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Risk Stratification to Promote Effective Shared Decision-Making for Colorectal Cancer Screening

This study has been completed.
Information provided by (Responsible Party):
Paul C Schroy, MD, MPH, Boston Medical Center Identifier:
First received: May 7, 2012
Last updated: November 10, 2016
Last verified: November 2016
Shared decision-making (SDM) has been advocated as a strategy for increasing colorectal cancer (CRC) screening rates. Our studies to date suggest that while the use of a novel computer-based decision aid facilitates several components of SDM from both the patient and provider perspective, there is a reluctance among providers to acquiesce to patient preferences for a particular screening strategy when its differs from their own. The overall objective of this study is to assess whether risk stratification for advanced colorectal neoplasia influences clinical decision-making related to screening test selection and adherence within a SDM framework. Eligible subjects will be randomized to either an experimental arm, in which they will be asked to complete a 6-item risk assessment questionnaire known as the "Advanced Colorectal Neoplasia Index [ACNI]" before reviewing a web-based decision aid, or a control arm, in which they will only review the decision aid. Both interventions will take place just before a prearranged office visit with their provider. The primary outcome will be screening test ordered; secondary outcomes will include test completion rates, value concordance, patient satisfaction with decision-making process and provider satisfaction. Outcomes will be evaluated using computerized tracking systems or validated instruments.

Condition Intervention
Colorectal Cancer
Behavioral: Risk Assessment

Study Type: Interventional
Study Design: Allocation: Randomized
Intervention Model: Parallel Assignment
Masking: Open Label
Primary Purpose: Health Services Research
Official Title: Impact of Risk Stratification on Shared Decision-Making for Colorectal Cancer Screening

Resource links provided by NLM:

Further study details as provided by Boston Medical Center:

Primary Outcome Measures:
  • Concordance between patient and provider test preferences [ Time Frame: 3 months ]

Secondary Outcome Measures:
  • Test-specific concordance for high vs. low risk patients [ Time Frame: 3 months ]
  • Satisfaction with decision-making process [ Time Frame: One month ]
  • Screening intentions [ Time Frame: 3 months ]
  • Screening test completion [ Time Frame: 6 months ]
  • Provider satisfaction [ Time Frame: Two years ]

Enrollment: 341
Study Start Date: April 2012
Study Completion Date: June 2016
Primary Completion Date: February 2016 (Final data collection date for primary outcome measure)
Arms Assigned Interventions
No Intervention: Standard Care
Subjects randomized to the control arm reviewing the web-based decision aid ( prior to a scheduled visit with their provider.
Experimental: Risk Assessment
Subjects randomized to the experimental arm will complete the ACNI risk assessment tool and then reviewing the web-based decision aid ( prior to a scheduled office visit with their provider.
Behavioral: Risk Assessment
Patients randomized to the experimental arm will be asked a complete the ACNI risk assessment tool after reviewing a web-based colorectal cancer decision aid The ACNI uses a point based system to stratify patients into low (mean rate of ACN ~3%)versus intermediate/high (~ 8%) risk groups based on responses to 6 items: age, sex (male/female), race/ethnicity (black, other), smoking history (never, <20 years, >20 years), daily alcohol intake (< 2 vs. >/=2 drinks) and use of non-steroidal anti-inflammatory drugs (ever, never).
Other Name: ACNI

Detailed Description:

Colorectal cancer (CRC) is the second leading cause of cancer-related death in the United States. Screening by any of at least 6 different methods is a cost-effective yet underutilized strategy for reducing both CRC incidence and mortality. Because these methods differ with respect to risks and benefits and because existing evidence fails to identify a single best strategy, most authoritative groups advocate a shared decision-making (SDM) approach when selecting an appropriate screening strategy. SDM is a sequential, interactive process involving information exchange, values clarification, decision-making and mutual agreement. To facilitate this process, patient-oriented decision aids have been developed to enable patients to identify a preferred strategy based on personal values and empower them to participate in the decision-making process. Our recent studies to date find that although decision aids enable patients to make informed choices, providers are often unwilling to acquiesce to patient preferences when they differ from their own. Since accurate risk assessment is a critical component of effective clinical decision-making, the investigators postulate that risk stratification for the point prevalence of advanced colorectal neoplasia will enable providers to incorporate objective risk-based criteria in their decision-making when considering patient preferences for screening. To that end, the investigators have recently developed and validated the so-called "Advanced Colorectal Neoplasia Index [ACNI]" that stratifies patients into low versus intermediate/high risk categories based on available clinical data, including age, sex, race/ethnicity, smoking history, daily alcohol intake and use of non-steroidal anti-inflammatory drugs. The overall objective of this study is to determine whether risk stratification using the ACNI influences clinical decision-making related to screening test selection and adherence to screening within a SDM framework.

Hypothesis: Providers who incorporate risk estimates of ACN in their decision-making when recommending screening tests are more likely to consider patient preferences for options other than colonoscopy than providers lacking this information.


Ages Eligible for Study:   50 Years to 75 Years   (Adult, Senior)
Sexes Eligible for Study:   All
Accepts Healthy Volunteers:   Yes

Inclusion Criteria:

  • English-speaking "average-risk" patients 50 to 75 years of age;
  • Due for CRC screening based on current recommendations (i.e. no prior screening or > 1year since last fecal occult blood testing [FOBT], > 3 years since last stool DNA test, > 5 years since last flexible sigmoidoscopy, virtual colonoscopy or double-contrast barium enema [DCBE], or > 10 years since last colonoscopy);
  • Under the direct care of a staff (attending) primary care provider or physician extender;
  • without major co-morbidities that preclude CRC screening.

Exclusion Criteria:

  • High-risk condition (personal history of colorectal cancer or polyps, family history of colorectal cancer or polyps involving one or more first degree relatives < 60 years of age, chronic inflammatory bowel disease);
  • Presence of "alarm" gastrointestinal symptoms, including rectal bleeding, recent change in bowel habits, abdominal pain, unexplained weight loss and iron deficiency anemia;
  • Comorbidities that preclude CRC screening by any method;
  • Lack of fluency in written and spoken English (since decision aid and personalized risk assessment tool will be in English only due to funding issues).
  Contacts and Locations
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Please refer to this study by its identifier: NCT01596582

United States, Massachusetts
Boston Medical center
Boston, Massachusetts, United States, 02118
Sponsors and Collaborators
Boston Medical Center
Principal Investigator: Paul C Schroy III, MD, MPH Boston Medical Center
  More Information

Responsible Party: Paul C Schroy, MD, MPH, BMC Attending Physician, Boston Medical Center Identifier: NCT01596582     History of Changes
Other Study ID Numbers: NCI-CA131197 
Study First Received: May 7, 2012
Last Updated: November 10, 2016

Keywords provided by Boston Medical Center:
Colorectal cancer screening
Shared decision-making
Patient preferences
Risk assessment
Advanced colorectal neoplasia

Additional relevant MeSH terms:
Colorectal Neoplasms
Intestinal Neoplasms
Gastrointestinal Neoplasms
Digestive System Neoplasms
Neoplasms by Site
Digestive System Diseases
Gastrointestinal Diseases
Colonic Diseases
Intestinal Diseases
Rectal Diseases processed this record on February 28, 2017