1
|
Usher-Smith JA, Masson G, Godoy A, Burge SW, Kitt J, Farquhar F, Cartledge J, Kimuli M, Burbidge S, Crosbie PAJ, Eckert C, Hancock N, Iball GR, Rogerson S, Rossi SH, Smith A, Simmonds I, Wallace T, Ward M, Callister MEJ, Stewart GD. Acceptability of adding a non-contrast abdominal CT scan to screen for kidney cancer and other abdominal pathology within a community-based CT screening programme for lung cancer: A qualitative study. PLoS One 2024; 19:e0300313. [PMID: 38950010 PMCID: PMC11216619 DOI: 10.1371/journal.pone.0300313] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2023] [Accepted: 02/27/2024] [Indexed: 07/03/2024] Open
Abstract
OBJECTIVES The Yorkshire Kidney Screening Trial (YKST) is a feasibility study of adding non-contrast abdominal CT scanning to screen for kidney cancer and other abdominal malignancies to community-based CT screening for lung cancer within the Yorkshire Lung Screening Trial (YLST). This study explored the acceptability of the combined screening approach to participants and healthcare professionals (HCPs) involved in the trial. METHODS We conducted semi-structured interviews with eight HCPs and 25 participants returning for the second round of scanning within YLST, 20 who had taken up the offer of the additional abdominal CT scan and five who had declined. Transcripts were analysed using thematic analysis, guided by the Theoretical Framework of Acceptability. RESULTS Overall, combining the offer of a non-contrast abdominal CT scan alongside the low-dose thoracic CT was considered acceptable to participants, including those who had declined the abdominal scan. The offer of the additional scan made sense and fitted well within the process, and participants could see benefits in terms of efficiency, cost and convenience both for themselves as individuals and also more widely for the NHS. Almost all participants made an instant decision at the point of initial invitation based more on trust and emotions than the information provided. Despite this, there was a clear desire for more time to decide whether to accept the scan or not. HCPs also raised concerns about the burden on the study team and wider healthcare system arising from additional workload both within the screening process and downstream following findings on the abdominal CT scan. CONCLUSIONS Adding a non-contrast abdominal CT scan to community-based CT screening for lung cancer is acceptable to both participants and healthcare professionals. Giving potential participants prior notice and having clear pathways for downstream management of findings will be important if it is to be offered more widely.
Collapse
Affiliation(s)
- Juliet A. Usher-Smith
- Department of Public Health and Primary Care, University of Cambridge, Cambridge, United Kingdom
| | - Golnessa Masson
- Department of Public Health and Primary Care, University of Cambridge, Cambridge, United Kingdom
| | - Angela Godoy
- Department of Oncology, University of Cambridge, Cambridge, United Kingdom
| | - Sarah W. Burge
- Department of Oncology, University of Cambridge, Cambridge, United Kingdom
| | - Jessica Kitt
- Department of Surgery, University of Cambridge, Cambridge, United Kingdom
| | - Fiona Farquhar
- Leeds Teaching Hospitals NHS Trust, Leeds, United Kingdom
| | - Jon Cartledge
- Leeds Teaching Hospitals NHS Trust, Leeds, United Kingdom
| | - Michael Kimuli
- Leeds Teaching Hospitals NHS Trust, Leeds, United Kingdom
| | - Simon Burbidge
- Leeds Teaching Hospitals NHS Trust, Leeds, United Kingdom
| | - Philip A. J. Crosbie
- Faculty of Biology, Medicine and Health, University of Manchester, Manchester, United Kingdom
| | - Claire Eckert
- Leeds Institute of Health Science, University of Leeds, Leeds, United Kingdom
| | - Neil Hancock
- Leeds Institute of Health Science, University of Leeds, Leeds, United Kingdom
| | - Gareth R. Iball
- Faculty of Health Studies, University of Bradford, Bradford, United Kingdom
| | | | - Sabrina H. Rossi
- Department of Surgery, University of Cambridge, Cambridge, United Kingdom
| | - Andrew Smith
- Leeds Teaching Hospitals NHS Trust, Leeds, United Kingdom
| | - Irene Simmonds
- Leeds Institute of Health Science, University of Leeds, Leeds, United Kingdom
| | - Tom Wallace
- Leeds Teaching Hospitals NHS Trust, Leeds, United Kingdom
| | - Matthew Ward
- Leeds Institute of Health Science, University of Leeds, Leeds, United Kingdom
| | - Matthew E. J. Callister
- Leeds Teaching Hospitals NHS Trust, Leeds, United Kingdom
- Leeds Institute of Health Science, University of Leeds, Leeds, United Kingdom
| | - Grant D. Stewart
- Department of Surgery, University of Cambridge, Cambridge, United Kingdom
| |
Collapse
|
2
|
Onega T, Garcia M, Beaber EF, Haas JS, Breslau ES, Tosteson ANA, Halm E, Chao CR, Barlow WE. Screening Beyond the Evidence: Patterns of Age and Comorbidity for Breast, Cervical, and Colorectal Cancer Screening. J Gen Intern Med 2024; 39:1324-1331. [PMID: 38097863 PMCID: PMC11169193 DOI: 10.1007/s11606-023-08562-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/16/2023] [Accepted: 12/01/2023] [Indexed: 06/13/2024]
Abstract
BACKGROUND Little evidence exists to guide continuation of screening beyond the recommended ages of national guidelines for breast, cervical, and colorectal cancers, although increasing age and comorbidity burden is likely to reduce the screening benefit of lower mortality. OBJECTIVE Characterize screening after recommended stopping ages, by age and comorbidities in a large, diverse sample. DESIGN Serial cross-sectional. PARTICIPANTS All individuals in the PROSPR-I consortium cohorts from 75 to 89 years of age for breast cancer screening, 66-89 years of age for cervical cancer screening, and 76-89 years of age for colorectal cancer screening from 2011 to 2013. The lower age thresholds were based on the guidelines for each respective cancer type. MAIN MEASURES Proportion of annual screening by cancer type in relation to age and Charlson comorbidity score and median years of screening past guideline age. We estimated the likelihood of screening past the guideline-based age as a function of age and comorbidity using logistic regression. KEY RESULTS The study cohorts included individuals screening for breast (n = 33,475); cervical (n = 459,318); and colorectal (n = 556,356) cancers. In the year following aging out, approximately 30% of the population was screened for breast cancer, 2% of the population was screened for cervical, and almost 5% for colorectal cancer. The median number of years screened past the guideline-based recommendation was 5, 3, and 4 for breast, cervical, and colorectal cancer, respectively. Of those screening > 10 years past the guideline-based age,15%, 46%, and 25% had ≥ 3 comorbidities respectively. Colorectal cancer screening had the smallest decline in the likelihood of screening beyond the age-based recommendation. CONCLUSIONS The odds of screening past guideline-based age decreased with comorbidity burden for breast and cervical cancer screening but not for colorectal. These findings suggest the need to evaluate shared decision tools to help patients understand whether screening is appropriate and to generate more evidence in older populations.
Collapse
Affiliation(s)
- Tracy Onega
- University of Utah and Huntsman Cancer Institute, Salt Lake City, UT, USA.
| | | | | | - Jennifer S Haas
- Harvard Medical School and Massachusetts General Hospital, Boston, MA, USA
| | | | | | - Ethan Halm
- Rutgers University, New Brunswick, NJ, USA
| | - Chun R Chao
- Kaiser Permanente Southern California, Pasadena, CA, USA
| | | |
Collapse
|
3
|
Najafi N, Addie M, Meterissian S, Kersten‐Oertel M. Breamy: An augmented reality mHealth prototype for surgical decision-making in breast cancer. Healthc Technol Lett 2024; 11:137-145. [PMID: 38638506 PMCID: PMC11022230 DOI: 10.1049/htl2.12071] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2023] [Accepted: 12/05/2023] [Indexed: 04/20/2024] Open
Abstract
Breast cancer is one of the most prevalent forms of cancer, affecting approximately one in eight women during their lifetime. Deciding on breast cancer treatment, which includes the choice between surgical options, frequently demands prompt decision-making within an 8-week timeframe. However, many women lack the necessary knowledge and preparation for making informed decisions. Anxiety and unsatisfactory outcomes can result from inadequate decision-making processes, leading to decisional regret and revision surgeries. Shared decision-making and personalized decision aids have shown positive effects on patient satisfaction and treatment outcomes. Here, Breamy, a prototype mobile health application that utilizes augmented reality technology to assist breast cancer patients in making more informed decisions is introduced. Breamy provides 3D visualizations of different surgical procedures, aiming to improve confidence in surgical decision-making, reduce decisional regret, and enhance patient well-being after surgery. To determine the perception of the usefulness of Breamy, data was collected from 166 participants through an online survey. The results suggest that Breamy has the potential to reduce patients' anxiety levels and assist them in decision-making.
Collapse
Affiliation(s)
- Niki Najafi
- Applied Perception Lab, Department of Computer Science and Software EngineeringConcordia UniversityMontrealQuébecCanada
| | - Miranda Addie
- Experimental SurgeryMcgill UniversityMontrealQuébecCanada
| | - Sarkis Meterissian
- Breast CenterMcGill University Health CentreMontrealQuébecCanada
- Department of Surgery, Faculty of MedicineMcGill UniversityMontrealQuébecCanada
| | - Marta Kersten‐Oertel
- Applied Perception Lab, Department of Computer Science and Software EngineeringConcordia UniversityMontrealQuébecCanada
| |
Collapse
|
4
|
Constantinou N, Marshall C, Marshall H. Reducing Barriers and Strategies to Improve Appropriate Screening Mammogram Attendance in Women 75 Years and Older. JOURNAL OF BREAST IMAGING 2024:wbad110. [PMID: 38394438 DOI: 10.1093/jbi/wbad110] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2023] [Indexed: 02/25/2024]
Abstract
Although breast cancer death rates have persistently declined over the last 3 decades, older women have not experienced the same degree in mortality reduction as younger women despite having more favorable breast cancer phenotypes. This occurrence can be partially attributed to less robust mammographic screening in older women, the propensity to undertreat with advancing age, and the presence of underlying comorbidities. With recent revisions to breast cancer screening guidelines, there has been a constructive shift toward more agreement in the need for routine mammographic screening to commence at age 40. Unfortunately, this shift in agreement has not occurred for cutoff guidelines, wherein the recommendations are blurred and open to interpretation. With increasing life expectancy and an aging population who is healthier now than any other time in history, it is important to revisit mammographic screening with advanced age and understand why older women who should undergo screening are not being screened as well as offer suggestions on how to improve screening mammogram attendance in this population.
Collapse
Affiliation(s)
- Niki Constantinou
- Department of Radiology, School of Medicine, Case Western Reserve University, Cleveland, OH, USA
- Department of Radiology, University Hospitals Cleveland Medical Center, Cleveland, OH, USA
| | - Colin Marshall
- Department of Radiology, School of Medicine, Case Western Reserve University, Cleveland, OH, USA
- Department of Radiology, University Hospitals Cleveland Medical Center, Cleveland, OH, USA
| | - Holly Marshall
- Department of Radiology, School of Medicine, Case Western Reserve University, Cleveland, OH, USA
- Department of Radiology, University Hospitals Cleveland Medical Center, Cleveland, OH, USA
| |
Collapse
|
5
|
Smith J, Dodd RH, Naganathan V, Cvejic E, Jansen J, Wallis K, McCaffery KJ. Screening for cancer beyond recommended upper age limits: views and experiences of older people. Age Ageing 2023; 52:afad196. [PMID: 37930739 DOI: 10.1093/ageing/afad196] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2023] [Revised: 08/21/2023] [Indexed: 11/07/2023] Open
Abstract
BACKGROUND Internationally, screening programmes and clinical practice guidelines recommend when older adults should stop cancer screening using upper age limits, but it is unknown how older adults view these recommendations. OBJECTIVE To examine older adults' views and experiences about continuing or stopping cancer screening beyond the recommended upper age limit for breast, cervical, prostate and bowel cancer. DESIGN Qualitative, semi-structured interviews. SETTING Australia, telephone. SUBJECTS A total of 29 community-dwelling older adults (≥70-years); recruited from organisation newsletters, mailing lists and Facebook advertisements. METHODS Interviews were audio-recorded, transcribed and analysed thematically using Framework Analysis. RESULTS Firstly, older adults were on a spectrum between trusting recommendations and actively deciding about cancer screening, with some who were uncertain. Secondly, participants reported limited in-depth discussions with health professionals about cancer screening. In primary care, discussions were focused on checking they were up to date with screening or going over results. Discussions mostly only occurred if older adults initiated themselves. Finally, participants had a socially- and self-constructed understanding of screening recommendations and potential outcomes. Perceived reasons for upper age limits were cost, reduced cancer risk or ageism. Risks of screening were understood in relation to their own social experiences (e.g. shared stories about friends with adverse outcomes of cancer treatment or conversations with friends/family about controversy around prostate screening). CONCLUSIONS Direct-to-patient information and clinician support may help improve communication about the changing benefit to harm ratio of cancer screening with increasing age and increase understanding about the rationale for an upper age limit for cancer screening programmes.
Collapse
Affiliation(s)
- Jenna Smith
- Wiser Healthcare, Sydney School of Public Health, Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia
- Sydney Health Literacy Lab, Sydney School of Public Health, Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia
| | - Rachael H Dodd
- Wiser Healthcare, Sydney School of Public Health, Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia
- Sydney Health Literacy Lab, Sydney School of Public Health, Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia
- The Daffodil Centre, The University of Sydney, Sydney, NSW, Australia
| | - Vasi Naganathan
- Centre for Education and Research on Ageing, Department of Geriatric Medicine, Concord Repatriation Hospital, Sydney, NSW, Australia
- Concord Clinical School, Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia
| | - Erin Cvejic
- Sydney Health Literacy Lab, Sydney School of Public Health, Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia
| | - Jesse Jansen
- Wiser Healthcare, Sydney School of Public Health, Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia
- Sydney Health Literacy Lab, Sydney School of Public Health, Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia
- School for Public Health and Primary Care, Faculty of Health, Medicine and Life Sciences, Maastricht University, Maastricht, The Netherlands
| | - Katharine Wallis
- General Practice Clinical Unit, The University of Queensland, Queensland, QLD, Australia
| | - Kirsten J McCaffery
- Wiser Healthcare, Sydney School of Public Health, Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia
- Sydney Health Literacy Lab, Sydney School of Public Health, Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia
| |
Collapse
|
6
|
Wang T, Dossett LA. Incorporating Value-Based Decisions in Breast Cancer Treatment Algorithms. Surg Oncol Clin N Am 2023; 32:777-797. [PMID: 37714643 DOI: 10.1016/j.soc.2023.05.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/17/2023]
Abstract
Given the excellent prognosis and availability of evidence-based treatment, patients with early-stage breast cancer are at risk of overtreatment. In this review, we summarize key opportunities to incorporate value-based decisions to optimize the delivery of high-value treatment across the breast cancer care continuum.
Collapse
Affiliation(s)
- Ton Wang
- Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Lesly A Dossett
- Department of Surgery, University of Michigan, Ann Arbor, MI, USA; Institute for Healthcare Policy and Innovation, University of Michigan, 1500 East Medical Center Drive, Ann Arbor, MI 48109, USA.
| |
Collapse
|
7
|
Brotzman LE, Zikmund-Fisher BJ. Perceived Barriers Among Clinicians and Older Adults Aged 65 and Older Regarding Use of Life Expectancy to Inform Cancer Screening: A Narrative Review and Comparison. Med Care Res Rev 2023; 80:372-385. [PMID: 36800914 DOI: 10.1177/10775587231153269] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/20/2023]
Abstract
While cancer screening guidelines increasingly recommend incorporating life expectancy estimates to inform screening decisions for older adults, little is known about how this happens in practice. This review summarizes current knowledge about primary care clinician and older adult (65+) perspectives about use of life expectancy to guide cancer screening decisions. Clinicians report operational barriers, uncertainty, and hesitation around use of life expectancy in screening decisions. They recognize it may help them more accurately weigh benefits and harms but are unsure how to estimate life expectancy for individual patients. Older adults face conceptual barriers and are generally unconvinced of the benefits of considering their life expectancy when making screening decisions. Life expectancy will always be a difficult topic for clinicians and patients, but there are advantages to incorporating it in cancer screening decisions. We highlight key takeaways from both clinician and older adult perspectives to guide future research.
Collapse
|
8
|
Dalton AF, Golin CE, Morris C, Kistler CE, Dolor RJ, Bertin KB, Suresh K, Patel SG, Lewis CL. Effect of a Patient Decision Aid on Preferences for Colorectal Cancer Screening Among Older Adults: A Secondary Analysis of a Randomized Clinical Trial. JAMA Netw Open 2022; 5:e2244982. [PMID: 36469317 PMCID: PMC9855297 DOI: 10.1001/jamanetworkopen.2022.44982] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
IMPORTANCE Guidelines recommend individualized decision-making for colorectal cancer (CRC) screening among adults aged 76 to 84 years, a process that includes a consideration of health state and patient preference. OBJECTIVE To determine whether a targeted patient decision aid would align older adults' screening preference with their potential to benefit from CRC screening. DESIGN, SETTING, AND PARTICIPANTS This is a prespecified secondary analysis from a randomized clinical trial. Participants aged 70 to 84 years who were not up to date with screening and had an appointment within 6 weeks were purposively sampled by health state (poor, intermediate, or good) at 14 community-based primary care practices and block randomized to receive the intervention or control. Patients were recruited from March 1, 2012, to February 28, 2015, and these secondary analyses were performed from January 15 to March 1, 2022. INTERVENTIONS Patient decision aid targeted to age and sex. MAIN OUTCOMES AND MEASURES The primary outcome of this analysis was patient preference for CRC screening. The a priori hypothesis was that the decision aid (intervention) group would reduce the proportion preferring screening among those in poor and intermediate health compared with the control group. RESULTS Among the 424 participants, the mean (SD) age was 76.8 (4.2) years; 248 (58.5%) of participants were women; and 333 (78.5%) were White. The proportion preferring screening in the intervention group was less than in the control group for those in the intermediate health state (34 of 76 [44.7%] vs 40 of 73 [54.8%]; absolute difference, -10.1% [95% CI, -26.0% to 5.9%]) and in the poor health state (24 of 62 [38.7%] vs 33 of 61 [54.1%]; absolute difference, -15.4% [95% CI, -32.8% to 2.0%]). These differences were not statistically significant. The proportion of those in good health who preferred screening was similar between the intervention and control groups (44 of 74 [59.5%] for intervention vs 46 of 75 [61.3%] for control; absolute difference, -1.9% [95% CI, -17.6% to 13.8%]). CONCLUSIONS AND RELEVANCE The findings of this secondary analysis of a clinical trial did not demonstrate statistically significant differences in patient preferences between the health groups. Additional studies that are appropriately powered are needed to determine the effect of the decision aid on the preferences of older patients for CRC screening by health state. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT01575990.
Collapse
Affiliation(s)
- Alexandra F. Dalton
- Division of General Internal Medicine, Department of Medicine, University of Colorado School of Medicine, Aurora
| | - Carol E. Golin
- Cecil G. Sheps Center for Health Services Research, The University of North Carolina at Chapel Hill
- Division of General Internal Medicine and Clinical Epidemiology, Department of Medicine, The University of North Carolina at Chapel Hill
- Gillings School of Global Public Health, Department of Health Behavior, The University of North Carolina at Chapel Hill
| | - Carolyn Morris
- Division of Data Sciences Safety and Regulatory, Division of Biostatistics, Department of Research & Development Solutions, IQVIA, Durham, North Carolina
| | - Christine E. Kistler
- Department of Family Medicine, School of Medicine, The University of North Carolina at Chapel Hill
| | - Rowena J. Dolor
- Division of General Internal Medicine, Department of Medicine, Duke University, Durham, North Carolina
| | - Kaitlyn B. Bertin
- Adult and Child Center for Outcomes Research and Delivery Science, University of Colorado Anschutz Medical Campus, Aurora
| | - Krithika Suresh
- Department of Biostatistics and Informatics, Colorado School of Public Health, University of Colorado Anschutz Medical Campus, Aurora
| | - Swati G. Patel
- Division of Gastroenterology and Hepatology, University of Colorado Anschutz Medical Campus, Aurora
- Rocky Mountain Regional Veterans Affairs Medical Center, Aurora, Colorado
| | - Carmen L. Lewis
- Division of General Internal Medicine, Department of Medicine, University of Colorado School of Medicine, Aurora
| |
Collapse
|
9
|
Wallis KA, Taylor DA, Fanueli EF, Saravanakumar P, Wells S. Older peoples' views on cardiovascular disease medication: a qualitative study. Fam Pract 2022; 39:897-902. [PMID: 35078221 DOI: 10.1093/fampra/cmab186] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND There is increasing evidence for the potential benefits and harms of cardiovascular disease (CVD) medications in older people (>75 years) prompting updating of clinical guidelines. We explored the views of older people about CVD medication to inform guideline development. METHODS Qualitative study using semistructured interviews and focus groups. An ethnically diverse group of community dwelling older people were purposefully recruited from northern New Zealand using flyers in primary care clinics, local libraries, social groups, and places of worship, and by word of mouth. Interviews and focus groups were digitally recorded, transcribed verbatim, and analysed using an iterative and inductive approach to thematic analysis. RESULTS Thirty-nine participants from 4 ethnic groups were recruited (mean 74 years; range 61-91 years; Māori (7), South Asian (8), European (9), and Pasifika (15)). Most participants were taking CVD medication/s. Four main themes emerged: (i) emphasizing the benefits of CVD medication and downplaying the harms; (ii) feeling compelled to take medication; (iii) trusting "my" doctor; and (iv) expecting medication to be continued. CONCLUSION Findings raise questions about older people's agency in decision-making regarding CVD medication. CVD risk management guidelines for older people could include strategies to support effective communication of the potential benefits and harms of CVD medication in older people, balancing life expectancy, and the expected duration of therapy.
Collapse
Affiliation(s)
- Katharine A Wallis
- School of Population Health, The University of Auckland, Auckland, New Zealand
- General Practice Clinical Unit, The University of Queensland, Level 8, Health Sciences Building, Brisbane, Qld, Australia
| | | | - Elizabeth F Fanueli
- School of Population Health, The University of Auckland, Auckland, New Zealand
| | | | - Susan Wells
- School of Population Health, The University of Auckland, Auckland, New Zealand
| |
Collapse
|
10
|
Characteristics Associated with Low-Value Cancer Screening Among Office-Based Physician Visits by Older Adults in the USA. J Gen Intern Med 2022; 37:2475-2481. [PMID: 34379279 PMCID: PMC9360208 DOI: 10.1007/s11606-021-07072-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2021] [Accepted: 07/22/2021] [Indexed: 10/20/2022]
Abstract
BACKGROUND After a certain age, cancer screening may expose older adults to unnecessary harms with limited benefits and represent inefficient use of health care resources. OBJECTIVE To estimate the frequency of cervical, breast, and colorectal cancer screening among adults older than US Preventive Services Task Force (USPSTF) age thresholds at which screening is no longer considered routine and to identify physician and patient factors associated with low-value cancer screening. DESIGN Observational study using pooled cross-sectional data (2011-2016) from the National Ambulatory Medical Care Survey, a nationally representative probability sample of US office-based physician visits. PARTICIPANTS Analyses for cervical and breast cancer screening were limited to visits by women over age 65 (N=37,818) and ages 75 and over (N=19,451), respectively. Analyses for colorectal cancer screening were limited to visits by patients over age 75 (N=31,543). MAIN MEASURES Cancer screening procedures were coded as low value using USPSTF age thresholds. KEY RESULTS Between 2011 and 2016, an estimated 509, 507, and 273 thousand potentially low-value Pap smears, mammograms, and colonoscopies/sigmoidoscopies, respectively, were ordered annually. Low-valuecervical cancer screening was less likely to occur for visits with older (vs. younger) patients. Compared to visits by non-HispanicWhite women, low-valuecervical and breast cancer screening was less likely to occur for visits by women whose race/ethnicitywas something other than non-HispanicWhite, non-HispanicBlack, or Hispanic. Obstetrician/gynecologistswere more likely to order low-valuePap smears and mammograms compared to family/generalpractice physicians. CONCLUSIONS Thousands of cervical, breast, and colorectal cancer screenings at ages beyond routine guideline thresholds occur each year in the USA. Further research is needed to understand whether this pattern represents clinical inertia and resistance to de-adoption of previous screening practices, or whether physicians and/or patients perceive a higher value in these tests than that endorsed by experts writing evidence-based guidelines.
Collapse
|
11
|
Bade B, Gwin M, Triplette M, Wiener RS, Crothers K. Comorbidity and life expectancy in shared decision making for lung cancer screening. Semin Oncol 2022; 49:S0093-7754(22)00057-4. [PMID: 35940959 DOI: 10.1053/j.seminoncol.2022.07.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2022] [Revised: 07/02/2022] [Accepted: 07/03/2022] [Indexed: 11/11/2022]
Abstract
Shared decision making (SDM) is an important part of lung cancer screening (LCS) that includes discussing the risks and benefits of screening, potential outcomes, patient eligibility and willingness to participate, tobacco cessation, and tailoring a strategy to an individual patient. More than other cancer screening tests, eligibility for LCS is nuanced, incorporating the patient's age as well as tobacco use history and overall health status. Since comorbidities and multimorbidity (ie, 2 or more comorbidities) impact the risks and benefits of LCS, these topics are a fundamental part of decision-making. However, there is currently little evidence available to guide clinicians in addressing comorbidities and an individual's "appropriateness" for LCS during SDM visits. Therefore, this literature review investigates the impact of comorbidities and multimorbidity among patients undergoing LCS. Based on available evidence and guideline recommendations, we identify comorbidities that should be considered during SDM conversations and review best practices for navigating SDM conversations in the context of LCS. Three conditions are highlighted since they concomitantly portend higher risk of developing lung cancer, potentially increase risk of screening-related evaluation and treatment complications and can be associated with limited life expectancy: chronic obstructive pulmonary disease, idiopathic pulmonary fibrosis, and human immunodeficiency virus infection.
Collapse
Affiliation(s)
- Brett Bade
- Veterans Affairs (VA) Connecticut Healthcare System, Section of Pulmonary, Critical Care, and Sleep Medicine, West Haven, CT, United States of America (USA); Yale University School of Medicine, Section of Pulmonary, Critical Care, and Sleep Medicine, New Haven, CT, USA.
| | - Mary Gwin
- University of Washington School of Medicine, Seattle, WA, USA
| | - Matthew Triplette
- University of Washington School of Medicine, Division of Pulmonary, Critical Care and Sleep Medicine, Seattle, WA, USA; Fred Hutchinson Cancer Center, Clinical Research Division, Seattle, WA, USA
| | - Renda Soylemez Wiener
- Center for Healthcare Organization & Implementation Research and Medical Service, VA Boston Healthcare System, Boston, MA, USA; The Pulmonary Center, Boston University School of Medicine, Boston, MA, USA
| | - Kristina Crothers
- University of Washington School of Medicine, Division of Pulmonary, Critical Care and Sleep Medicine, Seattle, WA, USA; VA Puget Sound Health Care System, Section of Pulmonary, Critical Care and Sleep Medicine, Seattle, WA, USA
| |
Collapse
|
12
|
Karam D, Vierkant RA, Ehlers S, Freedman RA, Austin J, Khanani S, Larson NL, Loprinzi CL, Couch F, Olson JE, Ruddy KJ. Surveillance mammography in older breast cancer survivors: Current practice patterns and patient perceptions. J Geriatr Oncol 2022; 13:1038-1042. [PMID: 35853817 DOI: 10.1016/j.jgo.2022.07.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2022] [Revised: 05/31/2022] [Accepted: 07/11/2022] [Indexed: 11/25/2022]
Abstract
INTRODUCTION Although the benefits of surveillance mammography for older breast cancer survivors have not been quantified prospectively, it is unlikely that mammography provides substantial benefit (and possible that mammography is harmful) to women with limited life expectancy and a low risk for in-breast cancer events. MATERIALS AND METHODS We identified 1268 women aged 77 and older with a history of Stage I-III breast cancer, who did not undergo bilateral mastectomy, were diagnosed with cancer at least three years prior to study entry, and who had consented to be surveyed as part of the Mayo Clinic Breast Disease Registry. We mailed them a one-time survey asking about their experiences with surveillance mammography. Women with metastatic disease were excluded. The primary endpoint was whether or not women reported at least one mammogram since breast cancer surgery. RESULTS Eight hundred forty-six of 1268 (67%) returned the survey, 734 of whom were eligible for analysis. The median age at the time of survey was 82, and the median time since cancer diagnosis was 12 years. Ninety-three percent reported having had at least one mammogram since their initial breast cancer surgery. Seventy-nine percent reported that they had surveillance mammography annually over the prior three years, including 76% of the 491 aged 80+ and 64% of the 189 aged 85 + . DISCUSSION Most older breast cancer survivors who have residual breast tissue are undergoing annual mammograms. Additional educational materials may be beneficial for patients and clinicians to better individualize plans for surveillance mammography in older breast cancer survivors.
Collapse
Affiliation(s)
- Dhauna Karam
- Department of Community Internal Medicine, Mayo Clinic Health System at Austin and Albert Lea, Albert Lea, MN 56007, USA.
| | - Robert A Vierkant
- Division of Clinical Trials and Biostatistics, Mayo Clinic, Rochester, MN 55905, USA
| | - Shawna Ehlers
- Division of Psychiatry and Psychology, Mayo Clinic, Rochester, MN 55905, USA
| | - Rachel A Freedman
- Division of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA 02215, USA
| | - Jessica Austin
- Division of Epidemiology, Mayo Clinic, Scottsdale, AZ 85259, USA
| | - Sadia Khanani
- Division of Radiology, Mayo Clinic, Rochester, MN 55905, USA
| | - Nicole L Larson
- Division of Medical Oncology, Mayo Clinic, Rochester, MN 55905, USA
| | | | - Fergus Couch
- Division of Medical Oncology, Mayo Clinic, Rochester, MN 55905, USA
| | - Janet E Olson
- Division of Medical Oncology, Mayo Clinic, Rochester, MN 55905, USA
| | - Kathryn J Ruddy
- Division of Medical Oncology, Mayo Clinic, Rochester, MN 55905, USA
| |
Collapse
|
13
|
Brotzman LE, Shelton RC, Austin JD, Rodriguez CB, Agovino M, Moise N, Tehranifar P. "It's something I'll do until I die": A qualitative examination into why older women in the U.S. continue screening mammography. Cancer Med 2022; 11:3854-3862. [PMID: 35616300 PMCID: PMC9582674 DOI: 10.1002/cam4.4758] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2021] [Revised: 02/11/2022] [Accepted: 02/14/2022] [Indexed: 01/01/2023] Open
Abstract
BACKGROUND Professional guidelines in the U.S. do not recommend routine screening mammography for women ≥75 years with limited life expectancy and/or poor health. Yet, routine mammography remains widely used in older women. We examined older women's experiences, beliefs, and opinions about screening mammography in relation to aging and health. METHODS We performed thematic analysis of transcribed semi-structured interviews with 19 women who had a recent screening visit at a mammography clinic in New York City (average age: 75 years, 63% Hispanic, 53% ≤high school education). RESULTS Three main themes emerged: (1) older women typically perceive mammograms as a positive, beneficial, and routine component of care; (2) participation in routine mammography is reinforced by factors at interpersonal, provider, and healthcare system levels; and (3) older women do not endorse discontinuation of screening mammography due to advancing age or poor health, but some may be receptive to reducing screening frequency. Only a few older women reported having discussed mammography cessation or the potential harms of screening with their providers. A few women reported they would insist on receiving mammography even without a provider recommendation. CONCLUSIONS Older women's positive experiences and views, as well as multilevel and frequently automated cues toward mammography are important drivers of routine screening in older women. These findings suggest a need for synergistic patient, provider, and system level strategies to reduce mammography overuse in older women.
Collapse
Affiliation(s)
- Laura E. Brotzman
- Department of Sociomedical SciencesColumbia University Mailman School of Public HealthNew YorkNew YorkUSA
| | - Rachel C. Shelton
- Department of Sociomedical SciencesColumbia University Mailman School of Public HealthNew YorkNew YorkUSA,Herbert Irving Comprehensive Cancer CenterColumbia University Medical CenterNew YorkNew YorkUSA
| | - Jessica D. Austin
- Department of Sociomedical SciencesColumbia University Mailman School of Public HealthNew YorkNew YorkUSA,Department of EpidemiologyColumbia University Mailman School of Public HealthNew YorkNew YorkUSA
| | - Carmen B. Rodriguez
- Department of EpidemiologyColumbia University Mailman School of Public HealthNew YorkNew YorkUSA
| | - Mariangela Agovino
- Department of EpidemiologyColumbia University Mailman School of Public HealthNew YorkNew YorkUSA
| | - Nathalie Moise
- Department of MedicineColumbia University Irving Medical CenterNew YorkNew YorkUSA
| | - Parisa Tehranifar
- Herbert Irving Comprehensive Cancer CenterColumbia University Medical CenterNew YorkNew YorkUSA,Department of EpidemiologyColumbia University Mailman School of Public HealthNew YorkNew YorkUSA
| |
Collapse
|
14
|
Enns JP, Pollack CE, Boyd CM, Massare J, Schoenborn NL. Discontinuing Cancer Screening for Older Adults: a Comparison of Clinician Decision-Making for Breast, Colorectal, and Prostate Cancer Screenings. J Gen Intern Med 2022; 37:1122-1128. [PMID: 34545468 PMCID: PMC8971256 DOI: 10.1007/s11606-021-07121-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2021] [Accepted: 08/25/2021] [Indexed: 12/30/2022]
Abstract
BACKGROUND While guidelines recommend against routine screening for breast, prostate, and colorectal cancers in older adults (65+ years) with <10-year life expectancy, many of these patients continue to be screened. How clinicians consider screening cessation across multiple cancer screening types is unknown. OBJECTIVE To compare and contrast clinicians' perspectives on discontinuing breast, prostate, and colorectal cancer screenings in older adults. DESIGN Qualitative, semi-structured interviews. PARTICIPANTS Primary care clinicians in Maryland (N=30) APPROACH: We conducted semi-structured interviews with individual clinicians. Interviews were recorded, transcribed, and analyzed using standard techniques of qualitative content analysis to identify major themes. KEY RESULTS Participants were mostly physicians (24/30) and women (16/30). Four major themes highlighted differences in decision-making across cancer screenings: (1) Clinicians reported more often screening beyond guideline-recommended ages for breast and prostate cancers than colorectal cancer; (2) clinicians had different priorities when considering the benefits/harms of each screening; for example, some prioritized continuing colorectal cancer screening due to the test's high efficacy while others prioritized stopping colorectal cancer screening due to high procedural risk; some prioritized continuing prostate cancer screening due to poor outcomes from advanced prostate cancer while others prioritized stopping prostate cancer screening due to high false positive test rates and harms from downstream tests; (3) clinicians discussed harms of prostate and colorectal cancer screening more readily than for breast cancer screening; (4) clinicians perceived more involvement with gastroenterologists in colonoscopy decisions and less involvement from specialists for prostate and breast cancer screening. CONCLUSIONS Our results highlight the need for more explicit guidance on how to weigh competing considerations in cancer screening (such as test accuracy versus ease of cancer treatment after detection). Recognizing the complexity of the benefit/harms analysis as clinicians consider multiple cancer screenings, future decision support tools, and clinician education materials can specifically address the competing considerations.
Collapse
Affiliation(s)
- Justine P Enns
- The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Craig E Pollack
- The Johns Hopkins University School of Public Health, Baltimore, MD, USA
| | - Cynthia M Boyd
- The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | | | | |
Collapse
|
15
|
Hoare S, Powell A, Modi RN, Armstrong N, Griffin SJ, Mant J, Burt J. Why do people take part in atrial fibrillation screening? Qualitative interview study in English primary care. BMJ Open 2022; 12:e051703. [PMID: 35296474 PMCID: PMC8928318 DOI: 10.1136/bmjopen-2021-051703] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
OBJECTIVES There is insufficient evidence to support national screening programmes for atrial fibrillation (AF). Nevertheless, some practitioners, policy-makers and special interest groups have encouraged introduction of opportunistic screening in primary care in order to reduce the incidence of stroke through earlier detection and treatment of AF. The attitudes of the public towards AF screening are unknown. We aimed to explore why AF screening participants took part in the screening. DESIGN Semistructured longitudinal interview study of participant engagement in the SAFER study (Screening for Atrial Fibrillation with ECG to Reduce stroke). We undertook initial interviews face to face, with up to two follow-up telephone interviews during the screening process. We thematically analysed and synthesised these data to understand shared views of screening participation. SETTING 5 primary care practices in the East of England, UK. PARTICIPANTS 23 people taking part in the SAFER study first feasibility phase. RESULTS Participants were supportive of screening for AF, explaining their participation in screening as a 'good thing to do'. Participants suggested screening could facilitate earlier diagnosis, more effective treatment, and a better future outcome, despite most being unfamiliar with AF. Participating in AF screening helped attenuate participants' concerns about stroke and demonstrated their commitment to self-care and being a 'good patient'. Participants felt that the screening test was non-invasive, and they were unlikely to have AF; they therefore considered engaging in AF screening was low risk, with few perceived harms. CONCLUSIONS Participants assessed the SAFER AF screening programme to be a legitimate, relevant and safe screening opportunity, and complied obediently with what they perceived to be a recommendation to take part. Their unreserved acceptance of screening benefit and lack of awareness of potential harms suggests that uptake would be high but reinforces the importance of ensuring participants receive balanced information about AF screening initiatives. TRIAL REGISTRATION NUMBER ISRCTN16939438; Pre-results.
Collapse
Affiliation(s)
- Sarah Hoare
- The Healthcare Improvement Studies Institute, Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
| | - Alison Powell
- The Healthcare Improvement Studies Institute, Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
| | - Rakesh Narendra Modi
- Primary Care Unit, Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
| | - Natalie Armstrong
- Department of Health Sciences, University of Leicester, Leicester, UK
| | - Simon J Griffin
- Primary Care Unit, Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
- MRC Epidemiology Unit, Institute of Metabolic Science, School of Clinical Medicine, University of Cambridge, Cambridge, UK
| | - Jonathan Mant
- Primary Care Unit, Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
| | - Jenni Burt
- The Healthcare Improvement Studies Institute, Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
| |
Collapse
|
16
|
Schonberg MA, Hamel MB, Davis RB, Karamourtopoulos M, Pinheiro A, Hayes MC, Wee CC, Kistler C. Primary Care Providers’ Perceptions of the Acceptability, Appropriateness, and Feasibility of a Mammography Decision Aid for Women Aged 75 and Older. MDM Policy Pract 2022; 7:23814683221074310. [PMID: 35097217 PMCID: PMC8796098 DOI: 10.1177/23814683221074310] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2021] [Accepted: 12/16/2021] [Indexed: 11/16/2022] Open
Abstract
Background. Clinicians need to find decision aids (DAs) useful for their successful implementation. Therefore, we aimed to conduct an exploratory study to learn primary care clinicians’ (PCPs) perspectives on a mammography DA for women ≥75 to inform its implementation. Methods. We sent a cross-sectional survey to 135 PCPs whose patients had participated in a randomized trial of the DA. These PCPs practiced at 1 of 11 practices in Massachusetts or North Carolina. PCPs were asked closed-ended and open-ended questions on shared decision making (SDM) around mammography with women ≥75 and on the DA’s acceptability, appropriateness, and feasibility. Results. Eighty PCPs participated (24 [30%] from North Carolina). Most (n = 69, 86%) thought that SDM about mammography with women ≥75 was extremely/very important and that they engaged women ≥75 in SDM around mammography frequently/always (n = 49, 61%). Regarding DA acceptability, 60% felt the DA was too long. Regarding appropriateness, 70 (89%) thought it was somewhat/very helpful and that it would help patients make more informed decisions; 55 (70%) would recommend it. Few (n = 6, 8%) felt they had other resources to support this decision. Regarding feasibility, 53 (n = 67%) thought it would be most feasible for patients to receive the DA before a visit from medical assistants rather than during or after a visit or from health educators. Most (n = 62, 78%) wanted some training to use the DA. Limitations. Sixty-nine percent of PCPs in this small study practiced in academic settings. Conclusions. Although PCPs were concerned about the DA’s length, most found it helpful and informative and felt it would be feasible for medical assistants to deliver the DA before a visit. Implications. Study findings may inform implementation of this and other DAs.
Collapse
Affiliation(s)
- Mara A. Schonberg
- Division of General Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Mary Beth Hamel
- Division of General Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Roger B. Davis
- Division of General Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Maria Karamourtopoulos
- Division of General Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Adlin Pinheiro
- Division of General Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Michelle C. Hayes
- Division of Geriatric Medicine and Department of Family Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Christina C. Wee
- Division of General Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Christine Kistler
- Division of Geriatric Medicine and Department of Family Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| |
Collapse
|
17
|
Smith J, Dodd RH, Hersch J, McCaffery KJ, Naganathan V, Cvejic E, Jansen J. Psychosocial and clinical predictors of continued cancer screening in older adults. PATIENT EDUCATION AND COUNSELING 2021; 104:3093-3096. [PMID: 33962825 DOI: 10.1016/j.pec.2021.04.027] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/16/2020] [Revised: 03/21/2021] [Accepted: 04/21/2021] [Indexed: 06/12/2023]
Abstract
OBJECTIVE Many older adults (aged 75+) continue cancer screening despite guidelines suggesting they should not. Using mixed-methods, we examined psychosocial and clinical factors associated with continued breast/prostate screening. METHODS We conducted an online, scenario-based, randomized study in Australia with participants aged 65+ years. The primary outcome was screening intention (10-point scale, dichotomized: low (1-5) and high (6-10)). We also measured demographic, psychosocial, and age-related clinical variables. Participants provided reason/s for their screening intentions in free-text. RESULTS 271 eligible participants completed the survey (aged 65-90 years, 71% adequate health literacy). Those who reported higher cancer anxiety, were men, screened more recently, had family history of breast/prostate cancer and were independent in activities of daily living, were more likely to intend to continue screening. Commonly reported reasons for intending to continue screening were grouped into six themes: routine adherence, the value of knowing, positive screening attitudes, perceived susceptibility, benefits focus, and needing reassurance. CONCLUSIONS Psychosocial factors may drive continued cancer screening in older adults and undermine efforts to promote informed decision-making. PRACTICE IMPLICATIONS When communicating benefits and harms of cancer screening to older adults, both clinical and psychosocial factors should be discussed to support informed decision-making.
Collapse
Affiliation(s)
- Jenna Smith
- Wiser Healthcare, Sydney School of Public Health, The University of Sydney, Sydney, Australia; Sydney Health Literacy Laboratory, Sydney School of Public Health, The University of Sydney, Sydney, Australia.
| | - Rachael H Dodd
- Wiser Healthcare, Sydney School of Public Health, The University of Sydney, Sydney, Australia; Sydney Health Literacy Laboratory, Sydney School of Public Health, The University of Sydney, Sydney, Australia
| | - Jolyn Hersch
- Wiser Healthcare, Sydney School of Public Health, The University of Sydney, Sydney, Australia; Sydney Health Literacy Laboratory, Sydney School of Public Health, The University of Sydney, Sydney, Australia
| | - Kirsten J McCaffery
- Wiser Healthcare, Sydney School of Public Health, The University of Sydney, Sydney, Australia; Sydney Health Literacy Laboratory, Sydney School of Public Health, The University of Sydney, Sydney, Australia
| | - Vasi Naganathan
- Centre for Education and Research on Ageing, Concord Clinical School, The University of Sydney, Sydney, Australia
| | - Erin Cvejic
- Sydney Health Literacy Laboratory, Sydney School of Public Health, The University of Sydney, Sydney, Australia
| | - Jesse Jansen
- Wiser Healthcare, Sydney School of Public Health, The University of Sydney, Sydney, Australia; Sydney Health Literacy Laboratory, Sydney School of Public Health, The University of Sydney, Sydney, Australia; School for Public Health and Primary Care, Faculty of Health, Medicine and Life Sciences, Maastricht University, Maastricht, the Netherlands
| |
Collapse
|
18
|
Smith J, Dodd RH, Gainey KM, Naganathan V, Cvejic E, Jansen J, McCaffery KJ. Patient-Reported Factors Associated With Older Adults' Cancer Screening Decision-making: A Systematic Review. JAMA Netw Open 2021; 4:e2133406. [PMID: 34748004 PMCID: PMC8576581 DOI: 10.1001/jamanetworkopen.2021.33406] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
IMPORTANCE Decisions for older adults (aged ≥65 years) and their clinicians about whether to continue to screen for cancer are not easy. Many older adults who are frail or have limited life expectancy or comorbidities continue to be screened for cancer despite guidelines suggesting they should not; furthermore, many older adults have limited knowledge of the potential harms of continuing to be screened. OBJECTIVE To summarize the patient-reported factors associated with older adults' decisions regarding screening for breast, prostate, colorectal, and cervical cancer. EVIDENCE REVIEW Studies were identified by searching databases from January 2000 to June 2020 and were independently assessed for inclusion by 2 authors. Data extraction and risk of bias assessment were independently conducted by 2 authors, and then all decisions were cross-checked and discussed where necessary. Data analysis was performed from September to December 2020. FINDINGS The search yielded 2475 records, of which 21 unique studies were included. Nine studies were quantitative, 8 were qualitative, and 4 used mixed method designs. Of the 21 studies, 17 were conducted in the US, and 10 of 21 assessed breast cancer screening decisions only. Factors associated with decision-making were synthesized into 5 categories: demographic, health and clinical, psychological, physician, and social and system. Commonly identified factors associated with the decision to undergo screening included personal or family history of cancer, positive screening attitudes, routine or habit, to gain knowledge, friends, and a physician's recommendation. Factors associated with the decision to forgo screening included being older, negative screening attitudes, and desire not to know about cancer. Some factors had varying associations, including insurance coverage, living in a nursing home, prior screening experience, health problems, limited life expectancy, perceived cancer risk, risks of screening, family, and a physician's recommendation to stop. CONCLUSIONS AND RELEVANCE Although guidelines suggest incorporating life expectancy and health status to inform older adults' cancer screening decisions, older adults' ingrained beliefs about screening may run counter to these concepts. Communication strategies are needed that support older adults to make informed cancer screening decisions by addressing underlying screening beliefs in context with their perceived and actual risk of developing cancer.
Collapse
Affiliation(s)
- Jenna Smith
- Wiser Healthcare, Sydney School of Public Health, Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia
- Sydney Health Literacy Lab, Sydney School of Public Health, Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia
| | - Rachael H. Dodd
- Wiser Healthcare, Sydney School of Public Health, Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia
- Sydney Health Literacy Lab, Sydney School of Public Health, Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia
| | - Karen M. Gainey
- Sydney Health Literacy Lab, Sydney School of Public Health, Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia
| | - Vasi Naganathan
- Centre for Education and Research on Ageing, Concord Clinical School, The University of Sydney, Sydney, NSW, Australia
| | - Erin Cvejic
- Sydney Health Literacy Lab, Sydney School of Public Health, Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia
| | - Jesse Jansen
- Wiser Healthcare, Sydney School of Public Health, Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia
- Sydney Health Literacy Lab, Sydney School of Public Health, Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia
- School for Public Health and Primary Care, Faculty of Health, Medicine and Life Sciences, Maastricht University, Maastricht, the Netherlands
| | - Kirsten J. McCaffery
- Wiser Healthcare, Sydney School of Public Health, Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia
- Sydney Health Literacy Lab, Sydney School of Public Health, Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia
| |
Collapse
|
19
|
Saman DM, Harry ML, Freitag LA, Allen CI, O’Connor PJ, Sperl-Hillen JM, Bianco JA, Truitt AR, Ekstrom HL, Elliott TE. Patient Perceptions of Using Clinical Decision Support for Cancer Screening and Prevention: "I wouldn't have thought about getting screened without it.". J Patient Cent Res Rev 2021; 8:297-306. [PMID: 34722797 PMCID: PMC8530236 DOI: 10.17294/2330-0698.1863] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
PURPOSE We sought to gain an understanding of cancer prevention and screening perspectives among patients exposed to a clinical decision support (CDS) tool because they were due or overdue for certain cancer screenings or prevention. METHODS Semi-structured qualitative interviews were conducted with 37 adult patients due or overdue for cancer prevention services in 10 primary care clinics within the same health system. Data were thematically segmented and coded using qualitative content analysis. RESULTS We identified three themes: 1) The CDS tool had more strengths than weaknesses, with areas for improvement; 2) Many facilitators and barriers to cancer prevention and screening exist; and 3) Discussions and decision-making varied by type of cancer prevention and screening. Almost all participants made positive comments regarding the CDS. Some participants learned new information, reporting the CDS helped them make a decision they otherwise would not have made. Participants who used the tool with their provider had higher self-reported rates of deciding to be screened than those who did not. CONCLUSIONS Learning about patients' perceptions of a CDS tool may increase understanding of how patient-tailored CDS impacts cancer screening and prevention rates. Participants found a personalized CDS tool for cancer screening and prevention in primary care useful and a welcome addition to their visit. However, many providers were not using the tool with eligible patients.
Collapse
|
20
|
Schuttner L, Haraldsson B, Maynard C, Helfrich CD, Reddy A, Parikh T, Nelson KM, Wong E. Factors Associated With Low-Value Cancer Screenings in the Veterans Health Administration. JAMA Netw Open 2021; 4:e2130581. [PMID: 34677595 PMCID: PMC8536952 DOI: 10.1001/jamanetworkopen.2021.30581] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
Abstract
IMPORTANCE Most clinical practice guidelines recommend stopping cancer screenings when risks exceed benefits, yet low-value screenings persist. The Veterans Health Administration focuses on improving the value and quality of care, using a patient-centered medical home model that may affect cancer screening behavior. OBJECTIVE To understand rates and factors associated with outpatient low-value cancer screenings. DESIGN, SETTING, AND PARTICIPANTS This cohort study assessed the receipt of low-value cancer screening and associated factors among 5 993 010 veterans. Four measures of low-value cancer screening defined by validated recommendations of practices to avoid were constructed using administrative data. Patients with cancer screenings in 2017 at Veterans Health Administration primary care clinics were included. Excluded patients had recent symptoms or historic high-risk diagnoses that may affect test appropriateness (eg, melena preceding colonoscopy). Data were analyzed from December 23, 2019, to June 21, 2021. EXPOSURES Receipt of cancer screening test. MAIN OUTCOMES AND MEASURES Low-value screenings were defined as occurring for average-risk patients outside of guideline-recommended ages or if the 1-year mortality risk estimated using a previously validated score was at least 50%. Factors evaluated in multivariable regression models included patient, clinician, and clinic characteristics and patient-centered medical home domain performance for team-based care, access, and continuity previously developed from administrative and survey data. RESULTS Of 5 993 010 veterans (mean [SD] age, 63.1 [16.8] years; 5 496 976 men [91.7%]; 1 027 836 non-Hispanic Black [17.2%] and 4 539 341 non-Hispanic White [75.7%] race and ethnicity) enrolled in primary care, 903 612 of 4 647 479 men of average risk (19.4%) underwent prostate cancer screening; 299 765 of 5 770 622 patients of average risk (5.2%) underwent colorectal cancer screening; 21 930 of 469 045 women of average risk (4.7%) underwent breast cancer screening; and 65 511 of 458 086 women of average risk (14.3%) underwent cervical cancer screening. Of patients screened, low-value testing was rare for 3 cancers, with receipt of a low-value test in 633 of 21 930 of women screened for breast cancer (2.9%), 630 of 65 511 of women screened for cervical cancer (1.0%), and 6790 of 299 765 of patients screened for colorectal cancer (2.3%). However, 350 705 of 4 647 479 of screened men (7.5%) received a low-value prostate cancer test. Patient race and ethnicity, sociodemographic factors, and illness burden were significantly associated with likelihood of receipt of low-value tests among screened patients. No single patient-, clinician-, or clinic-level factor explained the receipt of a low-value test across cancer screening cohorts. CONCLUSIONS AND RELEVANCE This large cohort study found that low-value breast, cervical, and colorectal cancer screenings were rare in the Veterans Health Administration, but more than one-third of patients screened for prostate cancer were tested outside of clinical practice guidelines. Guideline-discordant care has quality implications and is not consistently explained by associated multilevel factors.
Collapse
Affiliation(s)
- Linnaea Schuttner
- Health Services Research and Development, VA Puget Sound Health Care System, Seattle, Washington
- Department of Medicine, University of Washington, Seattle
| | | | - Charles Maynard
- Health Services Research and Development, VA Puget Sound Health Care System, Seattle, Washington
- Department of Health Systems and Population Health, University of Washington, Seattle
| | - Christian D. Helfrich
- Health Services Research and Development, VA Puget Sound Health Care System, Seattle, Washington
- Department of Health Systems and Population Health, University of Washington, Seattle
| | - Ashok Reddy
- Health Services Research and Development, VA Puget Sound Health Care System, Seattle, Washington
- Department of Medicine, University of Washington, Seattle
| | - Toral Parikh
- Department of Medicine, University of Washington, Seattle
- Geriatrics and Extended Care, VA Puget Sound Healthcare System
| | - Karin M. Nelson
- Health Services Research and Development, VA Puget Sound Health Care System, Seattle, Washington
- Department of Medicine, University of Washington, Seattle
| | - Edwin Wong
- Health Services Research and Development, VA Puget Sound Health Care System, Seattle, Washington
- Department of Health Systems and Population Health, University of Washington, Seattle
| |
Collapse
|
21
|
Austin JD, Tehranifar P, Rodriguez CB, Brotzman L, Agovino M, Ziazadeh D, Moise N, Shelton RC. A mixed-methods study of multi-level factors influencing mammography overuse among an older ethnically diverse screening population: implications for de-implementation. Implement Sci Commun 2021; 2:110. [PMID: 34565481 PMCID: PMC8474751 DOI: 10.1186/s43058-021-00217-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2021] [Accepted: 09/14/2021] [Indexed: 01/23/2023] Open
Abstract
BACKGROUND There is growing concern that routine mammography screening is overused among older women. Successful and equitable de-implementation of mammography will require a multi-level understanding of the factors contributing to mammography overuse. METHODS This explanatory, sequential, mixed-methods study collected survey data (n= 52, 73.1% Hispanic, 73.1% Spanish-speaking) from women ≥70 years of age at the time of screening mammography, followed by semi-structured interviews with a subset of older women completing the survey (n=19, 63.2% Hispanic, 63.2% Spanish-speaking) and providers (n=5, 4 primary care, 1 obstetrics and gynecology) to better understand multi-level factors influencing mammography overuse and inform potential de-implementation strategies. We conducted a descriptive analysis of survey data and content analysis of qualitative interview data. Survey and interview data were examined separately, compared, integrated, and organized according to Norton and Chambers Continuum of Factors Influencing De-Implementation Process. RESULTS Survey findings show that 87.2% of older women believe it is important to plan for an annual mammogram, 80.8% received a provider recommendation, and 78.9% received a reminder in the last 12 months to schedule a mammogram. Per interviews with older women, the majority were unaware of or did not perceive to have experienced overuse and intended to continue mammography screening. Findings from interviews with older women and providers suggest that there are multiple opportunities for older women to obtain a mammogram. Per provider interviews, almost all reported that reducing overuse was not viewed as a priority by the system or other providers. Providers also discussed that variation in mammography screening practices across providers, fear of malpractice, and monetary incentives may contribute to overscreening. Providers identified potential strategies to reduce overscreening including patient and provider education around harms of screening, leveraging the electronic health record to identify women who may receive less health benefit from screening, customizing system-generated reminder letters, and organizing workgroups to develop standard processes of care around mammography screening. CONCLUSIONS Multi-level factors contributing to mammography overuse are dynamic, interconnected, and reinforced. To ensure equitable de-implementation, there is a need for more refined and empirical testing of theories, models, and frameworks for de-implementation with a strong patient-level component that considers the interplay between multilevel factors and the larger care delivery process.
Collapse
Affiliation(s)
- Jessica D Austin
- Department of Epidemiology, Columbia University Mailman School of Public Health, New York, NY, USA
- Department of Sociomedical Sciences, Columbia University Mailman School of Public Health, 722 W 168th Street, New York, NY, 10032, USA
| | - Parisa Tehranifar
- Department of Epidemiology, Columbia University Mailman School of Public Health, New York, NY, USA
- Herbert Irving Comprehensive Cancer Center, Columbia University Medical Center, New York, NY, USA
| | - Carmen B Rodriguez
- Department of Epidemiology, Columbia University Mailman School of Public Health, New York, NY, USA
| | - Laura Brotzman
- Herbert Irving Comprehensive Cancer Center, Columbia University Medical Center, New York, NY, USA
| | - Mariangela Agovino
- Department of Epidemiology, Columbia University Mailman School of Public Health, New York, NY, USA
| | - Danya Ziazadeh
- Department of Epidemiology, Columbia University Mailman School of Public Health, New York, NY, USA
| | - Nathalie Moise
- Department of Medicine, Columbia University Irving Medical Center, New York, NY, USA
| | - Rachel C Shelton
- Department of Sociomedical Sciences, Columbia University Mailman School of Public Health, 722 W 168th Street, New York, NY, 10032, USA.
- Herbert Irving Comprehensive Cancer Center, Columbia University Medical Center, New York, NY, USA.
| |
Collapse
|
22
|
What Should We Recommend for Colorectal Cancer Screening in Adults Aged 75 and Older? ACTA ACUST UNITED AC 2021; 28:2540-2547. [PMID: 34287279 PMCID: PMC8293045 DOI: 10.3390/curroncol28040231] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2021] [Revised: 06/30/2021] [Accepted: 07/06/2021] [Indexed: 12/14/2022]
Abstract
The current recommendation to stop colorectal cancer screening for older adults is based on a lack of evidence due to systematic exclusion of this population from trials. Older adults are a heterogenous population with many available strategies for patient-centered assessment and decision-making. Evolutions in management strategies for colorectal cancer have made safe and effective options available to older adults, and the rationale to screen for treatable disease more reasonably, especially given the aging Canadian population. In this commentary, we review the current screening guidelines and the evidence upon which they were built, the unique considerations for screening older adults, new treatment options, the risks and benefits of increased screening and potential considerations for the new guidelines.
Collapse
|
23
|
Turbow SD, White MC, Breslau ES, Sabatino SA. Mammography use and breast cancer incidence among older U.S. women. Breast Cancer Res Treat 2021; 188:307-316. [PMID: 33666831 PMCID: PMC10846538 DOI: 10.1007/s10549-021-06160-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2021] [Accepted: 02/20/2021] [Indexed: 11/26/2022]
Abstract
PURPOSE The death rate for female breast cancer increases progressively with age, but organizations differ in their mammography screening recommendations for older women. To understand current patterns of screening mammography use and breast cancer diagnoses among older women, we examined recent national data on mammography screening use and breast cancer incidence and stage at diagnosis among women aged ≥ 65 years. METHODS We examined breast cancer incidence using the 2016 United States Cancer Statistics dataset and analyzed screening mammography use among women aged ≥ 65 years using the 2018 National Health Interview Survey. RESULTS Women aged 70-74 years had the highest breast cancer incidence rate (458.3 cases per 100,000 women), and women aged ≥ 85 years had the lowest rate (295.2 per 100,000 women). The proportion of cancer diagnosed at distant stage or with unknown stage increased with age. Over half of women aged 80-84 years and 26.0% of women aged ≥ 85 years reported a screening mammogram within the last 2 years. Excellent/very good/good self-reported health status (p = .010) and no dependency in activities of daily living/instrumental activities of daily living (p < .001) were associated with recent mammography screening. CONCLUSION Breast cancer incidence rates and stage at diagnosis vary by age. Many women aged ≥ 75 years receive screening mammograms. The results of this study point to areas for further investigation to promote optimal mammography screening among older women.
Collapse
Affiliation(s)
- Sara D Turbow
- Division of Preventive Medicine, Department of Family and Preventive Medicine and Division of General Internal Medicine, Department of Medicine, Emory University School of Medicine, 49 Jesse Hill Jr Dr. SE, Atlanta, GA, 30303, USA.
| | - Mary C White
- Division of Cancer Prevention and Control, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention (CDC), Atlanta, GA, USA
| | - Erica S Breslau
- Division of Cancer Control and Population Sciences, National Cancer Institute, National Institutes of Health, Bethesda, MD, USA
| | - Susan A Sabatino
- Division of Cancer Prevention and Control, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention (CDC), Atlanta, GA, USA
| |
Collapse
|
24
|
Cadet T, Aliberti G, Karamourtopoulos M, Jacobson A, Siska M, Schonberg MA. Modifying a Mammography Decision Aid for Older Adult Women with Risk Factors for Low Health Literacy. Health Lit Res Pract 2021; 5:e78-e90. [PMID: 34213995 PMCID: PMC8082954 DOI: 10.3928/24748307-20210308-01] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/03/2022] Open
Abstract
Background: Guidelines recommend that before being offered mammography screening, women age 75 years and older be informed of the uncertainty of benefit and potential for harm (e.g., being diagnosed with a breast cancer that would otherwise never have shown up in one's lifetime); however, few older women are informed of the risks of mammography screening and most overestimate its benefits. Objective: The aim of this study was to learn from women older than age 75 years who have predisposing risk factors for low health literacy (LHL) how they make decisions about mammography screening, whether an existing decision aid (DA) on mammography screening for them was acceptable and helpful, and suggestions for improving the DA. Methods: We conducted semi-structured interviews with 18 women who were between ages 75 and 89 years and had predisposing risk factors for LHL (i.e., answered somewhat to not at all confident to the health literacy screening question “How confident are you filling out medical forms by yourself?” and/or had an education level of some college or less). Key Results: Findings indicate that women in this study lacked knowledge and understanding that one can decide on mammography screening based on their personal values. Women were enthusiastic about screening based on an interest in taking care of themselves but rely on their providers for health care decisions. Overall, most women found the DA helpful and would recommend the use of the DA. Conclusions: Findings from this study provide formative data to test the efficacy of the modified DA in practice. Failing to consider the informational needs of adults with LHL in design of DAs could inadvertently exacerbate existing inequalities in health. It is essential that DAs consider older women's diverse backgrounds and educational levels to support their decision-making. [HLRP: Health Literacy Research and Practice. 2021;5(2):e78–e90.] Plain Language Summary: The goal of this research was to understand how women older than age 75 years with risk factors for low health literacy made decisions about getting mammograms, whether an educational pamphlet was helpful, and suggestions for improving it. This research helps in understanding how to involve this population in the process of designing patient-related materials for mammogram decision-making.
Collapse
Affiliation(s)
- Tamara Cadet
- Address correspondence to Tamara Cadet, PhD, MSW, MPH, Simmons University College of Social Sciences and Policy Practice, School of Social Work, 300 The Fenway, Boston, MA 02115;
| | | | | | | | | | | |
Collapse
|
25
|
Freedman RA, Minami CA, Winer EP, Morrow M, Smith AK, Walter LC, Sedrak MS, Gagnon H, Perilla-Glen A, Wildiers H, Wildes TM, Lichtman SM, Loh KP, Brain EGC, Ganschow PS, Hunt KK, Mayer DK, Ruddy KJ, Jagsi R, Lin NU, Canin B, LeStage BK, Revette AC, Schonberg MA, Keating NL. Individualizing Surveillance Mammography for Older Patients After Treatment for Early-Stage Breast Cancer: Multidisciplinary Expert Panel and International Society of Geriatric Oncology Consensus Statement. JAMA Oncol 2021; 7:609-615. [PMID: 33507222 DOI: 10.1001/jamaoncol.2020.7582] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
Importance There is currently no guidance on how to approach surveillance mammography for older breast cancer survivors, particularly when life expectancy is limited. Objective To develop expert consensus guidelines that facilitate tailored decision-making for routine surveillance mammography for breast cancer survivors 75 years or older. Evidence After a literature review of the risk of ipsilateral and contralateral breast cancer events among breast cancer survivors and the harms and benefits associated with mammography, a multidisciplinary expert panel was convened to develop consensus guidelines on surveillance mammography for breast cancer survivors 75 years or older. Using an iterative consensus-based approach, input from clinician focus groups, and critical review by the International Society for Geriatric Oncology, the guidelines were refined and finalized. Findings The literature review established a low risk for ipsilateral and contralateral breast cancer events in most older breast cancer survivors and summarized the benefits and harms associated with mammography. Draft mammography guidelines were iteratively evaluated by the expert panel and clinician focus groups, emphasizing a patient's risk for in-breast cancer events, age, life expectancy, and personal preferences. The final consensus guidelines recommend discontinuation of routine mammography for all breast cancer survivors when life expectancy is less than 5 years, including those with a history of high-risk cancers; consideration to discontinue mammography when life expectancy is 5 to 10 years; and continuation of mammography when life expectancy is more than 10 years. Individualized, shared decision-making is encouraged to optimally tailor recommendations after weighing the benefits and harms associated with surveillance mammography and patient preferences. The panel also recommends ongoing clinical breast examinations and diagnostic mammography to evaluate clinical findings and symptoms, with reassurance for patients that these practices will continue. Conclusions and Relevance It is anticipated that these expert guidelines will enhance clinical practice by providing a framework for individualized discussions, facilitating shared decision-making regarding surveillance mammography for breast cancer survivors 75 years or older.
Collapse
Affiliation(s)
- Rachel A Freedman
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Christina A Minami
- Division of Breast Surgery, Department of Surgery, Brigham and Women's Hospital, Boston, Massachusetts
| | - Eric P Winer
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Monica Morrow
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Alexander K Smith
- Division of Geriatrics, Department of Medicine, University of California, San Francisco, San Francisco.,Division of Geriatrics, Veterans Affairs Health Care System, San Francisco, California
| | - Louise C Walter
- Division of Geriatrics, Department of Medicine, University of California, San Francisco, San Francisco.,Division of Geriatrics, Veterans Affairs Health Care System, San Francisco, California
| | - Mina S Sedrak
- Department of Medical Oncology and Therapeutics Research, City of Hope, Duarte, California
| | - Haley Gagnon
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Adriana Perilla-Glen
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Hans Wildiers
- Department of General Medical Oncology and Multidisciplinary Breast Center, University Hospitals Leuven, KU Leuven, Leuven, Belgium
| | - Tanya M Wildes
- Division of Medical Oncology, Washington University School of Medicine, St Louis, Missouri
| | | | - Kah Poh Loh
- James P. Wilmot Cancer Institute, Division of Hematology/Oncology, Department of Medicine, University of Rochester School of Medicine and Dentistry, Rochester, New York
| | | | - Pamela S Ganschow
- Department of Medicine, Rush University Medical College and Cook County Health, Chicago, Illinois
| | - Kelly K Hunt
- Department of Breast Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston
| | - Deborah K Mayer
- Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill.,School of Nursing, University of North Carolina at Chapel Hill, Chapel Hill
| | | | - Reshma Jagsi
- Center for Bioethics and Social Sciences in Medicine, University of Michigan, Ann Arbor.,Department of Radiation Oncology, University of Michigan, Ann Arbor
| | - Nancy U Lin
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts
| | | | - Barbara K LeStage
- Dana-Farber Cancer Institute, Boston, Massachusetts.,Alliance for Clinical Trials in Oncology, Boston, Massachusetts
| | - Anna C Revette
- Survey and Data Management Core, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Mara A Schonberg
- Division of General Medicine, Department of Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Nancy L Keating
- Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts.,Division of General Internal Medicine, Brigham and Women's Hospital, Boston, Massachusetts
| |
Collapse
|
26
|
Abstract
Colorectal cancer (CRC) is a common and preventable malignancy, and routine CRC screening is recommended for average risk individuals between the ages of 50 and 75 years. Screening has been shown to decrease CRC incidence and mortality. Once patients are older than 75 years, the risk to benefit ratio of ongoing screening begins to shift. As comorbidities increase and life expectancy decreases, the future potential benefits of CRC prevention become less robust, and risk for screening-related complications grows. However, firm age cutoffs are not sufficient to guide these decisions, as there is substantial physiologic heterogeneity among individuals of the same age.
Collapse
Affiliation(s)
- Andrea L Betesh
- Department of Gastroenterology and Hepatology, New York-Presbyterian Hospital/Weill Cornell Medicine, 1305 York Avenue, 4th Floor, New York, NY 10021, USA.
| | - Felice H Schnoll-Sussman
- Department of Gastroenterology and Hepatology, New York-Presbyterian Hospital/Weill Cornell Medicine, 1315 York Avenue, Ground Floor, New York, NY 10021, USA
| |
Collapse
|
27
|
Roy S, Moss JL, Rodriguez-Colon SM, Shen C, Cooper JD, Lennon RP, Lengerich EJ, Adelman A, Curry W, Ruffin MT. Examining Older Adults' Attitudes and Perceptions of Cancer Screening and Overscreening: A Qualitative Study. J Prim Care Community Health 2020; 11:2150132720959234. [PMID: 33054558 PMCID: PMC7576932 DOI: 10.1177/2150132720959234] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023] Open
Abstract
Introduction/Objectives: Screening guidelines for breast, cervical, and colorectal cancer (CRC) are less clear for older adults due to the potential harms that may result from screening. Understanding older adults’ attitudes and perceptions, especially racial/ethnic minority and underserved adults, of cancer screening can help health care providers determine how best to communicate with older adults about cancer screening and screening cessation. The objective of this study was to determine how older adults primarily from minority/underserved backgrounds perceive cancer screening and overscreening. Methods: Four focus groups (n = 39) were conducted with adults (>=65 years of age) in 3 community settings in south-central Pennsylvania. Two focus groups were conducted in Spanish and translated to English upon transcription. Focus group data was managed and analyzed using QSR NVivo 12. Inductive thematic analysis was used to analyze the data where themes emerged following the coding process. Results: The focus group participants had an average age of 74 years and were primarily female (74%) and Hispanic (69%), with 69% reporting having less than a high school degree. Four key themes were identified from the focus groups: (1) importance of tailored and targeted education/information; (2) impact of physician/patient communication; (3) impact of barriers and facilitators to screening on cancer screening cessation; and (4) awareness of importance of screening. Participants were more likely to be agreeable to screening cessation if they received specific information regarding their health status and previous medical history from their physician as to why screening should be stopped and told by their physician that the screening decision is up to them. Conclusions: Older adults prefer individualized information from their physician in order to justify screening cessation but are against incorporating life expectancy into the discussion. Future research should focus on developing interventions to test the effectiveness of culturally tailored screening cessation messages for older adults.
Collapse
Affiliation(s)
| | | | | | - Chan Shen
- Penn State College of Medicine, Hershey, PA, USA
| | | | | | | | - Alan Adelman
- Penn State College of Medicine, Hershey, PA, USA
| | | | | |
Collapse
|
28
|
Austin JD, Shelton RC, Lee Argov EJ, Tehranifar P. Older Women’s Perspectives Driving Mammography Screening Use and Overuse: a Narrative Review of Mixed-Methods Studies. CURR EPIDEMIOL REP 2020. [DOI: 10.1007/s40471-020-00244-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
Abstract
Purpose of Review
Examining what older women know and perceive about mammography screening is critical for understanding patterns of under- and overuse, and concordance with screening mammography guidelines in the USA. This narrative review synthesizes qualitative and quantitative evidence around older women’s perspectives toward mammography screening.
Recent Findings
The majority of 43 identified studies focused on promoting mammography screening in women of different ages, with only four studies focusing on the overuse of mammography in women ≥ 70 years old. Older women hold positive attitudes around screening, perceive breast cancer as serious, believe the benefits outweigh the barriers, and are worried about undergoing treatment if diagnosed. Older women have limited knowledge of screening guidelines and potential harms of screening.
Summary
Efforts to address inequities in mammography access and underuse need to be supplemented by epidemiologic and interventional studies using mixed-methods approaches to improve awareness of benefits and harms of mammography screening in older racially and ethnically diverse women. As uncertainty around how best to approach mammography screening in older women remains, understanding women’s perspectives along with healthcare provider and system-level factors is critical for ensuring appropriate and equitable mammography screening use in older women.
Collapse
|
29
|
Schonberg MA, Karamourtopoulos M, Jacobson AR, Aliberti GM, Pinheiro A, Smith AK, Davis RB, Schuttner LC, Hamel MB. A Strategy to Prepare Primary Care Clinicians for Discussing Stopping Cancer Screening With Adults Older Than 75 Years. Innov Aging 2020; 4:igaa027. [PMID: 32793815 PMCID: PMC7413618 DOI: 10.1093/geroni/igaa027] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2020] [Indexed: 01/08/2023] Open
Abstract
Background and Objectives Adults older than 75 years are overscreened for cancer, especially those with less than 10-year life expectancy. This study aimed to learn the effects of providing primary care providers (PCPs) with scripts for discussing stopping mammography and colorectal cancer (CRC) screening and with information on patient’s 10-year life expectancy on their patients’ intentions to be screened for these cancers. Research Design and Methods Patient participants, identified via PCP appointment logs, completed a questionnaire pre- and postvisit. Primary care providers were given scripts for discussing stopping screening and information on patient’s 10-year life expectancy before these visits. Primary care providers completed a questionnaire at the end of the study. Patients and PCPs were asked about discussing stopping cancer screening and patient life expectancy. Patient screening intentions (1–15 Likert scale; lower scores suggest lower intentions) were compared pre- and postvisit using the Wilcoxon signed-rank test. Results Ninety patients older than 75 years (47% of eligible patients reached by phone) from 45 PCPs participated. Patient mean age was 80.0 years (SD = 2.9), 43 (48%) were female, and mean life expectancy was 9.7 years (SD = 2.4). Thirty-seven PCPs (12 community-based) completed a questionnaire. Primary care providers found the scripts helpful (32 [89%]) and thought they would use them frequently (29 [81%]). Primary care providers also found patient life expectancy information helpful (35 [97%]). However, only 8 PCPs (22%) reported feeling comfortable discussing patient life expectancy. Patients’ intentions to undergo CRC screening (9.0 [SD = 5.3] to 6.5 [SD = 6.0], p < .0001) and mammography screening (12.9 [SD = 3.0] to 11.7 [SD = 4.9], p = .08) decreased from pre- to postvisit (significantly for CRC). Sixty-three percent of patients (54/86) were interested in discussing life expectancy with their PCP previsit and 56% (47/84) postvisit. Discussion and Implications PCPs found scripts for discussing stopping cancer screening and information on patient life expectancy helpful. Possibly, as a result, their patients older than 75 years had lower intentions of being screened for CRC. Clinical Trials Registration Number NCT03480282
Collapse
Affiliation(s)
- Mara A Schonberg
- Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | | | - Alicia R Jacobson
- Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Gianna M Aliberti
- Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Adlin Pinheiro
- Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Alexander K Smith
- Division of Geriatrics, Department of Medicine, University of California San Francisco
| | - Roger B Davis
- Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Linnaea C Schuttner
- Health Services Research & Development, VA Puget Sound Health Care System, Seattle, Washington.,Department of Medicine, University of Washington, Seattle
| | - Mary Beth Hamel
- Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| |
Collapse
|
30
|
Schonberg MA, Jacobson AR, Karamourtopoulos M, Aliberti GM, Pinheiro A, Smith AK, Schuttner LC, Park ER, Hamel MB. Scripts and Strategies for Discussing Stopping Cancer Screening with Adults > 75 Years: a Qualitative Study. J Gen Intern Med 2020; 35:2076-2083. [PMID: 32128689 PMCID: PMC7351918 DOI: 10.1007/s11606-020-05735-z] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/07/2019] [Accepted: 02/10/2020] [Indexed: 01/23/2023]
Abstract
BACKGROUND Despite guidelines recommending not to continue cancer screening for adults > 75 years old, especially those with short life expectancy, primary care providers (PCPs) feel ill-prepared to discuss stopping screening with older adults. OBJECTIVE To develop scripts and strategies for PCPs to use to discuss stopping cancer screening with adults > 75. DESIGN Qualitative study using semi-structured interview guides to conduct individual interviews with adults > 75 years old and focus groups and/or individual interviews with PCPs. PARTICIPANTS Forty-five PCPs and 30 patients > 75 years old participated from six community or academic Boston-area primary care practices. APPROACH Participants were asked their thoughts on discussions around stopping cancer screening and to provide feedback on scripts that were iteratively revised for PCPs to use when discussing stopping mammography and colorectal cancer (CRC) screening. RESULTS Twenty-one (47%) of the 45 PCPs were community based. Nineteen (63%) of the 30 patients were female, and 13 (43%) were non-Hispanic white. PCPs reported using different approaches to discuss stopping cancer screening depending on the clinical scenario. PCPs noted it was easier to discuss stopping screening when the harms of screening clearly outweighed the benefits for a patient. In these cases, PCPs felt more comfortable being more directive. When the balance between the benefits and harms of screening was less clear, PCPs endorsed shared decision-making but found this approach more challenging because it was difficult to explain why to stop screening. While patients were generally enthusiastic about screening, they also reported not wanting to undergo tests of little value and said they would stop screening if their PCP recommended it. By the end of participant interviews, no further edits were recommended to the scripts. CONCLUSIONS To increase PCP comfort and capability to discuss stopping cancer screening with older adults, we developed scripts and strategies that PCPs may use for discussing stopping cancer screening.
Collapse
Affiliation(s)
- Mara A Schonberg
- Division of General Medicine and Primary Care, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, 1309 Beacon, Office 219, Brookline, MA, 02446, USA.
| | - Alicia R Jacobson
- Division of General Medicine and Primary Care, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, 1309 Beacon, Office 219, Brookline, MA, 02446, USA
| | - Maria Karamourtopoulos
- Division of General Medicine and Primary Care, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, 1309 Beacon, Office 219, Brookline, MA, 02446, USA
| | - Gianna M Aliberti
- Division of General Medicine and Primary Care, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, 1309 Beacon, Office 219, Brookline, MA, 02446, USA
| | - Adlin Pinheiro
- Division of General Medicine and Primary Care, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, 1309 Beacon, Office 219, Brookline, MA, 02446, USA
| | - Alexander K Smith
- Division of Geriatrics, Department of Medicine, University of California San Francisco, 533 Parnassus Ave, San Francisco, CA, 94143, USA
| | - Linnaea C Schuttner
- Health Services Research & Development, VA Puget Sound Health Care System, Department of Medicine, University of Washington, Seattle, WA. 1959 NE Pacific St, Seattle, WA, 98195, USA
| | - Elyse R Park
- Department of Psychiatry, Massachusetts General Hospital, 450 Brookline Avenue, Boston, MA, 02215, USA
| | - Mary Beth Hamel
- Division of General Medicine and Primary Care, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, 1309 Beacon, Office 219, Brookline, MA, 02446, USA
| |
Collapse
|
31
|
Moss JL, Roy S, Shen C, Cooper JD, Lennon RP, Lengerich EJ, Adelman A, Curry W, Ruffin MT. Geographic Variation in Overscreening for Colorectal, Cervical, and Breast Cancer Among Older Adults. JAMA Netw Open 2020; 3:e2011645. [PMID: 32716514 PMCID: PMC8127072 DOI: 10.1001/jamanetworkopen.2020.11645] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
IMPORTANCE National guidelines balance risks and benefits of population-level cancer screening among adults with average risk. Older adults are not recommended to receive routine screening, but many continue to be screened (ie, are overscreened). OBJECTIVE To assess the prevalence of overscreening for colorectal, cervical, and breast cancers among older adults as well as differences in overscreening by metropolitan status. DESIGN, SETTING, AND PARTICIPANTS The cross-sectional study examined responses to a telephone survey of 176 348 community-dwelling adults. Participants were included if they met age and sex criteria, and they were excluded from each cancer-specific subsample if they had a history of that cancer. Data came from the 2018 Behavioral Risk Factor Surveillance System, administered by the US Centers for Disease Control and Prevention. EXPOSURES Metropolitan status, according to whether participants lived in a metropolitan statistical area. MAIN OUTCOMES AND MEASURES Overscreening was assessed using US Preventive Services Task Force definitions, ie, whether participants self-reported having a screening after the recommended upper age limit for colorectal (75 years), cervical (65 years), or breast (74 years) cancer. RESULTS Of 176 348 participants (155 411 [88.1%] women; mean [SE] age, 75.0 [0.04] years; 150 871 [85.6%] non-Hispanic white; 60 456 [34.3%] with nonmetropolitan residence) the cancer-specific subsamples contained 20 937 [11.9%] men and 34 244 [19.4%] women for colorectal cancer, 82 811 [47.0%] women for cervical cancer, and 38 356 [21.8%] women for breast cancer. Overall, 9461 men (59.3%; 95% CI, 57.6%-61.1%) were overscreened for colorectal cancer; 14 463 women (56.2%; 95% CI, 54.7%-57.6%), for colorectal cancer; 31 988 women (45.8%; 95% CI, 44.9%-46.7%), for cervical cancer; and 26 198 women (74.1%; 95% CI, 73.0%-75.3%), for breast cancer. Overscreening was more common in metropolitan than nonmetropolitan areas for colorectal cancer among women (adjusted odds ratio [aOR], 1.23; 95% CI, 1.08-1.39), cervical cancer (aOR, 1.20; 95% CI, 1.11-1.29), and breast cancer (aOR, 1.36; 95% CI, 1.17-1.57). Overscreening for cervical and breast cancers was also associated with having a usual source of care compared with not (eg, cervical cancer: aOR, 1.87; 95% CI, 1.56-2.25; breast cancer: aOR, 2.08; 95% CI, 1.58-2.76), good, very good, or excellent self-reported health compared with fair or poor self-reported health (eg, cervical cancer: aOR, 1.21; 95% CI, 1.11-1.32; breast cancer: aOR, 1.47; 95% CI, 1.28-1.69), an educational attainment greater than a high school diploma compared with a high school diploma or less (eg, cervical cancer: aOR, 1.14; 95% CI, 1.06-1.23; breast cancer: aOR, 1.30; 95% CI, 1.16-1.46), and being married or living as married compared with other marital status (eg, cervical cancer: OR, 1.36; 95% CI, 1.26-1.46; breast cancer: OR, 1.54; 95% CI, 1.34-1.77). CONCLUSIONS AND RELEVANCE In this study, overscreening for cancer among older adults was high, particularly for women living in metropolitan areas. Overscreening could be associated with health care access and patient-clinician relationships. Additional research on why overscreening persists and how to reduce overscreening is needed to minimize risks associated with cancer screening among older adults.
Collapse
Affiliation(s)
| | | | - Chan Shen
- Penn State College of Medicine, Hershey, Pennsylvania
| | - Joie D Cooper
- Penn State College of Medicine, Hershey, Pennsylvania
| | | | | | - Alan Adelman
- Penn State College of Medicine, Hershey, Pennsylvania
| | - William Curry
- Penn State College of Medicine, Hershey, Pennsylvania
| | - Mack T Ruffin
- Penn State College of Medicine, Hershey, Pennsylvania
| |
Collapse
|
32
|
Smith J, Dodd RH, Hersch J, Cvejic E, McCaffery K, Jansen J. Effect of different communication strategies about stopping cancer screening on screening intention and cancer anxiety: a randomised online trial of older adults in Australia. BMJ Open 2020; 10:e034061. [PMID: 32532766 PMCID: PMC7295415 DOI: 10.1136/bmjopen-2019-034061] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
OBJECTIVE To assess different strategies for communicating to older adults about stopping cancer screening. DESIGN 4 (recommendation statement about stopping screening)×(2; time) online survey-based randomised controlled trial. SETTING Australia. PARTICIPANTS 271 English-speaking participants, aged 65-90, screened for breast/prostate cancer at least once in past decade. INTERVENTIONS Time 1: participants read a scenario in which their general practitioner (GP) informed them about the potential benefits and harms of cancer screening, followed by double-blinded randomisation to one of four recommendation statements to stop screening: control ('this screening test would harm you more than benefit you'), health status ('your other health issues should take priority'), life expectancy framed positively ('this test would not help you live longer') and negatively ('you may not live long enough to benefit'). Time 2: in a follow-up scenario, the GP explained why guidelines changed over time (anchoring bias intervention). MEASURES Primary outcomes: screening intention and cancer anxiety (10-point scale, higher=greater intention/anxiety), measured at both time points. SECONDARY OUTCOMES trust (in their GP, the information provided, the Australian healthcare system), decisional conflict and knowledge of the information presented. RESULTS 271 participants' responses analysed. No main effects were found. However, screening intention was lower for the negatively framed life expectancy versus health status statement (6.0 vs 7.1, mean difference (MD)=1.1, p=0.049, 95% CI 0.0 to 2.2) in post hoc analyses. Cancer anxiety was lower for the negatively versus positively framed life expectancy statement (4.8 vs 5.8, MD=1.0, p=0.025, 95% CI 0.1 to 1.9). The anchoring bias intervention reduced screening intention (MD=0.8, p=0.044, 95% CI 0.6 to 1.0) and cancer anxiety (MD=0.3, p=0.002, 95% CI 0.1 to 0.4) across all conditions. CONCLUSION Older adults may reduce their screening intention without reporting increased cancer anxiety when clinicians use a more confronting strategy communicating they may not live long enough to benefit and add an explicit explanation why the recommendation has changed. TRIAL REGISTRATION NUMBER Australian New Zealand Clinical Trials Registry (ACTRN12618001306202; Results).
Collapse
Affiliation(s)
- Jenna Smith
- School of Public Health, The University of Sydney, Sydney, New South Wales, Australia
| | - Rachael H Dodd
- School of Public Health, The University of Sydney, Sydney, New South Wales, Australia
| | - Jolyn Hersch
- School of Public Health, The University of Sydney, Sydney, New South Wales, Australia
| | - Erin Cvejic
- School of Public Health, The University of Sydney, Sydney, New South Wales, Australia
| | - Kirsten McCaffery
- School of Public Health, The University of Sydney, Sydney, New South Wales, Australia
| | - Jesse Jansen
- School of Public Health, The University of Sydney, Sydney, New South Wales, Australia
- School for Public Health and Primary Care, Maastricht University, Maastricht, Netherlands
| |
Collapse
|
33
|
Elmore JG, Ngo-Metzger Q. The Life and Death of Mammograms in Patients 75 Years and Older-To Screen or Not to Screen? JAMA Intern Med 2020; 180:843-844. [PMID: 32310253 DOI: 10.1001/jamainternmed.2020.0431] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Affiliation(s)
- Joann G Elmore
- David Geffen School of Medicine at UCLA, Los Angeles, California
| | - Q Ngo-Metzger
- Bernard J. Tyson School of Medicine, Kaiser Permanente, Pasadena, California
| |
Collapse
|
34
|
Breast Cancer Screening in Older Women: The Importance of Shared Decision Making. J Am Board Fam Med 2020; 33:473-480. [PMID: 32430383 PMCID: PMC7822071 DOI: 10.3122/jabfm.2020.03.190380] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/16/2019] [Revised: 12/17/2019] [Accepted: 12/18/2019] [Indexed: 12/29/2022] Open
Abstract
Incidence of breast cancer increases with age up until age 80. Screening mammography has demonstrated efficacy in decreasing mortality from breast cancer among women between 50 and 74 years of age. However, most major organizations do not include women over 74 in their recommendations due to the lack of evidence in this age-group. This article will review current recommendations for breast cancer screening in women over the age of 74. It will also present clear guidelines for primary care clinicians to follow that incorporate shared decision-making techniques, tools for estimating the risks and benefits of screening mammography, and strategies for integrating a patient's life expectancy and comorbidities into the decision-making process. We also emphasize the importance of using thoughtful communication strategies to fully engage older women in the breast cancer screening discussion.
Collapse
|
35
|
Malagón T, Mayrand MH, Ogilvie G, Gotlieb WH, Blake J, Bouchard C, Franco EL, Kulasingam S. Modeling the Balance of Benefits and Harms of Cervical Cancer Screening with Cytology and Human Papillomavirus Testing. Cancer Epidemiol Biomarkers Prev 2020; 29:1436-1446. [PMID: 32332032 DOI: 10.1158/1055-9965.epi-20-0190] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2020] [Revised: 04/03/2020] [Accepted: 04/16/2020] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Benefits of screening should outweigh its potential harms. We compared various metrics to assess the balance of benefits and harms of cervical cancer screening. METHODS We used a cervical cancer natural history Markov model calibrated to the Canadian context to simulate 100,000 unvaccinated women over a lifetime of screening with either cytology every 3 years or human papillomavirus (HPV) testing every 5 years. We estimated the balance of benefits and harms attributable to screening using various metrics, including colposcopies/life-year gained, and net lifetime quality-adjusted life-years (QALY) gained, a measure integrating women's health preferences. We present the average (minimum-maximum) model predictions. RESULTS Cytology-based screening led to 1,319,854 screening tests, 30,395 colposcopies, 13,504 life-years gained over a lifetime, 98 screening tests/life-year gained, 2.3 (1.6-3.3) colposcopies/life-year gained, and a net lifetime gain of 10,735 QALY (5,040-17,797). HPV-based screening with cytology triage in the same population would lead to 698,250 screening tests, 73,296 colposcopies, 15,066 life-years gained over a lifetime, 46 screening tests/life-year gained, 4.9 colposcopies/life-year gained (2.9-11.1), and a net lifetime gain of 11,690 QALY (4,409-18,742). HPV-based screening was predicted to prevent more cancers, but also incur more screening harms than cytology-based screening. CONCLUSIONS Metrics using colposcopies as the main harm outcome favored cytology-based screening, whereas metrics based on screening tests and health preferences tended to favor HPV-based screening strategies. IMPACT Whether HPV-based screening will improve the balance between benefits and harms of cervical cancer screening depends on how the balance between benefits and harms is assessed.
Collapse
Affiliation(s)
- Talía Malagón
- Division of Cancer Epidemiology, Department of Oncology, McGill University, Montreal, Quebec, Canada.
| | - Marie-Hélène Mayrand
- Departments of Obstetrics and Gynecology and Social and Preventive Medicine, Université de Montréal et CRCHUM, Montreal, Quebec, Canada
| | - Gina Ogilvie
- Faculty of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Walter H Gotlieb
- Division of Gynecologic Oncology, Jewish General Hospital, McGill University, Montreal, Quebec, Canada
| | - Jennifer Blake
- Society of Obstetricians and Gynaecologists of Canada, Ottawa, Ontario, Canada
| | - Céline Bouchard
- Centre Hospitalier Universitaire de Québec, Québec City, Quebec, Canada
| | - Eduardo L Franco
- Division of Cancer Epidemiology, Department of Oncology, McGill University, Montreal, Quebec, Canada
| | - Shalini Kulasingam
- Division of Epidemiology and Community Health, School of Public Health, University of Minnesota, Minneapolis, Minnesota
| |
Collapse
|
36
|
Shared decision making and prostate-specific antigen based prostate cancer screening following the 2018 update of USPSTF screening guideline. Prostate Cancer Prostatic Dis 2020; 24:77-80. [PMID: 32296126 DOI: 10.1038/s41391-020-0227-1] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2019] [Revised: 03/04/2020] [Accepted: 03/11/2020] [Indexed: 11/08/2022]
Abstract
BACKGROUND Previous study reported shared decision making was underused in PSA-based prostate cancer screening. In mid-2018, the US Preventive Service Task Force recommended shared decision making (SDM) before PSA-based prostate cancer screening among men aged 55-69 year while remained against PSA testing in men aged 70 or older. The objective of this study is to examine recent changes in SDM and prostate cancer screening following recent USPSTF recommendations. METHODS A retrospective cross-sectional study among men aged 50 years or older were conducted using 2015 and 2018 National Health Interview Survey data (n = 10,926). Outcomes included self-reported PSA testing for prostate cancer screening last year, and if yes, whether respondent ever had a discussion with the healthcare provider about its advantages and disadvantages. Analyses were stratified by respondent's age (50-54 vs. 55-69 vs. 70+). RESULTS Routine PSA screening rates remained stable from 34.3% in 2015 to 35.4% in first half of 2018, and 36.0% in second half of 2018 (p trend = 0.57). A similar pattern was found in men ≥70 years (p trend = 0.98). Receipt of SDM increased in men aged ≥50 years from 30.5% in 2015 to 33.6% in first half of 2018, and 36.7% in second half of 2018 (p trend = 0.002). The increase was most prominent in men aged 55 to 69 years (31.6, 36.9, and 40.2% in 2015, first half of 2018 and second half of 2018 respectively; p trend = 0.001). CONCLUSIONS Between 2015 and 2018, there was no significant increase in the PSA-based prostate cancer screening. However, a significant increasing trend in SDM was observed, especially in men aged 55-69 years.
Collapse
|
37
|
Chao CR, Xu L, Lonky NM. Adherence to Cervical Cancer Screening Guidelines Among Women Aged 66-68 Years in a Large Community-Based Practice. Am J Prev Med 2019; 57:757-764. [PMID: 31753257 DOI: 10.1016/j.amepre.2019.08.011] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/06/2019] [Revised: 08/04/2019] [Accepted: 08/05/2019] [Indexed: 11/30/2022]
Abstract
INTRODUCTION The 2012 national cervical cancer screening guidelines recommended cessation of screening after age 65 years in women with adequate prior screening. In this retrospective cohort study, adherence to these screening exit guidelines was examined. METHODS Women who turned age 66 years in 2012-2013 at Kaiser Permanente Southern California were followed through age 68 years for cervical cancer screening uptake. Adequacy of prior screening was assessed between age 56 and 65 years using electronic medical records. Guideline adherence was determined based on screening pattern between age 66 and 68 years. Patient- and physician-level correlates for guideline adherence were examined using multivariable logistic regression. Data collection and analyses were conducted in 2018. RESULTS A total of 14,778 women were included; 24% did not have adequate prior screening by age 65 years. Among those without adequate prior screening, the proportion screened after age 65 years ranged from 71% (177 of 249) in those whose most recent test was abnormal to 3% (34 of 1,330) in those who did not have any testing in 10 years. Prior screening pattern was the only factor associated with screening after age 65 years. Of those with adequate prior screening, 10% (1,135 of 11,295) continued to receive screening after age 65 years. Frequent office visits and having a male primary care physician were associated with continuing screening after age 65 years. CONCLUSIONS A considerable proportion of women did not have adequate prior screening by age 65 years. Of these, a large proportion did not receive screening after age 65 years, except those who had a recent abnormal screening result. Further research is needed to understand barriers for guideline adherence and rationales for clinical decision making.
Collapse
Affiliation(s)
- Chun R Chao
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, California.
| | - Lanfang Xu
- MedHealth Statistical Consulting Inc., Solon, Ohio
| | - Neal M Lonky
- Department of Obstetrics and Gynecology, Orange County Medical Center, Kaiser Permanente, Anaheim, California
| |
Collapse
|
38
|
Klamerus ML, Damschroder LJ, Sparks JB, Skurla SE, Kerr EA, Hofer TP, Caverly TJ. Developing Strategies to Reduce Unnecessary Services in Primary Care: Protocol for User-Centered Design Charrettes. JMIR Res Protoc 2019; 8:e15618. [PMID: 31769764 PMCID: PMC6904896 DOI: 10.2196/15618] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2019] [Revised: 10/04/2019] [Accepted: 10/08/2019] [Indexed: 12/13/2022] Open
Abstract
Background Overtreatment and overtesting expose patients to unnecessary, wasteful, and potentially harmful care. Reducing overtreatment or overtesting that has become ingrained in current clinical practices and is being delivered on a routine basis will require solutions that incorporate a deep understanding of multiple perspectives, particularly those on the front lines of clinical care: patients and their clinicians. Design approaches are a promising and innovative way to incorporate stakeholder needs, desires, and challenges to develop solutions to complex problems. Objective This study aimed (1) to engage patients in a design process to develop high-level deintensification strategies for primary care (ie, strategies for scaling back or stopping routine medical services that more recent evidence reveals are not beneficial) and (2) to engage both patients and primary care providers in further co-design to develop and refine the broad deintensification strategies identified in phase 1. Methods We engaged stakeholders in design charrettes—intensive workshops in which key stakeholders are brought together to develop creative solutions to a specific problem—focused on deintensification of routine overuse in primary care. We conducted the study in 2 phases: a 6.5-hour design charrette with 2 different groups of patients (phase 1) and a subsequent 4-hour charrette with clinicians and a subgroup of phase 1 patients (phase 2). Both phases included surveys and educational presentations related to deintensification. Phase 1 involved several design activities (mind mapping, business origami, and empathy mapping) to help patients gain a deeper understanding of the individuals involved in deintensification. Following that, we asked participants to review hypothetical scenarios where patients, clinicians, or the broader health system context posed a barrier to deintensification and then to brainstorm solutions. The deintensification themes identified in phase 1 were used to guide phase 2. This second phase primarily involved 1 design activity (WhoDo). In this activity, patients and clinicians worked together to develop concrete actions that specific stakeholders could take to support deintensification efforts. This activity included identifying barriers to the actions and approaches to overcoming those barriers. Results A total of 35 patients participated in phase 1, and 9 patients and 7 clinicians participated in phase 2. The analysis of the deintensification strategies and survey data is currently underway. The results are expected to be submitted for publication in early 2020. Conclusions Health care interventions are frequently developed without input from the people who are most affected. The exclusion of these stakeholders in the design process often influences and limits the impact of the intervention. This study employed design charrettes, guided by a flexible user-centered design model, to bring clinicians and patients with differing backgrounds and with different expectations together to cocreate real-world solutions to the complex issue of deintensifying medical services. International Registered Report Identifier (IRRID) RR1-10.2196/15618
Collapse
Affiliation(s)
- Mandi L Klamerus
- Center for Clinical Management Research, Department of Veterans Affairs, Ann Arbor, MI, United States
| | - Laura J Damschroder
- Center for Clinical Management Research, Department of Veterans Affairs, Ann Arbor, MI, United States
| | - Jordan B Sparks
- Center for Clinical Management Research, Department of Veterans Affairs, Ann Arbor, MI, United States
| | - Sarah E Skurla
- Center for Clinical Management Research, Department of Veterans Affairs, Ann Arbor, MI, United States
| | - Eve A Kerr
- Center for Clinical Management Research, Department of Veterans Affairs, Ann Arbor, MI, United States.,Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI, United States.,Medical School, University of Michigan, Ann Arbor, MI, United States
| | - Timothy P Hofer
- Center for Clinical Management Research, Department of Veterans Affairs, Ann Arbor, MI, United States.,Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI, United States.,Medical School, University of Michigan, Ann Arbor, MI, United States
| | - Tanner J Caverly
- Center for Clinical Management Research, Department of Veterans Affairs, Ann Arbor, MI, United States.,Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI, United States.,Medical School, University of Michigan, Ann Arbor, MI, United States
| |
Collapse
|
39
|
Cheung LC, Berg CD, Castle PE, Katki HA, Chaturvedi AK. Life-Gained-Based Versus Risk-Based Selection of Smokers for Lung Cancer Screening. Ann Intern Med 2019; 171:623-632. [PMID: 31634914 PMCID: PMC7191755 DOI: 10.7326/m19-1263] [Citation(s) in RCA: 65] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/22/2023] Open
Abstract
BACKGROUND Although risk-based selection of ever-smokers for screening could prevent more lung cancer deaths than screening according to the U.S. Preventive Services Task Force (USPSTF) guidelines, it preferentially selects older ever-smokers with shorter life expectancies due to comorbidities. OBJECTIVE To compare selection of ever-smokers for screening based on gains in life expectancy versus lung cancer risk. DESIGN Cohort analyses and model-based projections. SETTING U.S. population of ever-smokers aged 40 to 84 years. PARTICIPANTS 130 964 National Health Interview Survey participants, representing about 60 million U.S. ever-smokers during 1997 to 2015. INTERVENTION Annual computed tomography (CT) screening for 3 years versus no screening. MEASUREMENTS Estimated number of lung cancer deaths averted and life-years gained after development of a mortality model. RESULTS Using the calibrated and validated mortality model in U.S. ever-smokers aged 40 to 84 years and selecting 8.3 million ever-smokers to match the number selected by the USPSTF criteria in 2013 to 2015, the analysis estimated that life-gained-based selection would increase the total life expectancy from CT screening (633 400 vs. 607 800 years) but prevent fewer lung cancer deaths (52 600 vs. 55 000) compared with risk-based selection. The 1.56 million persons selected by the life-gained-based strategy but not the risk-based strategy were younger (mean age, 59 vs. 75 years) and had fewer comorbidities (mean, 0.75 vs. 3.7). LIMITATION Estimates are model-based and assume implementation of lung cancer screening with short-term effectiveness similar to that from trials. CONCLUSION Life-gained-based selection could maximize the benefits of lung cancer screening in the U.S. population by including ever-smokers who have both high lung cancer risk and long life expectancy. PRIMARY FUNDING SOURCE Intramural Research Program of the National Cancer Institute, National Institutes of Health.
Collapse
Affiliation(s)
- Li C Cheung
- National Cancer Institute, Bethesda, Maryland (L.C.C., C.D.B., H.A.K., A.K.C.)
| | - Christine D Berg
- National Cancer Institute, Bethesda, Maryland (L.C.C., C.D.B., H.A.K., A.K.C.)
| | - Philip E Castle
- Albert Einstein School of Medicine, Bronx, New York (P.E.C.)
| | - Hormuzd A Katki
- National Cancer Institute, Bethesda, Maryland (L.C.C., C.D.B., H.A.K., A.K.C.)
| | - Anil K Chaturvedi
- National Cancer Institute, Bethesda, Maryland (L.C.C., C.D.B., H.A.K., A.K.C.)
| |
Collapse
|
40
|
Schoenborn NL, Crossnohere NL, Janssen EM, Pollack CE, Boyd CM, Wolff AC, Xue QL, Massare J, Blinka M, Bridges JFP. Examining Generalizability of Older Adults' Preferences for Discussing Cessation of Screening Colonoscopies in Older Adults with Low Health Literacy. J Gen Intern Med 2019; 34:2512-2519. [PMID: 31452029 PMCID: PMC6848333 DOI: 10.1007/s11606-019-05258-2] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2018] [Revised: 04/23/2019] [Accepted: 07/09/2019] [Indexed: 01/02/2023]
Abstract
BACKGROUND/OBJECTIVES Many older adults receive unnecessary screening colonoscopies. We previously conducted a survey using a national online panel to assess older adults' preferences for how clinicians can discuss stopping screening colonoscopies. We sought to assess the generalizability of those results by comparing them to a sample of older adults with low health literacy. DESIGN Cross-sectional survey. SETTING Baltimore metropolitan area (low health literacy sample) and a national, probability-based online panel-KnowledgePanel (national sample). PARTICIPANTS Adults 65+ with low health literacy measured using a single-question screen (low health literacy sample, n = 113) and KnowledgePanel members 65+ who completed survey about colorectal cancer screening (national sample, n = 441). MEASUREMENTS The same survey was administered to both groups. Using the best-worst scaling method, we assessed relative preferences for 13 different ways to explain stopping screening colonoscopies. We used conditional logistic regression to quantify the relative preference for each explanation, where a higher preference weight indicates stronger preference. We analyzed each sample separately, then compared the two samples using Spearman's correlation coefficient, the likelihood ratio test to assess for overall differences between the two sets of preference weights, and the Wald test to assess differences in preference weights for each individual phrases. RESULTS The responses from the two samples were highly correlated (Spearman's coefficient 0.92, p < 0.0001). The most preferred phrase to explain stopping screening colonoscopy was "Your other health issues should take priority" in both groups. The three least preferred options were also the same for both groups, with the least preferred being "The doctor does not give an explanation." The explanation that referred to "quality of life" was more preferred by the low health literacy group whereas explanations that mentioned "unlikely to benefit" and "high risk for harms" were more preferred by the national survey group (all p < 0.001). CONCLUSION Among two different populations of older adults with different health literacy levels, the preferred strategies for clinicians to discuss stopping screening colonoscopies were highly correlated. Our results can inform effective communication about stopping screening colonoscopies in older adults across different health literacy levels.
Collapse
Affiliation(s)
| | - Norah L Crossnohere
- The Johns Hopkins University School of Public Health, Baltimore, MD, USA.,Department of Biomedical Informatics, Ohio State University, Columbus, OH, USA
| | | | - Craig E Pollack
- The Johns Hopkins University School of Public Health, Baltimore, MD, USA
| | - Cynthia M Boyd
- The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Antonio C Wolff
- The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Qian-Li Xue
- The Johns Hopkins University School of Medicine, Baltimore, MD, USA.,The Johns Hopkins University School of Public Health, Baltimore, MD, USA
| | | | - Marcela Blinka
- The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - John F P Bridges
- Department of Biomedical Informatics, Ohio State University, Columbus, OH, USA
| |
Collapse
|
41
|
Kotwal AA, Walter LC, Lee SJ, Dale W. Are We Choosing Wisely? Older Adults' Cancer Screening Intentions and Recalled Discussions with Physicians About Stopping. J Gen Intern Med 2019; 34:1538-1545. [PMID: 31147981 PMCID: PMC6667516 DOI: 10.1007/s11606-019-05064-w] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/01/2018] [Revised: 01/11/2019] [Accepted: 04/11/2019] [Indexed: 12/19/2022]
Abstract
BACKGROUND National guidelines recommend against cancer screening for older individuals with less than a 10-year life expectancy, but it is unknown if this population desires ongoing screening. OBJECTIVE To determine (1) if older individuals with < 10-year life expectancy have future intentions for cancer screening, (2) if they recall a doctor previously suggesting that screening is no longer needed, and (3) individual characteristics associated with intentions to seek screening. DESIGN National Social life Health and Aging Project (2015-2016), a nationally representative, cross-sectional survey. PARTICIPANTS Community-dwelling adults 55-97 years old (n = 3816). MAIN MEASURES Self-reported: (1) mammography and PSA testing within the last 2 years, (2) future intentions to be screened, and (3) discussion with a doctor that screening is no longer needed. Ten-year life expectancy was estimated using the Lee prognostic index. Multivariate logistic regression analysis examined intentions to pursue future screening, adjusting for sociodemographic and health covariates. KEY RESULTS Among women 75-84 with < 10-year life expectancy, 59% intend on future mammography and 81% recall no conversation with a doctor that mammography may no longer be necessary. Among men 75-84 with < 10-year life expectancy, 54% intend on future PSA screening and 77% recall no discussions that PSA screening may be unnecessary. In adjusted analyses, those reporting recent cancer screening or no recollection that screening may not be necessary were more likely to want future mammography or PSA screening (p < 0.001). CONCLUSION Over 75% of older individuals with limited life expectancy intend to continue cancer screening, and less than 25% recall discussing with physicians the need for these tests. In addition to public health and education efforts, these results suggest that older adults' recollection of being told by physicians that screening is not necessary may be a modifiable risk factor for reducing overscreening in older adults with limited life expectancy.
Collapse
Affiliation(s)
- Ashwin A Kotwal
- Division of Geriatrics, Department of Medicine, University of California, San Francisco, San Francisco, CA, USA.
- Geriatrics, Palliative, and Extended Care Service Line, San Francisco Veterans Affairs Medical Center, San Francisco, CA, USA.
| | - Louise C Walter
- Division of Geriatrics, Department of Medicine, University of California, San Francisco, San Francisco, CA, USA
- Geriatrics, Palliative, and Extended Care Service Line, San Francisco Veterans Affairs Medical Center, San Francisco, CA, USA
| | - Sei J Lee
- Division of Geriatrics, Department of Medicine, University of California, San Francisco, San Francisco, CA, USA
- Geriatrics, Palliative, and Extended Care Service Line, San Francisco Veterans Affairs Medical Center, San Francisco, CA, USA
| | - William Dale
- Department of Supportive Care Medicine, City of Hope National Medical Center, Duarte, CA, USA
| |
Collapse
|
42
|
Janssen EM, Pollack CE, Boyd C, Bridges JFP, Xue QL, Wolff AC, Schoenborn NL. How Do Older Adults Consider Age, Life Expectancy, Quality of Life, and Physician Recommendations When Making Cancer Screening Decisions? Results from a National Survey Using a Discrete Choice Experiment. Med Decis Making 2019; 39:621-631. [PMID: 31226903 DOI: 10.1177/0272989x19853516] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
Background. Older adults with limited life expectancy frequently receive cancer screening, although on average, harms outweigh benefits. We examined the influence of life expectancy on older adults' cancer screening decisions relative to three other factors. Methods. Adults aged 65+ years (N = 1272) were recruited from a national online survey panel. Using a discrete choice experiment, we systematically varied a hypothetical patient's life expectancy, age, quality of life, and physician's recommendation and asked whether the participant would choose screening. Participants were randomized to questions about colonoscopy or prostate-specific antigen/mammography screenings. Logistic regression produced preference weights that quantified the relative influence of the 4 factors on screening decisions. Results. 879 older adults completed the survey, 660 of whom varied their screening choices in response to the 4 factors we tested. The age of the hypothetical patient had the largest influence on choosing screening: the effect of age being 65 versus 85 years had a preference weight of 2.44 (95% confidence interval [CI]: 2.22, 2.65). Life expectancy (10 versus 1 year) had the second largest influence (preference weight: 1.64, CI: 1.41, 1.87). Physician recommendation (screen versus do not screen) and quality of life (good versus poor) were less influential, with preference weights of 0.90 (CI: 0.72, 1.08) and 0.68 (CI: 0.52, 0.83), respectively. Conclusions. While clinical practice guidelines increasingly use life expectancy in addition to age to guide screening decisions, we find that age is the most influential factor, independent of life expectancy, quality of life, and physician recommendation, in older adults' cancer screening choices. Strategies to reduce overscreening should consider the importance patients give to continuing screening at younger ages, even when life expectancy is limited.
Collapse
Affiliation(s)
- Ellen M Janssen
- Department of Health Policy and Management, Johns Hopkins School of Public Health, Baltimore, MD, USA.,Center for Medical Technology Policy, Baltimore, MD, USA
| | - Craig E Pollack
- The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Cynthia Boyd
- The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | | | - Qian-Li Xue
- The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Antonio C Wolff
- The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | | |
Collapse
|
43
|
Maratt JK, Calderwood AH. Colorectal Cancer Screening and Surveillance Colonoscopy in Older Adults. CURRENT TREATMENT OPTIONS IN GASTROENTEROLOGY 2019; 17:292-302. [PMID: 30969399 PMCID: PMC6584566 DOI: 10.1007/s11938-019-00230-9] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
PURPOSE OF REVIEW The purpose of this chapter is to highlight current recommendations regarding colorectal cancer (CRC) screening and post-polypectomy surveillance colonoscopy in older adults and to review the available literature in order to help inform decision-making in this age group. RECENT FINDINGS Age is a risk factor for CRC; however, older adults with a history of prior screening are at lower risk for CRC compared to those who have never been screened. Decision-making for CRC screening and post-polypectomy surveillance colonoscopy in older adults is complex and several factors including age, screening history, comorbidities, functional status, bowel preparation, prior experiences, preferences, and barriers need to be considered when weighing risks and benefits. Recent guidelines have started to incorporate life expectancy and prior screening history into their recommendations; however, how to incorporate these factors into actual clinical practice is less clear. There are limited data on the relative benefits of screening and surveillance in older adults and therefore, at this time, decision-making should be individualized and incorporate patient preferences in addition to medical factors.
Collapse
Affiliation(s)
- Jennifer K Maratt
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Michigan Medicine, Ann Arbor, MI, USA
- Veterans Affairs Ann Arbor Healthcare System, Ann Arbor, MI, USA
| | - Audrey H Calderwood
- Section of Gastroenterology, Department of Medicine, Dartmouth Geisel School of Medicine and the Dartmouth Institute for Health Policy and Clinical Practice, One Medical Center Drive, Lebanon, NH, 03756, USA.
| |
Collapse
|
44
|
Schoenborn NL, Boyd CM, Lee SJ, Cayea D, Pollack CE. Communicating About Stopping Cancer Screening: Comparing Clinicians' and Older Adults' Perspectives. THE GERONTOLOGIST 2019; 59:S67-S76. [PMID: 31100135 PMCID: PMC6524758 DOI: 10.1093/geront/gny172] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2018] [Indexed: 01/22/2023] Open
Abstract
BACKGROUND AND OBJECTIVES Older adults with limited life expectancy frequently receive cancer screening. We sought to compare the perspectives of clinicians and older adults on how to communicate about stopping cancer screening. RESEARCH DESIGN AND METHODS We used data from two studies involving semistructured in-person individual interviews, in which we asked about perspectives on communication about stopping cancer screening, with 28 primary care clinicians and 40 community-dwelling older adults, respectively. RESULTS We identified three major themes: (a) Consensus among primary care clinicians and older adults regarding communication around stopping cancer screening. Both groups considered discussing the benefits/risks of cancer screening and involving patients in the decision as important and mentioned framing screening cessation as shift in health priorities. (b) Differences in perceived reactions to stopping cancer screening. Primary care clinicians were concerned about patient reaction to stopping cancer screening, whereas older adults reported no negative reactions in the context of a trusting relationship. (c) Differences in views around whether to discuss life expectancy in the context of stopping cancer screening. Clinicians rarely discussed life expectancy in this context, whereas older adults were divided on whether life expectancy should be discussed. DISCUSSION AND IMPLICATIONS Given the heterogeneity in older adults' preferences, it is important to assess whether patients want to discuss life expectancy when discussing stopping cancer screening, though use of the specific term "life expectancy" may not be necessary. Instead, focusing discussion on the benefits/risks of cancer screening and mentioning shift in health priorities are acceptable communication strategies for both clinicians and older adults.
Collapse
Affiliation(s)
- Nancy L Schoenborn
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Cynthia M Boyd
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Sei J Lee
- Department of Medicine, University of California, San Francisco
| | - Danelle Cayea
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Craig E Pollack
- Department of Health Policy and Management, Johns Hopkins University School of Public Health, Baltimore, Maryland
| |
Collapse
|
45
|
Mack DS, Lapane KL. Screening Mammography Among Older Women: A Review of United States Guidelines and Potential Harms. J Womens Health (Larchmt) 2019; 28:820-826. [PMID: 30625008 DOI: 10.1089/jwh.2018.6992] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
In the United States, older women (aged ≥65 years) continue to receive routine screening mammography surveillance, despite limited evidence supporting the benefits to this subpopulation. This article reviews screening mammography guidelines and the potential harms of such screening for older women in the United States. Published guidelines and recommendations on screening mammography for older women from professional medical societies and organizations in the United States were reviewed from the mid-20th century to present. Observational data were then synthesized to present the documented harms from screening mammography among older women. In 1976, the American Cancer Society recommended to screen all women aged ≥40 years with no upper age limit. With time, other major U.S. medical societies adopted their own screening guidelines without a consensus on age of screening cessation. A population-wide screening effort has largely continued without an upper age limit and with it, a growing body of literature on the harms of screening older women. Reported harms from screening mammography procedures have included physical pain, psychological distress, excessive use of health services from overdiagnoses/false positives, and undue financial expenses. These costs are particularly pronounced among special populations with limited life expectancies such as those of very advanced age ≥80 years, long-term nursing home residents, and the cognitively impaired. When potential harms, remaining life years, and the viability of available treatments are considered, the burdens of screening mammography often outweigh the benefits for older women. For some cases, an individualized approach to recommendations would be appropriate. National guidelines should be updated to provide clear guidance for screening women of advanced age, especially those in special populations with limited life expectancies.
Collapse
Affiliation(s)
- Deborah S Mack
- 1 Clinical and Population Health Research Program, Graduate School of Biomedical Sciences, University of Massachusetts Medical School, Worcester, Massachusetts.,2 Department of Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, Massachusetts
| | - Kate L Lapane
- 2 Department of Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, Massachusetts
| |
Collapse
|
46
|
Piper MS, Maratt JK, Zikmund-Fisher BJ, Lewis C, Forman J, Vijan S, Metko V, Saini SD. Patient Attitudes Toward Individualized Recommendations to Stop Low-Value Colorectal Cancer Screening. JAMA Netw Open 2018; 1:e185461. [PMID: 30646275 PMCID: PMC6324357 DOI: 10.1001/jamanetworkopen.2018.5461] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
IMPORTANCE Guidelines for colorectal cancer (CRC) screening recommend an individualized approach in older adults that is informed by consideration of life expectancy and cancer risk. However, little is known about how patients perceive individualized screening recommendations. OBJECTIVE To assess veterans' attitudes toward and comfort with cessation of low-value CRC screening (defined as screening in a patient for whom the benefit is expected to be small based on quantitative estimates from hypothetical risk calculators). DESIGN, SETTING, AND PARTICIPANTS This survey study included patients older than 50 years who had undergone prior screening colonoscopy with normal results at the Veterans Affairs Ann Arbor Healthcare System. A total of 1500 surveys were mailed to potential participants from November 1, 2010, to January 1, 2012. Survey data were analyzed from January 1, 2016, to December 31, 2017. MAIN OUTCOMES AND MEASURES Response to the question, "If you personally had serious health problems that were likely to shorten your life and your doctor did not think screening would be of much benefit based on the calculator, how comfortable would you be with not getting any more screening colonoscopies?" RESULTS Of the 1500 surveys mailed, 85 were returned to sender, leaving 1415 potential respondents; 1054 of these respondents (median age range, 60-69 years; 884 [85.9%] white and 965 [94.2%] male) completed the survey (response rate, 74.5%). A total of 300 (28.7%) were not at all comfortable with cessation of low-value CRC screening, and 509 (49.3%) thought that age should never be used to decide when to stop screening. In addition, 332 (31.7%) thought it was not at all reasonable to use life expectancy calculators, and 255 (24.3%) thought it was not at all reasonable to use CRC risk calculators to guide these decisions. In ordered logistic regression analysis, factors associated with more comfort with screening cessation were (1) higher trust in physician (odds ratio [OR], 1.19; 95% CI, 1.07-1.32), (2) higher perceived health status (OR, 1.41; 95% CI, 1.23-1.61), and (3) higher barriers to screening (OR, 1.20; 95% CI, 1.11-1.30). Factors that were associated with less comfort with screening cessation included (1) greater perceived effectiveness of screening (OR, 0.86; 95% CI, 0.80-0.94) and (2) greater perceived threat of CRC (OR, 0.81; 95% CI, 0.73-0.89). CONCLUSIONS AND RELEVANCE The findings suggest that many veterans have strong preferences against screening cessation even when given detailed information about why the benefit may be low. Efforts to tailor screening recommendations may be met by resistance unless they are accompanied by efforts to address underlying perceptions about the benefit of screening.
Collapse
Affiliation(s)
- Marc S. Piper
- Division of Gastroenterology, Department of Internal Medicine, Providence-Providence Park Hospital, Michigan State University College of Human Medicine, Southfield
- Division of Gastroenterology, Department of Internal Medicine, University of Michigan, Ann Arbor
| | - Jennifer K. Maratt
- Division of Gastroenterology, Department of Internal Medicine, University of Michigan, Ann Arbor
| | - Brian J. Zikmund-Fisher
- Department of Health Behavior and Health Education, University of Michigan School of Public Health, Ann Arbor
- Division of General Medicine, Department of Internal Medicine, University of Michigan, Ann Arbor
| | - Carmen Lewis
- Division of General Internal Medicine, Department of Internal Medicine, University of Colorado, Aurora
| | - Jane Forman
- Veterans Affairs (VA) Health Services Research and Development Service Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, Michigan
| | - Sandeep Vijan
- Division of General Medicine, Department of Internal Medicine, University of Michigan, Ann Arbor
- Veterans Affairs (VA) Health Services Research and Development Service Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, Michigan
| | - Valbona Metko
- Division of Gastroenterology, Department of Internal Medicine, University of Michigan, Ann Arbor
| | - Sameer D. Saini
- Division of Gastroenterology, Department of Internal Medicine, University of Michigan, Ann Arbor
- Veterans Affairs (VA) Health Services Research and Development Service Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, Michigan
| |
Collapse
|
47
|
Maratt JK, Lewis CL, Saffar D, Weston LE, Myers A, Piper MS, Saini SD. Veterans' Attitudes Towards De-Intensification of Surveillance Colonoscopy for Low-Risk Adenomas. Clin Gastroenterol Hepatol 2018; 16:1999-2000. [PMID: 29609067 DOI: 10.1016/j.cgh.2018.03.029] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/03/2017] [Revised: 03/18/2018] [Accepted: 03/24/2018] [Indexed: 02/07/2023]
Affiliation(s)
- Jennifer K Maratt
- Department of Internal Medicine, Division of Gastroenterology and Hepatology, Michigan Medicine and Veterans Affairs Ann Arbor Healthcare System, Ann Arbor, Michigan
| | - Carmen L Lewis
- Department of Internal Medicine, University of Colorado, Aurora, Colorado
| | - Darcy Saffar
- Veterans Affairs Center for Clinical Management Research, Ann Arbor, Michigan
| | - Lauren E Weston
- Veterans Affairs Center for Clinical Management Research, Ann Arbor, Michigan
| | - Aimee Myers
- Department of Internal Medicine, Division of Gastroenterology and Hepatology, Michigan Medicine and Veterans Affairs Ann Arbor Healthcare System, Ann Arbor, Michigan
| | - Marc S Piper
- Division of Gastroenterology, Department of Internal Medicine, Providence-Providence Park Hospital, Michigan State University College of Human Medicine, Lansing, Michigan
| | - Sameer D Saini
- Department of Internal Medicine, Division of Gastroenterology and Hepatology, Michigan Medicine and Veterans Affairs Ann Arbor Healthcare System, Ann Arbor, Michigan; Veterans Affairs Center for Clinical Management Research, Ann Arbor, Michigan; Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, Michigan.
| |
Collapse
|
48
|
Calderwood AH, Anderson JC, Robinson CM, Butterly LF. Endoscopist Specialty Predicts the Likelihood of Recommending Cessation of Colorectal Cancer Screening in Older Adults. Am J Gastroenterol 2018; 113:1862-1871. [PMID: 30390031 PMCID: PMC6768595 DOI: 10.1038/s41395-018-0406-z] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2017] [Accepted: 10/03/2018] [Indexed: 12/11/2022]
Abstract
OBJECTIVES Although the 2008 US Preventive Services Task Force guidelines recommend against routine colorectal cancer (CRC) screening for adults aged 76-85, it is unclear what endoscopists recommend in practice. Our goal was to examine current practice around cessation of CRC screening in older adults. METHODS We included normal screening colonoscopy exams in adults ≥ 50 years old within the New Hampshire Colonoscopy Registry between 2009 and 2014. The primary outcome was endoscopists' recommendation against further screening. The main exposure variables included patient age, family history of CRC, and endoscopist characteristics. Descriptive statistics and univariate and multivariable logistic regression models were used. RESULTS Of 13,364 normal screening colonoscopy exams, 2914 (21.8%) were in adults aged ≥ 65 and were performed by 74 endoscopists. Nearly 100% of adults aged 65-69 undergoing screening colonoscopy were given the recommendation to return for screening colonoscopy in the future. Only 15% of average-risk patients aged 70-74 were told to stop receiving screening, while 85% were told to return at a future interval, most frequently in 10 years when they would be 80-84. In the multivariable model, advancing patient age and the absence of family history of CRC were significantly associated with a recommendation to stop colonoscopy. Gastroenterologists were more likely to recommend stopping colonoscopy in accordance with guidelines than other non-gastroenterology endoscopists (adjusted OR (95% CI) 2.3 (1.6-3.4)). CONCLUSIONS In a large statewide colonoscopy registry, the majority of older adults are told to return for future screening colonoscopy. Having a family history of CRC or a non-gastroenterology endoscopist increases the likelihood of being told to return for screening at advanced ages.
Collapse
Affiliation(s)
- Audrey H. Calderwood
- 1Section of Gastroenterology and Hepatology, Dartmouth Hitchcock Medical Center, Lebanon, NH, USA.,2The Geisel School of Medicine at Dartmouth, Hanover, NH, USA
| | - Joseph C. Anderson
- 2The Geisel School of Medicine at Dartmouth, Hanover, NH, USA.,3Department of Veterans Affairs Medical Center, White River Junction, Hartford, VT, USA
| | - Christina M. Robinson
- 1Section of Gastroenterology and Hepatology, Dartmouth Hitchcock Medical Center, Lebanon, NH, USA
| | - Lynn F. Butterly
- 1Section of Gastroenterology and Hepatology, Dartmouth Hitchcock Medical Center, Lebanon, NH, USA.,2The Geisel School of Medicine at Dartmouth, Hanover, NH, USA
| |
Collapse
|
49
|
Kistler CE, Golin C, Sundaram A, Morris C, Dalton AF, Ferrari R, Lewis CL. Individualized Colorectal Cancer Screening Discussions Between Older Adults and Their Primary Care Providers: A Cross-Sectional Study. MDM Policy Pract 2018; 3:2381468318765172. [PMID: 30288441 PMCID: PMC6157429 DOI: 10.1177/2381468318765172] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2017] [Accepted: 02/08/2018] [Indexed: 01/08/2023] Open
Abstract
Introduction. Discussions of colorectal cancer (CRC) screening with older adults should be individualized to maximize appropriate screening. Our aim was to describe CRC screening discussions and explore their associations with patient characteristics and screening intentions. Methods. Cross-sectional survey of 422 primary care patients aged ≥70 years and eligible for CRC screening, including open-ended questions about CRC screening discussions. Primary outcomes were the frequency with which CRC screening discussions occurred, who had those discussions, and the domains that emerged from thematic analysis of participants' brief reports of their discussions. We also examined the associations between 1) patient characteristics and whether a screening discussion occurred and 2) the domains discussed and what screening decisions were made. Results. Of 422 participants, 209 reported having discussions and 201 responded to open-ended questions about CRC discussions. In a regression analysis, several factors were associated with increased odds of having a discussion: participants' preference to pursue screening (odds ratio [OR] 2.3, 95% confidence interval [CI] 1.3, 3.9), good health (OR 2.9, 95% CI 1.7, 4.8), and receipt of the decision aid (OR 2.1, 95% CI 1.4, 3.2). Our thematic analysis identified five domains related to discussion content and three related to discussion process. The CRC screening-related information domain was the most commonly discussed content domain, and the timing/frequency domain was associated with increased odds of intent to pursue screening. Decision-making role, the most commonly discussed process domain, was associated with increased odds of the intent to forgo CRC screening. Conclusions and Relevance. CRC screening discussions varied by type of participant and content. Future work is needed to determine if interventions focused on specific domains alters the appropriateness of participants' colorectal cancer screening intentions.
Collapse
Affiliation(s)
- Christine E Kistler
- Department of Family Medicine, University of North Carolina at Chapel Hill School of Medicine, Chapel Hill, NC, USA
| | - Carol Golin
- Department of Medicine, and Department of Health Behavior, Gillings School of Global Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Anupama Sundaram
- School of Medicine, Northeast Ohio Medical University, Rootstown, OH, USA
| | - Carolyn Morris
- Department of Family Medicine, University of North Carolina at Chapel Hill School of Medicine, Chapel Hill, NC, USA
| | - Alexandra F Dalton
- Division of General Internal Medicine, University of Colorado School of Medicine, Aurora, CO, USA
| | - Renee Ferrari
- Cecil G. Sheps Center for Health Services Research, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Carmen L Lewis
- Division of General Internal Medicine, University of Colorado School of Medicine, Aurora, CO, USA
| |
Collapse
|
50
|
Degeling C, Barratt A, Aranda S, Bell R, Doust J, Houssami N, Hersch J, Sakowsky R, Entwistle V, Carter SM. Should women aged 70-74 be invited to participate in screening mammography? A report on two Australian community juries. BMJ Open 2018; 8:e021174. [PMID: 29903796 PMCID: PMC6009633 DOI: 10.1136/bmjopen-2017-021174] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
OBJECTIVE To elicit informed views from Australian women aged 70-74 regarding the acceptability of ceasing to invite women their age to participate in government-funded mammography screening (BreastScreen). DESIGN Two community juries held in 2017. SETTING Greater Sydney, a metropolis of 4.5 million people in New South Wales, Australia. PARTICIPANTS 34 women aged 70-74 with no personal history of breast cancer, recruited by random digit dialling and previously randomly recruited list-based samples. MAIN OUTCOMES AND MEASURES Jury verdict and rationale in response to structured questions. We transcribed audio-recorded jury proceedings and identified central reasons for the jury's decision. RESULTS The women's average age was 71.5 years. Participants were of diverse sociocultural backgrounds, with the sample designed to include women of lower levels of educational attainment. Both juries concluded by majority verdict (16-2 and 10-6) that BreastScreen should continue to send invitations and promote screening to their age group. Reasons given for the majority position include: (1) sending the invitations shows that society still cares about older women, empowers them to access preventive health services and recognises increasing and varied life expectancy; (2) screening provides women with information that enables choice and (3) if experts cannot agree, the conservative approach is to maintain the status quo until the evidence is clear. Reasons for the minority position were the potential for harms through overdiagnosis and misallocation of scarce health resources. CONCLUSIONS Preventive programmes such as mammography screening are likely to have significant symbolic value once they are socially embedded. Arguments for programme de-implementation emphasising declining benefit because of limited life expectancy and the risks of overdiagnosis seem unlikely to resonate with healthy older women. In situations where there is no consensus among experts on the value of established screening programmes, people may strongly prefer receiving information about their health and having the opportunity make their own choices.
Collapse
Affiliation(s)
- Chris Degeling
- Research for Social Change, University of Wollongong, Wollongong, New South Wales, Australia
- Wiser Healthcare, Sydney, Australia
| | - Alexandra Barratt
- Wiser Healthcare, Sydney, Australia
- Sydney School of Public Health, University of Sydney, Sydney, New South Wales, Australia
| | - Sanchia Aranda
- The Cancer Council Australia, Sydney, New South Wales, Australia
| | - Robin Bell
- Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Jenny Doust
- Centre for Research in Evidence-Based Practice, Faculty of Health Sciences and Medicine, Bond University, Gold Coast, Queensland, Australia
| | - Nehmat Houssami
- Wiser Healthcare, Sydney, Australia
- Sydney School of Public Health, University of Sydney, Sydney, New South Wales, Australia
| | - Jolyn Hersch
- Wiser Healthcare, Sydney, Australia
- Sydney School of Public Health, University of Sydney, Sydney, New South Wales, Australia
| | - Ruben Sakowsky
- Health Economics Research Unit, University of Aberdeen, Aberdeen, UK
| | - Vikki Entwistle
- Health Services Research Unit, University of Aberdeen, Aberdeen, UK
| | - Stacy M Carter
- Research for Social Change, University of Wollongong, Wollongong, New South Wales, Australia
- Wiser Healthcare, Sydney, Australia
| |
Collapse
|