Patients' preferences and priorities regarding colorectal cancer screening

Abstract

Background: US colorectal cancer screening guidelines for people at average risk for colorectal cancer endorse multiple screening options and recommend that screening decisions reflect individual patient preferences.

Methods: The authors used the analytic hierarchy process (AHP) to ascertain decision priorities of people at average risk for colorectal cancer attending primary care practices in Rochester, New York; Birmingham, Alabama; and Indianapolis, Indiana. The analysis included 4 decision criteria, 3 subcriteria, and 10 options.

Results: Four hundred eighty-four people completed the study; 66% were female, 49% were African American, 9% had low literacy skills, and 27% had low numeracy skills. Overall, preventing cancer was given the highest priority (mean priority 55%), followed by avoiding screening test side effects (mean priority 17%), minimizing false-positive test results (mean priority 15%), and the combined priority of screening frequency, test preparation, and the test procedure(s) (mean priority 14%). Hierarchical cluster analysis revealed 6 distinct priority groupings containing multiple instances of decision priorities that differed from the average value by a factor of 4 or more. More than 90% of the study participants fully understood the concepts involved, 79% met AHP analysis quality standards, and 88% were willing to use similar methods to help make important health care decisions.

Conclusion: These results highlight the need to facilitate incorporation of patient preferences into colorectal cancer screening decisions. The large number of study participants able and willing to perform the complex AHP analysis used for this study suggests that the AHP is a useful tool for identifying the patient-specific priorities needed to ensure that screening decisions appropriately reflect individual patient preferences.

Figure 1. An example comparison

This figure shows the format used to make the AHP comparisons.

Figure 2. Major decision criteria and logistical sub-criteria priorities

Boxplots showing the ranges of priorities assigned to the major decision criteria and the logistical sub-criteria. Prevent Cancer represents the chance of developing colorectal cancer. Avoid Side Effects represents the chance of a serious side effect such as intestinal perforation or bleeding. False Positives represents the chance of a false positive screening test requiring follow-up tests. Logistics refers to the combined importance of the three sub-criteria: Frequency, the frequency of screening; Preparation, the preparation required for screening tests; and Procedure, the nature of the screening test(s). The central box shows the values in the interquartile range from the 25^th to 75^th percentile. The horizontal line within the box shows the median. The upper and lower vertical lines illustrate values larger and smaller than the 75^th percentile and 25^th percentiles plus or minus 1.5 times the inter-quartile range respectively. Separate points represent values beyond these limits.

Figure 3. Criteria priority clusters

Figure 3a illustrates the range of priorities for the major decision criteria within each of the six major criteria clusters. Figure 3b illustrates the range of priorities within each of the four logistical sub-criteria clusters. Prevent Cancer represents the chance of developing colorectal cancer. Avoid Side Effects represents the chance of a serious side effect such as intestinal perforation or bleeding. False Positives represents the chance of a false positive screening test requiring follow-up tests. Logistics refers to the combined importance of the logistical sub-criteria. Frequency refers to the frequency of screening; Preparation, to the preparation required for screening tests; and Procedure, to the nature of the screening test(s). The central box shows the values in the interquartile range from the 25^th to 75^th percentile. The horizontal line within the box shows the median. The upper and lower vertical lines illustrate values larger and smaller than the 75^th percentile and 25^th percentiles plus or minus 1.5 times the inter-quartile range respectively. Separate points represent values beyond these limits.

Figure 3. Criteria priority clusters

Figure 3a illustrates the range of priorities for the major decision criteria within each of the six major criteria clusters. Figure 3b illustrates the range of priorities within each of the four logistical sub-criteria clusters. Prevent Cancer represents the chance of developing colorectal cancer. Avoid Side Effects represents the chance of a serious side effect such as intestinal perforation or bleeding. False Positives represents the chance of a false positive screening test requiring follow-up tests. Logistics refers to the combined importance of the logistical sub-criteria. Frequency refers to the frequency of screening; Preparation, to the preparation required for screening tests; and Procedure, to the nature of the screening test(s). The central box shows the values in the interquartile range from the 25^th to 75^th percentile. The horizontal line within the box shows the median. The upper and lower vertical lines illustrate values larger and smaller than the 75^th percentile and 25^th percentiles plus or minus 1.5 times the inter-quartile range respectively. Separate points represent values beyond these limits.