A National Survey of Primary Care Physicians' Methods for Screening for Fecal Occult Blood

  1. Marion R. Nadel, PhD;
  2. Jean A. Shapiro, PhD;
  3. Carrie N. Klabunde, PhD;
  4. Laura C. Seeff, MD;
  5. Robert Uhler, MA;
  6. Robert A. Smith, PhD; and
  7. David F. Ransohoff, MD
  1. From Centers for Disease Control and Prevention and American Cancer Society, Atlanta, Georgia; National Cancer Institute, Bethesda, Maryland; and University of North Carolina at Chapel Hill, Chapel Hill, North Carolina.

    Abstract

    Background: Screening with the fecal occult blood test (FOBT) has been shown to reduce colorectal cancer incidence and mortality in randomized, controlled trials. Although the test is simple, implementation requires adherence to specific techniques of testing and follow-up of abnormal results.

    Objective: To examine how FOBT and follow-up are conducted in community practice across the United States.

    Design: Cross-sectional national surveys of primary care physicians and the public.

    Setting: The Survey of Colorectal Cancer Screening Practices in Health Care Organizations and the 2000 National Health Interview Survey.

    Participants: 1147 primary care physicians who ordered or performed FOBT and 11 365 adults 50 years of age or older who responded to questions about FOBT use.

    Measurements: Self-reported data on details of FOBT implementation and follow-up of positive results.

    Results: Although screening guidelines recommend home tests, 32.5% (95% CI, 29.8% to 35.3%) of physicians used only the less accurate method of single-sample in-office testing; another 41.2% (CI, 38.3% to 44.0%) used both types of test. Follow-up of positive test results showed considerable nonadherence to guidelines, with 29.7% (CI, 27.1% to 32.4%) of physicians recommending repeating FOBT. Furthermore, sigmoidoscopy, rather than total colon examination, was commonly recommended to work up abnormal findings. Nearly one third of adults who reported having FOBT said they had only an in-office test, and nearly one third of those who reported abnormal FOBT results reported no follow-up diagnostic procedures.

    Limitations: The study was based on self-reports. Data from the National Health Interview Survey may underestimate the prevalence of in-office testing and inadequate follow-up.

    Conclusions: Mortality reductions demonstrated with FOBT in clinical trials may not be realized in community practice because of the common use of in-office tests and inappropriate follow-up of positive results. Education of providers and system-level interventions are needed to improve the quality of screening implementation.

    Article and Author Information

    • Grant Support: By the National Cancer Institute (contract no. N01-PC-85169) and the Centers for Disease Control and Prevention (interagency agreement no. 99FED06571).

    • Potential Financial Conflicts of Interest: Consultancies: D.F. Ransohoff (EXACT Sciences Corp. until 2002).

    • Requests for Single Reprints: Marion Nadel, PhD, Centers for Disease Control and Prevention, 4770 Buford Highway, Mailstop K-55, Atlanta, GA 30341-3717; e-mail, mrn1{at}cdc.gov.

    • Current Author Addresses: Drs. Nadel, Shapiro, and Seeff and Mr. Uhler: Centers for Disease Control and Prevention, 4770 Buford Highway, Mailstop K-55, Atlanta, GA 30341-3717.

    • Dr. Klabunde: National Cancer Institute, EPN 4005, 6130 Executive Boulevard, Bethesda, MD 20892.

    • Dr. Smith: American Cancer Society, 1599 Clifton Road, Atlanta, GA 30329-4251.

    • Dr. Ransohoff: School of Medicine, University of North Carolina at Chapel Hill, CB#7080, Room 326 Burnett-Womack Building, Chapel Hill, NC 27599-7080.

    • Author Contributions: Conception and design: M.R. Nadel, J.A. Shapiro, C.N. Klabunde, L.C. Seeff, R. Uhler, D.F. Ransohoff.

    • Analysis and interpretation of the data: M.R. Nadel, J.A. Shapiro, C.N. Klabunde, L.C. Seeff, R. Uhler, D.F. Ransohoff.

    • Drafting of the article: M.R. Nadel, J.A. Shapiro, R.A. Smith.

    • Critical revision of the article for important intellectual content: M.R. Nadel, J.A. Shapiro, C.N. Klabunde, L.C. Seeff, R. Uhler, R.A. Smith, D.F. Ransohoff.

    • Final approval of the article: M.R. Nadel, J.A. Shapiro, C.N. Klabunde, L.C. Seeff, R.A. Smith, D.F. Ransohoff.

    • Provision of study materials or patients: C.N. Klabunde.

    • Statistical expertise: M.R. Nadel, R. Uhler.

    • Obtaining of funding: M.R. Nadel, C.N. Klabunde.

    • Administrative, technical, or logistic support: M.R. Nadel, C.N. Klabunde.

    • Collection and assembly of data: C.N. Klabunde, R. Uhler.

    Summary for Patients

    • Summaries for Patients:Use of Colorectal Cancer Screening by Doctors in Practice Ann Intern Med January 18, 2005 142:I-26
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    1. Ann Intern Med January 18, 2005 vol. 142 no. 2 86-94
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