Ethnic Differences in Patient Experiences With and Preferences for Computed Tomography Colonography and Optical Colonoscopy

CLINICAL GASTROENTEROLOGY AND HEPATOLOGY 2007;5:1306 –1312

Racial/Ethnic Differences in Patient Experiences With and Preferences for Computed Tomography Colonography and Optical Colonoscopy ROSHINI C. RAJAPAKSA,* MICHAEL MACARI,‡ and EDMUND J. BINI*,§ *Division of Gastroenterology, ‡Department of Radiology, New York University School of Medicine, New York, New York; and §Division of Gastroenterology, VA New York Harbor Healthcare System, New York, New York

Background & Aims: Racial/ethnic minorities are less likely than whites to undergo colorectal cancer (CRC) screening. Although computed tomography colonography (CTC) is a less invasive alternative to optical colonoscopy (OC), it is not known whether CTC will increase acceptance of CRC screening in minorities. Methods: Patients undergoing OC for clinically indicated reasons had CTC followed by same-day OC. After the sedation from the OC had worn off, a questionnaire was administered to assess pain, discomfort, bloating, embarrassment, anxiety, and patient satisfaction using a 10-point scale (1 ⴝ least, 10 ⴝ greatest). Results: Of the 272 patients enrolled, there were 134 whites, 71 blacks, 53 Hispanics, and 14 who self-identified their race/ethnicity as other. Although the proportion of subjects who preferred CTC over OC was not significantly different (52.9% vs 47.1%, P ⴝ .36), racial/ethnic minorities were significantly less likely than whites to prefer CTC over OC (whites, 65.7%; blacks, 45.1%; Hispanics, 35.8%; and other, 35.7%; P < .001). Racial/ethnic minorities were less satisfied with CTC (whites, 8.4 ⴞ 1.7; blacks, 7.8 ⴞ 1.7; Hispanics, 7.4 ⴞ 1.8; and other, 7.5 ⴞ 2.1; P ⴝ .001) and were significantly less willing to undergo CTC again in the future (whites, 95.5%; blacks, 80.3%; Hispanics, 84.9%; and other, 85.7%; P ⴝ .006). Conclusions: Compared with white patients, OC is better tolerated and is preferred over CTC for evaluation of the colon among racial/ethnic minorities. Although CTC is less invasive than OC, our findings suggest that CTC is unlikely to overcome racial/ethnic disparities in CRC screening.

C

olorectal cancer (CRC) is the second leading cause of cancer-related mortality in the United States.1 Although it has been shown that screening for CRC can reduce mortality significantly, only a minority of eligible persons have undergone a CRC screening test.2–10 For example, the 2001 Behavioral Risk Factor Surveillance System conducted by the Centers for Disease Control and Prevention showed that only 44.6% of adults age 50 and older had ever had fecal occult blood testing and only 47.3% had ever had a lower endoscopy.6 One reason for the low rates of participation in CRC screening programs is the reluctance of patients to undergo an invasive endoscopic examination. Previous studies have shown that racial/ethnic differences exist in the proportion of people who undergo CRC screening, as well as racial/ethnic variation in the types of screening tests used.2,4,5,9,10 In addition, there are known racial/ethnic disparities in the incidence, clinical presen-

tation, and long-term outcome of CRC, with the highest incidence and mortality rates found in blacks.1,11,12 Computed tomographic colonography (CTC) is an evolving diagnostic technique that currently is promoted as a noninvasive method for imaging the colon. Previous studies have shown that CTC is a sensitive and specific test for detecting large colon polyps and cancers.13–15 To date, however, studies of patient acceptance of CTC vs optical colonoscopy (OC) have yielded conflicting results. Although the majority of studies have shown a patient preference for CTC,15–26 other studies have shown that patients prefer OC,27,28 or did not have a clear preference for either test.14,29 The reasons for these conflicting findings are unknown, but it is possible that some of the differences could be owing to racial/ethnic differences in how patients perceive these tests. Because previous studies have shown decreased participation in CRC screening in racial/ethnic minorities, we hypothesized that these groups would prefer a less invasive screening test than OC. Therefore, we conducted a prospective study to evaluate the hypotheses that there were marked racial/ethnic differences in patient experiences with and preferences for CTC and OC, and that racial/ethnic minorities were more likely than whites to prefer a less invasive test (CTC) over OC.

Methods Study Population Patients who were referred for OC for clinically indicated reasons at the VA New York Harbor Healthcare System between August 2000 and April 2003 were invited to participate in the study. Patients were excluded from this study if they had previous colonic surgery, if they were too debilitated to undergo CTC and OC, or if they refused or were unable to sign written informed consent. All patients provided written informed consent, and the study was reviewed and approved by the institutional review board at our medical center.

Study Design Before CTC and OC, all patients were interviewed by a trained research assistant to obtain detailed demographic and clinical information. Data collected on each patient included age, sex, self-reported race/ethnicity, level of education, annual household income, medical and other comorbid conditions, Abbreviations used in this paper: CRC, colorectal cancer; CTC, computed tomography colonography; OC, optical colonoscopy. © 2007 by the AGA Institute 1542-3565/07/$32.00 doi:10.1016/j.cgh.2007.05.023

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current medications (including aspirin, nonsteroidal anti-inflammatory drugs, and warfarin), whether they had a prior colon imaging test (colonoscopy, flexible sigmoidoscopy, or barium enema), prior history of adenomatous polyps, self-reported family history of CRC, and the presence of gastrointestinal symptoms. In addition, the primary indications for the current procedure were recorded on standardized data collection sheets. Patients had CTC before OC on the same morning. On the day before the CTC and OC, 1 of 2 bowel preparations, as prescribed by the participating gastroenterologists, was administered to the patient. The preparation consisted of two 45-mL doses of sodium phosphate (Phospho-Soda; Fleet Pharmaceuticals, Lynchburg, VA) or 4 L of polyethylene glycol electrolyte solution (Golytely; Braintree Laboratories, Braintree, MA). The sodium phosphate preparation was given unless the patient had ascites, renal insufficiency, or congestive heart failure. The CTC technique used at our medical center has been described in detail in previous studies.30 –34 Briefly, CTC was performed with a multidetector CT system (Siemens Plus 4 Volume Zoom; Siemens Medical Systems, Forcheim, Germany). An experienced technologist or nurse practitioner inserted a flexible rubber catheter into the rectum and insufflated the colon with room air according to the patients’ tolerance (minimum, 40 puffs). The catheter was left in the rectum, and a single supine scout CT image was obtained to verify adequate bowel distention. If adequate bowel distention was present, the CT examination was performed. If adequate bowel distention had not been achieved, additional air was insufflated into the rectum. After air insufflation, CTC was performed first in the supine position in a cephalocaudal direction to image the entire region of the colon and rectum. The patient then was placed in the prone position. Several additional puffs of air then were administered. After the acquisition of a second localizing scout image, the process was repeated over the same z-axis range.

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Immediately after CTC, patients were sent to the gastroenterology suite for OC. All endoscopic procedures were performed by gastroenterology fellows under attending supervision. OC was performed with conscious sedation using intravenous administration of midazolam and meperidine. A questionnaire was designed to capture patient experiences with and preferences for CTC and OC. The questionnaire was based on a previously validated instrument and was modified by the investigators after consultation with patients who had undergone both procedures.35 The questionnaire then was pretested in a group of 10 patients who had completed same-day CTC and OC. In addition, it was reviewed by a group of gastroenterologists and radiologists for face and content validity. The questionnaire was revised based on feedback from the patients, radiologists, and gastroenterologists, and then pretested again in 10 patients who had same-day CTC and OC. The final questionnaire assessed abdominal pain, discomfort, bloating, embarrassment, anxiety, and patient satisfaction. Each of these questions was scored on a scale from 1 to 10 (1 ⫽ least, 10 ⫽ greatest). In addition, we asked patients whether they preferred CTC or OC, whether they would be willing to undergo each of these procedures again in the future if their doctor recommended the test, and whether they would prefer to undergo a CTC or an OC in the future. The questionnaires were administered by a research assistant who was not involved in the care of the patient and did not perform either the CTC or OC. The research assistant interviewed the patients in the gastroenterology suite after the completion of both procedures (when the sedation had worn off and the patient was fully clothed and ready to be discharged home). In addition, the research assistant contacted patients by telephone 48 hours after the 2 examinations and the same questionnaire was administered to patients to evaluate the stability of the responses. The intraclass correlation coefficient for each question was

Table 1. Demographic and Clinical Characteristics of the Patients Stratified According to Race/Ethnicity

Age, ya Male Education ⬍12 y Annual income ⬍$15,000 NSAID or aspirin use Coumadin use Prior colonoscopy Prior flexible sigmoidoscopy Prior barium enema History of adenomas Family history of colorectal cancer Indications for OC Screening Positive fecal occult blood test Hematochezia Iron-deficiency anemia History of colon polyps Change in bowel habits

White (n ⫽ 134)

Black (n ⫽ 71)

Hispanic (n ⫽ 53)

Other (n ⫽ 14)

64.5 (57.0–70.0) 98.5% 38.8% 22.4% 47.8% 5.2% 37.3% 35.1% 26.9% 18.7% 17.2%

61.0 (53.0–70.0) 97.2% 63.4% 33.8% 42.3% 2.8% 29.6% 18.3% 19.7% 19.7% 15.5%

60.0 (52.5–70.5) 98.1% 60.4% 35.8% 41.5% 1.9% 43.4% 24.5% 30.2% 20.8% 17.0%

57.5 (53.0–63.0) 100.0% 14.3% 28.6% 21.4% 7.1% 28.6% 14.3% 7.1% 21.4% 21.4%

38.8% 20.1% 16.4% 7.5% 10.4% 6.7%

22.5% 31.0% 16.9% 11.3% 11.3% 7.0%

13.2% 13.2% 26.4% 26.4% 13.2% 7.5%

35.7% 14.3% 21.4% 7.1% 14.3% 7.1%

NSAID, nonsteroidal anti-inflammatory drugs. expressed as median (25th–75th percentile).

aData

P value .10 .87 ⬍.001 .18 .27 .63 .40 .04 .22 .98 .96 .01

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Table 2. Overall Patient Experiences With CTC and OC

Abdominal pain Discomfort Bloating Embarrassment Anxiety Satisfaction

CTC (n ⫽ 272)

OC (n ⫽ 272)

P value

3.4 ⫾ 2.3 4.1 ⫾ 2.4 5.5 ⫾ 2.8 2.2 ⫾ 1.9 3.3 ⫾ 2.8 8.0 ⫾ 1.8

4.0 ⫾ 2.5 3.7 ⫾ 2.4 3.1 ⫾ 2.2 1.9 ⫾ 1.8 3.6 ⫾ 2.8 8.1 ⫾ 1.8

.02 .08 ⬍.001 .001 .17 .38

NOTE. Patient experiences were scored on a scale of 1–10, with 1 being least and 10 being greatest.

greater than .90 and only the results of the questionnaire administered in the gastroenterology suite before discharge are reported in this article.

Study Outcomes The primary outcome of this study was patient experiences with and preferences for CTC and OC stratified according to race/ethnicity. We decided a priori to use the data from the questionnaire administered in the gastroenterology suite before discharge for all analyses. Secondary outcomes of this study included patient willingness to undergo each of these procedures again in the future if their doctor recommended the test, preferences for CTC vs OC in the future, and demographic and clinical variables associated with preferring CTC over OC.

Statistical Analysis Continuous data are expressed as means ⫾ SD for those variables that were distributed normally, and medians and interquartile range (25th–75th percentile) for those with a non-normal distribution. Continuous variables were compared among the 4 racial/ethnic groups using the Kruskal–Wallis test. Categoric variables are expressed as proportions and were compared using the ␹2 test. The Wilcoxon signed rank test was used to compare patient experiences and satisfaction between CTC and OC. We used the binomial exact test to evaluate whether patients preferred CTC vs OC, whereas we used the McNemar test to compare the proportion of patients who were willing to undergo CTC in the future with the proportion who were willing to undergo OC in the future. Multivariable logistic regression analysis was used to determine variables associated with preferring CTC over OC. The strength of the association between covariates and preferring

CTC over OC are expressed as odds ratios with 95% confidence intervals. Statistical analysis was performed using SPSS software version 14.0 for Windows (SPSS Inc., Chicago, IL) and a 2-tailed P value of less than .05 was considered statistically significant.

Results Patient Demographic and Clinical Characteristics Of the 356 eligible patients who were approached for participation in this study, 272 agreed to participate and completed both the CTC and OC. There were no significant differences between participants and nonparticipants with regard to age, sex, race/ethnicity, education level, or annual income (data not shown). The 272 subjects who were enrolled in the study were from diverse racial/ethnic backgrounds, including 134 non-Hispanic whites, 71 non-Hispanic blacks, 53 Hispanics, and 14 who self-identified their race/ethnicity as other. The demographic and clinical characteristics of the 272 patients stratified according to race/ethnicity are shown in Table 1. There were no significant differences in age or sex among the 4 racial/ethnic groups. However, a significantly higher proportion of blacks and Hispanics had less than 12 years of education. In addition, there were significant differences among racial/ethnic groups in the proportion of subjects who had a prior flexible sigmoidoscopy as well as in the indications for the present OC. Although screening was the most common indication for OC in whites and persons who designated their race/ethnicity as “other,⬙ a positive fecal occult blood test was the most common indication for OC in blacks, and hematochezia and iron-deficiency anemia were the most common indications for OC in Hispanics.

Overall Comparison of Computed Tomography Colonography and Optical Colonoscopy To evaluate patients’ overall experiences with CTC and OC, we compared the mean scores for both procedures using the Wilcoxon signed rank test (Table 2). Patients rated OC as significantly more painful than CTC, whereas they had significantly more bloating and embarrassment with CTC. There was a trend toward greater discomfort with CTC as compared with OC, but this was not statistically significant. However, there were no significant differences in the satisfaction scores between the 2 procedures.

Table 3. Patient Experiences With CTC Stratified According to Race/Ethnicity

Abdominal pain Discomfort Bloating Embarrassment Anxiety Satisfaction

White (n ⫽ 134)

Black (n ⫽ 71)

Hispanic (n ⫽ 53)

Other (n ⫽ 14)

P value

2.9 ⫾ 2.1 3.8 ⫾ 2.2 5.3 ⫾ 2.6 1.9 ⫾ 1.4 2.8 ⫾ 2.2 8.4 ⫾ 1.7

3.4 ⫾ 2.2 4.1 ⫾ 2.4 5.3 ⫾ 2.8 2.6 ⫾ 2.3 3.9 ⫾ 3.3 7.8 ⫾ 1.7

4.8 ⫾ 2.6 4.7 ⫾ 2.7 6.0 ⫾ 3.0 2.8 ⫾ 2.3 3.9 ⫾ 3.2 7.4 ⫾ 1.8

3.4 ⫾ 2.3 4.8 ⫾ 2.7 5.9 ⫾ 2.9 1.8 ⫾ 2.4 4.3 ⫾ 3.5 7.5 ⫾ 2.1

⬍.001 .19 .32 .03 .17 .001

NOTE. Patient experiences were scored on a scale of 1–10, with 1 being least and 10 being greatest.

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Table 4. Patient Experiences With OC Stratified According to Race/Ethnicity

Abdominal pain Discomfort Bloating Embarrassment Anxiety Satisfaction

White (n ⫽ 134)

Black (n ⫽ 71)

Hispanic (n ⫽ 53)

Other (n ⫽ 14)

P value

4.8 ⫾ 2.3 4.2 ⫾ 2.6 3.6 ⫾ 2.4 1.8 ⫾ 1.3 3.3 ⫾ 2.5 7.8 ⫾ 1.8

3.1 ⫾ 2.5 3.2 ⫾ 1.9 2.8 ⫾ 2.1 2.0 ⫾ 2.5 4.1 ⫾ 3.3 8.5 ⫾ 1.7

3.0 ⫾ 2.1 3.6 ⫾ 2.4 2.6 ⫾ 1.5 2.0 ⫾ 1.7 3.2 ⫾ 2.4 8.2 ⫾ 2.0

3.4 ⫾ 3.3 3.1 ⫾ 1.5 2.6 ⫾ 1.6 2.4 ⫾ 2.6 4.5 ⫾ 3.7 8.0 ⫾ 2.0

⬍.001 .07 .02 .08 .62 .004

NOTE. Patient experiences are scored on a scale of 1–10, with 1 being least and 10 being greatest.

Racial/Ethnic Differences in Patient Experiences With Computerized Tomography Colonography To evaluate racial/ethnic differences in patient experiences and satisfaction with CTC, we compared the mean scores among each of the 4 racial/ethnic groups. As shown in Table 3, there were significant racial/ethnic differences in the severity of abdominal pain, embarrassment, and satisfaction with CTC. The severity of abdominal pain was least in whites and greatest in Hispanics. Blacks and Hispanics had significantly more embarrassment with CTC than did whites or other racial/ethnic groups. In addition, whites were significantly more satisfied with CTC than were racial/ethnic minorities.

Racial/Ethnic Differences in Patient Experiences With Optical Colonoscopy In addition to finding significant racial/ethnic differences in patient experiences with CTC, we also found that there were significant racial/ethnic differences in patient experiences with OC. As shown in Table 4, there were significant racial/ ethnic differences in abdominal pain, bloating, and satisfaction scores, and a trend toward statistical significance for the discomfort and embarrassment scores. Abdominal pain, discomfort, and bloating scores were greatest in whites, whereas the embarrassment and anxiety scores were greatest in those who identified their race/ethnicity as “other.⬙ Blacks were most satisfied with OC, whereas whites were least satisfied with this procedure.

Patient Preferences for Computed Tomography Colonography Versus Optical Colonoscopy When asked whether they preferred the CTC or the OC, the proportion of subjects who favored the CTC was not significantly different from the proportion who preferred the OC (52.9% vs 47.1%, P ⫽ .36). If their doctor recommended it, significantly more patients reported that they would be willing to undergo OC in the future than the proportion of patients

who were willing to undergo CTC in the future (94.1% vs 89.0%, P ⫽ .045). When patients were asked to choose CTC or OC if they had to undergo one test in the future, there was no significant difference in the proportion who chose CTC instead of OC (53.7% vs 46.3%, P ⫽ .25). To determine the impact of race/ethnicity on patient preferences, we compared patient preferences among the 4 racial/ ethnic groups. As shown in Table 5, whites were significantly more likely than racial/ethnic minorities to report that they preferred CTC over the OC. Compared with racial/ethnic minorities, whites were significantly more willing to undergo CTC again in the future and would prefer the CTC over the OC.

Factors Associated With Patient Preferences for Computed Tomography Colonography Because factors other than race/ethnicity can impact patient preferences for CTC vs OC, we evaluated the association between baseline demographic and clinical variables and patient preferences for CTC over OC (Table 6). In the unadjusted analysis, racial/ethnic minorities, education of less than 12 years, and a personal history of colonic adenomas were associated significantly with a lower odds of preferring CTC over OC, whereas screening as an indication for the procedure was associated with an increased odds of preferring CTC over OC. After adjusting for all of the variables in Table 6, multivariable logistic regression analysis identified race/ethnicity and a personal history of colonic adenomas as the only 2 variables that were associated independently with patient preferences. Racial/ethnic minorities and those with a personal history of colonic adenomas were significantly less likely to prefer CTC over OC.

Discussion In the present study of 272 patients, we found that there were marked racial/ethnic differences in patient experiences with CTC and OC. Contrary to our a priori hypothesis, we found that racial/ethnic minorities actually preferred OC over CTC, whereas whites preferred CTC over OC. These findings

Table 5. Patient Preferences for CTC and OC Stratified According to Race/Ethnicity

Preferred CTC over OC Willing to undergo CTC again in the future Willing to undergo OC again in the future Prefer CTC over OC in the future

White (n ⫽ 134)

Black (n ⫽ 71)

Hispanic (n ⫽ 53)

Other (n ⫽ 14)

P value

65.7% 95.5% 93.3% 66.4%

45.1% 80.3% 94.4% 46.5%

35.8% 84.9% 96.2% 35.8%

35.7% 85.7% 92.9% 35.7%

⬍.001 .006 .89 ⬍.001

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Table 6. Factors Associated With Preferring the CTC Examination Over the OC Examination Fully adjusted analysisa

Unadjusted analysis

Age, y ⬍50 50–59 60–69 70⫹ Sex Female Male Race/ethnicity Non-Hispanic white Non-Hispanic black Hispanic Other Education ⬍ 12 y No Yes Annual income ⬍ $15,000 No Yes NSAID or aspirin use No Yes Coumadin use No Yes Prior colonoscopy No Yes Prior flexible sigmoidoscopy No Yes Prior barium enema No Yes History of adenomas No Yes Family history of colorectal cancer No Yes OC performed for screening No Yes

Odds ratio (95% CI)

P value

Odds ratio (95% CI)

P value

1.00 (reference) 1.36 (0.50–3.65) 1.59 (0.58–4.31) 0.93 (0.34–2.53)

— 0.55 0.36 0.88

1.00 (reference) 0.86 (0.28–2.60) 0.93 (0.29–2.92) 0.82 (0.26–2.58)

— 0.78 0.90 0.74

1.00 (reference) 4.61 (0.51–41.82)

— 0.17

1.00 (reference) 4.83 (0.49–47.63)

— 0.18

1.00 (reference) 0.43 (0.24–0.77) 0.29 (0.15–0.57) 0.29 (0.09–0.92)

— 0.005 ⬍.001 0.04

1.00 (reference) 0.50 (0.26–0.95) 0.31 (0.15–0.64) 0.24 (0.07–0.85)

— 0.04 .002 0.03

1.00 (reference) 0.61 (0.38–0.98)

— 0.04

1.00 (reference) 0.68 (0.38–1.21)

— 0.19

1.00 (reference) 0.66 (0.39–1.12)

— 0.12

1.00 (reference) 0.82 (0.45–1.51)

— 0.53

1.00 (reference) 0.94 (0.58–1.52)

— 0.81

1.00 (reference) 0.91 (0.53–1.57)

— 0.73

1.00 (reference) 1.58 (0.45–5.54)

— 0.47

1.00 (reference) 1.38 (0.34–5.56)

— 0.66

1.00 (reference) 0.69 (0.42–1.13)

— 0.14

1.00 (reference) 1.35 (0.62–2.97)

— 0.45

1.00 (reference) 1.28 (0.75–2.18)

— 0.37

1.00 (reference) 1.18 (0.62–2.24)

— 0.62

1.00 (reference) 0.82 (0.47–1.43)

— 0.49

1.00 (reference) 0.93 (0.49–1.75)

— 0.82

1.00 (reference) 0.34 (0.18–0.65)

— 0.001

1.00 (reference) 0.26 (0.10–0.65)

— 0.004

1.00 (reference) 1.32 (0.70–2.52)

— 0.39

1.00 (reference) 1.36 (0.64–2.91)

— 0.43

1.00 (reference) 1.74 (1.02–2.96)

— 0.04

1.00 (reference) 1.01 (0.52–1.95)

— 0.98

NSAID, nonsteroidal anti-inflammatory drugs. fully adjusted analysis was adjusted for all variables in the table.

aThe

have important clinical implications for CRC screening among the large population of racial/ethnic minorities in the United States. Although numerous studies have evaluated patient experiences with and preferences for CTC vs OC,14 –29,36 –38 little is known about whether these measurements differ according to race/ethnicity. In a study assessing patient attitudes toward CTC and OC, Angtuaco et al17 found that patient choices between CTC and OC did not differ according to race/ethnicity. However, these were potential patients who had not undergone either test, and only 20% of the subjects were older than age 50. These important limitations make it difficult to draw conclusions from this study.

In a more recent study comparing patient experiences with barium enema, CTC, and OC, Bosworth et al28 found limited racial differences in patient perceptions of the 3 tests. In that study, whites found CTC to be more inconvenient than blacks. Of the 3 colon imaging tests evaluated, 15.4% of blacks reported that they were least satisfied with CTC as compared with only 7.8% of whites. However, there were no statistically significant racial differences in patient comfort with either test or willingness to undergo either test again. Similar to Bosworth et al,28 we found that racial/ethnic minorities were less satisfied with CTC than whites. In contrast, the racial/ethnic differences in our study were greater in number and magnitude than those reported by Bosworth et al.28

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Although the reasons for these racial/ethnic differences are unknown, these findings have important implications for CRC screening and should be explored further in future studies. Another interesting and novel aspect of our study was the use of multivariable logistic regression analysis to determine factors associated with patient preferences for CTC vs OC. In addition to the finding that racial/ethnic minorities preferred OC more frequently than white patients, the only other variable that was associated independently with patient preferences was a personal history of adenomatous polyps. Patients who had a personal history of colonic adenomas had a strong preference for OC over CTC. This finding also was noted by van Gelder et al,24 who found that patients who had a polyp detected on OC preferred OC over CTC when surveyed 5 weeks after the procedures. The most likely explanation for this finding is that patients with prior polyps are aware that they are at increased risk of having polyps during follow-up evaluation and that there is a high likelihood that they will need OC to remove these lesions. The strengths of our study included the prospective study design, the relatively large sample size, the racial/ethnic diversity of our subjects, and the use of multivariable logistic regression analysis to adjust for potential confounding variables. In addition, this is one of only a few studies that evaluated racial/ ethnic differences in patient experiences with CTC and OC. Nonetheless, there are some important limitations of this study that should be considered when interpreting our findings. First, the study was conducted at a single medical center and the majority of our patients were men. Therefore, our findings may not be generalizable to other clinical settings or women. In addition, our patients already had agreed to undergo an OC when approached about entering the study, so our results may not be generalizable to those who may be reluctant to undergo any type of screening test. Although we found no differences between eligible participants and nonparticipants who were approached for enrollment in this study, we did not approach every patient scheduled to undergo OC because of limited resources. Furthermore, we did not include patients who refused to undergo OC and, as a result, our study population was biased toward individuals who are more amenable to CRC screening. Patients who refuse OC are an important group of individuals who certainly deserve consideration if we are to make a positive impact on the number of people who undergo CRC screening, although they are a difficult group to study. Another potential limitation of our study was the fact that 2 different preparations were used for the procedures. However, because each individual patient underwent a single preparation for both OC and CTC, it is unlikely that the choice of preparation had an impact on patient experiences with the 2 tests. The advent of prepless CTC using fecal tagging is a new technique that may have a positive impact on patient satisfaction with CTC compared with OC.39 Another potential limitation of this study was that it was performed with CT technology and insufflation techniques that are outdated and no longer used at most institutions. We used 4-row multidetector CT scanners that resulted in CT acquisition times of approximately 30 seconds. Current use of 16- and 64-row CT scanners allow acquisition times of 12 and 6 seconds, respectively. This quicker acquisition time may improve patient satisfaction with CTC, especially in those patients who have difficulty holding their breath.

PATIENT PREFERENCES FOR CTC AND OC

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The use of automated CO2 insufflation also may improve patient satisfaction with CTC. CO2 is absorbed much faster across the colonic surface than room air and, hence, the effects of colonic distension are lessened shortly after colonic insufflation. In addition, CTC data were networked to an offsite workstation where the radiologist interpreted the data. Because the patient had to proceed immediately from the CTC examination to colonoscopy, there was not an opportunity for the radiologist to discuss the results with the patient. It is possible that if there was an opportunity to show the findings to the patient, then the overall patient perception and acceptance of the procedure would be improved. In the future, CTC performed for screening could be coupled with same-day polypectomy if a polyp is detected at CTC. This would eliminate the need for repeat bowel cleansing and may improve patient perception of CTC and CRC screening in general. However, it is unclear how these CTC-related factors may impact racial/ethnic preferences for colon imaging tests. In conclusion, the strong preference for OC over CTC in racial/ethnic minorities found in this study suggests that promoting the use of CTC in these populations at the present time is unlikely to overcome racial/ethnic disparities in CRC screening. However, new CTC techniques and the use of prepless CTC are likely to change how patients perceive CTC, and it is possible that these technologic advances will help to overcome racial/ethnic disparities in CRC screening. References 1. Jemal A, Siegel R, Ward E, et al. Cancer statistics, 2007. CA Cancer J Clin 2007;57:43– 66. 2. Ko CW, Kreuter W, Baldwin LM. Effect of Medicare coverage on use of invasive colorectal cancer screening tests. Arch Intern Med 2002;162:2581–2586. 3. Seeff LC, Shapiro JA, Nadel MR. Are we doing enough to screen for colorectal cancer? Findings from the 1999 Behavioral Risk Factor Surveillance System. J Fam Pract 2002;51:761–766. 4. Nadel MR, Blackman DK, Shapiro JA, et al. Are people being screened for colorectal cancer as recommended? Results from the National Health Interview Survey. Prev Med 2002;35:199 – 206. 5. Richards RJ, Reker DM. Racial differences in use of colonoscopy, sigmoidoscopy, and barium enema in Medicare beneficiaries. Dig Dis Sci 2002;47:2715–2719. 6. Centers for Disease Control and Prevention. Colorectal cancer test use among persons aged ⬎ or ⫽ 50 years—United States, 2001. MMWR Morb Mortal Wkly Rep 2003;52:193–196. 7. Cokkinides VE, Chao A, Smith RA, et al. Correlates of underutilization of colorectal cancer screening among U.S. adults, age 50 years and older. Prev Med 2003;36:85–91. 8. Ioannou GN, Chapko MK, Dominitz JA. Predictors of colorectal cancer screening participation in the United States. Am J Gastroenterol 2003;98:2082–2091. 9. Cooper GS, Koroukian SM. Racial disparities in the use of and indications for colorectal procedures in Medicare beneficiaries. Cancer 2004;100:418 – 424. 10. Etzioni DA, Ponce NA, Babey SH, et al. A population-based study of colorectal cancer test use: results from the 2001 California Health Interview Survey. Cancer 2004;101:2523–2532. 11. Govindarajan R, Shah RV, Erkman LG, et al. Racial differences in the outcome of patients with colorectal carcinoma. Cancer 2003; 97:493– 498. 12. Agrawal S, Bhupinderjit A, Bhutani MS, et al. Colorectal cancer in African Americans. Am J Gastroenterol 2005;100:515–523. 13. Summers RM, Yao J, Pickhardt PJ, et al. Computed tomographic

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15.

16.

17.

18.

19.

20.

21.

22.

23.

24.

25.

26.

RAJAPAKSA ET AL

virtual colonoscopy computer-aided polyp detection in a screening population. Gastroenterology 2005;129:1832–1844. Cotton PB, Durkalski VL, Pineau BC, et al. Computed tomographic colonography (virtual colonoscopy): a multicenter comparison with standard colonoscopy for detection of colorectal neoplasia. JAMA 2004;291:1713–1719. Pickhardt PJ, Choi JR, Hwang I, et al. Computed tomographic virtual colonoscopy to screen for colorectal neoplasia in asymptomatic adults. N Engl J Med 2003;349:2191–2200. Morrin MM, Kruskal JB, Farrell RJ, et al. Endoluminal CT colonography after an incomplete endoscopic colonoscopy. AJR Am J Roentgenol 1999;172:913–918. Angtuaco TL, Banaad-Omiotek GD, Howden CW. Differing attitudes toward virtual and conventional colonoscopy for colorectal cancer screening: surveys among primary care physicians and potential patients. Am J Gastroenterol 2001;96:887– 893. Thomeer M, Bielen D, Vanbeckevoort D, et al. Patient acceptance for CT colonography: what is the real issue? Eur Radiol 2002; 12:1410 –1415. Svensson MH, Svensson E, Lasson A, et al. Patient acceptance of CT colonography and conventional colonoscopy: prospective comparative study in patients with or suspected of having colorectal disease. Radiology 2002;222:337–345. Bielen D, Thomeer M, Vanbeckevoort D, et al. Dry preparation for virtual CT colonography with fecal tagging using water-soluble contrast medium: initial results. Eur Radiol 2003;13:453– 458. Gluecker TM, Johnson CD, Harmsen WS, et al. Colorectal cancer screening with CT colonography, colonoscopy, and double-contrast barium enema examination: prospective assessment of patient perceptions and preferences. Radiology 2003;227:378 – 384. Ristvedt SL, McFarland EG, Weinstock LB, et al. Patient preferences for CT colonography, conventional colonoscopy, and bowel preparation. Am J Gastroenterol 2003;98:578 –585. Taylor SA, Halligan S, Saunders BP, et al. Acceptance by patients of multidetector CT colonography compared with barium enema examinations, flexible sigmoidoscopy, and colonoscopy. AJR Am J Roentgenol 2003;181:913–921. van Gelder RE, Birnie E, Florie J, et al. CT colonography and colonoscopy: assessment of patient preference in a 5-week follow-up study. Radiology 2004;233:328 –337. Iannaccone R, Laghi A, Catalano C, et al. Computed tomographic colonography without cathartic preparation for the detection of colorectal polyps. Gastroenterology 2004;127:1300 –1311. Juchems MS, Ehmann J, Brambs HJ, et al. A retrospective evaluation of patient acceptance of computed tomography colonography (“virtual colonoscopy”) in comparison with conventional

CLINICAL GASTROENTEROLOGY AND HEPATOLOGY Vol. 5, No. 11

27.

28.

29. 30. 31.

32.

33. 34.

35. 36.

37.

38.

39.

colonoscopy in an average risk screening population. Acta Radiol 2005;46:664 – 670. Akerkar GA, Yee J, Hung R, et al. Patient experience and preferences toward colon cancer screening: a comparison of virtual colonoscopy and conventional colonoscopy. Gastrointest Endosc 2001;54:310 –315. Bosworth HB, Rockey DC, Paulson EK, et al. Prospective comparison of patient experience with colon imaging tests. Am J Med 2006;119:791–799. Forbes GM, Mendelson RM. Patient acceptance of virtual colonoscopy. Endoscopy 2000;32:274 –275. Laks S, Macari M, Bini EJ. Positional change in colon polyps at CT colonography. Radiology 2004;231:761–766. Lui YW, Macari M, Israel G, et al. CT colonography data interpretation: effect of different section thicknesses—preliminary observations. Radiology 2003;229:791–797. Macari M, Bini EJ, Xue X, et al. Colorectal neoplasms: prospective comparison of thin-section low-dose multi-detector row CT colonography and conventional colonoscopy for detection. Radiology 2002;224:383–392. Macari M, Bini EJ, Jacobs SL, et al. Significance of missed polyps at CT colonography. AJR Am J Roentgenol 2004;183:127–134. Macari M, Bini EJ, Jacobs SL, et al. Colorectal polyps and cancers in asymptomatic average-risk patients: evaluation with CT colonography. Radiology 2004;230:629 – 636. Salmon P, Shah R, Berg S, et al. Evaluating customer satisfaction with colonoscopy. Endoscopy 1994;26:342–346. Edwards JT, Mendelson RM, Fritschi L, et al. Colorectal neoplasia screening with CT colonography in average-risk asymptomatic subjects: community-based study. Radiology 2004;230:459 – 464. The Multicentre Australian Colorectal Neoplasia Screening (MACS) Group. A comparison of colorectal neoplasia screening tests: a multicentre community-based study of the impact of consumer choice. Med J Aust 2006;184:546 –550. Taylor SA, Halligan S, Burling D, et al. Intra-individual comparison of patient acceptability of multidetector-row CT colonography and double-contrast barium enema. Clin Radiol 2005;60:207–214. Zalis ME, Perumpillichira JJ, Magee C, et al. Tagging-based, electronically cleansed CT colonography: evaluation of patient comfort and image readability. Radiology 2006;239:149 –159.

Address requests for reprints to: Edmund J. Bini, MD, MPH, Division of Gastroenterology, VA New York Harbor Healthcare System, 423 East 23rd Street, New York, New York 10010. e-mail: Edmund.Bini@ med.va.gov; fax: (212) 951-3481.