What determines individuals’ preferences for colorectal cancer screening programmes? A discrete choice experiment

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Abstract

Introduction

In many countries uptake of colorectal cancer (CRC) screening remains low.

Aim

To assess how procedural characteristics of CRC screening programmes determine preferences for participation and how individuals weigh these against the perceived benefits from participation in CRC screening.

Methods

A discrete choice experiment was conducted among subjects in the age group of 50–75 years, including both screening-naïve subjects and participants of a CRC screening programme. Subjects were asked on their preferences for aspects of CRC screening programmes using scenarios based on pain, risk of complications, screening location, preparation, duration of procedure, screening interval and risk reduction of CRC-related death.

Results

The response was 31% (156/500) for screening-naïve and 57% (124/210) for CRC screening participants. All aspects proved to significantly influence the respondents’ preferences. For both groups combined, respondents required an additional relative risk reduction of CRC-related death by a screening programme of 1% for every additional 10 min of duration, 5% in order to expose themselves to a small risk of complications, 10% to accept mild pain, 10% to undergo preparation with an enema, 12% to use 0.75 l of oral preparation combined with 12 h fasting and 32% to use an extensive bowel preparation. Screening intervals shorter than 10 years were significantly preferred to a 10-year screening interval.

Conclusion

This study shows that especially type of bowel preparation, risk reduction of CRC related death and length of screening interval influence CRC screening preferences. Furthermore, improving awareness on CRC mortality reduction by CRC screening may increase uptake.

Introduction

Colorectal carcinoma (CRC) is the second most frequently occurring malignancy in the European Union (EU), and the second leading cause of cancer-related death in the Western world.1 A recent study demonstrates that for many European countries CRC mortality rates are decreasing while incidence is rising, suggesting an increasing CRC prevalence.2 CRC screening is effective in reducing CRC mortality.3, 4, 5, 6, 7, 8, 9, 10, 11 Screening can reduce CRC mortality by early detection of CRC and endoscopic removal of premalignant precursors of CRC (adenomas).5, 11, 12 There are several methods available for CRC screening. The various types of faecal occult blood tests (FOBTs) primarily aiming at the early detection of CRC, whereas endoscopic screening tests (flexible sigmoidoscopy (FS), colonoscopy) are effective at both early detection and removal of premalignant lesions.12 Different screening methods are expected to have a different impact on CRC mortality reduction due to these differences in preventive potential. CRC screening methods also differ with respect to procedural characteristics, which determine the subject’s burden of a screening method. CRC screening methods perceived as the most burdensome (FS, colonoscopy) also have the largest potential for prevention of CRC.12 Currently, insufficient evidence is available to recommend one screening method over another.

Attendance is an important determinant of the effectiveness of CRC screening programmes. Uptake of CRC screening in a pilot screening programme in the Netherlands has remained lower than uptake of breast and cervical cancer screening.13, 14, 15 In many other countries, uptake of CRC screening, as well as continuing adherence to CRC screening, has also remained suboptimal.3, 4, 13, 16, 17, 18 It has been established that increasing colorectal cancer screening uptake, in comparison with other targets, has a large potential for reducing CRC-related mortality.19 Attendance rates depend on the willingness of individuals to undergo a certain screening test. This willingness may be influenced by perceived advantages and drawbacks of CRC screening tests and furthermore, by knowledge and awareness of CRC, CRC risk and CRC screening.18, 20, 21 Individuals may be willing to undergo a screening test despite several drawbacks in order to maximise health benefit or vice versa (to accept a lower health benefit in order to avoid several burdensome test characteristics). To optimise a CRC screening programme it is of paramount importance to gain insight in factors that influence population preferences for CRC screening programmes, and the trade-offs individuals are willing to make between benefits and drawbacks of a CRC screening programme. Research has shown that patient preferences can have a major impact on their willingness to use services and furthermore, there is an increasing emphasis on involvement of patients in health care decisions.22

This study therefore investigated preferences for CRC screening using a discrete choice experiment (DCE). DCE is a survey methodology with its origin in market research. DCEs are widely used for the assessment of preferences in transport and environmental economics and in marketing research.23 They are increasingly used for health care purposes.24, 25

It has been demonstrated that awareness of CRC and CRC screening in the Netherlands has remained low.21 There is currently no organised CRC screening programme in the Netherlands, except for hereditary or familial CRC. A similar situation is encountered in many countries in the EU, in fact, only approximately 50% of the target population is offered any type of screening for CRC. It is of particular importance to study preferences in a screening-naïve population, since they may guide the introduction and adjustment of new CRC screening programmes in these countries.

The aim of our study was to determine how procedural characteristics of various CRC screening methods determine preferences for participation, and how individuals weigh these against the expected health benefits from CRC screening. We compared the relative importance of aspects of the three most commonly used CRC screening tests: FOBT, FS and colonoscopy.

Section snippets

Study population

We conducted the study in two groups. The first group included a total of 500 screening-naïve individuals aged 50–74 years old who were randomly selected from the population registry of the region Rijnmond in the Southwest of the Netherlands. The region includes Rotterdam and surrounding suburbs and harbours 338,000 inhabitants in the target age groups. The second group included 210 participants of a randomised screening trial for CRC in the Netherlands from the same target population as

Respondents

The response rate was higher among CRC screening participants (59%; 124/210) than screening-naïve individuals (31%; 156/500) (Fig. 2, Table 2). The characteristics of the respondents are shown in Table 2. Among the screening-naïve group, 22% had undergone an endoscopy in the past. Within the group of CRC screening participants, 53% had previous endoscopy experience including 22% (16/72) of FOBT screenees and logically all FS screening subjects (48/48).

DCE results

Forty-three percent of the screening-naïve

Discussion

Our study demonstrates the importance of several procedural characteristics of CRC screening programmes for the preferences of potential and actual screenees: risk reduction of CRC-related death, preparation for the procedure, procedure-related pain and complications and screening interval. To optimise a screening programme, the attendance rate should be high. A high attendance rate is only possible when the utilised screening strategy and the information given connect with the preferences of

Conflict of interest statement

None declared.

Acknowledgement

This study was supported by grants from the Koningin Wilhelmina Fonds (EMCR 2008-4117 and EMCR 2006-3673).

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