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A New Decision Aid to Support Colorectal Cancer Screening in Singapore

The Decision Aid will provide patients with information about colorectal cancer and address any misconceptions patients might have.

A Decision Aid (DA) to support colorectal cancer screening in Singapore has been developed through a qualitative research study conducted by SingHealth Polyclinics (SHP). The development aimed to tackle the low screening rate of colorectal cancer (CRC) in Singapore due to knowledge deficits of this common cancer and social reasons such as inconvenience and a lack of reminders or recommendations.

The DA served as an aid for doctors to discuss with patients regarding information about CRC, the importance of screening, the options available, and the risks and benefits of each option. The tool helps to facilitate an individual’s decision-making to undertake CRC screening by addressing misconceptions and barriers of the patient, which would ultimately close the gaps of absent knowledge and doctor’s recommendation of CRC screening.

CRC is prevalent worldwide and is one of the most common types of cancer in Singapore. Singapore ranks twelfth globally, with CRC affecting the Age-Standardised Incidence Rate (ASIR) of 38.6 in males and 27.0 in females per 100,000 per year. According to Singapore Cancer Registry Annual Report 2015, a total of 9,807 new cases of CRC were diagnosed from 2011 to 2015.

A patient with early CRC may be asymptomatic. It starts with a non-cancerous colon polyp, which takes approximately 10 years to develop into a malignant cancer. This long period of progression makes it ideal for CRC screening, where there is early detection and early treatment with the removal of pre-malignant adenomas by colonoscopy.

The Singapore guidelines recommend that CRC screening should start at the age of 50 years old. The recommended population-based screening test for an average risk individual is the Faecal Occult Blood Test (FOBT), done annually, or the colonoscopy once every decade. Other screening tests include flexible sigmoidoscopy and Computed Tomographic (CT) colonography.

Nevertheless, the CRC screening rate in Singapore remains low. The 2019 Singapore National Health Survey revealed that less than half of Singapore residents aged 50 to 74 years had undergone CRC screening within the recommended screening frequency of either FOBT within the past one year or colonoscopy/sigmoidoscopy within the past 10 years. In general, Singapore residents with higher education levels were more likely to embark on the screening.

In this study, the researchers adapted and modified an American CRC screening DA to create a novel DA for the local population. The study was conducted at Tampines Polyclinic with a total of 27 participants aged between 50 and 77 years from all major ethnicities in Singapore. The participants went through five sessions of in-depth interviews (IDIs) and five focus group discussions (FGDs) to gather their perspectives of the DA.

Despite the varying educational qualifications, participants found the content easily comprehensible and of appropriate length. They agreed that the information was relevant and useful in assisting them to make a decision on CRC screening. They had a better understanding of the available options and were willing to share this newly acquired information with their families and close friends.

“Besides addressing the concerns of asymptomatic patients of average risk who may face difficulties deciding on a particular screening modality due to the lack of knowledge on various available options, the DA supports the challenges faced by family physicians as well. Conveying the information of CRC and the importance of screening to patients effectively, requires time and effort. However, they can now use the DA to facilitate the discussion and decision-making process with the patient,” said Dr. Julia Yuen, Associate Consultant, Tampines Polyclinic. Dr. Yuen is also the main author of this study.

“The participants generally had favourable perceptions of using the DA. There were also suggestions to digitalise the DA and adapt it to other languages. We have since revised the initial DA based on the participants’ input, and adapted the copy into Chinese and Malay languages”, added Dr. Yuen.

“We believe that shared decision making will reduce the gap of low screening rate among average risk profiles in Singapore. We postulate that a more person-centred and culturally adopted DA will better serve the patients, as such [an] approach puts a patient’s lifestyle and concerns into consideration, which would better facilitate patients’ decision-making to undertake CRC screening. Ultimately, the patient is the recipient of the screening, not the doctor,” said Clinical Associate Professor Tan Ngiap Chuan, Director of Research, SHP and Vice-chair, Research, SingHealth-Duke NUS Family Medicine Academic Clinical Programme (FM ACP).

“The DA is currently being used by doctors at the Tampines Polyclinic as a decision support tool. More evaluation will have to be done on the shared decision tool to validate for clinical practice,” added Dr. Tan. [APBN]

Source: SingHealth Polyclinics