-S16
        • Pignone M.P.
        • Bucholtz D.
        • Harris R.
        Patient preferences for colon cancer screening.
        J Gen Intern Med. 1999; 14: 432-437
        • Hawley S.T.
        • McQueen A.
        • Bartholomew L.K.
        • et al.
        Preferences for colorectal cancer screening tests and screening test use in a large multispecialty primary care practice.
        Cancer. 2012; 118: 2726-2734
        • Klabunde C.N.
        • Lanier D.
        • Nadel M.R.
        • McLeod C.
        • Yuan G.
        • Vernon S.W.
        Colorectal cancer screening by primary care physicians: recommendations and practices, 2006-2007.
        Am J Prev Med. 2009; 37: 8-16
        • 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
        • Inadomi J.M.
        • Vijan S.
        • Janz N.K.
        • et al.
        Adherence to colorectal cancer screening: a randomized clinical trial of competing strategies.
        Arch Intern Med. 2012; 172: 575-582
        • Stacey D.
        • Légaré F.
        • Col N.F.
        • et al.
        Decision aids for people facing health treatment or screening decisions.
        Cochrane Database Syst Rev. 2014; 1: CD001431
        • Barry M.J.
        • Edgman-Levitan S.
        Shared decision making—pinnacle of patient-centered care.
        N Engl J Med. 2012; 366: 780-781
        • Carcaise-Edinboro P.
        • Bradley C.J.
        Influence of patient-provider communication on colorectal cancer screening.
        Med Care. 2008; 46: 738-745
        • Holden D.
        • Jonas D.E.
        • Porterfield D.S.D.S.
        • Reuland D.S.
        • Harris R.
        Systematic review: enhancing use and quality of colorectal cancer screening.
        Ann Intern Med. 2010; 152: 668-676
        • Napoles A.M.
        • Santoyo-Olsson J.
        • Stewart A.L.
        • et al.
        Physician counseling on colorectal cancer screening and receipt of screening among Latino patients.
        J Gen Intern Med. 2015; 30: 483-489
        • Johnson-Kozlow M.
        • Roussos S.
        • Rovniak L.
        • Hovell M.
        Colorectal cancer test use among Californians of Mexican origin: influence of language barriers.
        Ethn Dis. 2009; 19: 315-322
        • Jerant A.F.
        • Arellanes R.E.
        • Franks P.
        Factors associated with Hispanic/non-Hispanic white colorectal cancer screening disparities.
        J Gen Intern Med. 2008; 23: 1241-1245
        • Afable-Munsuz A.
        • Liang S.Y.
        • Ponce N.A.
        • Walsh J.M.E.
        Acculturation and colorectal cancer screening among older Latino adults: differential associations by national origin.
        J Gen Intern Med. 2009; 24: 963-970
        • Schroy 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
        • Pignone M.P.
        • Harris R.
        • Kinsinger L.
        Videotape-based decision aid for colon cancer screening.
        Ann Intern Med. 2000; 133: 761-769
        • Lewis C.L.
        • Brenner A.T.
        • Griffith J.M.
        • Pignone M.P.
        The uptake and effect of a mailed multi-modal colon cancer screening intervention: a pilot controlled trial.
        Implement Sci. 2008; 3: 32
        • Miller D.P.
        • Spangler J.G.
        • Case L.D.
        • Goff D.C.
        • Singh S.
        • Pignone M.P.
        Effectiveness of a web-based colorectal cancer screening patient decision aid: a randomized controlled trial in a mixed-literacy population.
        Am J Prev Med. 2011; 40: 608-615
        • Dolan N.C.
        • Ramirez-Zohfeld V.
        • Rademaker A.W.
        • et al.
        The effectiveness of a physician-only and physician-patient intervention on colorectal cancer screening discussions between providers and African American and Latino patients.
        J Gen Intern Med. 2015; 30: 1780-1787
        • Schroy P.C.
        • Emmons K.M.
        • Peters E.
        • et al.
        Aid-assisted decision making and colorectal cancer screening: a randomized controlled trial.
        Am J Prev Med. 2012; 43: 573-583
        • American Cancer Society
        Cancer facts and figures for Hispanics/Latinos: 2012-2014. 2012;
        • Pignone M.
        • Winquist A.
        • Schild L.A.
        • et al.
        Effectiveness of a patient and practice-level colorectal cancer screening intervention in health plan members: the CHOICE trial.
        Cancer. 2011; 117: 3352-3362
        • Ko L.
        • Reuland D.
        • Jolles M.
        • Clay R.
        • Pignone M.
        Cultural and linguistic adaptation of a multimedia colorectal cancer screening decision aid for Spanish speaking Latinos.
        J Health Commun. 2014; 19: 192-209
        • Perreira K.M.
        Mexican families in North Carolina: the socio-historical contexts of exit and settlement.
        Southeast Geogr. 2011; 51: 260-286
        • Crowley M.
        • Lichter D.T.
        Social disorganization in new Latino destinations.
        Rural Sociol. 2009; 74: 573-604
        • Brenner A.T.
        • Getrich C.M.
        • Pignone M.
        • et al.
        Comparing the effect of a decision aid plus patient navigation with usual care on colorectal cancer screening completion in vulnerable populations: study protocol for a randomized controlled trial.
        Trials. 2014; 15: 275
        • Reuland D.S.
        • Ko L.K.
        • Fernandez A.
        • Braswell L.C.
        • Pignone M.P.
        Testing a Spanish-language colorectal cancer screening decision aid in Latinos with limited English proficiency: results from a pre-post trial and four month follow-up survey.
        BMC Med Inform Decis Mak. 2012; 12: 53
        • LaVange L.M.
        • Durham T.A.
        • Koch G.G.
        Randomization-based nonparametric methods for the analysis of multicentre trials.
        Stat Methods Med Res. 2005; 14: 281-301
        • Zink R.C.
        • Koch G.G.
        NParCov3: A SAS/IML macro for nonparametric randomization-based analysis of covariance.
        J Stat Softw. 2012; 50
        • Chew L.D.
        • Bradley K.A.
        • Boyko E.J.
        Brief questions to identify patients with inadequate health literacy.
        Fam Med. 2004; 36: 588-594
        • Jerant A.F.
        • Kravitz R.L.
        • Rooney M.
        • Amerson S.
        • Kreuter M.W.
        • Franks P.
        Effects of a tailored interactive multimedia computer program on determinants of colorectal cancer screening: a randomized controlled pilot study in physician offices.
        Patient Educ Couns. 2007; 66: 67-74
        • Frosch D.L.
        • Legare F.
        • Mangione C.M.
        Using decision aids in community-based primary care: a theory-driven evaluation with ethnically diverse patients.
        Patient Educ Couns. 2008; 73: 490-496
        • Griffith J.M.
        • Lewis C.L.
        • Brenner A.T.
        • Pignone M.P.
        The effect of offering different numbers of colorectal cancer screening test options in a decision aid: a pilot randomized trial.
        BMC Med Inform Decis Mak. 2008; 8 (-4): 4
        • Cronan T.A.
        • Devoscomby L.
        • Villalta I.
        • Gallagher R.
        Ethnic differences in colorectal cancer screening.
        J Psychosoc Oncol. 2008; 26: 63-86
        • 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
        • Ruffin M.Tt
        • Fetters M.D.
        • Jimbo M.
        Preference-based electronic decision aid to promote colorectal cancer screening: results of a randomized controlled trial.
        Prev Med. 2007; 45: 267-273
      3. Brown A. U.S. Hispanic and Asian populations growing, but for different reasons. Facttank. Published June 26, 2014. Accessed September 17, 2015.