Older adults' attitudes about continuing cancer screening later in life: a pilot study interviewing residents of two continuing care communities

External validation of an index to predict up to 9-year mortality of community-dwelling adults aged 65 and older

OBJECTIVES

To further validate an index predicting mortality in community-dwelling older adults.

DESIGN

A comparison of the performance of the index in predicting mortality among new respondents to the National Health Interview Survey (NHIS, 2001-2004) with that of respondents from the original development and validation cohorts (1997-2000) and a test of its performance over extended follow-up (up to 9 years) using the original cohorts. Follow-up mortality data were available through 2006.

SETTING

NHIS.

PARTICIPANTS

Twenty-two thousand fifty-seven new respondents to the NHIS (2001-2004) and 24,139 respondents from the original development and validation cohorts (1997-2000).

MEASUREMENTS

A risk score was calculated for each respondent based on the presence or absence of 11 factors (function, illnesses, behaviors, demographics) that make up the index. Using the Kaplan-Meier method, 5-year mortality estimates were computed for the new and original cohort respondents and 9-year mortality estimates for the original cohorts.

RESULTS

New respondents were similar to original cohort respondents but were slightly more likely to be aged 85 and older, report diabetes mellitus, and have a body mass index of 25.0 kg/m² or greater. The model performed as well in the new cohort as it had in the original cohort. New respondents with risk scores of 0 to 1 had a 2% risk of 5-year mortality, whereas respondents who scored 18 or higher had a 69% risk of 5-year mortality (range 3-71% risk of 5-year mortality in the development cohort). The index also demonstrated excellent calibration and discrimination in predicting 9-year mortality (range 7% risk for scores of 0-1 to 92% risk for scores of ≥ 18, original validation cohort extended).

CONCLUSION

These results further justify use of this index to estimate life expectancy in clinical decision-making.

Psychosocial determinants of socioeconomic inequalities in cancer screening participation: a conceptual framework

Cancer screening participation shows a strong, graded association with socioeconomic status (SES) not only in countries such as the United States, where insurance status can be a barrier for lower income groups, but also in the United Kingdom, where the National Health Service provides all health care to residents, including screening, for free. Traditionally, the literature on socioeconomic inequalities has focused on upstream factors, but more proximal (downstream) influences on screening participation also need to be examined, particularly those that address the graded nature of the association rather than focusing specifically on underserved groups. This review offers a framework that links some of the components and corollaries of SES (life stress, educational opportunities, illness experience) to known psychosocial determinants of screening uptake (beliefs about the value of early detection, fatalistic beliefs about cancer, self-efficacy). The aim is to explain why individuals from lower SES backgrounds perceive cancer screening tests as more threatening, more difficult to accomplish, and less beneficial. A better understanding of the mechanisms through which lower SES causes negative attitudes toward screening could facilitate the development of intervention strategies to reduce screening inequalities.

A targeted decision aid for the elderly to decide whether to undergo colorectal cancer screening: development and results of an uncontrolled trial

BACKGROUND

Competing causes of mortality in the elderly decrease the potential net benefit from colorectal cancer screening and increase the likelihood of potential harms. Individualized decision making has been recommended, so that the elderly can decide whether or not to undergo colorectal cancer (CRC) screening. The objective is to develop and test a decision aid designed to promote individualized colorectal cancer screening decision making for adults age 75 and over.

METHODS

We used formative research and cognitive testing to develop and refine the decision aid. We then tested the decision aid in an uncontrolled trial. The primary outcome was the proportion of patients who were prepared to make an individualized decision, defined a priori as having adequate knowledge (10/15 questions correct) and clear values (25 or less on values clarity subscale of decisional conflict scale). Secondary outcomes included overall score on the decisional conflict scale, and preferences for undergoing screening.

RESULTS

We enrolled 46 adults in the trial. The decision aid increased the proportion of participants with adequate knowledge from 4% to 52% (p < 0.01) and the proportion prepared to make an individualized decision from 4% to 41% (p < 0.01). The proportion that preferred to undergo CRC screening decreased from 67% to 61% (p = 0. 76); 7 participants (15%) changed screening preference (5 against screening, 2 in favor of screening)

CONCLUSION

In an uncontrolled trial, the elderly participants appeared better prepared to make an individualized decision about whether or not to undergo CRC screening after using the decision aid.

Plans to stop cancer screening tests among adults who recently considered screening

OBJECTIVE

We sought to estimate what proportion of adults plan to stop cancer screening tests among adults who recently considered screening and to explore factors associated with these screening plans.

DESIGN

Telephone Survey

PARTICIPANTS

A total of 1,237 participants aged 50 and older who reported having made one or more cancer screening decisions in the past 2 years completed 1,454 cancer screening modules for breast, prostate and colorectal screening.

MAIN RESULTS

Of all module respondents, 9.8% reported plans to stop screening, 12.6% for breast, 6.0 % for prostate and 9.5% for colon cancer. We found no statistically significant differences in plans to stop for those ages >or=70 (8.2%) compared to those ages 50 to 69 (10.2%) (p = 0.14.) Black respondents were less likely to report plans to stop than white respondents (OR = 0.32, 95% CI 0.12, 0.87). Participation in the decision-making process was associated with plans to stop screening; those who reported they made the final decision about screening (OR 5.9, 95% CI 1.4, 24.7) or made the decision with the health care provider (OR 4.1, 95% CI 1.0, 16.8) were more likely to have plans to stop screening compared to respondents who reported that their health care provider made the final decision.

CONCLUSIONS

Plans to stop screening were uncommon among participants who had recently faced a screening decision. Given the recent US Preventive Services Task Force recommendations limiting routine cancer screening for older adults, additional efforts to educate adults about the potential risks and benefits of screening may be warranted.

Colorectal cancer screening barriers and facilitators in older persons

BACKGROUND

This systematic review identifies factors that are most consistently mentioned as either barriers to or facilitators of colorectal cancer (CRC) screening in older persons.

METHODS

A systematic literature search (1995-2008) was conducted to identify studies that reported barriers to or facilitators of CRC screening uptake, compliance or adherence specifically for older persons (> or = 65 years). Information on study characteristics and barriers and facilitators related to subjects; healthcare providers; policies; and screening tests were then abstracted and analyzed.

RESULTS

Eighty-three studies met the eligibility criteria. Low level of education, African American race, Hispanic ethnicity, and female gender were the most frequently reported barriers, whereas being married or living with a partner was the most frequently reported facilitator. The most cited barrier related to healthcare providers was lack of screening recommendation by a physician; having a usual source of care was a commonly reported facilitator. Lack of health insurance, and dual coverage with Medicare and Medicaid were the most frequently reported barriers, whereas Medicare's coverage of screening colonoscopy was consistently reported as a facilitator.

CONCLUSIONS

Barriers to, and facilitators of, CRC screening among older persons are reported. Particular attention should be paid to modifiable factors that could become the focus of interventions aimed at increasing CRC screening participation in older persons.

How do physician assessments of patient preferences for colorectal cancer screening tests differ from actual preferences? A comparison in Canada and the United States using a stated-choice survey

BACKGROUND

Patient preferences can affect colorectal cancer (CRC) screening test use. We compared utility-based preferences for alternative CRC screening tests from a stated-preference discrete-choice survey of the general population and physicians in Canada and the United States.

METHODS

General population respondents (Canada, n = 501; US, n = 1087) participated in a survey with 12 choice scenarios and 9 CRC screening test attributes. Physicians (n = 100, both Canada and US) reported expected patient preferences. We estimated relative importance of attributes using bivariate probit regression analysis and calculated willingness-to-pay for various CRC screening tests.

RESULTS

In 28 and 31% of scenarios, Canadian and US respondents, respectively, chose no screening over a hypothetical test. Canadian (45%) and US (46%) physicians expected patients to choose no screening more often. For all groups the most important attribute was sensitivity, but physicians' perception of patients' preferences are significantly different from actual preferences. Other key attributes are those related to test performance or the testing process. Fecal DNA, colonoscopy, and virtual colonoscopy were the most preferred tests by all groups, but respondents were willing-to-pay more than physicians predicted.

CONCLUSION

Physicians' perception of patients' preferences are quite different from those of the general population. However, among general population and physicians, Canadian and US preferences were similar.

Cancer screening in a middle-aged general population: factors associated with practices and attitudes

BACKGROUND

The aim of this study was to identify factors associated with cancer screening practices and with general attitudes toward cancer screening in a general population.

METHODS

Mailed survey of 30-60 year old residents of Geneva, Switzerland, that included questions about screening for five cancers (breast, cervix uteri, prostate, colon, skin) in the past 3 years, attitudes toward screening, health care use, preventive behaviours and socio-demographic characteristics. Cancer screening practice was dichotomised as having done at least one screening test in the past 3 years versus none.

RESULTS

The survey response rate was 49.3% (2301/4670). More women than men had had at least one cancer screening test in the past 3 years (83.2% vs 34.5%, p < 0.001). A majority of women had had a cervical smear (76.6%) and a mammography (age 30-49: 35.0%; age 50 and older: 90.3%); and 55.1% of men 50-60 years old had been screened for prostate cancer. Other factors associated with screening included older age, higher income, a doctor visit in the past 6 months, reporting a greater number of preventive behaviours and a positive attitude toward screening. Factors linked with positive attitudes included female gender, higher level of education, gainful employment, higher income, a doctor visit in the past 6 months and a personal history of cancer.

CONCLUSION

Attitudes play an important role in cancer screening practices among middle-aged adults in the general population, independent of demographic variables (age and sex) that determine in part screening recommendations. Negative attitudes were the most frequent among men and the most socio-economically disadvantaged. The moderate participation rate raises the possibility of selection bias.

Ending cervical cancer screening: attitudes and beliefs from ethnically diverse older women

OBJECTIVE

Guidelines support ending cervical cancer screening in women aged 65-70 years and older with previous normal testing, but little is known about older women's attitudes and beliefs about ending screening.

STUDY DESIGN

We conducted face-to-face interviews with 199 women aged 65 and older in English, Spanish, Cantonese, or Mandarin.

RESULTS

Most interviewees were nonwhite (44.7% Asian, 18.1% Latina, and 11.6% African American). Most (68%) thought lifelong screening was either important or very important, a belief held more strongly by African American (77%) and Latina (83%) women compared with women in other ethnic groups (P < .01). Most (77%) had no plans to discontinue screening or had ever thought of discontinuing (69%). When asked if they would end screening if recommended by their physician, 68% responded "yes."

CONCLUSION

The majority of these women believe that lifelong cervical cancer screening is important. Many women, however, reported that they would end screening if recommended by their physician.

Does patient health and hysterectomy status influence cervical cancer screening in older women?

BACKGROUND

Decisions to screen older patients for cancer are complicated by the fact that aging populations are heterogeneous with respect to life expectancy.

OBJECTIVE

To examine national trends in the association between cervical cancer screening and age, health and hysterectomy status.

DESIGN AND PARTICIPANTS

Cross-sectional data from the 1993, 1998, 2000, and 2005 National Health Interview Surveys (NHIS) were used to examine trends in screening for women age 35-64 and 65+ years of age. We investigated whether health is associated with Pap testing among older women using the 2005 NHIS (N = 3,073). We excluded women with a history of cervical cancer or who had their last Pap because of a problem.

MEASUREMENTS

The dependent variable was having a Pap test within the past 3 years. Independent variables included three measures of respondent health (the Charlson comorbidity index (CCI), general health status and having a chronic disability), hysterectomy status and sociodemographic factors.

MAIN RESULTS

NHIS data showed a consistent pattern of lower Pap use among older women (65+) compared to younger women regardless of hysterectomy status. Screening also was lower among older women who reported being in fair/poor health, having a chronic disability, or a higher CCI score (4+). Multivariate models showed that over 50% of older women reporting poor health status or a chronic disability and 47% with a hysterectomy still had a recent Pap.

CONCLUSIONS

Though age, health and hysterectomy status appear to influence Pap test use, current national data suggest that there still may be overutilization and inappropriate screening of older women.

Factors influencing elderly women's mammography screening decisions: implications for counseling

Background

Although guidelines recommend that clinicians consider life expectancy before screening older women for breast cancer, many older women with limited life expectancies are screened. We aimed to identify factors important to mammography screening decisions among women aged 80 and older compared to women aged 65–79.

Methods

Telephone surveys of 107 women aged 80+ and 93 women aged 65–79 randomly selected from one academic primary care practice who were able to communicate in English (60% response rate). The survey addressed the following factors in regards to older women's mammography screening decisions: perceived importance of a history of breast disease, family history of breast cancer, doctor's recommendations, habit, reassurance, previous experience, mailed reminder cards, family/friend's recommendations or experience with breast cancer, age, health, and media. The survey also assessed older women's preferred role in decision making around mammography screening.

Results

Of the 200 women, 65.5% were non-Hispanic white and 82.8% were in good to excellent health. Most (81.3%) had undergone mammography in the past 2 years. Regardless of age, older women ranked doctor's recommendations as the most important factor influencing their decision to get screened. Habit and reassurance were the next two highly ranked factors influencing older women to get screened. Among women who did not get screened, women aged 80 and older ranked age and doctor's counseling as the most influential factors and women aged 65–79 ranked a previous negative experience with mammography as the most important factor. There were no significant differences in preferred role in decision-making around mammography screening by age, however, most women in both age groups preferred to make the final decision on their own (46.6% of women aged 80+ and 50.5% of women aged 65–79).

Conclusion

While a doctor's recommendation is the most important factor influencing elderly women's mammography screening decisions, habit and reassurance also strongly influence decision-making. Interventions aimed at improving clinician counseling about mammography, which include discussions around habit and reassurance, may result in better decision-making.

Interest in breast cancer chemoprevention among older women

OBJECTIVES

The study aim is to describe interest in breast cancer chemoprevention among older women without a history of breast cancer and to determine whether aging-related factors such as diminished life expectancy, increasing comorbidity and medication burden attenuate chemoprevention interest.

DESIGN

Cross-sectional survey.

SETTING

University of Pennsylvania Health System.

PARTICIPANTS

Four-hundred fifty-seven community-dwelling women aged 60-65 years old who were potentially eligible for breast cancer chemoprevention according to guidelines linking risk and eligibility to age.

MEASUREMENTS

Interest in breast cancer chemoprevention, Gail model breast cancer risk, perceived breast cancer risk, breast cancer worry, self-reported health status and comorbidities, and self-reported perceived life expectancy.

RESULTS

Of 457 participants, 11.2% reported being interested in taking chemoprevention, 40.9% reported no interest, and 47.9% reported being unsure about their interest in chemoprevention. Overall, interest in chemoprevention was not associated with individual Gail model breast cancer risk. In adjusted analysis, lack of interest among high-risk women was associated with low breast cancer worry and low perceived risk. Conversely, interest in chemoprevention among low risk women was associated with greater breast cancer worry. Age-related factors hypothesized to affect chemoprevention interest, including subjective life expectancy, increased comorbidity, and number of daily medications did not attenuate chemoprevention interest.

CONCLUSION

Breast cancer worry and perceived breast cancer risk contribute to the lack of correlation between interest in breast cancer chemoprevention and objective breast cancer risk. Perceived life expectancy, increased comorbidity, and medication burden do not attenuate chemoprevention interest among older women.