Improving Knowledge, Risk Perception, and Risk Communication Among Colorectal Adenoma Patients

Colorectal cancer (CRC) is the third leading cause of cancer-related mortality in the United States.  It is estimated that in 2010, there were 102,900 new cases of colon cancer, 39,670 new cases of rectal cancer, and 51,370 deaths related to colon and rectal cancer combined.  Screening is a cost-effective yet underused strategy for reducing CRC mortality and incidence.  Colorectal cancer almost always develops from precancerous polyps (abnormal growths) in the colon or rectum.  Precancerous polyps can be found through screening tests so that they can be removed before they turn into cancer.  Screening tests can also find colorectal cancer early, when treatment works best.  

Current data suggest that the first-degree relatives (FDR) of patients with colorectal adenomas, especially those diagnosed before age 60 or those with advanced pathology, may be at increased risk of CRC at an earlier age and hence more likely to benefit from screening than individuals at average risk.  As many as one in five people who develop CRC have other family members who have been affected by this disease.  Consequently, for individuals with FDRs diagnosed at a young age (before age 60), the U.S. Preventive Services Task Force (USPSTF) suggests an earlier start to screening than after age 50.  Effective risk communication between providers and their patients, and among the affected patient's family members will help to improve screening rates among those at familial risk of CRC. 

The computer-based educational program (CBEP) was developed for patients found to have adenomatous polyps during a colonoscopy.  The program aims to heighten awareness of the personal and familial implications of the diagnosis and to improve risk communication to first-degree relatives.  The CBEP is administered to patients after recovery from conscious sedation and before discharge home.  The intervention employs a PowerPoint presentation consisting of six screens of pictures and text.  The presentation uses colorful visual "cues" in the form of computer-based cartoons and actual endoscopic pictures of polyps with simple, yet informative captions to provide information concerning the following: (a) the two main types of colorectal polyps (adenomas and non-neoplastic hyperplastic polyps), (b) the relationship between adenomas and colorectal cancer, (c) the effectiveness of polypectomy for reducing colorectal cancer incidence, (d) the importance of surveillance, and (e) the need for communication with at-risk family members. 

In addition to the CBEP, a one-page personalized letter is employed to reinforce information presented during the "bedside" intervention and incorporate customized information on the basis of the patient's age, family history, and physician's recommendations for follow-up.  To heighten perceptions of susceptibility and effectiveness, the letter includes an endoscopic photograph of the patient's polyp, both pre-polypectomy and post-polypectomy.  The letter emphasizes that the polyp was an "adenoma" and that adenomas are "precancerous", reinforces the benefits of adenoma removal related to future cancer risk reduction and need for surveillance because of the risk of future adenomas, and provides follow-up recommendations regarding the timing of the surveillance colonoscopy.  The letter also reminds the recipient that first-degree family members have an increased risk of colorectal cancer and quantifies this risk for siblings and children on the basis of the patient's age and number of affected relatives, if any.  The personalized letter recommends to patients that they contact their first-degree relatives and encourage them to speak with their physicians about screening.

A few minutes are required to review the six PowerPoint slides and one-page personalized letter.

Individuals found to have adenomatous polyps during a colonoscopy represent the intended audience for this intervention.

This intervention is intended to take place at healthcare facilities that provide colonoscopies.

-- Bedside PowerPoint Intervention
-- Patient Letter

The study employed two intervention arms and one control arm with two levels of randomization.  Potential subjects were first assigned to either an intervention arm or control ("standard care") arm.  After recovery from conscious sedation and before discharge home, subjects in the intervention arm found to have a colorectal polyp participated in the CBEP.  Subjects who did not have a polyp were excluded from further analysis.  Once pathology of the polyp was available, subjects found to have an adenoma were randomly assigned after stratification by endoscopist to receive either a personalized letter or no additional intervention.  Patients pre-assigned to the standard care arm who were found to have adenomatous polyps at colonoscopy were identified on a monthly basis from the pathology department's computerized database.  All such patients were mailed a letter cosigned by their gastroenterologist within 4 weeks of their colonoscopy detailing the study and asking for their permission to participate in a follow-up telephone survey.  Approximately 3 months after enrollment, subjects from each study arm were contacted at home by telephone and asked to complete a brief survey, administered by a research assistant who was blinded to the subject's randomization status.  

The survey instrument assessed the following:

1. Patient's knowledge regarding colorectal cancer: included seven closed-ended knowledge items that tested the patient's recall of information described in the CBEP and highlighted in the personalized letter, including whether: polyps were abnormal growths; adenomas were precancerous; hyperplastic polyps were precancerous; adenoma patients were at increased risk of developing new adenomas; and parents, siblings, or children of adenoma patients were at increased risk of colorectal cancer.  The overall knowledge score could range from 0 to 7.
    
2. Patient's awareness of his or her own polyp's histology.
    
3. Perception of the patient's own and familial colorectal cancer risks: Patients were asked  whether they perceived themselves to be at higher, lower, or the same risk of getting another polyp or cancer than someone without polyps; and whether they perceived their parents, siblings, or children to be at higher, lower, or the same risk of colorectal cancer as the counterparts of someone without polyps.
    
4. The extent to which the patient communicated this risk to first-degree relatives: Patients were asked whether they had notified family members, and if so, whom and whether they recommended contacting the relatives' physicians to discuss their need for screening.  

Although 585 subjects began the study, data were collected on 315 male and female adenoma patients between the ages of 18 and 75 years (48.25% under the age of 60, 51.75% aged 60 or older).  The sample was 60.3% male; 61.9% White, 32.4% Black, and 5.7% Hispanic.

• Approximately 3 months after receiving a colonoscopy, adenoma patients assigned to the CBEP + personalized letter group had significantly higher mean composite knowledge scores than both the CBEP only group and the standard care group (p<.001).  There was no significant difference between the CBEP only group and the standard care group. 
  
   

• Approximately 3 months after receiving a colonoscopy, significantly more adenoma patients assigned to the CBEP + personalized letter group were aware their polyps were adenomatous (p<.001) as compared to patients in the CBEP only or standard care groups.  There was no significant difference between the CBEP only group and the standard care group. 
  
   

• Approximately 3 months after receiving a colonoscopy, significantly more adenoma patients assigned to the CBEP + personalized letter group perceived themselves to be at increased risk of both future adenomas (p=.009) and cancer (p=.006) and to perceive both their siblings (p=.001) and children (p=.001) at increased risk as compared to patients in the standard care group.  Risk perception was similar for the CBEP and standard care groups.
  
  
   

• Approximately 3 months after receiving a colonoscopy, significantly more adenoma patients assigned to the CBEP + personalized letter group reported they notified a first-degree relative of their diagnosis (p=.01) and recommended speaking to a physician about the need for screening (p=.003).  No significant differences for either outcome were observed between the CBEP and standard care groups.