The CIHR/CancerCare Manitoba Team in Primary Care Oncology Research is based in Winnipeg, Manitoba, Canada and is one of five Canadian Institutes of Health Research (CIHR) Primary Care Oncology New Emerging Team (PCO-NET) grant recipients (Additional file 1). The focus of our research is to investigate ways of supporting community-based family physicians in providing colorectal cancer services throughout the care continuum. We are a multi-disciplinary team of stakeholders and knowledge users including primary healthcare researchers, practitioners, policy and decision makers, and patients. The purpose of this team is to develop research initiatives that support evidence-based primary care oncology clinical practice, thus providing access to high quality cancer care.
Each week, approximately 430 Canadians will be diagnosed with colorectal cancer (CRC) and 175 will die of the disease, making it the second leading cause of cancer related death in Canada . In Manitoba, CRC is the third most commonly diagnosed cancer (with an estimated 810 new cases in 2011) and the second leading cause of death from cancer in men and women combined (with an estimated 320 deaths in 2011) . Colorectal cancer (CRC) screening rates for average risk individuals are sub-optimal in across Canada and in Manitoba . Self-reported data from Manitobans indicates that approximately 38% of eligible individuals have completed an FOBT in the past two years . This figure is close to that reported by Statistics Canada (2009) indicating FOBT screening rates for Manitobans of 41.9% . Increased screening would reduce the physical, emotional and economic burden of CRC. It has been estimated that if approximately 70% of Canadians aged 50 to 74 completed an FOBT every two years, followed up by colonoscopy for positive FOBTs, the CRC mortality rate could be reduced by 17% [4–6].
Ninety three percent of all cases of CRC occur in those over the age of 50 and the incidence rate of the disease is expected to increase by 20% by 2025 [1, 7]. CRC is a silent disease with overt symptoms not usually occurring until an advanced stage . Early detection and treatment is vital in reducing the disease impact because survival decreases with increasing stage of disease at diagnosis . Randomized control trials have shown that screening using the FOBT can reduce mortality from CRC by 25% . A number of Canadian organizations have outlined CRC screening recommendations emphasizing FOBT at least every two years for average risk men and women between 50 to 74 years of age [1, 11–14].
In Manitoba, patients may access FOBT screening through one of two routes: (1) a population-based screening program (ColonCheck) in Manitoba promotes screening through direct mailing, distribution at mammography clinics, the Mobile Breast Screening Program, publicity campaigns) but is not yet available to all Manitobans, and (2) Family physicians (FPs) which are the second access point to screening with an FOBT. The complexities of clinical practice and time constraints of the FP impact on the time available to adequately address all health concerns during the periodic health examination, especially prevention and screening . Today, family physicians are responsible for caring for patients with increasingly complex multiple morbidities [16, 17] and face challenges in addressing health promotion within the time constraints of clinical practice. Practitioners may also have insufficient time to access current evidence-based research findings and guidelines to support them in their CRC screening efforts , making knowledge translation activities between researchers and practitioners a vital component of the protocol objectives in the context of primary care research.
Tools that support family physicians in providing their patients with CRC screening information and support them in completing the test may prove useful in improving FOBT uptake among patients. In clinical practice, patients are usually given the FOBT through a laboratory requisition at their periodic health examination (PHE), provided the FOBT card from the physician’s support staff, or given it directly by their family physician and instructed to return it to the laboratory after they have completed it (unpublished observations; KC).
The first point of contact for a majority of patients seeking healthcare is with a community-based family physician. Family physicians play a key role in quality healthcare delivery, including CRC screening . Manitobans depend on their family physicians to inform them of the need for FOBT testing in the prevention of CRC . Physicians estimate it takes approximately four minutes to do a good job of explaining CRC and relevant screening options . This represents between 27 and 40% of the total time available during the periodic health examination. In 2005, a study by Stokamer et al. demonstrated an increase in FOBT compliance from 51.3% to 65.9% using intensive one-on-one CRC education by registered nurses that took an additional 4.6 minutes beyond the time of standard CRC screening patient education (consisting of written instructions for the FOBT and verbal instruction to return the completed test within two weeks) . Family physicians require supportive tools to facilitate FOBT recommendation and compliance among their patients to improve overall FOBT screening rates. Research is required to identify innovative methods of supporting family physicians in their role in CRC screening. Developing strategies aimed at supporting both the primary care provider as well as their patients has the potential to lead to substantial improvements in FOBT screening rates. Patient education about CRC and the importance of screening has been demonstrated to improve patient knowledge and compliance with FOBT [20, 21]. Substantial improvements in FOBT completion rates have been demonstrated by studies that emphasized the importance of the FOBT, increased patient confidence in their ability to complete the FOBT, taught patients how to do the test, and provided time for patients to ask and receive answers to their individual questions about CRC and the FOBT . Intervention strategies resulting in higher completion rates commonly involve one-on-one patient contact in clinics by registered nurses which is costly, time consuming , and uncommon in most community-based fee-for-service clinical practices in Manitoba. It may be more cost-effective to utilize a less expensive strategy, specifically a telephone support line managed by registered nurses. Another alternative may also involve access to a website with CRC information and FOBT assistance for patients. Although personalized emails from a physician reminding patients to undergo CRC screening and provided a link to a webpage with information about CRC did not improve FOBT compliance among patients , a multimedia educational computer program was demonstrated to be as effective as usual nurse counseling in educating patients and achieving adherence to FOBT screening .
Both patients and family physicians seem to be involved in a complex scenario resulting in sub-optimal colorectal cancer screening rates. There has been progress in patient awareness of colorectal cancer and the importance of screening . A number of unique barriers to FOBT screening remain which lead to poor patient compliance . In 2008, a colorectal cancer screening survey of 2,230 Manitobans aged 50 to 74 years demonstrated that only 26% had an FOBT within the previous year . Factors identified by patients in the survey as contributing to low uptake among those eligible for CRC screening included: i) lack of knowledge about CRC and understanding of the significance and role of CRC screening in preventing and detecting the disease ; ii) lack of familiarity with the purpose of the FOBT; (iii) barriers associated with the test itself including the instructions for performing the FOBT [24, 25] and iv) perception that the required collection of stool samples is an unpleasant task . Additional reasons given by patients for not completing the FOBT included that: i) they didn’t think it was really needed or necessary (19%); ii) they thought the test sounded complicated (3%); iii) they didn’t really understand the test and why they should do it; iv) they did not want to handle stool (3%); and v) they meant to but didn’t think about it or forgot (3%) . The survey also revealed that of those provided with an FOBT, 10% did not complete it. Among the reasons for completing an FOBT test, 79% of Manitobans surveyed said that it was included as part of a routine physical check-up or screening. Among those who did not do the test, 75% said it was because their doctor did not suggest it. This highlights the impetus and objectives of the protocol, to address the constraints of clinical practice and support family physicians in initiating CRC screening with their patients while at the same time, promoting patient understanding of the disease and the desire to take action and complete the test.
This protocol addresses the importance of promoting understanding of the FOBT among patients as well as their level of awareness, knowledge and education about CRC and screening practices. At the same time, it addresses the time constrains encountered by family physicians in adequately addressing CRC screening with their patients.
The patient decision aid used in this protocol is based on the Health Belief Model in that patient health prevention behaviors are largely determined by perceived susceptibility and seriousness of a health threat or personal risk , the patients’ consideration of benefits and barriers to action, including adequacy of information to cue action and self-efficacy or confidence in the ability to successfully take action . Patient barriers to FOBT compliance are consistent with the Health Belief Model as they include limited accurate knowledge and understanding of CRC and screening tests for CRC, low perception of personal risk for CRC in the average-risk population, inconvenience, aversion to stool testing, lack of confidence in the ability to do the FOBT, the perception that the FOBT is time consuming, and fear of the consequences of screening [18, 20].
In 2009, 66% of Canadians 45 years and older went online and represent an age group that is typically slower to adapt to and use the internet . In 2010, 77.1% of Canadians had home internet access compared to 73% of Manitobans. Among those using the internet from home, approximately 75% went online every day in a typical month and 70% searched for medical or health related information online . Seventy-four percent of females searched for information about health or medical conditions compared to 66.7 of men. In 2009, 71.6% of at home internet users were between 35–54 years of age compared to 69.1% of those 55–64 years, and 65.9% of those 65 years and older . In 2010, 80% of individuals between the ages 45–64 used the internet compared to approximately 51% aged 65–74 and 27% aged 75 years and older. Household income quartile as well as urban versus rural community internet access are factors influencing internet use . The role of the internet in assisting with and supporting positive health promotion behaviors in Manitoban’s age 50–74 years of age is currently unknown. Findings from the study outlined by this protocol will illuminate whether the internet is a possible medium for consideration as a means to support community-based family physicians in improving colorectal cancer screening of their patients.