Older Adults' Views and Communication Preferences About Cancer Screening Cessation

General practitioners' views and experiences of communicating with older people about cancer screening: a qualitative study

BACKGROUND

Older adults should be supported to make informed decisions about cancer screening. However, it is unknown how general practitioners (GPs) in Australia communicate about cancer screening with older people.

AIM

To investigate GPs' views and experiences of communicating about cancer screening (breast, cervical, prostate, and bowel) with older people (≥70 years).

DESIGN AND SETTING

Qualitative, semi-structured interviews, Australia.

METHOD

Interviews were conducted with GPs practising in Australia (n = 28), recruited through practice-based research networks, primary health networks, social media, and email invitation. Interviews were audio-recorded and analysed thematically using Framework Analysis.

RESULTS

Findings across GPs were organized into 3 themes: (i) varied motivation to initiate cancer screening discussions; some GPs reported that they only initiated screening within recommended ages (<75 years), others described initiating discussions beyond recommended ages, and some experienced older patient-initiated discussions; (ii) GPs described the role they played in providing screening information, whereby detailed discussions about the benefits/risks of prostate screening were more likely than other nationally funded screening types (breast, cervical, and bowel); however, some GPs had limited knowledge of recommendations and found it challenging to explain why screening recommendations have upper ages; (iii) GPs reported providing tailored advice and discussion based on personal patient preferences, overall health/function, risk of cancer, and previous screening.

CONCLUSIONS

Strategies to support conversations between GPs and older people about the potential benefits and harms of screening in older age and rationale for upper age limits to screening programmes may be helpful. Further research in this area is needed.

Crossing the deintensification chasm for older adults with diabetes

This editorial comments on the article by Haider et al.

A National Survey of Physicians' Views on the Importance and Implementation of Deintensifying Diabetes Medications

BACKGROUND

Guidelines recommend deintensifying hypoglycemia-causing medications for older adults with diabetes whose hemoglobin A1c is below their individualized target, but this rarely occurs in practice.

OBJECTIVE

To understand physicians' decision-making around deintensifying diabetes treatment.

DESIGN

National physician survey.

PARTICIPANTS

US physicians in general medicine, geriatrics, or endocrinology providing outpatient diabetes care.

MAIN MEASURES

Physicians rated the importance of deintensifying diabetes medications for older adults with type 2 diabetes, and of switching medication classes, on 5-point Likert scales. They reported the frequency of these actions for their patients, and listed important barriers and facilitators. We evaluated the independent association between physicians' professional and practice characteristics and the importance of deintensifying and switching diabetes medications using multivariable ordered logistic regression models.

KEY RESULTS

There were 445 eligible respondents (response rate 37.5%). The majority of physicians viewed deintensifying (80%) and switching (92%) diabetes medications as important or very important to the care of older adults. Despite this, one-third of physicians reported deintensifying diabetes medications rarely or never. While most physicians recognized multiple reasons to deintensify, two-thirds of physicians reported barriers of short-term hyperglycemia and patient reluctance to change medications or allow higher glucose levels. In multivariable models, geriatricians rated deintensification as more important compared to other specialties (p=0.027), and endocrinologists rated switching as more important compared to other specialties (p<0.006). Physicians with fewer years in practice rated higher importance of deintensification (p<0.001) and switching (p=0.003).

CONCLUSIONS

While most US physicians viewed deintensifying and switching diabetes medications as important for the care of older adults, they deintensified infrequently. Physicians had ambivalence about the relative benefits and harms of deintensification and viewed it as a potential source of conflict with their patients. These factors likely contribute to clinical inertia, and studies focused on improving shared decision-making around deintensifying diabetes medications are needed.

Tackling Guideline Non-concordance: Primary Care Barriers to Incorporating Life Expectancy into Lung Cancer Screening Decision-Making-A Qualitative Study

BACKGROUND

Primary care providers (PCPs) are often the first point of contact for discussing lung cancer screening (LCS) with patients. While guidelines recommend against screening people with limited life expectancy (LLE) who are less likely to benefit, these patients are regularly referred for LCS.

OBJECTIVE

We sought to understand barriers PCPs face to incorporating life expectancy into LCS decision-making for patients who otherwise meet eligibility criteria, and how a hypothetical point-of-care tool could support patient selection.

DESIGN

Qualitative study based on semi-structured telephone interviews.

PARTICIPANTS

Thirty-one PCPs who refer patients for LCS, from six Veterans Health Administration facilities.

APPROACH

We thematically analyzed interviews to understand how PCPs incorporated life expectancy into LCS decision-making and PCPs' receptivity to a point-of-care tool to support patient selection. Final themes were organized according to the Cabana et al. framework Why Don't Physicians Follow Clinical Practice Guidelines, capturing the influence of clinician knowledge, attitudes, and behavior on LCS appropriateness determinations.

KEY RESULTS

PCP referrals to LCS for patients with LLE were influenced by limited knowledge of the life expectancy threshold at which patients are less likely to benefit from LCS, discomfort estimating life expectancy, fear of missing cancer at the point of early detection, and prioritization of factors such as quality of life, patient values, clinician-patient relationship, and family support. PCPs were receptive to a decision support tool to inform and communicate LCS appropriateness decisions if easy to use and integrated into clinical workflows.

CONCLUSIONS

Our study suggests knowledge gaps and attitudes may drive decisions to offer screening despite LLE, a behavior counter to guideline recommendations. Integrating a LCS decision support tool that incorporates life expectancy within the electronic medical record and existing clinical workflows may be one acceptable solution to improve guideline concordance and increase confidence in selecting high benefit patients for LCS.

Bipolar Disorder Symptom Monitoring Measures: A Mixed-Methods Study of Patient Preferences

OBJECTIVE

To determine the perceived acceptability and helpfulness of bipolar disorder symptom measures and rank the measures in order of preference among individuals with bipolar disorder.

METHODS

We recruited 20 participants 18 years of age or older with any type of bipolar disorder from a primary care clinical site and a national advocacy organization. We used a simultaneous complementary mixed-method design involving completion of symptom measures, a semistructured interview, and numerical ranking of measures. Participants completed three symptom measures or combination of measures: 1) Affective Self-Rating Scale; 2) combination Patient Mania Questionnaire-9 (PMQ-9) and Patient Health Questionnaire-9 (PHQ-9); and 3) combination Altman Self-Rating Mania Rating Scale and PHQ-9. A semistructured interview was conducted, and participants ranked their preferences for measures. Interviews focused on participants' rationale for measuring preferences. Interviews were analyzed by two psychiatrist-investigators using content analysis, and themes were determined. Average rank of each measure was determined.

RESULTS

The average rank for each measure was 1.48 for the combination PMQ-9 and PHQ-9, 1.68 for the Affective Self-Rating Scale, and 2.85 for the combination Altman Self-Rating Mania Rating Scale and PHQ-9, indicating that the combination PMQ-9 and PHQ-9 (top-ranked measure by 55% of participants) was the most preferred among the three measures. Major themes that emerged from the data were: 1) measure format; 2) patient experience; 3) clinical practice; and 4) therapeutic effects.

CONCLUSIONS

Individuals with bipolar disorder preferred the combination PMQ-9 and PHQ-9 for use in monitoring treatment due to perceived strengths such as format, ease of completion and interpretation, accurate description of experiences, and feasibility of use in practice.

Variation in Receipt of Cancer Screening and Immunizations by 10-year Life Expectancy among U.S. Adults aged 65 or Older in 2019

IMPORTANCE

The likelihood of benefit from a preventive intervention in an older adult depends on its time-to-benefit and the adult's life expectancy. For example, the time-to-benefit from cancer screening is >10 years, so adults with <10-year life expectancy are unlikely to benefit.

OBJECTIVE

To examine receipt of screening for breast, prostate, or colorectal cancer and receipt of immunizations by 10-year life expectancy.

DESIGN

Analysis of 2019 National Health Interview Survey.

PARTICIPANTS

8,329 non-institutionalized adults >65 years seen by a healthcare professional in the past year, representing 46.9 million US adults.

MAIN MEASURES

Proportions of breast, prostate, and colorectal cancer screenings, and immunizations, were stratified by 10-year life expectancy, estimated using a validated mortality index. We used logistic regression to examine receipt of cancer screening and immunizations by life expectancy and sociodemographic factors.

KEY RESULTS

Overall, 54.7% of participants were female, 41.4% were >75 years, and 76.4% were non-Hispanic White. Overall, 71.5% reported being current with colorectal cancer screening, including 61.4% of those with <10-year life expectancy. Among women, 67.0% reported a screening mammogram in the past 2 years, including 42.8% with <10-year life expectancy. Among men, 56.8% reported prostate specific antigen screening in the past two years, including 48.3% with <10-year life expectancy. Reported receipt of immunizations varied from 72.0% for influenza, 68.8% for pneumococcus, 57.7% for tetanus, and 42.6% for shingles vaccination. Lower life expectancy was associated with decreased likelihood of cancer screening and shingles vaccination but with increased likelihood of pneumococcal vaccination.

CONCLUSIONS

Despite the long time-to-benefit from cancer screening, in 2019 many US adults age >65 with <10-year life expectancy reported undergoing cancer screening while many did not receive immunizations with a shorter time-to-benefit. Interventions to improve individualization of preventive care based on older adults' life expectancy may improve care of older adults.

Breast cancer screening motivation and behaviours of women aged over 75 years

OBJECTIVE

In Australia, breast screening is offered free every two years to women aged 50-74 years. Women aged ≥75 are eligible to receive a free mammogram but do not receive an invitation. This study aimed to explore the motivations and behaviours of women living in Australia aged ≥75 years regarding ongoing breast cancer screening given the public health guidance.

METHODS

Sixty women aged ≥75 were recruited from metropolitan, regional, and rural areas across Australia to participate in a descriptive qualitative study. Semi-structured interviews were used to seek reflection on women's experience of screening, any advice they had received about screening beyond 75, their understanding of the value of screening and their intention to participate in the future. Thematic analysis of transcripts led to the development of themes.

RESULTS

Themes resulting from the study included: reasons to continue and discontinue screening, importance of inclusivity in the health system and availability of information. Regular screeners overwhelmingly wished to continue screening and had strong beliefs in the benefits of screening. Women received limited information about the benefits or harms of screening beyond age 75 and very few had discussed screening with their Primary Healthcare Provider. No longer receiving an invitation to attend screening impacted many women's decision-making.

CONCLUSION

More information via structured discussion with health professionals is required to inform women about the risks and benefits of ongoing screening. No longer being invited to attend screening left many women feeling confused and for some this led to feelings of discrimination.

AGA Clinical Practice Update on Risk Stratification for Colorectal Cancer Screening and Post-Polypectomy Surveillance: Expert Review

DESCRIPTION

Since the early 2000s, there has been a rapid decline in colorectal cancer (CRC) mortality, due in large part to screening and removal of precancerous polyps. Despite these improvements, CRC remains the second leading cause of cancer deaths in the United States, with approximately 53,000 deaths projected in 2023. The aim of this American Gastroenterological Association (AGA) Clinical Practice Update Expert Review was to describe how individuals should be risk-stratified for CRC screening and post-polypectomy surveillance and to highlight opportunities for future research to fill gaps in the existing literature.

METHODS

This Expert Review was commissioned and approved by the American Gastroenterological Association (AGA) Institute Clinical Practice Updates Committee (CPUC) and the AGA Governing Board to provide timely guidance on a topic of high clinical importance to the AGA membership, and underwent internal peer review by the CPUC and external peer review through standard procedures of Gastroenterology. These Best Practice Advice statements were drawn from a review of the published literature and from expert opinion. Because systematic reviews were not performed, these Best Practice Advice statements do not carry formal ratings regarding the quality of evidence or strength of the presented considerations. Best Practice Advice Statements BEST PRACTICE ADVICE 1: All individuals with a first-degree relative (defined as a parent, sibling, or child) who was diagnosed with CRC, particularly before the age of 50 years, should be considered at increased risk for CRC. BEST PRACTICE ADVICE 2: All individuals without a personal history of CRC, inflammatory bowel disease, hereditary CRC syndromes, other CRC predisposing conditions, or a family history of CRC should be considered at average risk for CRC. BEST PRACTICE ADVICE 3: Individuals at average risk for CRC should initiate screening at age 45 years and individuals at increased risk for CRC due to having a first-degree relative with CRC should initiate screening 10 years before the age at diagnosis of the youngest affected relative or age 40 years, whichever is earlier. BEST PRACTICE ADVICE 4: Risk stratification for initiation of CRC screening should be based on an individual's age, a known or suspected predisposing hereditary CRC syndrome, and/or a family history of CRC. BEST PRACTICE ADVICE 5: The decision to continue CRC screening in individuals older than 75 years should be individualized, based on an assessment of risks, benefits, screening history, and comorbidities. BEST PRACTICE ADVICE 6: Screening options for individuals at average risk for CRC should include colonoscopy, fecal immunochemical test, flexible sigmoidoscopy plus fecal immunochemical test, multitarget stool DNA fecal immunochemical test, and computed tomography colonography, based on availability and individual preference. BEST PRACTICE ADVICE 7: Colonoscopy should be the screening strategy used for individuals at increased CRC risk. BEST PRACTICE ADVICE 8: The decision to continue post-polypectomy surveillance for individuals older than 75 years should be individualized, based on an assessment of risks, benefits, and comorbidities. BEST PRACTICE ADVICE 9: Risk-stratification tools for CRC screening and post-polypectomy surveillance that emerge from research should be examined for real-world effectiveness and cost-effectiveness in diverse populations (eg, by race, ethnicity, sex, and other sociodemographic factors associated with disparities in CRC outcomes) before widespread implementation.

Risk of Colorectal Cancer and Colorectal Cancer Mortality Beginning One Year after a Negative Fecal Occult Blood Test, among Screen-Eligible 76- to 85-Year-Olds

BACKGROUND

Colorectal cancer screening is universally recommended for adults ages 45 to 75 years. Noninvasive fecal occult blood tests are effective screening tests recommended by guidelines. However, empirical evidence to inform older adults' decisions about whether to continue screening is sparse, especially for individuals with prior screening.

METHODS

This study used a retrospective cohort of older adults at three Kaiser Permanente integrated healthcare systems (Northern California, Southern California, Washington) and Parkland Health. Beginning 1 year following a negative stool-based screening test, cumulative risks of colorectal cancer incidence, colorectal cancer mortality (accounting for deaths from other causes), and non-colorectal cancer mortality were estimated.

RESULTS

Cumulative incidence of colorectal cancer in screen-eligible adults ages 76 to 85 with a negative fecal occult blood test 1 year ago (N = 118,269) was 0.23% [95% confidence interval (CI), 0.20%-0.26%] after 2 years and 1.21% (95% CI, 1.13%-1.30%) after 8 years. Cumulative colorectal cancer mortality was 0.03% (95% CI, 0.02%-0.04%) after 2 years and 0.33% (95% CI, 0.28%-0.39%) after 8 years. Cumulative risk of death from non-colorectal cancer causes was 4.81% (95% CI, 4.68%-4.96%) after 2 years and 28.40% (95% CI, 27.95%-28.85%) after 8 years.

CONCLUSIONS

Among 76- to 85-year-olds with a recent negative stool-based test, cumulative colorectal cancer incidence and mortality estimates were low, especially within 2 years; death from other causes was over 100 times more likely than death from colorectal cancer.

IMPACT

These findings of low absolute colorectal cancer risk, and comparatively higher risk of death from other causes, can inform decision-making regarding whether and when to continue colorectal cancer screening beyond age 75 among screen-eligible adults.

Screening for cancer beyond recommended upper age limits: views and experiences of older people

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.

Factors Influencing Primary Care Practitioners' Cancer Screening Recommendations for Older Adults: a Systematic Review

BACKGROUND

Primary care practitioners (PCPs) play a key role in cancer screening decisions for older adults (≥ 65 years), but recommendations vary by cancer type and jurisdiction.

PURPOSE

To examine the factors influencing PCPs' recommendations for breast, cervical, prostate, and colorectal cancer screening for older adults.

DATA SOURCES

MEDLINE, Pre-Medline, EMBASE, PsycINFO, and CINAHL, searched from 1 January 2000 to July 2021, and citation searching in July 2022.

STUDY SELECTION

Assessed factors influencing PCPs' breast, prostate, colorectal, or cervical cancer screening decisions for older adults' (defined either as ≥ 65 years or < 10-year life expectancy).

DATA EXTRACTION

Two authors independently conducted data extraction and quality appraisal. Decisions were crosschecked and discussed where necessary.

DATA SYNTHESIS

From 1926 records, 30 studies met inclusion criteria. Twenty were quantitative, nine were qualitative, and one used a mixed method design. Twenty-nine were conducted in the USA, and one in the UK. Factors were synthesized into six categories: patient demographic characteristics, patient health characteristics, patient and clinician psycho-social factors, clinician characteristics, and health system factors. Patient preference was most reported as influential across both quantitative and qualitative studies. Age, health status, and life expectancy were also commonly influential, but PCPs held nuanced views about life expectancy. Weighing benefits/harms was also commonly reported with variation across cancer screening types. Other factors included patient screening history, clinician attitudes/personal experiences, patient/provider relationship, guidelines, reminders, and time.

LIMITATIONS

We could not conduct a meta-analysis due to variability in study designs and measurement. The vast majority of included studies were conducted in the USA.

CONCLUSIONS

Although PCPs play a role in individualizing cancer screening for older adults, multi-level interventions are needed to improve these decisions. Decision support should continue to be developed and implemented to support informed choice for older adults and assist PCPs to consistently provide evidence-based recommendations.

REGISTRATION

PROSPERO CRD42021268219.

FUNDING SOURCE

NHMRC APP1113532.

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

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.

Different Types of Patient Health Information Associated With Physician Decision-making Regarding Cancer Screening Cessation for Older Adults

Importance

Although guidelines use limited life expectancy to guide physician decision-making regarding cessation of cancer screening, many physicians recommend screening for older adults with limited life expectancies. Different ways of presenting information may influence older adults' screening decision-making; whether the same is true for physicians is unknown.

Objective

To examine how different ways of presenting patient health information are associated with physician decision-making about cancer screening cessation for older adults.

Design, Setting, and Participants

A national survey was mailed from April 29 to November 8, 2021, to a random sample of 1800 primary care physicians and 600 gynecologists from the American Medical Association Physician Masterfile. Primary care physicians were surveyed about breast, colorectal, or prostate cancer screenings. Gynecologists were surveyed about breast cancer screening.

Main Outcomes and Measures

Using vignettes of 2 older patients with limited life expectancies, 4 pieces of information about each patient were presented: (1) description of health conditions and functional status, (2) life expectancy, (3) equivalent physiological age, and (4) risk of dying from the specific cancer in the patient's remaining lifetime. The primary outcome was which information was perceived to be the most influential in screening cessation.

Results

The final sample included 776 participants (adjusted response rate, 52.8%; mean age, 51.4 years [range, 27-91 years]; 402 of 775 participants were men [51.9%]; 508 of 746 participants were White [68.1%]). The 2 types of information that were most often chosen as the factors most influential in cancer screening cessation were description of the patient's health or functional status (36.7% of vignettes [569 of 1552]) and risk of death from cancer in the patient's remaining lifetime (34.9% of vignettes [542 of 1552]). Life expectancy was chosen as the most influential factor in 23.1% of vignettes (358 of 1552). Physiological age was the least often chosen (5.3% of vignettes [83 of 1552]) as the most influential factor. Description of patient's health or functional status was the most influential factor among primary care physicians (estimated probability, 40.2%; 95% CI, 36.2%-44.2%), whereas risk of death from cancer was the most influential factor among gynecologists (estimated probability, 43.1%; 95% CI, 34.0%-52.1%). Life expectancy was perceived as a more influential factor in the vignette with more limited life expectancy (estimated probability, 27.9%; 95% CI, 24.5%-31.3%) and for colorectal cancer (estimated probability, 33.9%; 95% CI, 27.3%-40.5%) or prostate cancer (28.0%; 95% CI, 21.7%-34.2%) screening than for breast cancer screening (estimated probability, 14.5%; 95% CI, 10.9%-18.0%).

Conclusions and Relevance

Findings from this national survey study of physicians suggest that, in addition to the patient's health and functional status, the cancer risk in the patient's remaining lifetime and life expectancy were the factors most associated with physician decision-making regarding cancer screening cessation; information on cancer risk in the patient's remaining lifetime and life expectancy is not readily available during clinical encounters. Decision support tools that present a patient's cancer risk and/or limited life expectancy may help reduce overscreening among older adults.

A Qualitative Study of Perspectives of Older Adults on Deintensifying Diabetes Medications

BACKGROUND

While many older adults with type 2 diabetes have tight glycemic control beyond guideline-recommended targets, deintensifying (stopping or dose-reducing) diabetes medications rarely occurs.

OBJECTIVE

To explore the perspectives of older adults with type 2 diabetes around deintensifying diabetes medications.

DESIGN

This qualitative study used individual semi-structured interviews, which included three clinical scenarios where deintensification may be indicated.

PARTICIPANTS

Twenty-four adults aged ≥65 years with medication-treated type 2 diabetes and hemoglobin A1c <7.5% were included (to thematic saturation) using a maximal variation sampling strategy for diabetes treatment and physician specialty.

APPROACH

Interviews were independently coded by two investigators and analyzed using a grounded theory approach. We identified major themes and subthemes and coded responses to the clinical scenarios as positive (in favor of deintensification), negative, or ambiguous.

KEY RESULTS

Participants' mean age was 74 years, half were women, and 58% used a sulfonylurea or insulin. The first of four major themes was fear of losing control of diabetes, which participants weighed against the benefits of taking less medication (Theme 2). Few participants viewed glycemic control below target as a reason for deintensification and a majority would restart the medication if their home glucose increased. Some participants were anchored to their current diabetes treatment (Theme 3) driven by unrealistic views of medication benefits. A trusting patient-provider relationship (Theme 4) was a positive influence. In clinical scenarios, 8%, 4%, and 75% of participants viewed deintensification positively in the setting of poor health, limited life expectancy, and high hypoglycemia risk, respectively.

CONCLUSIONS

Optimizing deintensification requires patient education that describes both individualized glycemic targets and how they will change over the lifespan. Deintensification is an opportunity for shared decision-making, but providers must understand patients' beliefs about their medications and address misconceptions. Hypoglycemia prevention may be a helpful framing for discussing deintensification.

Risk of Colorectal Cancer and Colorectal Cancer Mortality Beginning Ten Years after a Negative Colonoscopy, among Screen-Eligible Adults 76 to 85 Years Old

BACKGROUND

Few empirical data are available to inform older adults' decisions about whether to screen or continue screening for colorectal cancer based on their prior history of screening, particularly among individuals with a prior negative exam.

METHODS

Using a retrospective cohort of older adults receiving healthcare at three Kaiser Permanente integrated healthcare systems in Northern California (KPNC), Southern California (KPSC), and Washington (KPWA), we estimated the cumulative risk of colorectal cancer incidence and mortality among older adults who had a negative colonoscopy 10 years earlier, accounting for death from other causes.

RESULTS

Screen-eligible adults ages 76 to 85 years who had a negative colonoscopy 10 years earlier were found to be at a low risk of colorectal cancer diagnosis, with a cumulative incidence of 0.39% [95% CI, 0.31%-0.48%) at 2 years that increased to 1.29% (95% CI, 1.02%-1.61%) at 8 years. Cumulative mortality from colorectal cancer was 0.04% (95% CI, 0.02%-0.08%) at 2 years and 0.46% (95% CI, 0.30%-0.70%) at 8 years.

CONCLUSIONS

These low estimates of cumulative colorectal cancer incidence and mortality occurred in the context of much higher risk of death from other causes.

IMPACT

Knowledge of these results could bear on older adults' decision to undergo or not undergo further colorectal cancer screening, including choice of modality, should they decide to continue screening. See related commentary by Lieberman, p. 6.

Effect of a Patient Decision Aid on Preferences for Colorectal Cancer Screening Among Older Adults: A Secondary Analysis of a Randomized Clinical Trial

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.

Physician Attitudes About Using Life Expectancy to Inform Cancer Screening Cessation in Older Adults-Results From a National Survey

This survey study assessed physicians’ attitudes about the use of life expectancy as a guide in the decision to stop cancer screening in older adults.

A comprehensive prognostic tool for older adults: Predicting death, ADL disability, and walking disability simultaneously

BACKGROUND

Many clinical and financial decisions for older adults depend on the future risk of disability and mortality. Prognostic tools for long-term disability risk in a general population are lacking. We aimed to create a comprehensive prognostic tool that predicts the risk of mortality, of activities of daily living (ADL) disability, and walking disability simultaneously using the same set of variables.

METHODS

We conducted a longitudinal analysis of the nationally-representative Health and Retirement Study (HRS). We included community-dwelling adults aged ≥70 years who completed a core interview in the 2000 wave of HRS, with follow-up through 2018. We evaluated 40 predictors encompassing demographics, diseases, physical functioning, and instrumental ADLs. We applied novel methods to optimize three models simultaneously while prioritizing variables that take less time to ascertain during backward stepwise elimination. The death prediction model used Cox regression and both the models for walking disability and for ADL disability used Fine and Gray competing-risk regression. We examined calibration plots and generated optimism-corrected statistics of discrimination using bootstrapping. To simulate unavailable patient data, we also evaluated models excluding one or two variables from the final model.

RESULTS

In 6646 HRS participants, 2662 developed walking disability, 3570 developed ADL disability, and 5689 died during a median follow-up of 9.5 years. The final prognostic tool had 16 variables. The optimism-corrected integrated area under the curve (iAUC) was 0.799 for mortality, 0.685 for walking disability, and 0.703 for ADL disability. At each percentile of predicted mortality risk, there was a substantial spread in the predicted risks of walking disability and ADL disability. Discrimination and calibration remained good even when missing one or two predictors from the model. This model is now available on ePrognosis (https://eprognosis.ucsf.edu/alexlee.php) CONCLUSIONS: Given the variability in disability risk for people with similar mortality risks, using individualized risks of disabilities may inform clinical and financial decisions for older adults.

Variation in Communication of Competing Risks of Mortality in Prostate Cancer Treatment Consultations

PURPOSE

Men with prostate cancer prefer patient-specific, quantitative assessments of longevity in shared decision making. We sought to characterize how physicians communicate the 3 components of competing risks-life expectancy (LE), cancer prognosis and treatment-related survival benefit-in treatment consultations.

MATERIALS AND METHODS

Conversation related to LE, cancer prognosis and treatment-related survival benefit was identified in transcripts from treatment consultations of 42 men with low- and intermediate-risk disease across 10 multidisciplinary providers. Consensus of qualitative coding by multiple reviewers noted the most detailed mode of communication used to describe each throughout the consultation.

RESULTS

Physicians frequently failed to provide patient-specific, quantitative estimates of LE and cancer mortality. LE was omitted in 17% of consultations, expressed as a generalization (eg "long"/"short") in 17%, rough number of years in 31%, probability of mortality/survival at an arbitrary timepoint in 17% and in only 19% as a specific number of years. Cancer mortality was omitted in 24% of consultations, expressed as a generalization in 7%, years of expected life in 2%, probability at no/arbitrary timepoint in 40% and in only 26% as the probability at LE. Treatment-related survival benefit was often omitted; cancer mortality was reported without treatment in 38%, with treatment in 10% and in only 29% both with and without treatment. Physicians achieved "trifecta"-1) quantifying probability of cancer mortality 2) with and without treatment 3) at the patient's LE-in only 14% of consultations.

CONCLUSIONS

Physicians often fail to adequately quantify competing risks. We recommend the "trifecta" approach, reporting 1) probability of cancer mortality 2) with and without treatment 3) at the patient's LE.

Characteristics Associated with Low-Value Cancer Screening Among Office-Based Physician Visits by Older Adults in the USA

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.

Comorbidity and life expectancy in shared decision making for lung cancer screening

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.

"It's something I'll do until I die": A qualitative examination into why older women in the U.S. continue screening mammography

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.

Discontinuing Cancer Screening for Older Adults: a Comparison of Clinician Decision-Making for Breast, Colorectal, and Prostate Cancer Screenings

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.

Life expectancy estimates based on comorbidities and frailty to inform preventive care

BACKGROUND

Long-term prognostication is important to inform preventive care in older adults. Existing prediction indices incorporate age and comorbidities. Frailty is another important factor in prognostication. In this project, we aimed at developing life expectancy estimates that incorporate both comorbidities and frailty.

METHODS

In this retrospective cohort study, we used data from a 5% sample of Medicare beneficiaries with and without history of cancer from Surveillance, Epidemiology, and End Results (SEER) cancer registry areas. We included adults aged 66-95 years who were continuously enrolled in fee-for-service Medicare for ≥1 year from 1998 to 2014. Participants were followed for survival until 12/31/2015, death, or disenrollment. Comorbidity (none, low/medium, high) and frailty categories (low, high) were defined using established methods for claims. We estimated 5- and 10-year survival probabilities and median life expectancies by age, sex, comorbidities, and frailty.

RESULTS

The study included 479,646 individuals (4,128,316 person-years), of whom most were women (58.7%). Frailty scores varied widely among participants in the same comorbidity category. In Cox models, both comorbidities and frailty were independent predictors of mortality. Individuals with high comorbidities (HR, 3.24; 95% CI, 3.20-3.28) and low/medium comorbidities (HR, 1.36; 95% CI, 1.34-1.39) had higher risks of death than those with no comorbidities. Compared to low frailty, high frailty was associated with higher risk of death (HR, 1.55; 95% CI, 1.52-1.58). Frailty affected life expectancy estimates in ways relevant to preventive care (i.e., distinguishing <10-year versus >10-year life expectancy) in multiple subgroups.

CONCLUSION

Incorporating both comorbidities and frailty may be important in estimating long-term life expectancies of older adults. Our life expectancy tables can aid clinicians' prognostication and inform simulation models and population health management.

Patient-Reported Factors Associated With Older Adults' Cancer Screening Decision-making: A Systematic Review

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.

How do people understand overtesting and overdiagnosis? Systematic review and meta-synthesis of qualitative research

RATIONALE

The public should be informed about overtesting and overdiagnosis. Diverse qualitative studies have examined public understandings of this information. A synthesis was needed to systematise the body of evidence and yield new, generalisable insights.

AIM

Synthesise data from qualitative studies exploring patient and public understanding of overtesting and overdiagnosis.

METHODS

We searched Scopus, CINAHL, Ovid MEDLINE and PsycINFO databases from inception to March 18, 2020. We included published English-language primary studies exploring the perspectives of patients/the public about overtesting/overdiagnosis from any setting, year and relating to any condition. Only qualitative parts of mixed-methods studies were synthesised. We excluded studies that only examined overtreatment or sampled people with specialised medical knowledge. Two authors independently selected studies, extracted data, assessed the methodological quality of included studies using the CASP tool, and assessed confidence in the synthesis findings using the GRADE-CERQual approach. Data was analysed using thematic meta-synthesis, utilising descriptive and interpretive methods.

RESULTS

We synthesised data from 21 studies, comprising 1638 participants, from 2754 unique records identified. We identified six descriptive themes, all graded as moderate confidence (indicating they are likely to reasonably represent the available evidence): i) high confidence in screening and testing; ii) difficulty in understanding overuse; iii) acceptance that overuse can be harmful; iv) rejection or problematisation of overuse; v) limited impacts of overuse information on intended test and screening uptake; vi) desire for information and shared decision-making regarding overuse. The descriptive themes were underpinned by two analytic themes: i) perceived intrinsic value of information and information gathering, and; ii) differences in comprehension and acceptance of overuse concepts.

CONCLUSIONS

This study identified novel and important insights about how lay people interpret overuse concepts. It will guide the development of more effective public messages about overuse, highlighting the importance of interpretative frameworks in these communications.

What Should We Recommend for Colorectal Cancer Screening in Adults Aged 75 and Older?

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.

Patients' Willingness to Share Limited Endoscopic Resources: A Brief Report on the Results of a Large Regional Survey

Background. In some health care systems, patients face long wait times for screening colonoscopy. We sought to assess whether patients at low risk for colorectal cancer (CRC) would be willing to delay their own colonoscopy so higher-risk peers could undergo colonoscopy sooner. Methods. We surveyed 1054 Veterans regarding their attitudes toward repeat colonoscopy and risk-based prioritization. We used multivariable regression to identify patient factors associated with willingness to delay screening for a higher-risk peer. Results. Despite a physician recommendation to stop screening, 29% of respondents reported being "not at all likely" to stop. However, 94% reported that they would be willing to delay their own colonoscopy for a higher-risk peer. Greater trust in physician and greater health literacy were positively associated with willingness to wait, while greater perceived threat of CRC and Black or Latino race/ethnicity were negatively associated with willingness to wait. Conclusion. Despite high enthusiasm for repeat screening, patients were willing to delay their own colonoscopy for higher-risk peers. Appealing to altruism could be effective when utilizing scarce resources.

Association Between Receipt of Cancer Screening and All-Cause Mortality in Older Adults

IMPORTANCE

Guidelines recommend against routine breast and prostate cancer screenings in older adults with less than 10 years' life expectancy. One study using a claims-based prognostic index showed that receipt of cancer screening itself was associated with lower mortality, suggesting that the index may misclassify individuals when used to inform cancer screening, but this finding was attributed to residual confounding because the index did not account for functional status.

OBJECTIVE

To examine whether cancer screening remains significantly associated with all-cause mortality in older adults after accounting for both comorbidities and functional status.

DESIGN, SETTING, AND PARTICIPANTS

This cohort study included individuals older than 65 years who were eligible for breast or prostate cancer screening and who participated in the 2004 Health and Retirement Study. Data were linked to Medicare claims from 2001 to 2015. Data analysis was conducted from January to November 2020.

MAIN OUTCOMES AND MEASURES

A Cox model was used to estimate the association between all-cause mortality over 10 years and receipt of screening mammogram or prostate-specific antigen (PSA) test, adjusting for variables in a prognostic index that included age, sex, comorbidities, and functional status. Potential confounders (ie, education, income, marital status, geographic region, cognition, self-reported health, self-care, and self-perceived mortality risk) of the association between cancer screening and mortality were also tested.

RESULTS

The breast cancer screening cohort included 3257 women (mean [SD] age, 77.8 [7.5] years); the prostate cancer screening cohort included 2085 men (mean [SD] age, 76.1 [6.8] years). Receipt of screening mammogram was associated with lower hazard of all-cause mortality after accounting for all index variables (adjusted hazard ratio [aHR], 0.67; 95% CI, 0.60-0.74). A weaker, but still statistically significant, association was found for screening PSA (aHR 0.88; 95% CI, 0.78-0.99). None of the potential confounders attenuated the association between screening and mortality except for cognition, which attenuated the aHR for mammogram from 0.67 (95% CI, 0.60-0.74) to 0.73 (95% CI, 0.64-0.82) and the aHR for PSA from 0.88 (95% CI, 0.78-0.99) to 0.92 (95% CI, 0.80-1.05), making PSA screening no longer statistically significant.

CONCLUSIONS AND RELEVANCE

In this study, cognition attenuated the observed association between cancer screening and mortality among older adults. These findings suggest that existing mortality prediction algorithms may be missing important variables that are associated with receipt of cancer screening and long-term mortality. Relying solely on algorithms to determine cancer screening may misclassify individuals as having limited life expectancy and stop screening prematurely. Screening decisions need to be individualized and not solely dependent on life expectancy prediction.

Examining primary care physician rationale for not following geriatric choosing wisely recommendations

Background

The objective is to understand why physicians order tests or treatments in older adults contrary to published recommendations.

Methods

Participants: Physicians above the median for ≥ 1 measures of overuse representing 3 Choosing Wisely topics. Measurements: Participants evaluated decisions in a semi-structured interview regarding: 1) Screening men aged ≥ 76 with prostate specific antigen 2) Ordering urine studies in women ≥ 65 without symptoms 3) Overtreating adults aged ≥ 75 with insulin or oral hypoglycemic medications. Two investigators independently coded transcripts using qualitative analysis.

Results

Nineteen interviews were conducted across the three topics resulting in four themes. First, physicians were aware and knowledgeable of guidelines. Second, perceived patient preference towards overuse influenced physician action even when physicians felt strongly that testing was not indicated. Third, physicians overestimated benefits of a test and underemphasized potential harms. Fourth, physicians were resistant to change when patients appeared to be doing well.

Conclusions

Though physicians expressed awareness to avoid overuse, deference to patient preferences and the tendency to distort the chance of benefit over harm influenced decisions to order testing. Approaches for decreasing unnecessary testing must account for perceived patient preferences, make the potential harms of overtesting salient, and address clinical inertia among patients who appear to be doing well.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12875-021-01440-w.

Active surveillance as a management option for cervical intraepithelial neoplasia 2: An online experimental study

OBJECTIVE

To investigate framing of active surveillance as a management option for cervical intraepithelial neoplasia (CIN)2 in women of childbearing age.

METHODS

We conducted a between-subjects factorial (2 × 2) randomised experiment. Women aged 25-40 living in Australia were presented with the same hypothetical pathway of testing human papillomavirus (HPV)-positive, high-grade cytology and a diagnosis of CIN2, through an online survey. They were randomised to one of four groups to evaluate the effects of (i) framing (method of explaining resolution of abnormal cells) and (ii) inclusion of an overtreatment statement (included versus not). Primary outcome was management choice following the scenario: active surveillance or surgery.

RESULTS

1638 women were randomised. Overall, preference for active surveillance was high (78.9%; n = 1293/1638). There was no effect of framing or providing overtreatment information, or their interaction, on management choice. After adjusting for intervention received, age, education, and other model covariates, participants were more likely to choose active surveillance over surgery if they had not already had children, had plans for children in the future, had no family history of cancer, had no history of endometriosis, had adequate health literacy, and more trust in their GP. Participants were less likely to choose active surveillance over surgery if they were more predisposed to seek health care for minor problems.

CONCLUSIONS

Although we found no framing effect across the four conditions, we found a high level of preference for active surveillance with associations of increased preference that accord with the desire to minimise potential risks of CIN2 treatment on obstetric outcomes. These are valuable data for future clinical trials of active surveillance for management of CIN2 in younger women of childbearing age.

TRIAL REGISTRATION

Australian New Zealand Clinical Trials Registry (ACTRN12618002043213, 20/12/2018, prior to participant enrolment).

Using an Agent-based Model to Examine Deimplementation of Breast Cancer Screening

OBJECTIVE

The objective of this study was to examine the potential impact of provider social networks and experiences with patients on deimplementation of breast cancer screening.

RESEARCH DESIGN

We constructed the Breast Cancer-Social network Agent-based Model (BC-SAM), which depicts breast cancer screening decisions, incidence, and progression among 10,000 women ages 40 and over and the screening recommendations of their providers over a 30-year period. The model has patient and provider modules that each incorporate social network influences. Patients and providers were connected in a network, which represented patient-patient peer connections, provider-provider peer connections, connections between providers and patients they treat, and friend/family relationships between patients and providers. We calibrated provider decisions in the model using data from the CanSNET national survey of primary care physicians in the United States, which we fielded in 2016.

RESULTS

First, assuming that providers' screening recommendations for women ages 50-74 remain unchanged but their recommendations for screening among younger (below 50 y old) and older (75+ y old) women decrease, we observed a decline in predicted screening rates for women ages 50-74 due to spillover effects. Second, screening rates for younger and older women were slow to respond to changes in provider recommendations; a 78% decline in provider recommendations to older women over 30 years resulted in an estimated 23% decline in patient screening in that group. Third, providers' experiences with unscreened patients, friends, and family members modestly increased screening recommendations over time (7 percentage points). Finally, we found that provider peer effects can have a substantial impact on population screening rates and can entrench existing practices.

CONCLUSION

Modeling cancer screening as a complex social system demonstrates a range of potential effects and may help target future interventions designed to reduce overscreening.

Patient-reported Health Status, Comorbidity Burden, and Prostate Cancer Treatment

OBJECTIVE

To determine whether patient-reported health status, more so than comorbidity, influences treatment in men with localized prostate cancer.

METHODS

Using Surveillance, Epidemiology, and End Results data linked with Medicare claims and CAHPS surveys, we identified men aged 65-84 diagnosed with localized prostate cancer from 2004 to 2013 and ascertained their National Cancer Institute (NCI) comorbidity score and patient-reported health status. Adjusting for demographics and cancer risk, we examined the relationship between these measures and treatment for the overall cohort, low-risk men aged 65-74, intermediate/high-risk men aged 65-74, and men aged 75-84.

RESULTS

Among 2724 men, 43.0% rated their overall health as Excellent/Very Good, while 62.7% had a comorbidity score of 0. Beyond age and cancer risk, patient-reported health status was significantly associated with treatment. Compared to men reporting Excellent/Very Good health, men in Poor/Fair health less often received treatment (odds ratio [OR] 0.71, 95% confidence interval [CI] 0.56-0.90). Younger men with intermediate/high-risk cancer in Good (OR 0.60, 95% CI 0.41-0.88) or Fair/Poor (OR 0.49, 95% CI 0.30-0.79) health less often underwent prostatectomy vs radiation compared to men in Excellent/Very Good health. In contrast, men with NCI comorbidity score of 1 more often received treatment (OR 1.37, 95% CI 1.11-1.70) compared to men with NCI comorbidity score of 0.

CONCLUSION

Patient-reported health status drives treatment for prostate cancer in an appropriate direction whereas comorbidity has an inconsistent relationship. Greater understanding of this interplay between subjective and empiric assessments may facilitate more shared decision-making in prostate cancer care.

Addressing Disparities in Lung Cancer Screening Eligibility and Healthcare Access. An Official American Thoracic Society Statement

Background: There are well-documented disparities in lung cancer outcomes across populations. Lung cancer screening (LCS) has the potential to reduce lung cancer mortality, but for this benefit to be realized by all high-risk groups, there must be careful attention to ensuring equitable access to this lifesaving preventive health measure.Objectives: To outline current knowledge on disparities in eligibility criteria for, access to, and implementation of LCS, and to develop an official American Thoracic Society statement to propose strategies to optimize current screening guidelines and resource allocation for equitable LCS implementation and dissemination.Methods: A multidisciplinary panel with expertise in LCS, implementation science, primary care, pulmonology, health behavior, smoking cessation, epidemiology, and disparities research was convened. Participants reviewed available literature on historical disparities in cancer screening and emerging evidence of disparities in LCS.Results: Existing LCS guidelines do not consider racial, ethnic, socioeconomic, and sex-based differences in smoking behaviors or lung cancer risk. Multiple barriers, including access to screening and cost, further contribute to the inequities in implementation and dissemination of LCS.Conclusions: This statement identifies the impact of LCS eligibility criteria on vulnerable populations who are at increased risk of lung cancer but do not meet eligibility criteria for screening, as well as multiple barriers that contribute to disparities in LCS implementation. Strategies to improve the selection and dissemination of LCS in vulnerable groups are described.

Colorectal Cancer Screening in the Elderly

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.

Examining Older Adults' Attitudes and Perceptions of Cancer Screening and Overscreening: A Qualitative Study

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.

Comparing the Preferences of Patients and the General Public for Treatment Outcomes in Type 2 Diabetes Mellitus

BACKGROUND

Healthcare treatments and interventions are traditionally evaluated from the societal perspective, but a more patient-centric perspective has been proposed in recent years. We sought to compare preferences of patients and the general public for treatment outcomes of type 2 diabetes using both best-worst scaling (BWS) and rating approaches.

METHODS

A survey evaluating the treatment priorities for type 2 diabetes was conducted in the United States. Members of the general public and patients with type 2 diabetes were recruited from a nationally sampled panel. Participants indicated the importance of seven potential treatment outcomes (hypoglycemic events, glycated hemoglobin [A1c], weight loss, mental health, functioning, glycemic stability, and cardiovascular health) using (1) BWS case 1 and (2) a rating task. Preference differences from BWS prioritizations were explored using mixed logistic regression (BWS preference weights were probability re-scaled so that the weightings of the seven items collectively summed to 100). The consistency of scale between samples was explored using heteroskedastic conditional logistic regression of BWS data. Spearman rank correlation was used to compare standardized BWS preference weights and rating scores for each group. Both groups evaluated the BWS and rating activities using debriefing questions.

RESULTS

The public and patient samples included 314 and 313 respondents, respectively. The public was on average 16 years younger than patients (48 vs 64 years, P < 0.001). In BWS, patients and the public both ranked A1c, glycemic stability, and cardiovascular health within their top three outcomes. Patients valued the outcome A1c most highly and found it twice as important as did the public (41.0 vs 20.2, P < 0.001). The public valued cardiovascular health most highly, and found it to be twice as important than did patients (31.3 vs 17.4, P < 0.001). Patients were more consistent in their preferences than the public (λ = 1.66, P = 0.01). Preferences elicited using BWS and rating approaches were highly correlated for both patients (ρ = 0.96) and the public (ρ = 0.92). Patients were more likely than the public to endorse the BWS as easy to answer (P < 0.001), easy to understand (P < 0.001), consistent with preferences (P < 0.001), and relevant (P < 0.001). Both patients and the public found the rating activity easier to answer and understand, and more consistent with their preferences, than the BWS (P < 0.001).

CONCLUSIONS

We provide some of the first evidence demonstrating a difference in patient and public treatment priorities for diabetes. That patients were more consistent in their preferences than the public and found the BWS and Likert rating instruments more relevant suggests that patient priorities may be more appropriate than those of the general public in some medical decision-making contexts.

Overview of High Yield Geriatrics Assessment for Clinic and Hospital

Geriatric assessment is a comprehensive, multifaceted, and interdisciplinary evaluation of medical, socioeconomic, environmental, and functional concerns unique to older adults; it can be focused or broadened according to the needs of the patient and the concerns of clinical providers. Herein, the authors present a high-yield framework that can be used to assess older adult patients across a variety of settings.

Cancer Screening Among Older Adults: a Geriatrician's Perspective on Breast, Cervical, Colon, Prostate, and Lung Cancer Screening

PURPOSE OF REVIEW

We summarize the evidence of benefits, harms, and tools to assist in individualized decisions among older adults in screening for breast, prostate, colon, lung, and cervical cancer.

RECENT FINDINGS

The benefits of cancer screening in older adults remain unclear due to minimal inclusion of adults > 75 years old in most randomized controlled trials. Indirect evidence suggests that the benefits of screening seen in younger adults (< 70 years old) can be extrapolated to older adults when they have an estimated life expectancy of at least 10 years. However, older adults, especially those with limited life expectancy, may be at increased risk for experiencing harms of screening, including overdiagnosis of clinically unimportant diseases, complications from diagnostic procedures, and distress after false positive test results. We provide a framework to integrate key factors such as health status, risks and benefits of specific tests, and patient preferences to guide clinicians in cancer screening decisions in older adults.

A Strategy to Prepare Primary Care Clinicians for Discussing Stopping Cancer Screening With Adults Older Than 75 Years

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

Scripts and Strategies for Discussing Stopping Cancer Screening with Adults > 75 Years: a Qualitative Study

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.

Effect of different communication strategies about stopping cancer screening on screening intention and cancer anxiety: a randomised online trial of older adults in Australia

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).

Assessment of Clinician Decision-making on Cancer Screening Cessation in Older Adults With Limited Life Expectancy

IMPORTANCE

Despite clinical practice guidelines recommending against routine cancer screening in older adults with limited life expectancy, older adults are still frequently screened for breast, colorectal, and prostate cancers.

OBJECTIVE

To examine primary care clinicians' decision-making on stopping breast, colorectal, or prostate cancer screening in older adults with limited life expectancy.

DESIGN, SETTING, AND PARTICIPANTS

In qualitative interviews coupled with medical record-stimulated recall, clinicians from 17 academic and community clinics affiliated with a large health system were asked how they came to specific cancer screening decisions in 2 or 3 of their older patients with less than 10-year of estimated life expectancy, including patients with and without recent screening. Patients were surveyed by telephone. Data collection occurred between October 2018 and May 2019.

MAIN OUTCOMES AND MEASURES

Clinician interviews were audio-recorded and transcribed verbatim. Transcripts were analyzed with qualitative content analysis to identify major themes. Patient surveys assessed perception of cancer screening decisions, importance of clinician recommendation, and willingness to stop screening.

RESULTS

Twenty-five primary care clinicians (mean [SD] age, 47.1 [9.7] years; 14 female [56%]) discussed 53 patients during medical record-stimulated recall, ranging from 2 to 3 patients per clinician; 46 patients and 1 caregiver (mean [SD] age 74.9 [5.4]; 31 female [66%]) participated in the survey. Clinician interviews revealed 5 major themes: (1) cancer screening decisions were not always conscious, deliberate decisions; (2) electronic medical record alerts were connected with less deliberate decision-making; (3) cancer screening was not binary and clinicians often considered other options to scale back screening without actually stopping; (4) in addition to patient characteristics, clinicians were influenced by patient request and anecdotal experiences; and (5) influences outside of the primary care clinician-patient dyad were important, such as from specialists and patients' family or friends. Patient surveys asked approximately 64 cancer screening decisions of 47 patients. Patients did not recall approximately half (31 of 64) of their cancer screening decisions. Among those with recent screening, the mean score for willingness to stop screening was 3.2 (95% CI 2.5-3.9) on a 5-point Likert scale (with 1 indicating "extremely unlikely" and 5 indicating "extremely likely"). In most screening decisions that involved specialists (13 of 16), patients valued specialists' recommendations over those of primary care clinicians.

CONCLUSIONS AND RELEVANCE

Cancer screening decision-making is complex. Study findings suggest that strategies that facilitate more deliberate decision-making may be important in cancer screening of older adults with limited life expectancy.

Breast Cancer Screening in Older Women: The Importance of Shared Decision Making

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.

Modeling the Balance of Benefits and Harms of Cervical Cancer Screening with Cytology and Human Papillomavirus Testing

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.

Understanding the public's role in reducing low-value care: a scoping review

BACKGROUND

Low-value care initiatives are rapidly growing; however, it is not clear how members of the public should be involved. The objective of this scoping review was to systematically examine the literature describing public involvement in initatives to reduce low-value care.

METHODS

Evidence sources included MEDLINE, EMBASE, and CINAHL databases from inception to November 26, 2019, grey literature (CADTH Tool), reference lists of included articles, and expert consultation. Citations were screened in duplicate and included if they referred to the public's perception and/or involvement in reducing low-value care. Public included patients or citizens without any advanced healthcare knowledge. Low-value care included medical tests or treatments that lack efficacy, have risks that exceed benefit, or are not cost-effective. Extracted data pertained to study characteristics, low-value practice, clinical setting, and level of public involvement (i.e., patient-clinician interaction, research, or policy-making).

RESULTS

The 218 included citations were predominantly original research (n = 138, 63%), published since 2010 (n = 192, 88%), originating from North America (n = 146, 67%). Most citations focused on patient engagement within the patient-clinician interaction (n = 156, 72%), using tools that included shared decision-making (n = 66, 42%) and patient-targeted educational materials (n = 72, 46%), and reported both reductions in low-value care and improved patient perceptions regarding low-value care. Fewer citations examined public involvement in low-value care policy-making (n = 33, 15%). Among citations that examined perspectives regarding public involvement in initiatives to reduce low-value care (n = 10, 5%), there was consistent support for the utility of tools applied within the patient-clinician interaction and less consistent support for involvement in policy-making.

CONCLUSIONS

Efforts examining public involvement in low-value care concentrate within the patient-clinician interaction, wherein patient-oriented educational materials and shared decision-making tools have been commonly studied and are associated with reductions in low-value care. This contrasts with inclusion of the public in low-value care policy decisions wherein tools to promote engagement are less well-developed and involvement not consistently viewed as valuable.

TRIAL REGISTRATION

Open Science Framework (https://osf.io/6fsxm).