How to counsel a patient with a positive Cologuard (colon cancer screening test) result who is hesitant to undergo a colonoscopy?

Counseling Patients with Positive Cologuard Results Who Are Hesitant About Colonoscopy

A follow-up colonoscopy is absolutely necessary after a positive Cologuard test, as delaying beyond 6 months significantly increases the risk of colorectal cancer and advanced-stage disease. 1, 2

Understanding the Importance of Timely Follow-up

When counseling patients with positive Cologuard results who are hesitant about colonoscopy, it's essential to address several key points:

1. Explain the meaning of a positive result:

   • A positive Cologuard test indicates the presence of abnormal DNA and/or blood that could signal colorectal cancer or precancerous lesions
   • Cologuard has a sensitivity of 92.3% for colorectal cancer but only detects about 42.4% of advanced precancerous lesions 3
   • The test cannot determine the exact nature of the abnormality - only colonoscopy can do this

2. Emphasize the risks of delay:

   • Research shows that delaying colonoscopy beyond 6 months after a positive stool test significantly increases:
     • Overall risk of colorectal cancer (58% higher odds) 2
     • Risk of advanced-stage disease (116% higher odds) 2, 4
   • The risk continues to increase with longer delays:
     • 10-12 month delay: 48% higher risk of any colorectal cancer 4

     • 12 month delay: 125% higher risk of any colorectal cancer and 222% higher risk of advanced disease 4

Addressing Common Patient Concerns

Fear and Anxiety

• Acknowledge that anxiety about the procedure is normal
• Explain that modern colonoscopy is generally safe with low complication rates
• Discuss sedation options that make the procedure comfortable

Preparation Concerns

• Explain that while bowel preparation is unpleasant, it's brief and essential for accurate results
• Offer tips to make preparation more tolerable (flavor mixing, staying near bathroom, clear schedule)
• Newer preparation options may be available that are lower volume or split-dose

Procedural Concerns

• Explain the procedure step by step
• Emphasize that most patients sleep through the procedure with sedation
• Discuss the short recovery time (usually able to return to normal activities the next day)

Explaining the Health Belief Model Factors

Research shows that patients are more likely to complete colonoscopy when they understand 1:

1. Perceived threat - Help patients understand the real risk of colorectal cancer
2. Cues to action - Provide clear instructions and reminders
3. Reduced barriers - Address specific concerns about the procedure
4. Health behavior - Connect this decision to their overall health goals

Recommended Counseling Approach

1. Start with clear risk communication: "Your positive Cologuard test means we found abnormal DNA or blood in your stool that needs further investigation. This doesn't necessarily mean you have cancer, but we need to find out what caused this positive result."

2. Emphasize time sensitivity: "Research shows that waiting more than 6 months for follow-up significantly increases the risk of finding cancer and finding it at a more advanced stage. The guidelines recommend colonoscopy within 3 months of a positive result." 1, 3

3. Address specific concerns: "What specific concerns do you have about getting a colonoscopy?" (Then address each concern specifically)

4. Explain the preventive benefit: "Colonoscopy can both detect AND prevent cancer by removing polyps before they become cancerous. This is something Cologuard cannot do."

5. Offer support resources:

   • Written information about the procedure
   • Contact information for questions
   • Assistance with scheduling and preparation

Common Pitfalls to Avoid

1. Dismissing the positive result - Never suggest waiting or repeating the Cologuard test instead of colonoscopy
2. Minimizing concerns - Take patient fears seriously and address them directly
3. Information overload - Focus on key points and check understanding
4. Failing to follow up - Ensure a system is in place to track patients with positive results who haven't completed colonoscopy

Conclusion

When a patient has a positive Cologuard result but is hesitant about colonoscopy, effective counseling requires addressing their specific concerns while clearly communicating the risks of delay. By using a structured approach that emphasizes the importance of timely follow-up and addresses barriers to completion, healthcare providers can improve colonoscopy adherence rates and potentially save lives through early detection and prevention of colorectal cancer.