Project Summary
This research project is in progress. PCORI will post the research findings on this page within 90 days after the results are final.
What is the research about?
Thousands of people in the United States die every year from colorectal cancer, or CRC, a condition that can be treated if found early through screening. One common screening method is colonoscopy, which uses a probe with a camera to view the colon from the inside. Another is stool testing, which looks for blood or changes in cells in a patient’s stool. Each test has different benefits and harms. For example, colonoscopy is an invasive test but it’s good at finding cancer and polyps that may turn into cancer. Stool tests are less invasive but not as good at finding polyps or cancer.
When patients know their risk of having cancer or a polyp that may turn into cancer, it can help them work with their providers to choose the screening test that’s right for them. For example, patients at high risk may prefer colonoscopy, which can remove polyps when they are found. Patients at low risk may prefer stool testing. Risk for cancer or polyps is based on factors such as the patient’s age and family history.
In this study, the research team is comparing ways of communicating with patients and clinicians about the patient’s risk of having cancer or a polyp that may turn into cancer. Each way uses a decision aid to present the patient’s risk. Decision aids help people choose between two or more options based on what is most important to them.
The research team wants to know how these approaches affect how patients make choices about CRC screening.
Who can this research help?
Results may help clinics considering ways to help doctors and patients make CRC screening decisions.
What is the research team doing?
The research team is recruiting 1,100 patients who are due for CRC screening. The team is dividing the patients into four groups at different clinics. They are assigning the groups by chance to receive information about CRC screening in one of four ways:
- Patients view an online decision aid with general information about CRC and the benefits and harms of colonoscopy and stool tests.
- Patients view the online decision aid plus a personalized message with an estimate of their risk for CRC.
- Patients view the online decision aid without the personalized message. Their provider receives an electronic health record, or EHR, message with an estimate of the patient’s risk.
- Patients view the online decision aid with the personalized message. Their provider receives an EHR message with an estimate of the patient’s risk.
After six months, the research team is checking patients’ EHRs to see if they received CRC screening, what type of screening they received, and whether they received their screening of choice. The team is also talking to patients to see if they made an informed choice about screening, how patients perceive their CRC risk, and if they felt conflicted about their choice. Healthcare system leaders, providers, and patients are helping to design and carry out this study.
Research methods at a glance
| Design Elements | Description |
|---|---|
| Design | Randomized controlled trial |
| Population | 1,100 individuals ages 50–75 from primary care clinics in central Indiana who are due for screening and have no high-risk family or personal history |
| Interventions/ Comparators |
|
| Outcomes |
Primary: screening uptake, decision quality Secondary: perceived CRC risk, decision conflict |
| 6-month follow-up for primary outcomes |
COVID-19-Related Study
How Did the COVID-19 Pandemic Affect Adult Cancer Screening in Two Indiana Health Systems?
Results Summary
In response to the COVID-19 public health crisis in 2020, PCORI launched an initiative to enhance existing research projects so that they could offer findings related to COVID-19. The initiative funded this study and others.
What was this COVID-19 study about?
Getting screened for cancer can help doctors find and treat cancer early. But at the start of the COVID-19 pandemic, most cancer screening stopped. Cancer screening has started again. But questions remain about how health system staff, doctors, and patients experienced these changes to cancer screening during the pandemic.
In this study, the research team wanted to learn how the COVID-19 pandemic affected cancer screening in two health systems in Indiana. The team interviewed health system staff, doctors, and patients about their experiences.
What were the results?
Changes in cancer screening during the pandemic.
Health system staff and doctors reported more use of telehealth visits or home care during the pandemic. Telehealth is a way to provide care to patients remotely using phone, video, or monitoring devices that can help manage care. For example, health systems moved to home-based stool test screening for patients with an average risk of colon cancer instead of in-person screening with colonoscopy.
Health system staff and doctors reported a few barriers to screening:
- No approaches in place to do cancer screening when they moved away from in-person visits
- Staffing shortages due to sickness, burnout, and staff finding other jobs
- Patients avoiding the doctor’s office because of fear of getting COVID-19
Patient experiences with cancer screening during the pandemic.
- Some patients felt encouraged by COVID-19 safety measures for cancer screening. Other patients didn’t. For example, wearing a mask made some patients feel anxious.
- Patients didn’t trust the information they received about COVID-19. Some patients said they did their own research to find COVID-19 information.
- Patients who didn’t get screened for cancer said they were more likely to wait to go to the doctor or didn’t go at all because of COVID-19.
Who was in the study?
This study included 20 staff and doctors who worked at two health systems in central Indiana. It also included 61 patients who were receiving care at these health systems and were due for breast, cervical, colorectal, or lung cancer screening. Of these patients, 54 percent were White, 39 percent were Black, and 7 percent identified as other races. The average age was 56, and 77 percent were women.
What did the research team do?
The research team interviewed health system staff between January 2021 and March 2022. They interviewed patients between August 2021 and February 2022.
Patients, community members, and health systems helped design the study.
What were the limits of the study?
The study took place in Indiana. Results may differ in other states.
How can people use the results?
Health system staff and doctors can use the results when considering how to provide cancer screening to patients during public health emergencies.
Professional Abstract
In response to the COVID-19 public health crisis in 2020, PCORI launched an initiative to enhance existing research projects so that they could offer findings related to COVID-19. The initiative funded this study and others.
Background
The COVID-19 pandemic disrupted cancer screening. Although screening has restarted, questions remain about how screening has changed since the onset of the pandemic, and the perspectives of patients and health systems about these changes.
Objective
(1) To identify the barriers to and facilitators of effective cancer screening and prevention during the COVID-19 pandemic from the perspectives of health system administrators, clinicians, and staff; (2) To identify patient knowledge, attitudes, and beliefs about cancer screening and prevention during the COVID-19 pandemic
Study Design
| Design Element | Description |
|---|---|
| Design | Mixed-methods study |
| Population | 20 health system administrators, clinicians, and clinical support staff; 61 adult patients due for breast, cervical, colorectal, or lung cancer screening who did or did not receive screening and received care at 2 health systems in Indiana |
| Outcomes | Barriers to and facilitators of cancer screening and prevention during the COVID-19 pandemic; patient knowledge, attitudes, and beliefs about cancer screening and prevention during the COVID-19 pandemic |
| Data Collection Timeframe | January 2021–March 2022 |
This mixed-methods study examined how the COVID-19 pandemic affected adult cancer screening in two health systems in Indiana.
Between January 2021 and March 2022, researchers conducted key informant interviews with 20 health system administrators, clinicians, and staff to identify the barriers to and facilitators of effective cancer screening and prevention during the COVID-19 pandemic.
Also, between August 2021 and February 2022, researchers conducted semi structured interviews with patients to identify patient knowledge, attitudes, and beliefs about cancer screening and prevention during the COVID-19 pandemic. The semi structured interviews included 61 patients who were due for breast, cervical, colorectal, or lung cancer screening within two health systems in central Indiana. Of these patients, 52% completed a screening in 2020; 54% were White, 39% were Black, and 7% identified as other races. The average age was 56, and 77% were female.
Researchers analyzed interview transcripts and identified themes.
Patients, community members, and health system representatives helped design the study.
Results
Healthcare system staff and clinicians shifted clinical services from in-person delivery to telehealth delivery during a statewide government shutdown. For example, colonoscopy screening for average-risk patients shifted to home-based stool test screening. Health system staff and clinicians reported a few barriers to screening:
- A lack of systemwide strategies to address cancer prevention and a lack of infrastructure for cancer screening during the government-ordered shutdown
- Clinical staffing shortages due to alternate employment opportunities, burnout, and COVID-19-related and other illnesses
- Patients who were afraid to get cancer screening due to COVID-19 concerns
In addition, patient surveys found that:
- Some patients felt reassured by COVID-19 precautions implemented by health systems, while other patients reported that precautions were a barrier to cancer screening.
- Patients reported that they did not trust information about COVID-19. Some patients said they did their own research to find COVID-19 information.
- Patients who did not receive cancer screening during the pandemic were more likely to report that they delayed or avoided medical care due to concerns related to COVID-19 (48% non-screened versus 16% screened; p=0.006).
Limitations
Researchers interviewed health system staff, clinicians, and patients in Indiana. Results may differ in other locations.
Conclusions and Relevance
This study described barriers and facilitators to cancer screening during the COVID-19 pandemic.
Peer Review Summary
The Peer-Review Summary for this COVID-19 study will be posted here soon.
Final Enhancement Report
This COVID-19 study's final enhancement report is expected to be available by February 2024.