Older adults given personalized information about the benefits and risks of screening for colorectal cancer (CRC) were more likely to receive screening orders that were more aligned with benefit, a cluster randomized trial of U.S. veterans showed.
Across two VA facilities involving 431 patients, 62.8% of those who received a multilevel intervention of personalized information were given screening orders within 2 weeks of their visit compared with 65.9% of control patients (adjusted difference -4.0 percentage points, 95% CI -15.4 to 7.4), reported Sameer Saini, MD, of the LTC Charles S. Kettles VA Healthcare System in Ann Arbor, Michigan, and colleagues in JAMA Internal Medicine.
In a prespecified interaction analysis, the proportion of patients receiving orders was lower in the intervention group versus the control group for those in the lowest-benefit quartile (59.4% vs 71.1%), and was higher in the intervention group compared with the control group for those in the highest-benefit quartile (67.6% vs 52.2%; interaction P=0.049).
Furthermore, fewer patients in the intervention group underwent screening at 6 months after their clinic visit compared with controls (41.4% vs 55.9%; adjusted difference -13.4 percentage points, 95% CI -25.3 to -1.6).
Although routine screening for CRC is recommended for most people from the ages of 45 through 75, its benefits are not uniform over this age range.
“In particular, as an individual gets older, acquires health problems, and has negative CRC screening test results, the benefit of screening for that individual decreases, and the potential harm increases,” Saini and team wrote, noting that there is currently no patient-centered approach that can help guide patients and physicians with decision making on screening when there are competing health issues.
Aasma Shaukat, MD, MPH, of the NYU Grossman School of Medicine in New York City, told MedPage Today that Saini and colleagues “did a thorough job at designing the educational intervention.”
She noted that a personalized informational booklet “might be another tool that primary care physicians may use, in addition to their own tools or ways of discussing shared decision making depending on their patient population.”
“This is an important study to understand if providing information about age and related risks and benefits of colonoscopy helps improve bringing patients to colonoscopy that are likely to benefit,” she said. “One caveat is that [the study] was done only in veterans, and generalizability needs to be studied. Also, patients 76 and older were not included.”
For this parallel unmasked study, Saini and colleagues included 431 U.S. veterans ages 70 to 75 years attending a primary care visit at an academic VA medical center or one of its connected outpatient clinics from November 2015 to February 2019. All patients were at average risk for CRC and were due for screening.
The intervention group received a detailed decision-aid booklet on the benefits and harms of screening that had information personalized to the patient’s age, sex, prior CRC screening, and comorbidities. Patients in the control group received a booklet with information about screening that was not personalized for them. All participants received primary care physician education and system-level modifications to support personalized screening.
The mean age of patients was 71.5 years, 98.4% were men, and 86.8% were white. Although 21.5% of these patients were college graduates, nearly 30% were considered to have limited health literacy. Of these patients, 81.4% had undergone prior screening, with 78.6% having undergone prior fecal immunochemical testing.
A total of 258 (59.9%) participants were randomized to the intervention, and 173 (40.1%) were assigned to the control group. A total of 102 primary care physicians were invited to participate; all agreed and were randomized to a study group. Most (76.1%) were attending physicians.
Saini and colleagues noted that their findings may not be generalizable to a broader population, since their study included mostly white men.
The study was funded by grants from the VA Health Services Research and Development Center and the National Cancer Institute.
Saini reported grants and nonfinancial support from the Department of Veterans Affairs. Co-authors also reported relationships with the VA and the NIH.
JAMA Internal Medicine
Source Reference: Saini SD, et al “Personalized multilevel intervention for improving appropriate use of colorectal cancer screening in older adults: a cluster randomized clinical trial” JAMA Intern Med 2023; DOI: 10.1001/jamainternmed.2023.5656.