Despite the best efforts of all healthcare providers, colon cancer screening is underutilized, with screening rates ranging anywhere from 58–76% based on the state of residence. At best we are still failing to screen about a quarter of the population. With an approximate lifetime risk of 1 in 23 people to develop colorectal cancer (CRC), this is an unacceptable number of patients facing this preventable cancer that go undiagnosed.
Patients have serious concerns about CRC screening with the most common barriers to screening being fear of colonoscopy and of the bowel preparation, amongst others. These barriers coupled with the lack of understanding of the risks, benefits, and the efficacy of screening contribute to our inadequate screening. This study aims to prove that through education, and most importantly comprehension, patients will choose one of the 6 recommended CRC screening tests that best fits their preferences.
Our study, presented at the 2018 American College of Gastroenterology Annual Meeting, involved 24 patients who previously refused colonoscopy on 3 separate occasions and had no other CRC screening. These patients viewed a virtual reality (VR) demonstration, created by TheBodyVR, to see if this additional education would improve the uptake of screening.
Prior to the VR demonstration, the patients completed a 5-item questionnaire, which evaluated their baseline knowledge of CRC risk, polyps, and screening as well as determined barriers to prior screening. Questions included: Do you believe you are at risk for colon cancer? What is your understanding of screening in the reduction of CRC risk? What is your understanding of a colon polyp being the first step in the development of colon cancer? How strongly do you believe that screening can prevent colon cancer?
The patient then viewed the VR demonstration which started with an overview of CRC, beginning with the statistic that approximately 1 in 23 average-risk individuals would develop colon cancer, and the effect of screening on the reduction of the mortality. This was followed by a tour through a virtual colon (where the viewer is basically in a spaceship), explaining and showing what a polyp is and how polyps can evolve into cancer.
Finally, the demonstration reviews and compares the strengths and weaknesses of all USPSTF-recommended CRC screening tests. This review divides the screening options into invasive and non-invasive tests, then assess each for specific risks, need for bowel preparation, need for sedation, and subsequent screening interval. At the finale, the demonstration provides a side-by-side comparison of the tests and their relative strengths, weakness, and risks.
After the study, the patients completed the same questionnaire. In this study, there was a statistically significant improvement in knowledge in all questions. Ultimately, 23 of 24 patients who previously refused CRC screening on 3 separate occasions chose to undergo screening after the VR demonstration, and about 50% have performed the screening 60 days out from the study’s completion. This was a difficult population that previously felt strongly against screening, and after the demonstration, the vast majority reconsidered their initial decision.
We suspect that many of those not screened in the U.S. simply do not understand the importance of CRC screening. Our hope is that VR tools such as this one serve multiple purposes. The first and foremost is to increase the uptake of screening. Second, we believe this will offload the provider from having a long, complex, and tedious conversation in an area many providers may not be comfortable with. In most circumstances, the Primary Care provider is responsible for this discussion, and in many cases, they do not have the full understanding of all USPSTF approved tests, their risks and benefits and the entirety of what they entail. Historically, this conversation was held in the gastroenterologist's office, but with the advent of “open access,” this conversation discussing options is rarely held. The de facto screening offering in high-resource areas is colonoscopy and in low-resource areas, gFOBT or FIT.
Our next step is to perform this study again to see whether our success can be replicated—enrolling more patients at multiple centers and focusing on patients that have refused screenings in the past. For this, we will need help, and if anyone reading this op-ed is interested in having their center participate in this study, please email me at firstname.lastname@example.org. Our hope is that educational demos such as ours will help increase the uptake of CRC screening and reduce morbidity and mortality from CRC.
Dr. Nathaniel Ernstoff is a second-year Gastroenterology fellow at the University of Miami. He performed his residency and chief residency in Internal Medicine at Mount Sinai Beth Israel in Manhattan. He has a background in mechanical engineering and video game design and is combining his different interests to improve patient education.