What influences family physicians' cancer screening decisions when practice guidelines are unclear or conflicting?

OBJECTIVES: To determine (a) the respondents' perceptions of 4 unclear or conflicting cancer screening guidelines: prostate-specific antigen (PSA) for men over 50, mammography for women 40-49, colorectal screening by fecal occult blood testing (FOBT), and colonoscopy for patients over 40; and (b) the influence of various factors on the decision to order these tests.

STUDY DESIGN: National Canadian mail survey of randomly selected family physicians.

POPULATION: Family physicians in active practice (n=565) selected from rural and urban family medicine sites in 5 provinces representing the main regions in Canada.

OUTCOME MEASURED: Agreement with guideline statements, and decision to order screening test in 6 clinical vignettes.

RESULTS: Of 565 surveys mailed, 351 (62.1%) were returned. Most respondents agreed with the Canadian Task Force recommendations, and most believed that various guidelines for 3 of the 4 screens were conflicting (PSA 86.6%; mammography 67.5%; FOBT 62.4%). Patient anxiety about cancer, patient expectations of being tested, and a positive family history of cancer increased the odds that the 4 tests would be ordered. A good quality patient-MD relationship decreased the odds of ordering a mammogram. Screening decisions were also significantly influenced by the respondents' beliefs about whether screening was recommended and whether screening could cause more harm than good. A physician's sensitivity to his or her colleagues' practice influenced screening decisions regarding PSA and mammography.

CONCLUSIONS: These results suggest a conceptual framework for understanding the determinants of screening behavior when guidelines are unclear or conflicting.