Patient, Clinician, and Communication Factors Associated With Colorectal Cancer Screening

Alex H. Krist, MD, MPH; Camille J. Hochheimer, PhD; Roy T. Sabo, PhD; Jon Puro, MHA; Eric Peele; Paulette Lail-Kashiri, MPH; Sally W. Vernon, PhD


J Am Board Fam Med. 2020;33(5):779-784. 

In This Article

Abstract and Introduction


Introduction: Screening for colorectal cancer is beneficial. Yet, screening remains suboptimal, and underserved populations are at greater risk for not being appropriately screened. Although many barriers to screening are understood, less is known about how the decision-making process on whether to receive colonoscopy or stool testing influences screening.

Methods: As part of a randomized controlled trial to test engaging underserved populations in preventive care through online, personalized, educational material, 2417 patients aged 50 to 74 years were randomly selected from the 70,998 patients with an office visit the year prior and mailed a survey to assess decision-making for colorectal cancer screening. Twenty practices in practice-based research networks from 5 diverse states participated. Survey data were supplemented with electronic health record data.

Results: Among respondents, 64% were or became up to date with screening within 3 months of their office visit. The main factor associated with being up to date was the length of the patient-clinician relationship (<6 months vs 5+ years: odds ratio [OR], 0.49; 95% CI, 0.30–0.80). Sharing the decision about screening options with the clinician was a predictor for being up to date compared with patients who made the decision for themselves (OR, 1.75; 95% CI, 1.27–2.44). Only 36% of patients reported being given a choice about screening options. Traditional factors like race, employment, insurance, and education were not associated with screening.

Conclusions: Having a long-term relationship with a primary care clinician and sharing decisions may be key drivers to ensure evidence-based preventive care for underserved populations.


Colorectal cancer screening saves lives; yet, less than two-thirds of Americans who should be screened are up to date with screening.[1] Minorities, individuals living in poverty, uninsured, and Medicaid beneficiaries disproportionately suffer greater morbidity and mortality from colorectal cancer.[2] Although there is some debate as to whether biologic factors contribute to disparities in colorectal cancer outcomes for minorities, there is clear evidence that a lack of screening, delays in starting screening, inadequate follow-up of abnormal results, and treatment delays are all factors.[3,4] Accordingly, a major focus of care has been to ensure that all adults age 50 to 74 years complete colon cancer screening.

Top barriers to screening include not knowing that screening is indicated, not being told by a clinician to be screened, financial concerns, misconceptions on benefits and harms of screening, fear about finding cancer, and test-specific barriers (eg, not wanting to handle stool or not wanting to do a bowel preparation).[5] Interventions such as one-on-one education, clinician and patient alerts and reminders, reduced out-of-pocket expenses, and reduced structural barriers have all been shown to increase screening rates.[6]

Although the barriers to screening are well documented and there are interventions to promote screening, less is known about the relative importance of patient, clinician, health system, and communication factors associated with recommended screening, particularly for more underserved populations. Knowing the relative importance of these barriers may help to inform which interventions should be prioritized for implementation.