Cost, convenience main barriers to colonoscopy screening for CRC

Perceived barriers to healthcare, such as cost and inconvenience, discourage patients with positive faecal immunochemical test (FIT) results from undergoing follow-up colonoscopy for colorectal cancer (CRC) screening, according to a recent Singapore study.

“Our study … identified key factors that could help guide subsequent interventions to improve compliance in these higher risk individuals who are tested positive on FIT and yet not compliant to colonoscopy,” the researchers said.

The researchers enrolled 394 participants (median age 66 years, 53,8 percent men) who tested positive on FIT. Qualitative, semi-structured interviews followed by locally validated questionnaires were prospectively administered over the phone. Information extracted include sociodemographic factors, knowledge of CRC and CRC screening, and health behaviours.

All participants had been referred for follow-up colonoscopy evaluation, but only 50.8 percent (n=200) attended and were designated as the doer group; those who opted to not undergo further screening were designated as nondoers. [Cancer Med 2021;doi:10.1002/cam4.4275]

Quantitative analysis of questionnaire responses showed that most participants (80.2 percent) were aware that CRC was among the top 3 cancers in Singapore. Moreover, 73.9 percent and 84.3 percent knew that changes in bowel habits and presence of blood in stool were symptoms. Awareness of the common sources for CRC screening information was likewise high.

In terms of health behaviours, most participants were aware of the perceived severity of CRC leading to death (84.8 percent) and suffering (91.6 percent). Doers were more than twice as likely to believe that CRC would affect their work.

Notably, neither denial over a diagnosis nor fear posed barriers to colonoscopy evaluation. Instead, costs and convenience emerged as more important factors. For instance, nondoers were significantly more likely to perceive CRC as an expensive disease to treat (adjusted odds ratio [OR], 2.15, 95 percent confidence interval [CI], 1.1–4.2; p=0.026).

Similarly, nondoers were more than thrice as likely to agree that seeing a doctor to undergo CRC screening was inconvenient (adjusted OR, 3.44, 95 percent CI, 1.5–7.89; p=0.004).

In qualitative analysis, three main themes emerged, which served to validate the quantitative findings. First, participants showed high levels of CRC awareness. Doers tended to be more aware, saying that regular calls and reminders were unnecessary as they already had the information they needed. Nondoers, on the other hand, appreciated such reminders.

Second, personal motivation was the most important driving factor behind health-seeking behaviours. Participants said that the value of their lives was the main reason they sought medical advice, and that they were not deterred by the fear of a diagnosis or the embarrassment of the procedure. Costs also factored heavily into their decision to see a doctor.

Finally, participants emphasized the importance of social support and professional advocacy, saying that these are important to highlight in public outreach to improve CRC awareness and screening compliance.

“Engagement of family and close friends and re-evaluating the internal processes may be helpful to increase compliance towards completing CRC screening in these higher risk individuals,” the researchers said. “Ultimately, a higher CRC screening compliance rate in any community will enable earlier detection and treatment of CRC and reduce overall healthcare and social burdens for any country.”